Every finding on record at Vivo Healthcare Lakeland

Based on observation, interview, and record review the facility did not ensure dental services were provided for one resident (#1) out of one resident sampled for timely dental care. Findings included: On 3/26/2026 at 10:33 A.M. an interview was conducted with Resident #1 who stated receiving dental care at the facility was always a big issue. Resident #1 stated their mouth feels weird and that the resident had told the facility numerous times. Resident #1 stated he had seen the dentist one time and never after that. Resident #1 said, Yes, I have ongoing dental problems with dental pain when I eat. Resident #1 stated he mainly eats soft stuff to accommodate the discomfort. Resident #1 stated there was an issue with scheduling his dental appointments and that the facility stated it was due to insurance or paperwork. The resident stated they had to start initiating his appointments because with the facility takes forever. The resident said once the appointments are scheduled at the last minute his appointments are cancelled without a reason given. Review of Resident #1's admission record revealed an original admission date of 07/18/2024 with diagnoses to include muscle wasting and atrophy not elsewhere classified, multiple sites, legal blindness and anemia. Review of Resident #1's Minimum Data Set (MDS), dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, meaning his cognition was intact. Review of Section L - Oral/Dental Status, revealed there was no response for mouth or facial pain, discomfort, or difficulty with chewing, broken teeth, loosely fitting or partial dentures (chipped, cracked, uncleanable, or loose). Review of Resident #1's physician order summary report from [Name of Company] Dental Services from 8/18/2025 showed the patient has root fragment on tooth #8 that is mobile and causing slight discomfort. Patient interested in extraction of root fragment. Review of Resident #1's progress notes revealed there was no evidence of documentation of the tooth pain, a broken tooth, or mention of dental services. A review of the Social Service's progress notes revealed there was no documentation regarding offering dental services to Resident #1, or documentation for rationale as to why the resident did not have access to dental services. On 3/26/2026 at 4:19 PM an interview was conducted with the Social Services Director (SSD) who stated they had an email from March 11, 2026, showing [Name of Company] dental services was there and there was no patient responsibility for Resident #1. She stated she was not sure what that meant. The SSD stated the dental company was at the facility on 2/27/2026 and the resident was not seen. The SSD provided a note from [Name of Company] Dental Services from 8/18/2025 revealing the patient had root fragments on tooth #8 that was mobile and causing slight discomfort. The SSD stated the resident was interested in extraction of the root fragment. The SSD stated she did not have an answer as to why the resident had not received a follow up to the 8/18/2025 dentist visit. The SSD stated she had seen the resident multiple times since that visit, and he had not mentioned anything to her either about being in pain. The SSD stated that she would reach out to the dental company today to further investigate what they meant by no patient responsibility. The SSD stated Resident #1 was seen on 8/18/2025 by an in-house dentist for dental and per the notes it showed the root fragment for tooth #8 that was mobile and causing slight discomfort and the patient interested in extraction of root fragment. On 3/26/2026 at 5:41 PM an interview was conducted with the SSD who stated Resident #1's income was so low, and the resident does not have enough to cover patient liability for dental. The SSD stated trying to reach out to the family today to see if they would cover it and no one had gotten back to them. Review of the undated facility policy titled, Dental Policy revealed - It is the policy of this facility to assist residents in obtaining routine, to the extent covered under the state plan and emergency dental care. Under definition it revealed, emergency dental services includes services needed to treat broken, or otherwise damaged teeth, or any other problem of the oral cavity that required immediate attention by a dentist.

Based on observation, interviews, and record review the facility failed to follow sanitary infection control practices related to 1) proper storage and disposal of toileting items in two resident rooms (112 and 110), 2) proper nail length for three staff members (Staff P, Staff M, Staff Q), 3) and proper hand hygiene during meal service for one observed meal (6/23/25) during four days of survey. Findings Included: 1. During an observation on 06/23/2025 at 11:10 a.m., of room [ROOM NUMBER] B a plastic urinal was located opened on floor under the bed, with a wet area. During an observation on 06/23/2025 at 11:04 a.m., of room [ROOM NUMBER] bathroom an adult brief with yellow and brown markings was located in front of the toilet on the floor. (photographic evidence obtained) 2. During an observation on 06/23/2025 at 9:44 a.m., Staff P, Registered Nurse (RN), was observed with artificial nails longer than 1/4 inch. During an observation on 06/23/2025 at 9:43 a.m., Staff M, RN was observed with artificial nails longer than 1/4 inch. During an observation on 06/25/2025 at 10:50 a.m., Staff Q, CNA was observed with artificial nails longer than 1/4 inch. During an interview on 06/25/20235 at 4:00 p.m., Staff B, Assistant Director of Nursing (ADON) and Infection Preventionist (IP), stated she would expect for urinals and adult briefs to be disposed of properly and not be on the floors. On 06/19/2025 she provided education to staff who needed to have their nails cut down. She highlighted the dress code policy where it states nails should not be longer than a 1/4 an inch. There is a number of nursing staff who need to go and get them cut down as they go and get their nails done. Typically they go every 2 weeks and I am expecting for the staffs nails to be in compliance by that time frame. 3. A lunch meal observation was conducted on 06/23/25 at 12:29 p.m. Observed Staff S, CNA serve 4 separate meal trays. No hand hygiene was performed. Staff S. then sat down next to an unidentified resident and began assisting with the meal. Staff S was observed coughing in her hand and wiping her face and using the same hand to feed the resident. No hand hygiene was performed throughout the observation. On 06/25/25 at 4:12 p.m. an interview with the DON and Infection Preventionist was conducted. They stated the expectation for staff for hand hygiene is performing hand hygiene when entering or exiting a resident room. Also in between touching or caring for residents. Staff should also perform hand hygiene while feeding, and in between residents. It would not be appropriate for staff to touch their face or cough into their hand and not perform hand hygiene while feeding a resident. A Review of the facility's policy titled Infection Prevention and Control Program, last revision date 1/2025, revealed the following: Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections as per accepted national standard and guidelines. 4. Standard Precautions: a: All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. b: Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures .

Based on observation, interviews and record review, the facility failed to provide Activities of Daily Living (ADL) for two residents (#154) related to removal of facial hair and (#367) related to showers out of four residents sampled for ADL. Findings Included: 1. During an interview on 06/23/25 at 11:10 a.m., Resident #154 was observed with long white strands of hair on her lip and chin. Resident #154 stated I wish they would help me pluck this hair off of my face. Review of Resident #154's admission record revealed an admission date of 05/21/2025. Resident #154 was admitted to the facility with diagnosis to include Need for Assistance with Personal Care, Neuromuscular Dysfunction of Bladder, Unspecified, Colostomy Status, Muscle Wasting and Atrophy, Not Elsewhere Classified, Multiple Sites and Multiple Sclerosis. Review of Resident #154's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C. Cognitive Patterns, a Brief Interview Mental Status (BIMS) of 14 out of 15 showing intact cognition. Review of Section GG. Functional Abilities revealed for oral hygiene Resident #154 needs supervision or touching assistance, where helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently for oral hygiene. For shower/bathe Resident #154 was dependent, where helper does all the effort. Residents do none of the effort to complete the activity. Or the assistance of two or more helpers is required for the residents to complete the activity. During an interview on 06/25/2025 at 5:47 p.m., Staff O, Certified Nursing Assistant (CNA), stated she assists residents with bathing, eating, or any daily activities they cannot do on their own. This includes trimming nails and shaving. She stated she had not asked Resident #154 if she would like assistance with removing her facial hair. During an interview on 06/25/2025 at 5:13 p.m., the Director of Nursing (DON) stated when staff are providing residents with their showers/baths staff should offer to help remove any unwanted facial. 2. On 06/24/2025 at 9:51 A.M. Staff L, Certified Nursing Assistant (CNA) was observed in Resident #367 room and stated, Lord have mercy, maybe I'll give you a shower today. There was a foul odor coming from Resident #367 side of the room. At 9:57 A.M., Staff M, Registered Nurse (RN) and Staff L, CNA, were observed speaking to each other at the nurses cart. Staff M, RN advised Staff L, CNA not to give Resident #367 a shower because it would be too difficult to cover his neck. Staff M, RN said to Staff L, CNA the foul odor was coming from Resident #367's clothes and not from the resident himself. An interview was conducted with Staff L, CNA and Staff M, RN on 6/25/2025 at 2:28 P.M. Staff L, CNA said Resident #367 is dependent on bathing and showering and he requires someone to help him. Staff L, CNA said she doesn't know what Resident #367's preferences are because he is only alert to himself. Staff L, CNA stated, he normally doesn't refuse a shower, but I gave him a bath in bed the other day. Staff L, CNA stated, if Resident #367 refuses, I wait and him ask again, and then I let the nurse know. Staff L, CNA said the nurse is supposed to chart it on the computer. Staff M, RN stated, I will only notify the doctor if it starts to affect Resident #367's health. An interview was conducted with the Director of Nursing (DON) on 6/26/2025 at 3:00 P.M. The DON stated, the facility provides handwritten shower sheets to the CNA's and the nurses are supposed to sign the sheets after they review them. After the nurse reviews the sheet, the sheet go to the Unit Manager (UM) for review and then the sheets are filed somewhere in the UM's office. A review of the admission Record for Resident #367 showed he was admitted to the facility on [DATE] with diagnoses including but not limited to Muscle Wasting and Atrophy and Immunodeficiency. As of 6/25/2025, Minimum Data Set (MDS), Section C, was not completed. A review of the task record titled, bathing for Resident #367 revealed the activity did not occur four out of five opportunities. A review of the facility issued shower sheet for Resident #367 dated 6/20/2025, revealed a note reading, Refused Shower, Resident was picky and didn't want shower. The shower sheet was not signed by a nurse or unit manager. A review of the Baseline Care Plan for Resident #367 dated 6/19/2025 revealed his preference is to receive a shower and the bathing support required is a one-person physical assist. Review of the facility policy titled, Activities of Daily Living (ADL's), implemented on 9/1/2023 and revised on 1/2025 states, The facility will, based on the resident's comprehensive assessment and consistent with the resident's need and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable; Care and services will be provided for the following activities of daily living: Bathing, dressing, grooming, and oral care. Under the paragraph titled, Policy Explanation and Compliance Guidelines, Section 3 states, A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observations, record reviews, and interviews, the facility failed to ensure a homelike environment for four resident rooms (Rooms # 407, 422, 429) out of eight rooms sampled and failed to store equipment appropriately in one out of two shower rooms. Findings include: During a facility tour conducted on 6/23/2025 at 11:00 a.m., room [ROOM NUMBER] was observed with pictures hanging off the wall over a resident bed. room [ROOM NUMBER] observed with a high-rise seat positioned over the toilet in the resident's bathroom with dirty tape attached to the seat. room [ROOM NUMBER] was observed with torn, unfinished dry wall behind a resident's bed. During an observation made on 6/23/2025 at 11:00 a.m., one of two shower rooms was used as a storage room to store a bed, walker, and reclining chairs. An interview was conducted on 6/26/2025 at 8:45 a.m., with Staff T, Registered Nurse, RN/ Unit Manager. Staff T stated she has worked at the facility for 4 years. She stated she did not know why equipment was stored in the shower room because the staff knew equipment cannot be stored there. She stated whenever she knows items are stored in the shower room, she would report them to the maintenance director to have the items removed. She stated she was not aware of the high-rise toilet seat with tape on it in room [ROOM NUMBER], the torn, unfinished dry wall behind the resident bed in room [ROOM NUMBER] and the hanging picture in room [ROOM NUMBER]. She stated these issues should have been reported to her or the Interdisciplinary team should have reported this during their daily room rounds so these issues could have been addressed. An interview was conducted on 6/26/2025 at 12:30 p.m., with the Director of Maintenance. He said he is made aware of repairs in the building when staff put concerns in the system. He stated he was not aware of the equipment stored in one of the shower rooms on 400 hall, the picture hanging off the wall in room [ROOM NUMBER], the high-rise chair in the bathroom in 422 with tape on it, and the dry wall hole in room [ROOM NUMBER]. He stated he would have expected staff to report these issues to the maintenance department. An interview was conducted on 6/26/2025 at 12:30 p.m., with the Nursing Home Administrator, NHA, The Maintenance Director and The Regional Director. The NHA stated all managers have room assignments they go over in their morning meetings identifying any concerns. If there is something that needs to be repaired, they put it in maintenance system. If it's something for housekeeping, they let him know by verbal communication. She stated her expectation is these things should have been taken care of. Her managers should have reported these items so these things could be fixed. They had a discussion with all staff that they have to report everything needed to be repaired. The NHA stated managers conduct rounds daily and these things should have been reported. Review of the facility policy titled, Safe and Homelike Environment Revision Date: 1/2025, showed the following: Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the residents can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Policy Explanation and Compliance Guidelines: 3. Housekeeping and maintenance service will be provided as necessary to maintain a sanitary, orderly and comfortable environment. 9. General Considerations: f. Report any unresolved environmental concerns to the Administrator. (Photographic Evidence obtained )

Based on observation, interview, and record review, the facility failed to ensure alleged resident to resident violations were reported to the governing agency in accordance with the State law for one (Resident #28) out of two residents sampled. Findings include: On 06/23/2025 at 2:08 P.M. an observation of Resident #28 revealed she had a dark purple and bluish area around her left eye. A review of Resident #28's admission Record showed she was admitted to the facility on [DATE] with diagnoses including but not limited to Anoxic Brain Damage, Autistic Disorder, Chronic Pain Syndrome, and Aphasia. A review of Resident #28's Minimum Data Set (MDS), Section C, dated 3/30/2025 revealed a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. A review of a Change in Condition Assessment for Resident #28 dated 6/17/2025 revealed, swelling and bruising noted around left eye with intervention of X-Ray of left side of face, ice as needed. A review of the Facial X-Ray for Resident #28 dated 6/17/2025 revealed The osseous structures are unremarkable including grossly intact orbital rims. Maxillary sinuses are unremarkable. No blowout fracture is seen. A review of a progress note titled, Incident Note dated 6/17/2025 written by the Director of Nursing (DON) for Resident #28 reads, Resident #28 was in bed when another resident mistakenly thought the bed was hers and got in Resident #28's bed. Resident #28 noted to have slight redness to left orbit area. Medical Doctor (MD) and family notified. A review of a progress note titled, Skin/Wound Note dated 6/18/2025 reads, Noted swelling and bruising noted around left eye, Resident #28 is unable to state how this happened. An interview was conducted with Staff G, Licensed Practical Nurse (LPN) on 6/25/2025 at 1:44 P.M. She stated, I was off work when it happened. I was told by the night nurse Resident #28's roommate (Resident #49) sat on her head. She said she believes the night nurse did an incident report at the time. The night shift staff moved the roommate to a different room after the incident. Staff G, LPN stated, I personally would have done an assessment on the roommate as well as a behavior progress note because I found Resident #49 in another resident's bed a few days before this happened. An interview was conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on 6/26/2025 at 9:20 A.M. The DON stated, We moved Resident #49 into the room with Resident #28. Resident #49 was placed in B bed (by the window) and she is used to being in A Bed (by the door). Resident #49 mistakenly got into A bed with Resident #28. The DON said the staff witnessed Resident #49's forehead hit Resident #28's forehead/left eye area. The DON stated, it was not hard contact, but they made contact. She said the night staff separated the two residents, assessed them, and didn't see any injuries. The DON stated, I reported it to Resident #28's family member and he expressed no concerns. Staff K, LPN Unit Manager, communicated with Resident #49's family. The DON said they moved Resident #49 to an A Bed (by the door) assignment. The NHA said an incident report was created by the DON the next day. The DON said the staff witnessed Resident #49's head come in contact with Resident #28's head, but they were not able to stop it from happening beforehand. Another interview was conducted with the DON on 6/26/2025 at 1:45 P.M. The DON stated, We did not report this to the state agencies or law enforcement. We didn't consider it a resident to resident. There was no intent or physical aggression by either party. There must be intent of abuse to be reportable. A review of the facility's policy titled: Abuse, Neglect, and Exploitation implemented on 9/1/2023 and revised on 1/2025 states, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Part IV showed: Identification of Abuse, Neglect, and Exploitation, Section B: Possible indicators of abuse include, but are not limited to: physical marks such as bruises or patterned appearances such as a handprint, belt or ring mark on a resident's body. Part VII showed: Reporting/Response, Section A: The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within the specified time frames: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involves abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Section B: The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.

Based on interviews and record reviews, the facility failed to ensure Preadmission Screening and Resident Review (PASRR) assessments were updated for two residents (#69, #141) out of twelve residents sampled for PASRR. Findings include: 1. A review of Resident #69's admission Record revealed he was admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia. Secondary diagnoses included mood disorder, major depressive disorder and insomnia. Review of the Level I PASARR, dated 03/24/2025 showed in Section II: Other Indications for PASRR Screen Decision-Making, questions 1 through 7 were marked No. A Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder (including Alzheimer's disease). Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASARR evaluation not required was marked. 2. A review of Resident #141's admission Record revealed she was admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia. Secondary diagnoses included mood disorder, major depressive disorder and generalized anxiety disorder. Review of the Level I PASRR, dated 04/23/2025 showed in Section II: Other Indications for PASRR Screen Decision-Making, questions 1 through 4 were marked No. Question 5: Does the resident have a primary diagnosis of dementia was marked yes. A Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder (including Alzheimer's disease). Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required was marked. On 06/26/25 at 3:31 p.m. an interview with the Social Services Director (SSD) was conducted. She stated when an admission comes in, she looks over their diagnosis, looks at medications, then waits a few days for psychiatry to see them. She then goes into the program and completes it, and then she uploads the document into the medical record. She stated if she has to do a Level II, she will submit. She stated Gradual Dose Reduction (GDR) meetings are when she would find out a new diagnosis or if the psychiatry provider visits the resident and gives a new diagnosis, they would send an email about any changes. She stated she has begun fixing PASRR's which require a Level II once survey started on 06/23/25. She stated she would know if the resident would need a Level II from the questions in the system where she fills out the PASRR. She stated she is not familiar with the regulation. Review of the policy titled Resident Assessment - Coordination with PASRR Program revised 01/2025 revealed the following: Policy: Policy Explanation and Compliance Guidelines 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. a. PASRR Level I- initial pre-screening that is completed prior to admission i: Negative Level I screen-permits admission to proceed and ends the PASRR process unless a possible serious mental disorder or intellectual disability arises later. ii. Positive Level I screen- necessitated a PASRR Level II evaluation prior to admission. 7. The Social Services Director shall be responsible for keeping track of each resident's PASRR screening status and referring to the appropriate authority.

Based on observations, record review, and interviews, the facility failed to develop and implement a person-centered comprehensive care plan to meet goals and address the resident's medical, physical, mental and psychosocial needs for three residents (#363, #28, and #49) out of thirty five residents sampled. Findings include: 1. On 6/24/2025 at 9:57 A.M., Resident #363 was observed with both legs over the right side of his bed. The bed was in a high position where the resident's feet were dangling in the air. The floor on the right side of his bed contained a bedside table, an overflowing trash can, a tied-up bag full of linens, and three wheelchair footrest adapters. There were no staff around the room at this time. An unknown staff member came to the resident's room, and she stated, I left the room to find someone to help her transfer him into the wheelchair. On 6/26/2025 at 11:21 A.M., Resident #363 was observed with both legs over the right side of his bed again. The bed was in a lowered position where his right foot was touching the ground. The right side of his bed contained a bedside table and an empty trash can. The mattress on the bed was not a scoop mattress. A review of the admission Record for Resident #363 showed he was admitted to the facility on [DATE] with diagnoses including but not limited to Parkinson's Disease with Dyskinesia and Abnormalities of Gait and Mobility. A review of Resident #363's Minimum Data Set (MDS), Section C, dated 5/8/2025 revealed a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. A review of the assessments documented for Resident #363 revealed he had twelve documented falls since his admission on [DATE]. A review of the task record labeled ADL (Activities of Daily Living) Walk for Resident #363 revealed the activity occurred six times in ninety opportunities. A review of the Comprehensive Care Plan for Resident #363 revealed a focus documenting he is at risk for falls related to decreased cognition, decreased mobility, and history of falls. The interventions of this focus are as follows: Ensure residents' bed is in lowest locked position when in bed; 2/24/2025 Dycem to Wheelchair & Anti-Tippers; 3/12/2025 Drop Seat Wheelchair; 4/26/2025 Scoop Mattress; 5/30/2025 Falls unavoidable due to poor safety awareness- Keep pathways clear; 6/11/2025 staff to offer periodic walking throughout the day. An interview was conducted with Staff G, Licensed Practical Nurse (LPN) on 6/25/2025 at 2:00 P.M. She stated, I keep Resident #363 in the day room when he's awake and redirect him to sit back down when he tries to stand up. I also make sure he is clean and dry. Staff G, LPN said, she doesn't know if the interventions in the comprehensive care plan are working, stating, I just try and keep an eye on Resident #363. An interview was conducted with Staff H, Certified Nursing Assistant (CNA) on 6/26/2025 at 11:15 A.M. She stated, I don't know what the specific interventions are for Resident #363. I make sure he's dry, the wheelchair is locked, and he is in a safe environment. Staff H, CNA said she can look at the Kardex to find out what the interventions are, she just hasn't looked yet because Resident #363 just moved to this unit last night. Staff H, CNA stated, if the interventions were not working, I will tell my nurse. She stated, Resident #363 fell yesterday {6/25/2025}. I was cleaning another resident, and the other CNA was in the restroom. Another CNA was showering a resident, and the nurse was putting another resident in their bed. Me and the Nurse had just cleaned him and put him right next to the nursing station in his wheelchair. Next thing I know, he was on the floor at the nursing station. Staff H, CNA said nobody saw it happen, the nurse assessed Resident #363, and three staff members put him back into his wheelchair. An interview was conducted with Staff I, LPN on 6/26/2025 at 11:31 A.M. Staff I, LPN stated, I was told in report Resident #363 was a fall risk. He fell yesterday and I am doing neuro checks every 4 hours. The CNA took Resident #363 vital signs at 7:45 A.M. and I didn't write them down yet. Staff I, LPN said, she doesn't know how to access his comprehensive care plan to review it and the interventions are reported to her in the nurse-to-nurse report at shift change. Staff I, LPN stated, I was told we are putting Resident #363 near the nursing station, and we take turns watching him. 2. An observation on 06/23/2025 at 2:08 P.M. revealed Resident #28 had a dark purple and bluish area around her left eye. A review of the admission Record for Resident #28 showed she was admitted to the facility on [DATE] with diagnoses including but not limited to Anoxic Brain Damage, Autistic Disorder, Chronic Pain Syndrome, and Aphasia. A review of Resident #28's Minimum Data Set (MDS), Section C, dated 3/30/2025 revealed a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. A review of a progress note titled, Narrative Nurses Note for Resident #28 written on 6/17/2025 reads, Note Text: nurse practitioner into visit with patient, swelling and bruising noted on left side of face, resident shows no signs or symptoms of pain, x-ray of left side of face, Family updated on care plan. A review of the Comprehensive Care Plan for Resident #28 revealed no focuses, goals, or interventions regarding treatment or monitoring of her left eye. An interview was conducted with Staff G, Licensed Practical Nurse (LPN) on 6/25/2025 at 1:44 P.M. She stated, I was off work when it happened. I was told by the night nurse Resident #28's roommate (Resident #49) sat on her head. She said she believes the night nurse did an incident report at the time. The night shift staff moved the roommate to a different room after the incident. Staff G, LPN stated, I personally would have done an assessment on the roommate as well as a behavior progress note because I found Resident #49 in another resident's bed a few days before this happened. 3. A review of a progress note dated 4/16/2025 for Resident #49 reads, Note Text: staff reported to nurse that resident had placed hands around another resident neck in choking manner. Resident separated from other resident, vitals checked resident checked for injuries, Medical Doctor (MD) family and Psych notified of incident, order for Urinalysis (UA) received, resident placed on one-on-one supervision. A review of a progress note dated 6/16/2025 for Resident #49 reads, Note Text: Resident #49 confused and crawled into bed with roommate Resident #28, thinking/insisting that was her bed. Resident #49 was redirected to her own bed by the window. Resident #49 will be moved to a bed by the door. Family notified and is okay with the move. A review of the admission Record for Resident #49 showed she was admitted to the facility on [DATE] with diagnoses including but not limited to Insomnia and Anxiety Disorder. A review of Resident #49's Minimum Data Set (MDS), Section C, dated 3/29/2025 revealed a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. A review of the Comprehensive Care Plan for Resident #49 revealed a focus of, exhibits the following behaviors: crying, refuses dental care at times, will make inappropriate comments to staff at times; 4/16/2025 Resident was the aggressor in altercation with another resident in which residents were separated to de-escalate the situation. The goal is, will exhibit a decrease in the number of behavior episodes by the next review date. The intervention is, 4/16/2025 Psych to eval, urinalysis ordered, Resident put on 1:1. Further review of Resident #49's comprehensive care plan revealed no other behavior focuses, goals, or interventions. An interview was conducted with Staff J, Minimum Data Set (MDS) Coordinator on 6/26/2025 at 11:42 A.M. She said she updates the care plan as she reads the order listing report every day. She stated, If it's not from the order listing, it's word of mouth from the nursing staff on changes needing to be made. At our clinical meeting every morning, the interdisciplinary team discusses the falls and then we decide which interventions would be appropriate for each fall. There is an intervention for every fall incident. There always must be a new intervention; even if we've chosen everything, we must write something. Staff J, MDS Coordinator said, the comprehensive care plans must be individualized, or they don't work. Staff J, MDS Coordinator stated, we leave the intervention in the comprehensive care plan even if it's not working. We just need to add something as an intervention when an incident happens. She said she updates the interdisciplinary team in the morning, but not the nursing staff. An interview was conducted with the Director of Nursing (DON) on 6/26/2025 at 1:54 P.M. The DON said any change with a resident is discussed in the morning clinical meeting. The MDS Coordinator updates the comprehensive care plan every day. The DON said the nurses make a progress note in the medical record with possible interventions as well as putting it in the incident report. Updates to the comprehensive care plans are made as needed, quarterly, annually, and after meetings with the family. The DON stated, The CNA's can look in task record on the computer and nurses should be able to open and adjust the comprehensive care plan as needed. I think most of them know how to do that, but I'm sure some do not. The DON stated, when there is an incident with a resident, there should be a new intervention that is geared based on the root cause analysis of why the incident happened. This is done every incident. If the interventions are not working, the interdisciplinary team would reevaluate and determine a new intervention. The DON said the interventions are not dated in the comprehensive care plan. A review of the facility's policy titled, Comprehensive Care Plan implemented on 9/1/2023 and revised on 1/2025 showed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with residents rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Under section titled, Policy Explanation and Compliance Guidelines: 3): The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being. 6): The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the residents' progress. Alternative interventions will be documented, as needed. 8): Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

2. During an observation from the hallway on 06/24/2025 at 9:46 a.m., Resident #146 was observed sitting up on the side of his bed with his legs hanging off, sleeping. Resident #146 was observed to have on a white T-shirt and a brief. Review of Resident #146's admission record revealed and admission date of 03/19/2025. Resident #146 was admitted to the facility with diagnosis to include Parkinson's Disease Without Dyskinesia, Without Mention of Fluctuations, Other Lack of Coordination, Major Depressive Disorder, Recurrent, Moderate, Mood Disorder Due To Known Physiological Condition with Mixed Features, Unspecified Dementia, Unspecified Severity, With Mood Disturbance. Review of Resident #146's Quarterly Minimum Data Set (MDS), dated [DATE] revealed, Section C-Cognitive Patterns had a Brief Interview Mental Status (BIMS) of 06 out of 15 indicating severe cognitive impairment. During an interview on 06/25/2025 at 5:47 p.m., Staff O, Certified Nursing Assistant (CNA), stated residents should be treated with dignity by speaking with the residents, pulling the privacy curtain and closing the door while providing care. You should not be able to see a resident's brief from the hallway. They should have bottoms on or have a blanket to cover them while they are sleeping. During an interview on 06/25/2025 at 5:13 p.m., the Director of Nursing (DON), stated You should not be able to see a residents brief from the hallway. Review of the facility's policy, dated 09/01/2023, titled Promoting/Maintaining Resident Dignity revealed the following: Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Compliance Guidelines .12. Maintain resident privacy. Based on observations, interviews, and record review, the facility failed to ensure two residents (#316 and #146) were treated in a dignified manner out of three residents sampled for dignity. Findings included: During an observation on 06/24/25 at 9:47 a.m., Resident #316 was observed from the 100 Wing hallway in her wheelchair with her night gown pulled up and briefs exposed. Resident #316 was admitted to the facility on [DATE] with a primary diagnosis of muscle wasting and atrophy. Review of Resident #316's quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Statues (BIMS) score of 12, indicating moderate cognitive impairment. Section GG-Functional abilities revealed the resident needed substantial/maximal assistance with the ability to dress and undress below the waist, including fasteners. Review of Resident #316's care plan, dated 6/23/25, revealed she is dependent on staff for meeting emotional, intellectual, physical, and social needs with Immobility and Physical Limitations. During an interview on 6/26/25 at 10:25 a.m. with Staff D, Certified Nursing Assistant (CNA), she stated, Dignity was considered ensuring the resident is treated with respect. She stated she has had training on preserving resident dignity and if she did notice a resident in an undignified situation, she would redirect the resident to their room and fix the issue. During an interview on 6/26/25 at 10:30 a.m. with Staff E, (CNA), she stated, Dignity is considering the way people are treated as well as their living circumstances. She stated she has had training on dignity and if she noticed a resident in an undignified situation, she would redirect the resident to their room and fix the issue.

Based on observation, interviews and record review the facility failed to provide nursing care and services related to 1) failure to schedule appointments for one (Resident #134); and 2) failure to administer medications in a timely manner for two (Resident #106 and Resident #90) out of 35 residents sampled. Findings Included: 1. During an interview on 06/25/2025 at 9:13 a.m., Resident #134 stated he had a catheter, but they recently removed it. He stated he had not seen a Urologist. During an interview on 06/25/2025 at 9:56 a.m., Resident #134's Family Member (FM) and emergency contact stated Resident #134 was referred to see a Urologist at the beginning of June, but has never been told if it was scheduled. The FM stated, the resident saw a Neurologist because he recently started having what she believed to be seizures when he sits up in bed. The Neurologist ordered a imaging exam (MRI) and the test has not had done. I have asked the doctor and the nurses about scheduling the MRI with sedation because he is claustrophobic several times and no one has followed up with me. Review of Resident #134's admission record revealed an admission date of 05/23/2025. Resident #134 was admitted with diagnosis to include Unspecified Sequelae of Cerebral Infarction, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Mood Disorder Due To Known Physiological Condition with Mixed Features, Major Depressive Disorder, Recurrent, Moderate and Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. Review of Resident #134's Quarterly Minimum Data Set (MDS), dated [DATE], Section C- Cognitive Patterns revealed a Brief Interview Mental Status (BIMS) of 06 out of 15 showing severe cognitive impairment. Review of Section H. Bladder and Bowel revealed Appliances, Indwelling Catheter. Review of Resident #134's orders revealed: 06/05/2025 Urology Consult stat (emergent) for Urinary Retention related to benign prostatic hyperplasia with lower urinary tract symptoms. No order for Magnetic Resonance Imaging (MRI) was found. Review of Resident #134's progress notes revealed: 3/24/25: The patient was seen for a follow-up on therapy. He was sent to the hospital on 3/22/25 due to increased altered mental status and returned without new orders. His FM reported consulting with the patient's neurologist, who recommended an MRI. The order has been placed. The patient is calm, resting in bed without complaints. No additional reports from staff. 5/9/25: Follow up patient on therapy and overall health. FM was there and expressed concerns about an MRI to be done to diagnose or know how advance is the patients dementia. Patient is unable to get an MRI because he is unable to stay still, and it was suggested that the patient be put to sleep to have the MRI done. FM requested to speak to the physician personally and information was relayed to the physician. 5/27/25: Patient seen today for follow up on status post hospitalization. Patient was also accompanied with FM. FM stated that the hospital made an attempt to remove the catheter and do a voiding trial but failed. FM expressed concern about patient dementia diagnosis and needing an MRI to determine future care. Expressed to FM will forward information to the physician. 6/2/25: Patient was seen today for overall care and therapy. Patient FM stated that he is much better today. Spouse states that she would like to know cognitively where the patient is at mentally. Patient needs an MRI and needs to be sedated to do so. FM requests to speak to physician so she will be able to know how to move forward in patient care. 6/5/25: Patient was seen today for follow up on therapy and overall health. Staff stated that patient removed the Foley catheter and voiding trial was in process. Stated to staff that if patient does not void to straight cath again and in six hours if patient has not voided insert Foley but use a leg bag. Staff has stated that the since the patient has been restless that the meatus has been slightly split. Will order urology consult. During an interview on 06/25/2025 at 9:45 a.m., Staff R, Driver/Transportation stated she sets up all the appointments for residents. When residents need an appointment the nursing staff fills out a form and puts it into a folder outside of her door. She then arranges transportation and schedules the appointments. I was not aware Resident #134 needed an appointment to see a Urologist. He saw a Neurologist, who ordered an MRI, but his wife wants him to be sedated for the MRI, but I am not sure what happened with that. During an interview on 06/25/2025 at 11:03 a.m., Staff P, Registered Nurse (RN) stated she was not aware of Resident #134 needing an MRI. I believe he was supposed to see a Urologist but cannot remember why. The physician will notify the nurse of any new orders. The nurses put the order in and then a form is filled out and given to the appointment Transportation and she sets the appointments up for the residents. During an interview on 06/25/2025 at 11:15 a.m., Staff N, Licensed Practical Nurse (LPN) and Unit Manager (UM), stated if residents need an appointment only the Transportation person schedules the appointments. The nurses fill out a form and put it in a folder. She reviewed Resident #134's chart and found an order for Resident #134 to see a Urologist. The order was put it in on 06/05/2025 for stat. I don't see any notes from the Urologist, and I don't see an order for an MRI. During an interview on 06/25/2025 at 5:13 p.m., the Director of Nursing (DON), stated transportation facilitates the appointments and transportation. A stat order would mean the resident needs to be seen quickly. I know we were having an issue with Resident #134's insurance and that is why he has not had his MRI or seen the Urologist. This should be documented in a note in the residents' chart. We will talk with the physician and offer for the resident go to the hospital since he has not been seen by the Urologist. The facility did not have a policy for review. 2. A review of Resident # 90's admission Record revealed she was admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, and hypokalemia. A review of Resident #90's Quarterly Minimum Data Set (MDS) dated [DATE] Section C-Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) summary score of 15 indicating she was cognitively intact. A review of the Medication Admin Audit Report for 06/23/25 revealed the following medications were not administered in a timely manner: -Losartan Potassium oral tablet 50 milligram (mg), Give 1 tablet by mouth one time a day for hypertension: Schedule time-9:00 a.m.; administration time-1:02 p.m. -Tradjenta 5 mg oral tablet, Give 1 tablet by mouth one time a day for DM {diabetes mellitus): Schedule time-9:00 a.m.; administration time-1:06 p.m. -Lasix oral tablet 40 mg, Give 1 tablet by mouth two times a day for edema: Schedule time- 9:00 a.m.; administration time-1:02 p.m. -Prednisone oral tablet, give 1 tablet by mouth one time a day for inflammation .: Schedule time- 9:00 a.m.; administration time-1:03 p.m. -Pantoprazole sodium oral tablet delayed release 40 mg, Give 1 tablet by mouth one time a day .: Schedule time- 9:00 a.m.; administration time-1:03 p.m. -Aspirin oral tablet delayed release 81 mg, give 1 tablet by mouth one time a day: Schedule time- 9:00 a.m.; administration time-1:01 p.m. -Mucinex oral tablet extended release 12-hour 600 mg, give 1 tablet by mouth every 12 hours for cough: Schedule time- 9:00 a.m.; administration time-1:02 p.m. -Lidocaine patch, apply to left foot topically one time a day for pain On in the AM, Off in the PM: Schedule time- 9:00 a.m.; administration time-1:08 p.m. -Breztri Aerosphere inhalation aerosol, 2 puff inhale orally every morning and at bedtime: Schedule time- 9:00 a.m.; administration time-1:07 p.m. 3. A review of Resident #106's admission Record revealed Resident #106 was admitted to the facility on [DATE] with diagnoses to include: Parkinson's disease, mood disorder, anemia, major depressive disorder, neurocognitive disorder with Lewy bodies. A review of the Medication Admin Audit Report for 06/23/25 revealed the following medication was not administered in a timely manner: -Gabapentin oral capsule, give one capsule by mouth 3 times a day for pain: Schedule time- 9:00 a.m.; administration time-1:29 p.m. During an interview on 06/24/25 at 10:22 a.m. with Staff M, Registered Nurse (RN) she stated her medications are late daily. Staff M stated she has help, but not always when she needs it and administration are in meetings all day. She stated it is hard to give all the medications because the residents aren't always in their room and you have to go find them, or their family will take them out for the day, so they won't get their meds. Medications are supposed to be given up to one hour before and one hour after, so if a medication is scheduled at 9 :00 a.m. I have from 8:00-10:00 a.m. to give it. It would be late after 10 a.m. During an interview on 06/25/25 at 5:00 p.m. with the Director of Nursing (DON), she stated medications should not be given late. She went on to state if nurses are having a hard time passing their medications on time, they need to be helped. A review of the policy titled Medication Administration with a revision date of 1/2025 revealed the following: Policy: Policy Explanation and Compliance Guidelines: 10. Review MAR {Medication Administration Record} to identify medication to be administered. 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route and time. b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by the physician.

Based on interview and record review the facility did not ensure side effect monitoring was in place for one resident (#141) out of five residents sampled for unnecessary medications. Findings include: A review of Resident #141's admission Record revealed she was admitted to the facility on [DATE] with diagnoses to include dementia, psychotic disorder with delusions, mood disorder, major depressive disorder and generalized anxiety disorder. A review of Resident #141's Order Summary Report revealed the following orders: - Divalproex Sodium Oral Tablet Delayed Release 250 milligram (MG) (Divalproex Sodium) Give 3 tablet by mouth three times a day for bipolar disorders, seizures - OLANZapine Oral Tablet 7.5 MG (Olanzapine) Give 1 tablet by mouth at bedtime for Bipolar Disorders - Lasix Oral Tablet 40 MG (Furosemide) Give 1 tablet by mouth one time a day for HTN [hypertension] - Potassium Chloride ER [extended release] Oral Tablet Extended Release 20 MEQ (Potassium Chloride) Give 1 tablet by mouth one time a day for Supplemental management - HydrALAZINE HCl Oral Tablet 10 MG (Hydralazine HCl) Give 1 tablet by mouth four times a day for HTN A review of the June 2025 Treatment Administration Record (TAR) revealed the following: -Behavior monitoring- Antipsychotic .with a start date of 01/03/25 and a discontinue date of 06/10/25. -Monitor for antipsychotic side effect .with a start date of 01/03/25 and a discontinue date of 06/10/25. A review of the Psychiatry Progress Note dated 06/16/25 revealed the following: Reason for today's visit: follow-up for medication and behavior management and lab monitoring. Assessment and Plan: Generalized anxiety disorder-will continue to monitor for improvement or worsening of the following signs and symptoms of anxiety .Will also monitor for side effects or adverse effects of the medication . Major depressive disorder: Will continue to monitor, document, and report worsening symptoms of depression . Psychotic disorder: will continue to monitor for improvement or worsening of the following signs and symptoms of psychosis: delusions, hallucinations, disorganized speech and disorganized catatonic behavior . A review of Resident #141's active care plan revealed the following: Care Plan: Focus-Resident has a mood problem related to (r/t) receives anticonvulsant for mood disorder. Intervention-administer medications as ordered. Monitor/document for side effects and effectiveness. On 06/26/25 at 5:00 p.m. an interview with the Director of Nursing (DON) was conducted. She stated these medications should have side effect monitoring in the medical record. She stated the admitting nurse would enter those side effects. She stated they have had a lot of education on psych medications lately and monitoring for side effects. A review of the policy titled Medication Administration with a revision date of 1/2025 revealed the following: Policy: Policy Explanation and Compliance Guidelines: 10. Review MAR {Medication Administration Record} to identify medication to be administered. 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route and time. a. Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects. 20. Report and document and adverse side effects .

Based on observation, interviews and record review, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-eight medication opportunities were observed, and two errors were identified for one resident (#133) out of six residents observed. These errors constituted a 7.14% medication error rate. Findings included: On 06/25/25 at 9:31 a.m. an observation was made of Staff F, Registered Nurse (RN). Staff F dispensed the following medications for Resident #133. -Losartan 100 milligram (mg) tablet -Lidocaine patch -Zonisamide 100 mg tablet -Nifedipine 60 mg capsule -MiraLAX powder Staff F began by dispensing one Losartan 100mg tablet into a small medicine cup. The staff member then poured an unidentified amount of MiraLAX into the same small medicine cup. She stated it is about a capful of MiraLAX and that's how much they give. Staff F then poured the powder and Losartan tablet from the small medicine cup into a larger drinking cup. The staff member then pulled an additional Losartan 100mg tablet and placed it into a separate empty medicine cup. The other two medications were added to the medicine cup. Staff F proceeded to pour water in the larger cup with the MiraLAX. This was stopped before administration to the resident for safety. Staff F was made aware of the additional Losartan tablet mixed with the MiraLAX powder. The staff member scooped out the tablet with a spoon and stated it should not be in there and was wondering what happened to the tablet. A review of Resident #133's Order Summary revealed the following medication orders: -Losartan Potassium oral tablet 100MG, Give 1 tablet by mouth one time a day for HTN {hypertension} -MiraLAX Powder (Polyethylene Glycol 3350), Give 1 packet by mouth one time a day for bowel On 06/26/25 at 5:00 p.m. an interview with the Director of Nursing (DON) was conducted. She stated the MiraLAX order wasn't written correctly, it should show the strength and what to mix it with. She stated MiraLAX should have been poured into the bottle cap instead of a small medication cup and should not have been mixed with another medication because MiraLAX should be given by itself. A review of the policy titled Medication Administration with a revision date of 1/2025 revealed the following: Policy: Policy Explanation and Compliance Guidelines: 10. Review MAR {Medication Administration Record} to identify medication to be administered. 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route and time.

Based on record review, observation and interviews, the facility failed to ensure food was properly stored and free of expired food(s) for residents in the kitchen. Findings included: During an observation on 06/23/2025 at 9:38 a.m., of the Walk in Freezer revealed 4 boxes with a red label and writing Tyson; A brown box with a red label, and black writing Keep frozen 0°F-10°F; 2 brown boxes with red writing Frozen Cookie Dough; A brown box with black writing; A bag of ice; A white container with green and red markings; A clear container with purple writing; Unidentifiable debris. (photographic evidence obtained) During an observation on 06/23/2025 at 9:42 a.m., of the Walk in Fridge, revealed A brown box with a clear bottle with a green liquid, a yellow rag, and white bags; A brown cardboard box with wrinkled green bell peppers with gray and black bio growth; A tan 4 wheeled cart with an open green tabbed can; A box of tomatoes with yellow string particles; A silver container labeled boiled eggs with the plastic wrap ripped; A white bucket with an open green lid labeled pickles with an expiration date of 06/16/2025. (photographic evidence obtained) During an observation on 06/23/2025 at 9:56 a.m., of the Trailer Freezer, multiple open brown cardboard boxes stacked on top of each other. (photographic evidence obtained) During an interview on 06/23/2025 at 9:40 a.m., the Certified Dietary Manager (CDM) stated We are not using the walk-in freezer, because the door is not closing properly and holding the temperature. We have a freezer trailer we are using for all the frozen foods. Staff must have pulled the chicken and put it in there out of convenience. They may have pulled it to serve for tonight. During an interview on 06/23/2025 at 11:16 a.m., CDM stated the walk-in freezer should not have had anything in it. Everything has been thrown out and I did education with kitchen staff. During an interview on 06/25/2025 at 10:34 a.m., with the CDM, Kitchen Manager and Nursing Home Administrator (NHA), the NHA reviewed the photographic evidence and stated she expects the kitchen to be clean and for food to be stored properly. Food that is in poor condition should be discarded. Review of the facility's policy dated 11/2023, titled Sanitation Inspection, revealed the following: Policy: It is the policy of this facility, as part of the departments sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations.

Based on observations, interviews, and record review, the facility failed to protect the resident's right to be free from neglect for two residents (#1 and #2) out of five residents identified by the facility at risk for elopement, to prevent elopement. Serious harm occurred on 4/19/25, when Resident #1 was allowed to walk away from the facility unnoticed, walk along high traffic streets for eight miles, and end up on an Interstate Highway where he was found by the [State Highway Patrol]. Resident #1 was taken to a higher level of care for evaluation and treatment of dehydration. On 3/25/25 Resident #2 exited the facility through an emergency exit door and was found 10 -15 feet from the door walking away from the facility. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/ or death to Resident #1 and resulted in the determination of Immediate Jeopardy occurring on 4/19/25. The findings of Immediate Jeopardy were determined to be removed on 4/30/25 and the scope and severity was reduced to D after verification of removal of immediacy of harm. Findings included: Review of the medical record revealed Resident #1 was admitted on [DATE], with diagnoses including other specified disorders of [the] brain, unspecified lack of expected normal physiological development in childhood, anemia, mood disorder due to known physiological condition with mixed features, major depressive disorder, recurrent, moderate, hypertension, psychotic disorder with delusions due to known physiological condition, pedestrian on foot injured in collision with motor vehicle in nontraffic accident, pelvis fracture, skull and facial bone fractures, and lung contusion. A review of Resident #1's physician order summary report, dated 4/01/2025-4/30/2025, revealed the following: - Divalproex 250 mg (milligrams) AM (morning) dose and Divalproex 500 mg at bedtime for unspecified mood disorder. -Mirtazapine 15 mg for major depressive disorder. -Risperidone 0.5 mg for psychotic disorder with delusions. Review of Resident #1's physician attestation of a resident incapacitated form, dated 7/31/24, revealed the resident is physically and cognitively unable to communicate a willful and knowing health decision. Review of Resident #1's Brief Interview for Mental Status (BIMS), dated 3/31/25, revealed a score of 0, indicating severe cognitive impairment. Review of Resident# 1's Activity Participation Note, dated 3/24/25, revealed He gets around on his own and enjoys sitting in the porch enjoying fresh air . Review of Resident# 1's Narrative Nurses Note, dated 3/29/25, revealed Resident has been up walking about facility. Staff on 100 unit didn't know him and they tried to tell him he couldn't go and to go back to his floor. He went down towards the porch where he sits. Review of Resident# 1's Narrative Nurses Note, dated 3/30/25, revealed Male resident on 400 stuck up his middle finger at Resident #1, he leaned towards the other resident and mumbles no giving him (other resident) the finger back. I redirected Resident #1 back towards his room. Review of the Resident# 1's eInteract SBAR (situation, background, assessment, recommendation) summary for a Provider Note, dated 3/30/25, showed the following: Nursing observations Resident alleged to have hit another resident, [MD] and family notified, Psych consult, Psychosocial monitoring q (every) shift x (for) 72 hours, Lab work, and enhanced monitoring x 72 hours. Resident is not easily understood, reminded not to touch other residents. Review of Resident #1's Interdisciplinary Team (IDT) Narrative Note, dated 3/31/25, showed Review of incident resident allegedly hit another resident on the back . BIMS 0, post allegation abuse protocol initiated. Review of Resident #1's Medication Administration Report (MAR), dated April 2024, behavior monitoring, either 0 indicating none or N/A is documented daily from 4/1/25 to 4/18/25. Review of Resident #1's laboratory results, reported on 3/5/25, showed Valproic Acid (Depakote) 32.4 L (low) (range 50-100). Review of Resident #1's laboratory results, reported on 4/4/25 showed Valproic Acid (Depakote) 39.3 L (range 50-100) and Ammonia 125 H (high) (range 27-102). Review of the Resident# 1's eInteract SBAR summary for a Provider Note, dated 4/19/25 at 9:39 P.M., showed, Resident visually observed while in back of law enforcement vehicle and during transfer from one law enforcement vehicle to another. At the time, there were no injuries or signs or symptoms of medical distress . Resident transported to the ED (emergency department) for further evaluation. Review of Resident #1's care plan showed the following: Focus area: initiated on 4/22/25, elopement risk/wanderer related to history of leaving the facility impaired safety awareness, wanders aimlessly. The interventions included the following: allow to wander safely on the secured unit, distract resident from wandering by offering pleasant diversions, structures activities, food, conversation, television, books; provide structured activities: .walking inside and outside . Review of Resident# 1's Psychiatric report, dated 3/31/25, revealed Per staff report, the resident was involved in an altercation with another resident ., the patient allegedly struck another resident on the back of the head. Primary concern: impulsivity and agitation in the context of severe cognitive impairment. Depakote and Ammonia level ordered. Monitoring: continue to assess behavioral changes and adjust interventions as needed. The mental status exam showed Resident #1's thought association was non intact. During an interview on 4/28/25 at 10:10 A.M. Staff J, LPN said Resident #1 mumbles and is hard to understand, Walks all over the building, mumbles a lot. She said they are often short and sometimes work 12-16-hour shifts. During an interview on 4/28/25 at 10:20 A.M. the Activities Director, (AD) said prior to 4/19/25 the door from the facility to the non-smoking patio was left unlocked and residents could enter the patio unsupervised. She said Resident #1 told her he Wanted to go home. During an observation and interview on 4/28/25 at 12:46 P.M., Resident #1 was sitting on the side of his bed eating lunch. Resident #1's speech was slurred and difficult to understand. He said he was walking to see mother when he was found on the Interstate. During an interview on 4/28/25 at 1:00 P.M. Staff C, LPN, Unit Manager (UM) said on 4/19/25 at approximately 7:20 P.M. she received a call from Staff B, RN, NS telling her an elopement drill had been started because they could not find [Resident #1]. She notified the Nursing Home Administrator (NHA) and the Risk Manager (RM) immediately. Staff C, LPN, UM said, at approximately 730 P.M. a group text was sent to all department heads to come to the facility. The exit doors were checked. Staff C, LPN UM said she did not participate in the elopement investigation. During an interview and observation on 4/28/25 at 1:10 P.M. with the Director of Maintenance (DOM) and the Regional Maintenance Director, the DOM said the maintenance staff checks all facility exit doors daily. The DOM said the exit doors have a magnetic lock, and the process is to push the door for 15 seconds to verify the latch and alarm works. He said when the latch is disengaged a secondary keyed alarm is activated. He said, in the screened patio area, the screen door to exit the building has a padlock which is checked daily. The DOM said doors are checked between 8:00 A.M. and 10:00 A.M., Monday through Thursday and around 3:00 P.M. on Friday. The DOM said he checked all the exit doors on 4/18/25. The DOM stated on 4/19/25 after Resident #1 eloped all doors were checked; no issues were identified. He said the secondary alarm batteries were changed as a preventative measure. He said on 4/19/25 the screen in the lower portion of the patio screen door was pushed out and the rubber tubing to hold the mesh in place was laying on the ground. On 4/28/25 at 1:10 P.M. during a tour of the screened patio, observation revealed the screen door was secure with a padlock. The screen on the lower portion of the door screen was intact and a silver metal grate was secured on the exterior. During an interview on 4/28/25 at 1:32 PM with Staff H, Licensed Practical Nurse (LPN), Minimum Data Set (MDS) Nurse said on 4/19/25 at about 7:30 P.M. he received a group text notification a resident was not in the building, with instructions to come and assist. When Staff H, LPN, MDS arrived at a 7:40 P.M., the local police department was on the scene, and he was the first manager to arrive, and he accompanied the officer to search the facility for Resident #1. Staff H, LPN, MDS said, Staff O, Certified Nursing Assistant (CNA), unlocked the door to search the immediate area. He said, In the 400-hall screened in area they observed the bottom screen broken, blowing in the wind. Staff H, LPN, MDS said at approximately 8:20 P.M. a police officer told him Resident #1 was found. Staff H, LPN, MDS said, when the State Highway Patrol arrived with Resident #1, he assisted the Director of Nursing (DON) to assess, check neuros. He said the facility staff asked a local police officer to transport Resident #1 to a local hospital, they felt it was a safe transfer, a courtesy, did not have to use other resources. Review of the [State Highway Patrol (SHP)] call history record revealed the following: On 4/19/25 at 6:38 P.M. a pedestrian [Resident #1]; was found sitting down on the side of the Interstate-4 (I-4), westbound at mile marker number thirty-seven. [The posted speed on I-4 is 70 MPH]. At 6:50 P.M. the SHP contacted EMS [Emergency Medical Services] to check subject out (Resident #1). At 6:54 PM pedestrian possible mental disability. At 6:55 P.M. attempted to call emergency . At 6:56 P.M. [Resident #1] is trying to get home in [city] to [address listed on an expired identification card]. At 7:20 P.M. dispatch to transport Resident #1 to [address], in a different county. At 8:08 P.M. the report revealed [Resident #1] doesn't live at listed address any longer. At 8:10 P.M., Resident #1's family member told the police the name and address of the facility where Resident #1 lived. At 8:23 P.M. dispatch rerouted transport to the facility where Resident #1 lived. At 8:24 P.M. Local Police called to report subject missing At 8:26 P.M. trooper is returning subject to nursing home now and [local police] have officers at [the] nursing home now. At 8:31 P.M. [Resident #1] has been missing from nursing home all day had not reported it to [local police] yet. At 10:05 P.M. nursing home took custody. [local police] is transporting to [Local Hospital]. Review of the [Local Police] case report revealed the following: On 4/19/25 at 7:34 P.M. Resident #1, a missing, an endangered adult was reported. At 7:36 P.M. The local police department arrived at the facility upon arrival spoke with {Resident #1's nurse, Staff NN, Licensed Practical Nurse (LPN)}, who stated she last saw her patient {Resident #1} at 5:40 P.M., when he was walking towards the patio on the south side of the facility. {Staff NN, LPN} stated he usually walks the hallways or sits on the patio and looks outside. He {Resident #1} has been diagnosed with major depression, psychotic disorder, and brain disorders. There was a large hole in the patio screen door. I did not observe any footprints in the dirt near the door. {LPD} dispatch notified us that {SHP} located {Resident #1} near mile marker 37 on I-4 WB (westbound). Resident #1 was to walk to his former address { .Road}, {city}. {Resident #1} was returned to the facility by the State Highway Patrol. {Resident #1} was placed in a secure unit. The facility administrator was notified. {Resident #1} was taken to a local hospital for altered mental status. After arrival at the facility the local police responding officer received notification [Resident #1] had been located by the [SHP] The local police report showed transported to a local hospital for altered mental status. Review of Resident #1's local hospital records, showed the following: On 4/20/25 at 12:43 A.M. history and physical examination revealed the Chief Complaint was patient missing from {facility name} .found by law enforcement and brought to the ED patient non-verbal in triage. Patient is a {age} year old male with a history of unspecified brain disorders, prior skull fracture, and psychotic disorder, who is chronically housed at {name of facility}. Patient was reported missing and was found by the State Highway Patrol. He is difficult to obtain a reliable history due to significant dysarthria (motor speech disorder) and developmental delay, .he is intermittently redirectable and moderately communitive. {Resident #1's} laboratory testing was notable for Blood Urea Nitrogen (BUN) of 31 mg/dL (deciliter) (ref range 8-23), Creatinine of 2.09 mg/dL increased from 1.13 mg/dL baseline. (ref range 0.67-1.17), and Potassium of 5.2 mmol/L. (ref range 3.5-5.1) .Patient was admitted for further work up and management of AKI (acute kidney injury) and mild hyperkalemia (elevated potassium). Assessment and Plan: Acute kidney insufficiency, .dehydration, .acute kidney injury most likely secondary to volume depletion. Interventions included the following: monitor renal function , IV (intravenous) fluids, monitor intake and output, .Potassium 5.2 likely secondary to AKI. On 4/20/25 Resident #1's laboratory report revealed BUN 29 mg/dL, creatinine 1.47 mg/dL and potassium 4.7 mmol/L. On 4/21/25 Resident #1 was discharged from the local hospital and returned to the facility. Review Resident #1's Hospital to Nursing Home Medical Center Transfer Form (Form 5000-3008), dated 4/21/25, showed a primary diagnosis of dehydration. On 4/29/25 at 8:20 A.M. during an interview the Medical Records Director she said she interacts with Resident #1 on a regular basis, and they have a good rapport. She said Resident #1 usually saunters around the facility and does not bother anyone. She said Resident #1 normally sits in the nonsmoking (screened in) patio and prefers verbal redirection rather than being touched. She said prior to the incident on 4/19/25 Resident #1 stated he wanted to go home. On 4/29/25 at 8:52 A.M. during an interview and observation, with assistance of the Medical Records Director, Resident #1 said and gestured he left the facility from the non-smoking patio door. He said and gestured his removal of part of the screen on the patio door, crawling out to exit the facility. Resident #1 said he walked mile, mile (a long distance) and the police picked him up and took him to his former home in [city]. He said he did not have a key to open the door. Resident #1 said and gestured the police transported him back to the facility. Resident #1 was unable to communicate the time he exited the facility. Resident #1 was observed walking in a shuffle gait with tremors to bilateral upper extremities. On 4/29/25 at 9:09 A.M., during an interview Staff A, CNA said on 4/19/25 she was assigned to take care of Resident #1 during the 7:00 A.M. -3:00 P.M. and the 3:00 P.M. to 11:00 P.M. shifts. She stated before the incident Resident #1 did not have any behaviors, she said he normally walks down the 300 hall and sits in the screened patio area. Staff A, CNA said on 4/19/25 she went to the dining room around 5:00 P.M. and that was the last time I saw [Resident #1]. Staff A, CNA, said around 5:45 P.M. she went to Resident #1's room and noticed He had not touched his food. She said she went to check the screen patio where Resident #1 usually sits and the door [to enter from the hallway] was locked. Staff A, CNA notified Staff NN, Licensed Practical Nurse (LPN) to Call Code Amber (missing resident code) because she Knew the resident was not in the building because I looked in all the usual places the resident would have been. Staff A, said most of the staff began searching for Resident #1 and searched longer than we should have, there is a time limit for the {facility name} to search for a resident before they call the police, and they searched longer. Staff A, CNA said she did not see any damage to the door in the screened patio area, because the door from the hallway was locked. She said the hallway door was locked by someone in the activity department around 5:30 P.M. Staff A, CNA said Resident #1 was an elopement risk before this event but has never tried to leave. On 4/29/25 at 9:09 A.M. during an interview with Staff NN, Licensed Practical Nurse (LPN), said she was assigned to Resident #1 on 4/19/25 during the elopement. Staff NN said Resident #1 Likes to walk all over the facility. Staff NN, LPN said Staff A, CNA, told her Resident #1 had not eaten his dinner. Staff NN, LPN said she administered medications to Resident #1 at approximately 4:45 P.M. and the last time she saw the resident was around 5:00 P.M. Staff NN, LPN said Staff A, CNA Came up to me around 6:40 P.M. and asked if I had seen {Resident #1} because he had not touched his dinner. Staff NN, LPN said she told Staff A, CNA to check Resident #1's usual spots, In the green room on 400 Hall. Staff NN, LPN said she was not aware They locked the porch at a specific time, but she wanted Staff A, CNA to check All the areas the resident usually walks. Staff NN, LPN said Staff A, CNA told her Resident #1 was not on the porch. She said a Code [NAME] was called around 6:48 or 6:50 P.M. Staff NN, LPN said another nurse notified Staff B, Registered Nurse (RN) Nursing Supervisor (NS). Staff B, RN, NS notified the police and Resident #1's representative. Staff NN, LPN said when the police arrived an Activity person unlocked the green room, that's when I saw the screen was cut, the police put an alert out and they found the resident on I-4. Staff NN, LPN said they Only have 10 minutes to notify police during an elopement. On 4/29/25 at 11:01 A.M. during a telephone interview with Resident #1's Primary Care Physician (PCP) he stated he was notified of Resident #1's elopement and I was surprised to hear {Resident #1} got out. Resident #1's PCP said he did not have much information regarding recommendations because the facility had alarms on all their doors. The PCP said when Resident #1 returned from the hospital he was assigned to the 200 Hall, the locked unit, and now Resident #1 is back in his previous room. The PCP said, The facility should put Resident #1 back on the more secured unit, (200 hall) because it is safer for him, and he could be watched all the time. He said, It was very concerning when he was notified Resident #1 was found on I-4. On 4/29/25 at 11:15 A.M. during a telephone interview with the facility's Medical Director he said he was notified on 4/19/25 Resident #1 eloped from the facility and was found on I-4. He said Resident #1 is not his patient, but he has seen the resident walk all over the facility. The Medical Director said, the only recommendation is to have more monitoring for this patient. He said, I don't' think he would benefit from a locked unit because he likes to walk around. During an interview on 4/29/25 at 11:30 A.M. with Staff B, RN, NS she said on 4/19/25 she went to lunch about 7:09 P.M., while on lunch break she received a call from one of the nurses, telling her a resident [Resident #1] was missing. She said by the time she came back into the facility the code had been called, and she saw staff looking for {Resident #1}. Staff B RN, NS, said she notified the Director of Nursing (DON) and the Risk Manager (RM) to let them know the resident was missing. Then she contacted Resident #1's family member to see if {the family member} had picked up {Resident #1} from the facility. Staff B, RN, NS said she called the local police around 7:34 pm, 15 to 20 minutes after she was informed the resident was missing. She said she was familiar with Resident #1 because he walks all over the facility and the last time she saw the resident was in the morning. Staff B, RN, NS, said, As soon as management arrived at the facility, they took over the investigation. An interview was conducted on 04/29/25 at 3:00 P.M. with Staff BB, Activity Assistant (AA). Staff BB said the door from the hallway to the screened patio used to remain unlocked. Staff BB, AA, said she was working on 4/19/25 and arrived at work at 8:30 A.M. and did not leave the facility until 9:00 P.M. She said Resident #1 usually comes to the patio around 9:30 A.M. or 10:00 A.M. and after lunch he returns to the patio usually around 3:30 P.M. and stays until it is time to lock the door. Staff BB, AA said Resident #1 usually sits in a chair on the patio porch and looks out the door, and on 4/19/25 she did not see the Resident #1 all day. Staff BB, AA said, I think he wanted to go home for Easter. Staff BB, AA said she locked the door from the hallway to the patio around 5:15 P.M. A phone interview was conducted on 4/29/25 at 4:06 PM with Resident #1's representative. The Resident Representative (RR) said on 4/19/25 someone from the facility called to ask if he had checked the resident out from the facility. The RR said he told the facility around 6:00 P.M. or 7:00 P.M. a call was received from a State Trooper saying Resident #1 was found sitting on the side of I-4 and wanted a ride to his home. The RR said he informed the State Trooper Resident #1 does not live at the address and gave them the facility's name and address. The RR said he was concerned about a call he received from the facility today about finding another facility for Resident #1. The RR said the facility's Social Service said they would assist him with finding another facility, but he was concerned because, It was hard to get {Resident #1} admitted to the current facility, and he does not know how he will be able to find another facility. During an interview on 4/29/2025 at 4:45 P.M. with the NHA and the RM, the RM said elopement risk residents are identified before admission when a referral is received. After admission they use different tools such as the Hospital to Nursing Home Medical Center Transfer Form (Form 5000-3008), Preadmission and Resident Review (PASRR) forms, the history and physical, and the medication lists to determine if there are elopement concerns. She said nurses complete an elopement assessment on admission and the resident is given a score to indicate their elopement risk. She said if the resident has a score of 5 and above, they are at risk. The NHA said not all residents identified as an elopement risk are placed in the locked unit. There are different factors that could place a resident on the locked unit, such as preferences related to dementia care. The NHA said there are elopement books on every unit and the receptionist desk with pictures of residents identified as high risk for elopement. The NHA said information related to elopement risk is in the Electronic Health Record (EHR) on the resident profile. They said staff use care plans and Kardex for resident specific interventions. The NHA stated elopement risks are assessed on admission, quarterly and as needed. On 4/30/2025 at 11:38 A.M. an interview was conducted with the NHA and RM to review the facility's investigation of Resident #1's elopement on 4/19/25. They were notified Resident #1 was missing at approximately 7:21 P.M. by Staff C, LPN, UM. The NHA said a group message was sent to managers to report to the facility immediately. The NHA said the facility's investigation of the elopement on 4/19/25 showed the following: 4:53 P.M. Staff NN, LPN administered medication to Resident #1. 5:00 P.M. Staff A, CNA observed Resident #1 across the hall from the screened porch area. 6:00 PM Resident #1's meal was left in his room; 6:30 P.M. the State Highway Patrol found Resident #1 on I-4 and MM 37. 6:50 P.M. Staff A noticed the meal had not been eaten, 7:05 P.M. Code [NAME] was called, 7:21 P.M. Staff B, RN NS notified Staff C, LPN, UM; 7:25 P.M. Staff B, RN NS notified Resident #1's representative; 7:42 P. M. local police department arrived; 9:10 P.M. Resident #1 arrived to the facility. When Resident #1 said he wanted to go home, he was transported by the State Highway Patrol to an address listed on identification card for the resident. Resident #1 was taken to [city] approximately 45 minutes from the facility and the State Highway Patrol had to transport him back to the facility. The local police department transported Resident #1 to a local hospital. The NHA said the facility concluded that the door from the hallway to the screened patio was not secure and residents had unsupervised access. The NHA said there was a delay in notifying the local police department and they should have been notified after 10 minutes. A review of Resident #2's admission record revealed an admission date of 11/5/23 with the following diagnoses: Heredity and idiopathic neuropathy, asthma with status asthmaticus, protein calorie malnutrition, chronic obstructive pulmonary disease (COPD), mood disorder, major depressive disorder, and dementia. A Review of Resident #2's MDS, dated [DATE], Section C-Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of is 0 indicating severe cognitive impairment. A review of Section E-Behavior showed wandering behavior has occurred 1-3 days. A review of Resident #2's Care Plan, dated 4/21/25 showed the following: Focus area of elopement/wanderer r/t History of attempts to leave facility unattended, Impaired safety awareness with an initiated date of 4/21/25 and interventions for this focus area to include allow to wander safely on the secure unit. A review of Resident's #2 Narrative Nurses Note, dated 3/25/25, showed nurse heard alarm from side door on 300 hall door was open wide nurse observed {Resident #2} ambulating away from the building. {Resident #2} stated she was trying to leave. She was assisted to her room and placed on one-to-one observation. During a telephone interview on 4/29/25 at 11:15 A.M. the facility's Medical Director said he was not familiar with Resident #2. He stated he did not consider Resident #2 exiting the facility's locked door to be an elopement. He stated he does not have any concerns about the supervision of the residents. He stated he would be more concerned if these types of events happened more frequently. An interview was conducted on 4/30/25 at 2:26 P.M. with the NHA and the DON regarding the facility investigation of Resident #2's elopement on 3/25/25. They stated the investigation showed: At 6:45 Staff AA, LPN observed Resident #2 walking on 300 Hall At approximately 7:00 P.M. Staff AA, LPN heard the emergency exit door alarm, exited the medication room and observed Resident #2 walking away from the door, approximately 23 feet from the doorway. At 7:08 P.M. the NHA was notified of the elopement. The NHA said on 3/26/26 there was an Ad Hoc committee meeting held and after investigating the event the facility concluded Resident #2's elopement was an isolated event. The NHA said the facility provided a review of the Abuse, Neglect and Exploitation policy, wandering and elopement education, and increased the frequency of elopement drills. A review of the facility's policy titled Abuse, Neglect and Exploitation, revision date 4/2004, showed the following: Policy: It is the policy of this facility to provide protections for the health, welfare .and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect . Definitions: Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Policy Explanation and Compliance Guidelines: The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. b. Establish policies and procedures to investigate any such allegations; and c. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, reporting procedures, and dementia management and resident abuse prevention; . Employee Training topics will include: 1. Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation; 5. Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect such as: .b wandering ort elopement-type behaviors Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect .G. Addressing features of the physical environment that may make abuse, neglect, exploitation, and misappropriation of resident property more likely to occur. Coordination with QAPI: The facility has written policies and procedures that define how staff will communicate and coordinate situations of abuse, neglect, misappropriation of resident property, and exploitation with the QAPI program. Review of the facility's policy titled Exit Doors, implementation date 9/1/23, showed the following: Definitions- Egress refers to the action of going out of or leaving a place. Policy Explanation and Compliance Guidelines: Check operation of magnetic door locks (if applicable) 1. Inspect door lock mounting and operation and inspect panic hardware .3. Any magnetically locked doors must automatically unlock during a fire alarm (verify this during your normal fire drill) .Check delayed egress operation (if applicable) 1. Push door release hard for a fraction of a second - door should not open and alarm should not sound 2. Apply pressure to the door release for the pre-determined nuisance period setting (normally 1-3 seconds) 3. Door should go into irreversible unlocking sequence 3 a. Door alarm will sound 3 b. Door will automatically open within 15 seconds . Ensure signs are placed on doors adjacent to the release device that read 'Push until alarm sounds. Door can be opened in 15 seconds Document results of inspection in logbook. Review of the facility's policy titled Elopements and Wandering, implementation date, [undated], showed the following: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person centered plan of care addressing the unique factors contributing to wandering or elopement risk. Definitions: Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit), or non-goal directed or aimless. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. Policy Explanation and Complia[TRUNCATED]

Based on interviews and record review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to implement an effective performance improvement plan to prevent the elopement of one resident (#1) out of five residents identified by the facility at risk for elopement. Findings included: 1. A review of Resident #2's admission record revealed an admission date of 11/5/23 with the following diagnoses: Heredity and idiopathic neuropathy, asthma with status asthmaticus, protein calorie malnutrition, chronic obstructive pulmonary disease (COPD), mood disorder, major depressive disorder, and dementia. A Review of Resident #2's Minimum Data Set (MDS), dated [DATE], Section C-Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of is 0 indicating severe cognitive impairment. A review of Section E-Behavior showed wandering behavior has occurred 1-3 days. A review of Resident #2's Care Plan, dated 4/21/25 showed the following: Focus area of elopement/wanderer r/t History of attempts to leave facility unattended, Impaired safety awareness with an initiated date of 4/21/25 and interventions for this focus area to include allow to wander safely on the secure unit. A review of Resident's #2 Narrative Nurses Note, dated 3/25/25, showed nurse heard alarm from side door on 300 hall door was open wide nurse observed {Resident #2} ambulating away from the building. {Resident #2} stated she was trying to leave. She was assisted to her room and placed on one-to-one observation. During a telephone interview on 4/29/25 at 11:15 A.M. the facility's Medical Director said he was not familiar with Resident #2. He stated he did not consider Resident #2 exiting the facility's locked door to be an elopement. He stated he does not have any concerns about the supervision of the residents. He stated he would be more concerned if these types of events happened more frequently. An interview was conducted on 4/30/25 at 2:26 P.M. with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) regarding the facility investigation of Resident #2's elopement on 3/25/25. They stated the investigation showed: -At 6:45 Staff AA, LPN observed Resident #2 walking on 300 Hall -At approximately 7:00 P.M. Staff AA, LPN heard the emergency exit door alarm, exited the medication room and observed Resident #2 walking away from the door, approximately 23 feet from the doorway. -At 7:08 P.M. the NHA was notified of the elopement. The NHA said on 3/26/25, an Ad Hoc QAPI committee meeting was held to discuss the 3/25/25 incident when a resident was found walking away from the facility. The NHA said committee response was to focus on a More person-centered approach The QAPI committee decided to increase the frequency of elopement drills, review all residents who were at risk for elopement and update their care plans. The NHA said the committee reeducated staff about abuse, neglect, and exploitation, the wandering, and elopement policies. The NHA said there was an increase in focus on door checks, elopement drills, and ensuring elopement risk residents were included in the elopement book. The NHA said they reviewed the investigation and audit process through QA to ensure we completed a thorough investigation. The NHA said the Medical Director was part of the QAPI plan we put in place., and he did not have any additional recommendations. A review of the facility's elopement audits, completed between 3/26/25 and 4/26/25, revealed five resident records for elopement evaluations, elopement care plans with interventions on [NAME], and verifying the elopement book was correct. The audits revealed no deviations were identified. Review of the facility's staff education sign in sheets, dated 3/27-4/1/2025, revealed 256 staff signatures for education titled Prevention of Resident Elopement-Video. 2. Review of the medical record revealed Resident #1 was admitted on [DATE], with diagnoses including other specified disorders of [the] brain, unspecified lack of expected normal physiological development in childhood, anemia, mood disorder due to known physiological condition with mixed features, major depressive disorder, recurrent, moderate, hypertension, , psychotic disorder with delusions due to known physiological condition, pedestrian on foot injured in collision with motor vehicle in nontraffic accident, pelvis fracture, skull and facial bone fractures, and lung contusion. A review of Resident #1's physician order summary report, dated 4/01/2025-4/30/2025, revealed the following: - Divalproex 250 mg (milligrams) AM (morning) dose and Divalproex 500 mg at bedtime for unspecified mood disorder. -Mirtazapine 15 mg for major depressive disorder. -Risperidone 0.5 mg for psychotic disorder with delusions. Review of Resident #1's physician attestation of a resident incapacitated form, dated 7/31/24, revealed the resident is physically and cognitively unable to communicate a willful and knowing health decision. Review of Resident #1's Brief Interview for Mental Status (BIMS), dated 3/31/25, revealed a score of 0, indicating severe cognitive impairment. Review of Resident# 1's Activity Participation Note, dated 3/24/25, revealed He gets around on his own and enjoys sitting in the porch enjoying fresh air . Review of Resident# 1's Narrative Nurses Note, dated 3/29/25, revealed Resident has been up walking about facility. Staff on 100 unit didn't know him and they tried to tell him he couldn't go and to go back to his floor. He went down towards the porch where he sits. On 4/19/25, when Resident #1 was allowed to walk away from the facility unnoticed, walk along high traffic streets for eight miles, and end up on an Interstate Highway where he was found by the [State Highway Patrol]. Resident #1 was taken to a higher level of care for evaluation and treatment of dehydration. Review of the Resident# 1's eInteract SBAR summary for a Provider Note, dated 4/19/25 at 9:39 P.M., showed, Resident visually observed while in back of law enforcement vehicle and during transfer from one law enforcement vehicle to another. At the time, there were no injuries or signs or symptoms of medical distress . Resident transported to the ED (emergency department) for further evaluation. On 4/28/25 at 10:05. A.M. Resident #1 was observed lying in the bed with his head covered and determined to be sleeping by the pattern of his breathing During an interview on 4/28/25 at 10:10 A.M. Staff J, LPN said Resident #1 mumbles and is hard to understand, Walks all over the building, mumbles a lot. She said they are often short and sometimes work 12-16-hour shifts. During an interview on 4/28/25 at 10:20 A.M. the Activities Director, (AD) said prior to 4/19/25 the door from the facility to the non-smoking patio was left unlocked and residents could enter the patio unsupervised. She said Resident #1 told her he Wanted to go home. During an observation and interview on 4/28/25 at 12:46 P.M., Resident #1 was sitting on the side of his bed eating lunch. Resident #1's speech was slurred and difficult to understand. He said he was walking to see mother when he was found on the Interstate. During an interview on 4/28/25 at 1:00 P.M. Staff C, LPN, Unit Manager (UM) said on 4/19/25 at approximately 7:20 P.M. she received a call from Staff B, RN, NS telling her an elopement drill had been started because they could not find [Resident #1]. She notified the Nursing Home Administrator (NHA) and the Risk Manager (RM) immediately. Staff C, LPN, UM said, at approximately 730 P.M. a group text was sent to all department heads to come to the facility. The exit doors were checked. Staff C, LPN UM said she did not participate in the elopement investigation. During an interview and observation on 4/28/25 at 1:10 P.M. with the Director of Maintenance (DOM) and the Regional Maintenance Director, the DOM said the maintenance staff checks all facility exit doors daily. The exit doors have a magnetic lock, and the process is to push the door for 15 seconds to verify the latch and alarm works. When the latch is disengaged a secondary keyed alarm is also activated. He said, in the screened patio area, the screen door to exit the building has a padlock which is checked daily. The DOM said doors are checked between 8:00 A.M. and 10:00 A.M., Monday through Thursday and around 3:00 P.M. on Friday. The DOM said he checked all the exit doors on 4/18/25. On 4/19/25 after Resident #1 eloped all doors were checked; no issues were identified. The secondary alarm batteries were changed as a preventative measure. On 4/19/25 the screen in the lower portion of the patio screen door was pushed out and the rubber tubing to hold the mesh in place was laying on the ground. On 4/28/25 at 1:10 P.M. during a tour of the screened patio, the screen door was secure with a padlock. The screen on the lower portion of the door screen was intact and a silver metal grate was secured on the exterior. During an interview on 4/28/25 at 1:32 PM with Staff H, LPN, Minimum Data Set (MDS) Nurse said on 4/19/25 at about 7:30 P.M. he received a group text notification a resident was not in the building, with instructions to come and assist. When Staff H, LPN, MDS arrived at a 7:40 P.M., the local police department was on the scene, and he was the first manager to arrive, and he accompanied the officer to search the facility for Resident #1. Staff H, LPN, MDS said, Staff OO, unlocked the door to search the immediate area. He said, In the 400-hall screened in area they observed the bottom screen broken, blowing in the wind. Staff H, LPN, MDS said at approximately 8:20 P.M. a police officer told him Resident #1 was found. Staff H, LPN, MDS said, when the State Highway Patrol arrived with Resident #1, he assisted the DON to assess, check neuros. He said the facility staff asked a local police officer to transport Resident #1 to a local hospital, they felt it was a safe transfer, a courtesy, did not have to use other resources. On 4/29/25 at 8:52 A.M. during an interview and observation, with assistance of the Medical Records Director, Resident #1 said and gestured he left the facility from the non-smoking patio door. He said and gestured his removal of part of the screen on the patio door, crawling out to exit the facility. Resident #1 said he walked mile, mile (a long distance) and the police picked him up and took him to his former home in [city]. He said he did not have a key to open the door. Resident #1 said and gestured the police transported him back to the facility. Resident #1 was unable to communicate the time he exited the facility. Resident #1 was observed walking in a shuffle gait with tremors to bilateral upper extremities. On 4/29/25 at 9:09 A.M., during an interview Staff A, CNA said on 4/19/25 she was assigned to take care of Resident #1 during the 7:00 A.M. -3:00 P.M. and the 3:00 P.M. to 11:00 P.M. shifts. She stated before the incident Resident #1 did not have any behaviors, she said he normally walks down the 300 hall and sits in the screened patio area. Staff A, CNA said on 4/19/25 she went to the dining room around 5:00 P.M. and that was the last time I saw [Resident #1]. Staff A, CNA, said around 5:45 P.M. she went to Resident #1's room and noticed He had not touched his food. She said she went to check the screen patio where Resident #1 usually sits and the door [to enter from the hallway] was locked. Staff A, CNA notified Staff NN, Licensed Practical Nurse (LPN) to Call Code Amber (missing resident code) because she Knew the resident was not in the building because I looked in all the usual places the resident would have been. Staff A, said most of the staff began searching for Resident #1 and searched longer than we should have, there is a time limit for the {facility name} to search for a resident before they call the police, and they searched longer. Staff A, CNA said she did not see any damage to the door in the screened patio area, because the door from the hallway was locked. She said the hallway door was locked by someone in the activity department around 5:30 P.M. Staff A, CNA said Resident #1 was an elopement risk before this event but has never tried to leave. On 4/29/25 at 9:09 A.M. during an interview with Staff NN, Licensed Practical Nurse (LPN), said she was assigned to Resident #1 on 4/19/25 during the elopement. Staff NN said Resident #1 Likes to walk all over the facility. Staff NN, LPN said Staff A, CNA, told her Resident #1 had not eaten his dinner. Staff NN, LPN said she administered medications to Resident #1 at approximately 4:45 P.M. and the last time she saw the resident was around 5:00 P.M. Staff NN, LPN said Staff A, CNA Came up to me around 6:40 P.M. and asked if I had seen {Resident #1} because he had not touched his dinner. Staff NN, LPN said she told Staff A, CNA to check Resident #1's usual spots, In the green room on 400 Hall. Staff NN, LPN said she was not aware They locked the porch at a specific time, but she wanted Staff A, CNA to check All the areas the resident usually walks. Staff NN, LPN said Staff A, CNA told her Resident #1 was not on the porch. She said a Code [NAME] was called around 6:48 or 6:50 P.M. Staff NN, LPN said another nurse notified Staff B, Registered Nurse (RN) Nursing Supervisor (NS). Staff B, RN, NS notified the police and Resident #1's representative. Staff NN, LPN said when the police arrived an Activity person unlocked the green room, that's when I saw the screen was cut, the police put an alert out and they found the resident on I-4. Staff NN, LPN said they Only have 10 minutes to notify police during an elopement. During an interview on 4/29/25 at 11:30 A.M. with Staff B, RN, NS she said on 4/19/25 she went to lunch about 7:09 P.M., while on lunch break she received a call from one of the nurses, telling her a resident [Resident #1] was missing. She said by the time she came back into the facility the code had been called, and she saw staff looking for {Resident #1}. Staff B RN, NS, said she notified the Director of Nursing (DON) and the Risk Manager (RM) to let them know the resident was missing. Then she contacted Resident #1's family member to see if {the family member} had picked up {Resident #1} from the facility. Staff B, RN, NS said she called the local police around 7:34 pm, 15 to 20 minutes after she was informed the resident was missing. She said she was familiar with Resident #1 because he walks all over the facility and the last time she saw the resident was in the morning. Staff B, RN, NS, said, As soon as management arrived at the facility, they took over the investigation. Review of the facility's policy titled Exit Doors, implementation date 9/1/23, showed the following: Definitions- Egress refers to the action of going out of or leaving a place. Policy Explanation and Compliance Guidelines: Check operation of magnetic door locks (if applicable) 1. Inspect door lock mounting and operation and inspect panic hardware .3. Any magnetically locked doors must automatically unlock during a fire alarm (verify this during your normal fire drill) .Check delayed egress operation (if applicable) 1. Push door release hard for a fraction of a second - door should not open and alarm should not sound 2. Apply pressure to the door release for the pre-determined nuisance period setting (normally 1-3 seconds) 3. Door should go into irreversible unlocking sequence 3 a. Door alarm will sound 3 b. Door will automatically open within 15 seconds . Ensure signs are placed on doors adjacent to the release device that read 'Push until alarm sounds. Door can be opened in 15 seconds Document results of inspection in logbook. Review of the facility's policy titled Elopements and Wandering, implementation date, [undated], showed the following: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person centered plan of care addressing the unique factors contributing to wandering or elopement risk. Definitions: Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit), or non-goal directed or aimless. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. Policy Explanation and Compliance Guidelines: 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement· for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary.4.Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering. 4 a. Residents will be assessed. For risk of elopement and unsafe wandering upon admission and throughout their stay 4 c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. dedicate supervision will be provided to help prevent accidents or elopements. 5. Procedure for Locating Missing Resident 5 a. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (e.g. internal alert code). 15c. If the resident is not located in the building or on· the grounds, Administrator or designee will notify the police department 5 d. DON or designee shall notify the physician and family member or legal representative. Review of the facility's Elopement Prevention Tips, undated, showed the following: react to statements such as I want to go home; Observe for aimless wandering, .Review physical plant to be sure door alarms are working and that unauthorized areas are properly locked to prevent resident entry; Consider use of a chain of custody for high risk residents, develop a schedule for periodic checks on the resident; When the resident is involved in other activities or disciplines in the facility, such as dining and activity programs, the nursing assistant may give responsibility to that department for the periodic check, until the resident is returned to the assigned nursing assistant; never assume everyone knows the resident is a wanderer, make it clear to dining room aids, new staff and whoever is involved in the resident's care even for a short period of time . A Quality Assurance and Performance Improvement Policy was not provided at the time of the survey for review.

Cross Reference F921 Based on observations, interviews, and record review, the facility failed to provide supervision and failed to prevent accident hazards to prevent a fall with injury for one resident (#6) of 19 ambulatory residents in the memory care unit. The facility failed to replace a clean-out drain located in a high traffic area of the facility's memory care unit and failed to promptly and effectively address flooring issues, resulting in an unsafe walkway, where Resident #6 tripped and fell . On 1/20/2025, Resident #6 was ambulating in the hallway outside her room and suffered a fall significantly impairing the ability to walk independently and complete Activities of Daily Living (ADLs) at her prior functional level. The resident suffered a significant change due to a fractured right femoral head requiring a surgical intervention of a right hip arthroplasty. The facility's failure to provide supervision and prevent accident hazards caused serious harm and injuries to Resident #6 and placed 18 additional ambulatory residents in the memory care unit at risk for serious injury, harm, and/or death. This failure resulted in the determination of Immediate Jeopardy on 1/20/25. The findings of Immediate Jeopardy were determined to be removed on 2/28/25 and the severity and scope was reduced to a D. Findings included: A review of Resident #6's admission record revealed the resident was [AGE] years old, originally admitted to the facility on [DATE], with a recent hospital stay from 1/20/25 to 1/26/25. The record showed diagnoses to include a displaced fracture of base of neck of right femur subsequent encounter for closed fracture with routine healing, aftercare following joint replacement surgery, difficulty in walking, presence of right artificial hip joint, and dementia and other diseases classified elsewhere unspecified severity with agitation. A review of the Situation, Background, Appearance, and Review (SBAR) Communication Form and Progress Note revealed Resident #6 had a change in condition of a fall on 1/20/25. The Situation section of the form documented status post fall, trip and fall in hallway, complaining of lower back and right leg pain. The Background section documented the resident has new pain with an intensity of 9 out of 10 (10 being the worst). The Appearance section documented status post fall in hallway, left in place due to pain on movement. 911 called. The Review and Notify section documented that the primary care clinician was notified on 1/20/2025 at 8:40 a.m. with recommendations to send to the emergency room (ER) for evaluation. The Family Member (FM) was notified on 1/20/2025 at 8:44 a.m. A review of Resident #6's hospital History and Physical Report, dated 1/20/25 at 12:59 p.m. revealed this [AGE] year-old female had a medical history of dementia, dyslipidemia, and COPD [chronic obstructive pulmonary disease]. The nursing home resident, presented to the hospital from the nursing home after a fall. The patient was found on the ground and complaining of right hip pain. The patient's baseline was confused, and she could only recognize her [FM]. The completed radiology imaging studies, on 1/20/25 at 10:44 a.m. showed a right femoral neck fracture. The Computed Tomography Scan (CT) of the pelvis without contrast, on 1/20/25 at 10:04 a.m., revealed impacted right femoral neck fracture with angulation and mild displacement. The X-ray results of the right femur and right hip with pelvis showed normal mineralization. A review of a hospital consultation note dated 1/20/25 at 6:04 p.m. showed the resident was complaining of right hip pain and the physical examination showed the right lower extremity was shortened and externally rotated. The assessment/plan showed resident would benefit from operative intervention of the right hip in order to provide stability to the fracture and promote satisfactory healing, to improve pain, to facilitate early motion and mobilization and to prevent complications associated with prolonged bedrest. The risks, benefits, complications, and alternatives treatments were explained to the patient and FM. This included the possibilities of infection, deep vein thrombosis, reaction to anesthesia, neurovascular compromise, death or dying on the table, incomplete relief of symptoms, and chronic pain or stiffness. A review of the operative report on 1/21/25 at 9:08 a.m., showed Resident #6 had undergone a right hip hemiarthroplasty. The post-operative X-ray results showed the prosthesis was well-seated with no evidence of hardware loosening or failure. A review of Resident #6's clinical record at the facility prior to the 1/20/25 fall with a fracture revealed a quarterly Minimum Data Set (MDS), dated [DATE]. The cognitive pattern (Section C) showed a Brief Interview of Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. The functional abilities assessment (Section GG) revealed the resident was independent with eating, oral and toileting hygiene, and upper/lower body dressing. The resident required supervision with shower/bathing self, putting on/taking off footwear, and personal hygiene. The resident was independent with rolling left to right, sitting to lying, lying to sitting, sit to stand, transferring from chair/bed-to-chair, toilet transferring, walking 10 feet and walking 50 feet with two turns. The resident required partial assistance with tub/shower transfer, and supervision with walking 150 feet. The resident was always incontinent of bladder and frequently incontinent of bowel (Section H). The health conditions assessment (Section J) revealed the resident had no pain 5 days prior to the assessment, and had not fallen since admission/entry, reentry, or prior assessment. A review of Resident #6's last Physical Therapy (PT) Discharge Summary (prior to the 1/20/25 fall with a fracture) was dated 12/26/2024 and showed the resident was able to ambulate with no assistive device with modified independence (MI) for up to 300 ft. or as tolerated on level surface with verbal cues for directional changes. A review of Resident #6's last Fall Risk Evaluation (prior to the 1/20/25 fall with a fracture) was dated for a last known fall on 11/25/24 with a fall risk score of 9 (a score of 8 or higher indicates a fall risk). A review of a facility note dated 1/26/25 at 5:30 p.m., showed Resident #6 returned to the facility from the hospital following a right hip hemiarthroplasty (related to the fall on 1/20/25). The record showed the resident was in pain whenever touched. The resident had a surgical wound on the right thigh. A review of a Fall Risk Evaluation conducted on 1/26/2025 at 5:39 p.m. showed the last known fall was on 1/20/25. The resident's fall risk score was 17. A review of a PT Evaluation dated 1/27/2025 showed Resident #6's prior level of function (PLOF) for bed mobility and transfers was independent with a baseline on 1/27/2025 of total assistance. The PLOF for walking was supervision with rolling walker up to 200 feet with a baseline on 1/27/25 of unable. A review of Resident #6's 5-day MDS (post fall and hospitalization ), dated 1/28/25, revealed the resident had a BIMS score of 00, indicating severe impairment. The functional abilities assessment showed the resident was dependent on eating, oral and toileting hygiene, shower/bathing, upper/lower body dressing, and putting on/taking off footwear. The resident was dependent for rolling left to right, sitting to lying, lying to sitting, sit to stand, transferring from chair/bed-to-chair, toilet transferring, car transferring, walking 10 feet, walking 50 feet with two turns, and walking 150 feet. The assessment showed the resident was using a manual wheelchair. The resident was incontinent of bowel and bladder. The health conditions revealed frequent pain, no falls in the last month prior to admission/entry or reentry, no fracture related to a fall in the 6 months prior to admission/entry or reentry and had major surgery during the 100 days prior to admission. A review of Resident #6's care plan initiated on 8/21/2024 and revised on 1/30/2025 revealed the resident was at risk for falls related to history of falls, poor safety awareness, incontinence, dementia, psychotropic medication use, and neuropathy. The interventions for the care plan included: Ensure resident has a safe environment: (Specify: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position; handrails on walls, personal items within reach) initiated on 8/21/2024. 1/20/2025 Keep environment/walkway free of trip hazards initiated on 1/20/25 and revised on 1/30/2025. 10/25/2024 Family to assist with decluttering room for safety initiated on 11/25/2024 and revised on 1/30/2025. 2/12/2025 Scoop mattress initiated on 2/13/2025. During a facility tour on 2/24/25 at 10:30 a.m. an area of rough and uneven concrete approximately 3ft (feet) x 2 ft in the middle of the corridor of the 200-hall located inside the memory care unit. The uneven concrete area had a drain cap located near the middle that was raised. The concrete area was a known high-traffic area, outside of the secured memory care dining room, the nurses' station, and just outside of Resident #6's room. A review of an electronic work order created on 12/18/24 at 6:31 p.m. by Staff G, Licensed Practical Nurse (LPN) revealed clean out cover missing, location 200 hallway, priority level medium, and a note/comment to repair drain on 200 hallway asap [as soon as possible]. The status of the order was updated by the Director of Maintenance (DOM) on 12/27/24 at 2:49 p.m. as Set to Completed. A Room Audit Form, for Project Clean OUT 200 Hall with a start date of 12/18/24 revealed daily notes monitoring the clean out cover area from 12/18/24 to 1/24/25 documented by the DOM. The first entry on the log, dated 12/18/2024, showed the (DOM) placed a metal sheet cover over the drain opening with tape. The entry on 12/27/24, the day the work order status was updated, showed a visual inspection was done in the morning and fresh tape was applied that evening. None of the entries between 12/18/24 and 12/27/24 showed any additional work outside of visual inspection and applications of fresh tape was completed. A review of the audit log revealed no documentation to show the area was visually inspected to ensure safety of residents, staff, and visitors on 12/21/24, 12/22/24, 12/25/24, 12/28/24, 12/29/24, 12/31/24, 1/4/25, 1/5/25, 1/10/25, 1/11/25, 1/12/25, 1/15/25, 1/16/25, 1/22/25, and 1/23/25. The log showed on 1/20/25 morning - Resident [#6] fall, fresh tape -plumber called -Received Quote & Sent. The log showed on 1/24/25 evening - Job completed. A review of an email dated 2/25/25 confirmed the plumbing company had completed a repair of the area on the 200 hall on 1/24/25, 4 days after Resident #6 fell and 37 days after the original work order was created. An interview on 2/25/25 at 1:34 p.m. with Staff C, Certified Nursing Assistant (CNA) revealed she witnessed Resident #6's incident on 1/20/25. Staff C, CNA reported Resident #6 was in the hallway with her FM. The resident was attempting to detach herself from tape on the floor in the unrepaired plumbing area that was covered with concrete. The staff member stated the tape was not holding anything down. Staff C saw Resident #6 lose her balance and fall. Review of a written statement by Staff C, CNA dated 1/20/25 at 8:30 a.m. showed Staff C was coming down the hall with a breakfast tray and witnessed Resident #6 trip and fall over an area on the floor. The tape was coming up and Resident #6's foot got caught on it. On 2/25/25 at 9:45 a.m., an interview was conducted with the DOM. He stated on 200-hall, the memory care unit, a resident had pulled the clean-out cap off, on 12/18/24. The DOM reported roping the area off and cutting a metal piece to fit on top of the missing cap. He stated this was done after Resident #6 had fallen. The DOM stated the facility had plumbers come in on 1/24/25. The DOM stated from 12/18/24 to 1/24/25, he had put several patches on the area, and went back every day to make sure it was secure and safe. The DOM reported the plumbers removed the tile all the way around the clean out cap, leaving a cemented patch. On 2/25/25 at 10:46 a.m., the DOM observed the 200 hall and showed the area where Resident #6 had fallen in the hallway. The area was near the nursing station in the 200-hall and just outside of Resident 6's room at that time of the 1/20/25 incident. The DOM observed an additional area of missing floor tiles on the 200 hall and stated the facility had just received the diamond blades to smooth out the concrete. He stated the plumbers had to remove the tiles to fix a plumbing issue. During the time of this interview, the DOM confirmed the area where Resident #6 had fallen was still uneven due to the concrete patch left by the plumbers on 1/24/25. A follow-up interview on 2/26/25 beginning at 3:05 p.m. with the DOM revealed the rough concrete patch observed during the survey beginning on 2/24/25 was part of the repair. The DOM stated he had to research a replacement cap since the missing cover was so old. The DOM stated the plumber did not have a cap to fit the cast iron piping, so the plumber had to make the hole bigger and cut pipe to fix it. The DOM revealed this repair happened in the middle of January. The DOM stated he had put a metal plate on the area trying to save the company money in December 2024. The DOM reported he was researching it to try to fix it himself before calling the plumbers in, but after Resident #6's fall, he was done searching for the replacement and decided to get plumbers in. The DOM stated he felt the location where Resident #6 fell was safe and felt the [brand name] tape was a good tape to use as a temporary fix. The DOM reported the diamond grinding wheel, needed to smooth out concrete, had been back ordered and came in last week. The DOM said he had looked at local merchants for the grinding wheel, but they did not have the size needed in stock. The DOM stated the diamond wheel was delivered on 2/14/25, the day before he went on vacation. Review of the online merchant's receipt for the 4.5-inch diamond concrete grinding wheel showed the order was placed on 1/27/25 and shipped on 1/27/25. At the time of this interview, the area where Resident #6 fell was still not fully repaired leaving a rough and uneven flooring surface in this high traffic area. During an interview on 2/25/25 at 2:15 p.m., the Director of Nursing (DON) stated Resident #6 had been ambulating in the hallway with a family member and her foot kind of got stuck on tape. The DON reported the FM grabbed the resident had pulled her, then the resident lost her balance and fell . The DON stated the resident had a history of osteopenia and because of right hip pain the resident was left on floor. The DON stated she interviewed Staff B/CNA, Staff C/CNA, and Staff E, Licensed Practical Nurse (LPN). The DON stated Staff E, LPN was sitting at the desk and did not witness the fall, but heard the resident call out and saw her lying on the right side. The DON confirmed Resident #6 suffered a fall, was transferred out to the hospital, had surgery and came back to the facility. The DON stated Resident #6 had suffered a previous fall on 10/25/24. She stated the resident had a big chair in her room at the time so the family decluttered the room and when the resident started ambulating, the facility ensured the environment was free of clutter and slip hazards to prevent additional falls. An interview was conducted on 2/26/25 at 12:00 p.m. with Staff J, Licensed Practical Nurse/Unit Manager (LPN/UM). The staff member described the area of concrete as similar to other drains on unit, showing a circular drain with a square metal outer plate. Staff J, LPN/UM stated the residents on the unit like to pick at it and had pulled the square metal plate up. Staff J, LPN/UM stated maintenance had covered the area with a metal square that was approximately the same size as the missing plate and secured it to the floor with yellow and black striped industrial tape so it would be recognized as a caution area. Staff J, LPN/UM stated she doubted the residents in the memory care unit would have recognized the tape as a caution area. The staff member stated the concrete area was a high-traffic area as it was between the dining room, Resident #6's room, and the nursing station on the memory care unit. Staff J, LPN/UM stated they had a lot of residents wandering up and down the hallways due to dementia on the unit. Staff J, LPN/UM said she could only report it to maintenance, and then it was out of her hands. Staff J, LPN/UM stated the metal and tape was a hazard, and during the repair period, the area had become larger in size. A review of a work order dated 12/3/24 at 2:24 p.m. showed Staff J, LPN/UM reported missing tile on the floor of the 200 hallway with a medium priority level. The work order was acknowledged by the DOM on 12/27/24 at 3:30 p.m. with a status of Set to-In-Progress. The work order was updated on 2/26/25 at 2:17 p.m. by the DOM with a status of Set to completed. On 2/24/25 at 10:18 a.m., a second area in hall 200 towards the front of the facility, near the janitor supply closet #3 was observed with 12 missing tiles. The area was in the walking path of residents in the memory care unit. The area had a raised drain with a cap near the middle of it. An immediate interview was conducted with Staff B, Certified Nursing Assistant (CNA) who confirmed the area had been in disrepair for a long time and estimated it to be approximately 6 to 8 months. On 2/24/25 at 10:38 a.m., the entrance ramp to the 400-hall was observed missing five full carpet squares (approximately 2 ft x 2 ft) and 5 half carpet squares leaving exposed concrete with a raised drain that was not level to the concrete, and the carpet that remained was not level with the concrete. A yellow traffic cone was placed in the corner from the hallway to the ramp. This area was the inside entrance for residents, staff and visitors to access the 400-hall and used frequently by residents with ambulation devices and wheelchairs. On 2/27/25 at 2:04 p.m., the Regional DOM reported not being aware of the flooring issue. The Regional DOM stated depending on severity, if something could not be handled in-house the facility contacted vendors for repairs. The Regional DOM expected something to be implemented promptly, within one to two weeks for the safety of the residents. During a facility tour of the 200 hall on 02/27/2025 at 2:21 p.m. with the Nursing Home Administrator (NHA), revealed tiles that were popping up on the edges where the facility had replaced flooring using old tiles. The NHA confirmed the area was a hazard for someone with a shuffling gait. The NHA stated the tiles needed to be put down again and better. The NHA stated her expectation was an immediate fix for any hazard affecting residents. The NHA observed the area where Resident #6 fell and stated she expected the area to be safe for the residents. The NHA stated it was unacceptable to wait to repair the floors. Photographic evidence was obtained. Review of the Fall Prevention Program, implemented on 9/1/24, revealed Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The policy defined a fall as an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force (e.g. resident pushes another resident). The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere. The policy explanation and compliance guidelines showed the facility utilized a standardized risk assessment for determining a resident's fall risk. Low/moderate risk protocols include implementation of universal environmental interventions that decrease the risk of a resident falling, including, but not limited to: A clear pathway to the bathroom and bedroom doors. A review of the facility's immediate actions to remove the Immediate Jeopardy included: 1. Immediate Action: Environmental rounds completed, identified areas of concern noted. Summoned Corporate Plant Operations support team for assistance. Quality review completed for all current residents sustaining a fall to ensure plan of care is in place in the past 6 months, no discrepancies noted. Medical Record Review of all residents with falls with major injury in the past 6 months conducted; no discrepancies noted. 99.5% of all facility staff were educated by 9:00 a.m. on 2/28/2025. Initiated and assigned direct care staff member as Hallway Safety Monitor on secure unit (200 Hall) for additional supervision. Hallway Safety Monitor will be assigned for 24 hours a day X 7 days to establish a pattern of ambulatory residents. When pattern is established, Hallway Safety Monitor will be staffed from 0700 to 2300 daily X 14 days. Then, as pattern is further established, Hallway Safety Monitor will be staffed 12 hours daily X 30 days. Hallway Safety Monitor staffing hours will be adjusted as indicated. 2. Identification of others at risk was accomplished by: On 2/26/25-2/27/25 The Director of Clinical Services (DCS) and designee(s) reassessed all residents residing in the facility for fall risk via Fall Risk Evaluation. Facility implemented Activities Invitation Rounds for residents identified at risk for falls. Activities staff will encourage identified residents to attend activities of choice and document on log to establish a pattern of attendance/ preferences. The Care Plan Coordinator(s) completed review of care plans to ensure all residents identified as at risk for falls (Fall Risk Score of 8 or higher) had safety measures, as well as resident specific interventions in place and to ensure the safety measures and resident specific interventions are also reflected on the Kardex so that the CNA's have access to this information. Quality review completed for monitoring of environmental hazards with a focus on uneven surfaces and fall hazards. Identified environmental concerns addressed by priority level, initiated repairs and ongoing. Record review of Resident #6 completed. Therapy screen completed on 1/22/2025; PT/OT services ongoing. Resident seen by psych provider. No changes in mood or mentation noted. Pain Management in place. Resident has orders for pharmacological pain intervention: Tylenol, Lidocaine External Patch, and Tramadol as of 2/27/25. Resident was previously on Norco, but medication was discontinued. 3.Actions to Prevent Occurrence/Recurrence: NHA, DCS, and Plant Operations/Maintenance Director re-educated on ensuring resident environment is free of hazards with emphasis on timely completion. Regional DCS educated the DCS on the facility's Fall Prevention Program, all facility fall related policies, how to conduct an RCA, and how to ensure incident investigations are timely and complete. DCS/designee re-educated staff on facility Fall Prevention Program guidelines, following care plan/Kardex interventions, as well as all facility fall related policies. DCS/Designee re-educated staff on Abuse, Neglect, Exploitation Policy. DCS/Designee re-educated staff on Residents' Rights. DCS/Designee re-educated staff on Accidents and Supervision Policy. DCS/Designee re-educated staff on Recognizing & Reporting Hazards. DCS/Designee re-educated staff on Redirecting Residents with Cognitive Deficits from Environmental Hazards DCS/Designee re-educated staff on securing hazardous areas until plant ops clears, ensuring no harm. The Director of Clinical Services/designee to conduct quality monitoring of new admission fall risk evaluation completion to ensure that risk factors, safety measures, and resident specific interventions are reflected on the care plan and Kardex five times weekly x 8 weeks, three times weekly x 2 weeks; twice weekly x 2 weeks, then weekly and PRN (as needed) as indicated. A Performance Improvement Plan (PIP) has been initiated to report on the above monitoring and auditing procedures. All finding from the PIP will be presented at the monthly Quality Assessment & Assurance (QAA) meeting. Monitoring/auditing and reporting will continue for a minimum of three months. 4. NHA/Plant Ops/Designee will round to ensure facility is free of hazards daily X 7 days, then daily X 5 days, then twice weekly x 8 weeks; then weekly and PRN as indicated. DON/designee will review all falls at the clinical meeting with the IDT (interdisciplinary) daily X 5 (Business Days) for 4 weeks to ensure appropriate fall interventions are implemented, the resident's care plan has been reviewed and revised, and the Kardex has been update; then 3 x weekly X 4, then twice weekly x 4, then weekly x 4, then monthly x 3; and PRN as indicated. Regional DCS will review falls weekly for three months to ensure a RCA (root cause analysis) has been conducted and that resident specific interventions are reflected in the care plan as well as updated on the Kardex. These audits will be submitted to the Quality Assurance Performance Improvement (QAPI) Committee by the assigned auditors for three months. Verification of the facility's removal plan was conducted by the survey team on 2/28/25. On 2/28/25 observations were made to ensure the facility repaired the concrete area in the 200-hall to include level tiles and repaired the area at the end of the 200-hall to ensure the tiled area was level. The facility removed the carpet on the 400-ramp and replaced it with two pieces of rolled carpet. The facility educated 99% of their staff on notifying supervisors of accident hazards and to notify other management if the hazard was not repaired. Interviews were conducted with 77 staff members, which included the NHA, the DOM, 13 licensed nurses, 17 CNAs, and 45 other staff members across all shifts. The staff members were able to state that they had been trained and were knowledgeable about the new procedures. Interview with the NHA on 2/28/25 revealed a couple of the staff were not reachable, but a system was put into place for education prior to their next working day. Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on 2/28/25 and the non-compliance was reduced to a scope and severity of D.

Cross Reference F689 Based on observations, interviews and record reviews, the facility failed to provide a safe environment, free from flooring hazards for staff, the public, and 19 ambulatory residents in the facility's secure memory care unit. One (Resident #6) of the 19 ambulatory residents fell on [DATE], sustained a fracture to the right femoral head (top of thigh bone), required a transfer to a higher level of care, and surgical intervention due to a floor repair that was not completed by the facility. The injuries to Resident #6 caused a significant decline in her ability to ambulate and complete activities of daily living (ADLs) at her prior functional level. The facility's failure to maintain a safe walking environment caused serious injury and harm to Resident #6 and placed 18 additional ambulatory memory care residents, staff, and visitors at risk for serious injury, harm, and/or death. This failure resulted in the determination of Immediate Jeopardy on 1/20/25. The findings of Immediate Jeopardy were determined to be removed on 2/28/25 and the severity and scope was reduced to a D. Findings included: A review of an electronic work order created on 12/18/24 at 6:31 p.m. by Staff G, Licensed Practical Nurse (LPN) revealed clean out cover missing, location 200 hallway, priority level medium, and a note/comment to repair drain on 200 hallway asap [as soon as possible]. The status of the order was updated by the Director of Maintenance (DOM) on 12/27/24 at 2:49 p.m. as Set to Completed. A Room Audit Form, for Project Clean OUT 200 Hall with a start date of 12/18/24 revealed daily notes monitoring the clean out cover area from 12/18/24 to 1/24/25 documented by the DOM. The first entry on the log, dated 12/18/2024, showed the (DOM) placed a metal sheet cover over the drain opening with tape. The entry on 12/27/24, the day the work order status was updated, showed a visual inspection was done in the morning and fresh tape was applied that evening. None of the entries between 12/18/24 and 12/27/24 showed any additional work outside of visual inspection and applications of fresh tape was completed. A review of the audit log revealed no documentation to show the area was visually inspected to ensure safety of residents, staff, and visitors on 12/21/24, 12/22/24, 12/25/24, 12/28/24, 12/29/24, 12/31/24, 1/4/25, 1/5/25, 1/10/25, 1/11/25, 1/12/25, 1/15/25, 1/16/25, 1/22/25, and 1/23/25. The log showed on 1/20/25 morning - Resident [#6] fall, fresh tape -plumber called -Received Quote & Sent. The log showed on 1/24/25 evening - Job completed. A review of an email dated 2/25/25 confirmed the plumbing company had completed a repair of the area on the 200 hall on 1/24/25, 4 days after Resident #6 fell and 37 days after the original work order was created. During a facility tour on 2/24/25 at 10:30 a.m. an area of rough and uneven concrete approximately 3ft (feet) x 2 ft in the middle of the corridor of the 200-hall located inside the memory care unit. The uneven concrete area had a drain cap located near the middle that was raised. The concrete area was a known high-traffic area, outside of the secured memory care dining room, the nurses' station, and just outside of Resident #6's room. A review of Resident #6's admission record revealed the resident was [AGE] years old, originally admitted to the facility on [DATE], with a recent hospital stay from 1/20/25 to 1/26/25. The record showed diagnoses to include a displaced fracture of base of neck of right femur subsequent encounter for closed fracture with routine healing, aftercare following joint replacement surgery, difficulty in walking, presence of right artificial hip joint, and dementia and other diseases classified elsewhere unspecified severity with agitation. A review of the Situation, Background, Appearance, and Review (SBAR) evaluation for Resident #6, dated 1/20/25, showed the resident tripped and fell in the hallway, complaining of lower back and right leg pain. The evaluation revealed new pain in the right thigh, lower back and right leg with an intensity score of 9 of 10. The documentation revealed the resident was left in place due to pain on movement, and the primary physician placed an order to send the resident to the emergency room (ER) for evaluation on 1/20/25 at 8:40 a.m. An interview on 2/25/25 at 1:34 p.m. with Staff C, Certified Nursing Assistant (CNA) revealed she witnessed Resident #6's incident on 1/20/25. Staff C, CNA reported Resident #6 was in the hallway with her Family Member (FM). The resident was attempting to detach herself from tape on the floor in the unrepaired plumbing area that was covered with concrete. The staff member stated the tape was not holding anything down. Staff C saw Resident #6 lose her balance and fall. Review of a written statement by Staff C, CNA dated 1/20/25 at 8:30 a.m. showed Staff C was coming down the hall with a breakfast tray and witnessed Resident #6 trip and fall over an area on the floor. The tape was coming up and Resident #6's foot got caught on it. A review of Resident #6's hospital History and Physical Report, dated 1/20/25 at 12:59 p.m. revealed This is a [AGE] year-old female with medical history of dementia, dyslipidemia, COPD [chronic obstructive pulmonary disease], nursing home resident, presented to hospital for [sic] facility after a fall. Patient was found on the ground and complaining of right hip pain, patient's baseline is confused, only be able to recognize her [FM], but nobody else, be able to eat by herself. When I saw the patient, her [FM] at bedside, provided all the history. The completed radiology imaging studies, on 1/20/25 at 10:44 a.m. showed a right femoral neck fracture. The Computed Tomography Scan (CT) of the pelvis without contrast, on 1/20/25 at 10:04 a.m., revealed impacted right femoral neck fracture with angulation and mild displacement. The X-ray results of the right femur and right hip with pelvis showed normal mineralization. A review of a hospital consultation note dated 1/20/25 at 6:04 p.m. showed the resident was complaining of right hip pain and the physical examination showed the right lower extremity was shortened and externally rotated. The assessment/plan showed resident would benefit from operative intervention of the right hip in order to provide stability to the fracture and promote satisfactory healing, to improve pain, to facilitate early motion and mobilization and to prevent complications associated with prolonged bedrest. The risks, benefits, complications, and alternatives treatments were explained to the patient and FM. This included the possibilities of infection, deep vein thrombosis, reaction to anesthesia, neurovascular compromise, death or dying on the table, incomplete relief of symptoms, and chronic pain or stiffness. A review of the operative report on 1/21/25 at 9:08 a.m., showed Resident #6 had undergone a right hip hemiarthroplasty. The post-operative X-ray results showed the prosthesis was well-seated with no evidence of hardware loosening or failure. A review of the hospital Physical Therapy (PT) evaluation dated 1/22/25 at 9:38 a.m., revealed the FM had reported a prior functioning of being able to mobilize with a walker. The PT assessment showed Impairments/Limitations: Ambulation deficits, Bed mobility deficits, Cognitive deficits, Range of motion deficits, Safety awareness deficits, Transfer deficits, Transition deficits Barriers to Safe Discharge: Insight into deficits, Needs Assist for Mobility, Needs Assist for Transfer, Safety awareness Summary of Findings: Pt. [patient] very confused, unable to follow commands, dep[endent] for all mobility. A review of a facility note dated 1/26/25 at 5:30 p.m., showed Resident #6 returned to the facility from the hospital following a right hip hemiarthroplasty. The record showed the resident was in pain whenever touched. The resident had a surgical wound on right thigh and staff recommended rehab unit for the resident. During an interview on 2/25/25 at 2:15 p.m., the Director of Nursing (DON) stated Resident #6 had been ambulating in the hallway with a family member and her foot kind of got stuck on tape. The DON reported the FM grabbed the resident had pulled her, then the resident lost her balance and fell . The DON stated the resident had a history of osteopenia and because of right hip pain the resident was left on floor. The DON stated she interviewed Staff B/CNA, Staff C/CNA, and Staff E, Licensed Practical Nurse (LPN). The DON stated Staff E, LPN was sitting at the desk and did not witness the fall, but heard the resident call out and saw her lying on the right side. The DON confirmed Resident #6 suffered a fall, was transferred out to the hospital, had surgery and came back to the facility. The DON stated Resident #6 had suffered a previous fall on 10/25/24. She stated the resident had a big chair in her room at the time so the family decluttered the room and when the resident started ambulating, the facility ensured the environment was free of clutter and slip hazards to prevent additional falls. On 2/25/25 at 9:45 a.m., an interview was conducted with the DOM. He stated on 200-hall, the memory care unit, a resident had pulled the clean-out cap off, on 12/18/24. The DOM reported roping the area off and cutting a metal piece to fit on top of the missing cap. He stated this was done after Resident #6 had fallen. The DOM stated the facility had plumbers come in on 1/24/25. The DOM stated from 12/18/24 to 1/24/25, he had put several patches on the area, and went back every day to make sure it was secure and safe. The DOM reported the plumbers removed the tile all the way around the clean out cap, leaving a cemented patch. On 2/25/25 at 10:46 a.m., the DOM observed the 200 hall and showed the area where Resident #6 had fallen in the hallway. The area was near the nursing station in the 200-hall and just outside of Resident 6's room at that time of the 1/20/25 incident. The DOM observed an additional area of missing floor tiles on the 200 hall and stated the facility had just received the diamond blades to smooth out the concrete. He stated the plumbers had to remove the tiles to fix a plumbing issue. During the time of this interview, the DOM confirmed the area where Resident #6 had fallen was still uneven due to the concrete patch left by the plumbers on 1/24/25. An interview was conducted on 2/26/25 at 12:00 p.m. with Staff J, Licensed Practical Nurse/Unit Manager (LPN/UM). The staff member described the area of concrete as similar to other drains on unit, showing a circular drain with a square metal outer plate. Staff J, LPN/UM stated the residents on the unit like to pick at it and had pulled the square metal plate up. Staff J, LPN/UM stated maintenance had covered the area with a metal square that was approximately the same size as the missing plate and secured it to the floor with yellow and black striped industrial tape so it would be recognized as a caution area. Staff J, LPN/UM stated she doubted the residents in the memory care unit would have recognized the tape as a caution area. The staff member stated the concrete area was a high-traffic area as it was between the dining room, Resident #6's room, and the nursing station on the memory care unit. Staff J, LPN/UM stated they had a lot of residents wandering up and down the hallways due to dementia on the unit. Staff J, LPN/UM said she could only report it to maintenance, and then it was out of her hands. Staff J, LPN/UM stated the metal and tape was a hazard, and during the repair period, the area had become larger in size. A follow-up interview on 2/26/25 beginning at 3:05 p.m. with the DOM revealed the rough concrete patch observed during the survey beginning on 2/24/25 was part of the repair. The DOM stated he had to research a replacement cap since the missing cover was so old. The DOM stated the plumber did not have a cap to fit the cast iron piping, so the plumber had to make the hole bigger and cut pipe to fix it. The DOM revealed this repair happened in the middle of January. The DOM stated he had put a metal plate on the area trying to save the company money in December 2024. The DOM reported he was researching it to try to fix it himself before calling the plumbers in, but after Resident #6's fall, he was done searching for the replacement and decided to get plumbers in. The DOM stated he felt the location where Resident #6 fell was safe and felt the [brand name] tape was a good tape to use as a temporary fix. The DOM reported the diamond grinding wheel, needed to smooth out concrete, had been back ordered and came in last week. The DOM said he had looked at local merchants for the grinding wheel, but they did not have the size needed in stock. The DOM stated the diamond wheel was delivered on 2/14/25, the day before he went on vacation. Review of the online merchant's receipt for the 4.5-inch diamond concrete grinding wheel showed the order was placed on 1/27/25 and shipped on 1/27/25. At the time of this interview, the area where Resident #6 fell was still not fully repaired leaving a rough and uneven flooring surface in this high traffic area. On 2/27/25 at 2:04 p.m., the Regional DOM reported not being aware of the flooring issue. The Regional DOM stated depending on severity, if something could not be handled in-house the facility contacted vendors for repairs. The Regional DOM expected something to be implemented promptly, within one to two weeks for the safety of the residents. On 2/24/25 at 10:18 a.m., a second area in hall 200 towards the front of the facility, near the janitor supply closet #3 was observed with 12 missing tiles. The area was in the walking path of residents in the memory care unit. The area had a raised drain with a cap near the middle of it. An immediate interview was conducted with Staff B, Certified Nursing Assistant (CNA) who confirmed the area had been in disrepair for a long time and estimated it to be approximately 6 to 8 months. A review of a work order dated 12/3/24 at 2:24 p.m. showed Staff J, LPN/UM reported missing tile on the floor of the 200 hallway with a medium priority level. The work order was acknowledged by the DOM on 12/27/24 at 3:30 p.m. with a status of Set to-In-Progress. The work order was updated on 2/26/25 at 2:17 p.m. by the DOM with a status of Set to completed. On 2/24/25 at 10:38 a.m., the entrance ramp to the 400-hall was observed missing five full carpet squares (approximately 2 ft x 2 ft) and 5 half carpet squares leaving exposed concrete with a raised drain that was not level to the concrete, and the carpet that remained was not level with the concrete. A yellow traffic cone was placed in the corner from the hallway to the ramp. This area was the inside entrance for residents, staff and visitors to access the 400-hall and used frequently by residents with ambulation devices and wheelchairs. During a facility tour of the 200 hall on 02/27/2025 at 2:21 p.m. with the Nursing Home Administrator (NHA), revealed tiles that were popping up on the edges where the facility had replaced flooring using old tiles. The NHA confirmed the area was a hazard for someone with a shuffling gait. The NHA stated the tiles needed to be put down again and better. The NHA stated her expectation was an immediate fix for any hazard affecting residents. The NHA observed the area where Resident #6 fell and stated she expected the area to be safe for the residents. The NHA stated it was unacceptable to wait to repair the floors. Photographic evidence was obtained. A review of the Maintenance Director's job description signed on 10/24/24 by the DOM revealed: Position Purpose: Directs the day-to-day activities of the maintenance department in accordance with current federal, state, and local standards, guidelines and regulations governing the facility, and to ensure the facility is maintained in a safe and comfortable manner. The major duties and responsibilities included: Plans, develops, organizes, implements, evaluates, and directs the Maintenance Department, its programs and activities. Ensures the facility remains in compliance with all federal, state, and local regulations for life safety code compliance. Reviews the department's policies, procedure manuals, job descriptions, etc., at least annually for revisions and makes recommendations to the Assistant Administrator/Administrator. Prepares operating and staffing budgets for maintenance and monitors monthly. Ensures maintenance staff are properly trained on safety policies and procedures as well as monitors compliance. Ensures proper planning, direction, participation, and supervision of both preventative and unplanned maintenance and repair activities in the facility, which includes painting, plumbing, carpentry, HVAC, and electrical work. Purchases within budgetary responsibilities [sic] the general maintenance tools, supplies and equipment, safety equipment, and trains others in their appropriate use. Ensures that services performed by outside vendors are properly completed/supervised in accordance with contracts/work orders . Ensures facility's compliance with multiple OSHA standards . Develops and implements preventative maintenance tasks, document instructions and procedures for the preventative maintenance of facility and utility components and office equipment, as well as, mechanical, air conditioning, heating, and electrical systems, etc. Schedules department work hours (including vacation and holiday schedules), personnel, work assignments, etc., to expedite work . Ensures the facility's compliance with the law and other regulatory terms such as safety and building codes . Runs, operates, and assesses technical aspects of facility machinery, equipment, and buildings. A review of the Job Description for the Administrator signed on 1/9/24 revealed: Position Purpose: Leads, guides, and directs the operations of the health care facility in accordance with local, state, and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents. The major duties and responsibilities included: Plans, develops, organizes, implements, evaluates and directs the overall operation of the facility as well as its programs and activities, in accordance with current state and federal laws and regulations. Plans, develops, organizes, implements, evaluates, and directs the facility's programs and activities in accordance with guidelines issued by the governing body. Identifies, in conjunction with the Director of Nursing and selected department heads, the facility's key performance indicators. Establishes an ongoing system to monitor these key indicators such as the Quality Assurance and Performance Improvement process throughout the facility . Leads and coordinates daily, weekly, bi-monthly or monthly management team meetings to discuss priorities and develop solutions with facility leaders such as census, collections, clinical health, survey readiness, customer service satisfaction, activity participation, etc . Evaluates work performance of department heads and maintains accountability across all departments in concert with Human Resources for expected performance outcomes in each respective department . Knows and understands .Code of Federal Regulations, Appendix PP State Operations Manual .Life Safety Code regulations .and all other regulatory entities that may apply . Performs rounds to observe residents and ensure overall needs are being met. Knows residents by name and sight. Practices management by walking around. Makes himself/herself available to employees at all levels by practicing an open-door policy. A review of the policy titled, Safe and Homelike Environment, implemented 9/1/23, revealed: In accordance with resident's rights, the facility will provide a safe, clean, comfortable, and home like environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Definitions included: Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas, and activity areas; Orderly is defined as an uncluttered physical environment that is neat and well-kept. Policy explanation and compliance guidelines: Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. General Considerations: Report any unresolved environmental concerns to the Administrator. A review of the facility's immediate actions to remove the Immediate Jeopardy included: 1. Immediate Action: NHA and Plant Operations Director performed environmental rounds on 2/26/2025, identified areas of concern noted and reported in the electronic maintenance records system. Work orders started in order of priority for hazards causing uneven surfaces, fall risk hazards, and items with potential to risk resident safety. Summoned Corporate Plant Operations support team for assistance on 2/26/2025 Initiated repairs of identified areas of concern on 2/26/2025 Tiles in high traffic area of secure unit (200 Hall, outside room [ROOM NUMBER]) repaired on 2/26/2025, part of repaired tiles began to shift, tiles replaced again on 2/27/2025. Tiles in high traffic area of secure unit (200 Hall, outside room [ROOM NUMBER]) repaired on 2/26/2025 400 Hall ramp missing carpet tiles replaced on 2/26/2025, carpet tile surface continues to be uneven, all carpet tiles were removed from ramp and replaced with one solid carpet piece. On 2/27/2025 surveyors and NHA completed environmental rounds of the facility noting areas of continued concern. List compiled of concerns from environmental tour, all items entered in the electronic maintenance records system. 300 Hall clean out with uneven surface repaired. 99.5% of all facility staff were educated by 9:00 a.m. on 2/28/2025. Initiated and assigned direct care staff member as Hallway Safety Monitor on secure unit (200 Hall) for additional supervision. Hallway Safety Monitor will be assigned 24 hours a day X 7 days to establish a pattern of ambulatory residents. When pattern is established, Hallway Safety Monitor will be staffed from 0700 to 2300 daily X 14 days. Then, as pattern is further established, Hallway Safety Monitor will be staffed 12 hours daily X 30 days. Hallway Safety Monitor staffing hours will be adjusted as indicated. 2. Identification of others at risk was accomplished by: Quality review completed for monitoring of environmental hazards with a focus on uneven surfaces and fall hazards. NHA/Designee rounded facility to survey for environmental hazards. Identified environmental concerns reported via electronic maintenance records system, addressed by priority level, and repairs initiated and will be ongoing 3. Actions to Prevent Occurrence/Recurrence: NHA, DCS (Director of Clinical Services), and Plant Operations/Maintenance Director re-educated on ensuring resident environment is free of hazards with emphasis on timely completion. DCS/Designee re-educated staff on Accidents and Supervision Policy. DCS/Designee re-educated staff on Recognizing & Reporting Hazards. DCS/Designee re-educated staff on Redirecting Residents with Cognitive Deficits from Environmental Hazards. DCS/Designee re-educated staff on securing hazardous areas until plant ops clears, ensuring no harm. Initiation and Assignment of direct care staff member as Hallway Safety Monitor for secure unit (200 Hall) for additional supervision and hazard identification. A Performance Improvement Plan (PIP) has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly Quality Assessment & Assurance (QAA) meeting. Monitoring/auditing and reporting will continue for a minimum of three months or until substantial compliance is determined. 4. NHA/Plant Ops/Designee will round to ensure facility is free of hazards daily X 7 days, then daily X 5 days, then twice weekly x 8 weeks; then weekly and PRN (as needed) as indicated. These audits will be submitted to the Quality Assurance Performance Improvement (QAPI) Committee by the assigned auditors for three months. Verification of the facility's removal plan was conducted by the survey team on 2/28/25. On 2/28/25 observations were made to ensure the facility repaired the concrete area in the 200-hall to include level tiles and repaired the area at the end of the 200-hall to ensure the tiled area was level. The facility removed the carpet on the 400-ramp and replaced it with two pieces of rolled carpet. The facility educated 99% of their staff on notifying supervisors of accident hazards and to notify other management if the hazard was not repaired. Interviews were conducted with 77 staff members, which included the NHA, the DOM, 13 licensed nurses, 17 CNAs, and 45 other staff members across all shifts. The staff members were able to state that they had been trained and were knowledgeable about the new procedures. Interview with the NHA on 2/28/25 revealed a couple of the staff were not reachable, but a system was put into place for education prior to their next working day. Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on 2/28/25 and the non-compliance was reduced to a scope and severity of D.

Based on observation of videos posted on social media platforms without consent, review of resident records, policy and procedures review, and staff, family and resident interviews, the facility did not ensure personal privacy and confidentiality for ten of sixteen sampled residents (#7, #8, #9, #10, #11, #12, #13, #14, #15, and #16). Findings Included: Review and observation of videos posted on social media platforms on 8/8/24, 10/2/24, 10/8/24, 12/2/24, and additional dates that could not be determined showed Resident #7, #8, #9, #10, #11, #12, #13, #14, #15, and #16 dancing or in the background of the videos, which also contained various staff members. These videos were recorded in various locations within the facility to include the secure memory care unit and hallways with room numbers where residents resided. Review of the social media videos showed they were originally posted by Staff I, Admissions Coordinator and had been reposted and edited by an unknown number of users on social media. Multiple videos were shown to share the first name of Resident #10 by Staff I, Admissions Coordinator, which was then included into other videos posted by unknown users across various social media platforms. A web browser search using Staff I's social media username showed videos containing Resident #10 with over 406,600 views, 70,600 likes, and 2,456 comments. The original videos were found to be removed; however, they could still be viewed under the search engine preview using Staff I's social media username. Review of the admission record for Resident #10 revealed she had resided in the facility since 2023 and lived in the secure memory care unit during the period the videos were posted. Resident #10's admission record included diagnoses of mood disorder due to known physiological condition with mixed features, dementia in other disease classified elsewhere-severe with mood disturbance, brief psychotic disorder, major depressive disorder - recurrent severe with psychotic symptoms, and anxiety disorder. Review of the annual minimum data set (MDS) assessment completed on 9/28/24 showed a brief interview of mental status score (BIMS) score of 3, indicating severe cognitive impairment. The quarterly MDS completed 12/28/24 also showed a BIMS indicating severe cognitive impairment. A phone interview was conducted with Resident #10's Family Member (FM) on 2/25/2025 at 2:31 p.m. The FM stated she was informed by facility administration around a week and a half ago about videos on [name of social media platform]. The FM reported receiving a call from an unknown nurse a week prior to that, telling her about the videos. The FM stated she would not have consented to Resident #10 being posted on social media and stated, absolutely not. Review of the admission record for Resident #8 revealed she had resided in the facility since 2023 and lived in the secure unit during the period the videos were posted. Resident #8's diagnoses included major depressive disorder -recurrent/moderate, mood disorder due to known physiological condition with mixed features, depression, anxiety disorder, adult failure to thrive, unspecified dementia -unspecified severity, with other behavioral disturbance, and altered mental status. Review of the quarterly MDS assessment completed on 12/27/24 showed a BIMS score of 00, indicating severe cognitive impairment. A phone interview was conducted with Resident #8's FM on 2/25/2025 at 2:19 p.m. She stated she was notified this week of videos being posted on social media, but did not know what social media pages. She was told it was just dancing. She stated no one had contacted her for consent prior to the posting of videos on social media. Review of the admission record for Resident #14 revealed he had resided in the facility since 2022 and lived in the secure unit during the period the videos were posted. Resident #8's diagnoses included metabolic encephalopathy, generalized anxiety disorder, unspecified protein calorie malnutrition, mood disorder due to known physiological condition, and dementia in other diseases classified elsewhere with psychotic disturbance. A determination of incapacity form was signed by the physician on 9/6/2024. Review of the quarterly MDS assessments completed on 10/8/24 and 1/8/2025 showed a BIMS score of 00, indicating severe cognitive impairment. A phone interview was conducted with Resident #14's Health Care Surrogate (HCS) on 2/25/2025 at 12:54 p.m. The HCS stated Resident #14 was unable to give consent due to Dementia and he did not give consent nor was he asked to provide consent for Resident #14 to be posted on social media. He stated he was called this week and told that the videos were on the facility's social media page. He was not told the videos were posted on social media platforms and said he would not have given consent for that. Review of the admission record for Resident #13 revealed she had resided in the facility since September of 2024 and lived in the secure unit when the videos were posted. Resident #13's diagnoses included unspecified dementia, psychotic disturbance, mood disturbance, and anxiety. A physician attestation of incapacity form dated 6/21/24 showed the resident was cognitively unable to communicate a willful and knowing health decision. Review of a quarterly MDS, dated [DATE] showed the resident had short term and long term memory problems and moderately impaired decision making skills. A phone interview was conducted with Resident #13's FM on 2/25/2025 at 1:16 p.m. The FM stated the resident was lucid enough to discuss this matter with. An interview was conducted with Resident #13 on 2/25/2025 at 1:43 p.m. She stated she had not been asked about being on social media postings and did not want to be included on postings. The resident said there was too much information out there, and she wanted to lay low. Review of the admission record for Resident #7 revealed she had resided in the facility on the secured unit since early 2024. Resident #7's diagnoses included unspecified dementia, mood disorder, anxiety disorder, brief psychotic disorder, and major depressive disorder. An incapacity statement was signed by the physician on 4/5/2024, which showed the resident was incapable of exercising her rights to consent to medical and mental health treatment, to contract, and to make decisions about her social environment or other social aspects of her life. Resident #7's record showed indicated a court appointed guardian was in place. Review of an annual MDS assessment dated [DATE] showed a BIMS score of 00, indicating severe cognitive impairment. Review of Resident #7's record revealed no documentation that her legal guardian consented to the posting of the resident on social media. Review of the admission record for Resident #12 revealed he had resided in the facility's secured unit since October 2024 with diagnoses to include cognitive communication deficit and major depressive disorder, A physician attestation of incapacity form dated 1/10/2025 showed the resident was cognitively unable to communicate a willful and knowing health decision. A significant change MDS assessment was completed 12/16/2024 with a BIMS score of 3, indicating severe cognitive impairment. A phone interview was conducted with Resident #12's FM on 2/25/2025 at 2:48 p.m The family member stated that did not consent to posting videos of the resident on social media. The FM reported she would have expected to be asked for consent prior to any postings on social media. Review of the admission record for Resident #15 revealed she had resided in the facility's secured unit since 2023 with diagnoses to include unspecified dementia with behavioral disturbance, mood disorder, major depressive disorder, and anxiety. A physician attestation of incapacity form dated 8/6/23 showed the resident was cognitively unable to communicate a willful and knowing health decision. Review of the last two quarterly MDS assessments completed 10/12/24 and 1/12/25 showed a BIMS score of 0, indicating severe cognitive impairment. Review of Resident #15's record revealed no documentation of consent for social media video postings. Interview with Resident #15's FM on 2/26/2025 at 11:40 a.m. confirmed he did not provide consent but did not express concerns. Review of the admission record for Resident #9 revealed she was a long term resident of the facility since 2022 and resided on the secured unit at the time of the social media postings. Resident #9's diagnoses included unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance , and anxiety. A significant change MDS was completed on 11/24/2024 with a BIMS score of 00, indicating severe cognitive impairment. Review of Resident #9's record revealed no documentation of consent for social media video postings. A call was placed to Resident #9's FM on 02/25/2025 at 1:48 p.m. with no answer received. A voicemail was left, but no return call was received. Review of the admission record for Resident #16 revealed she resided in the facility's secured unit since 2023 with diagnoses to include dementia, psychotic disturbance, mood disorder, mood disturbance and anxiety. A physician attestation of incapacity form dated 1/13/2025 showed the resident was cognitively unable to communicate a willful and knowing health decision. A quarterly MDS assessment was completed 1/23/25 with a BIMS score of 10, indicating moderate cognitive impairment. Review of Resident #16's record revealed no documentation of consent for social media video postings. Review of the admission record for Resident #11 revealed he resided in the facility's secured unit since 2023 with diagnoses to include unspecified dementia without behavioral disturbance, major depressive disorder, psychotic disturbance, mood disorder, mood disturbance and anxiety. A physician attestation of incapacity form dated 3/18/2022 showed the resident was cognitively unable to communicate a willful and knowing health decision. A quarterly MDS assessment was completed 2/1/2025 with a BIMS score of 6, indicating severe cognitive impairment. Review of Resident #11's record revealed no documentation of consent for social media video postings. An interview was conducted with the Nursing Home Administrator (NHA) and Regional Nurse Consultant (RNC) on 2/24/2025 at 12:50 p.m. The RNC stated she saw a sports reel come across her social media webpage a couple of weeks ago and recognized the facility and Staff I, Admissions Coordinator. The RNC reported informing the NHA. The NHA stated she found videos of the residents posted on a social media platform by Staff I, Admissions Coordinator. The NHA identified Resident #8 and Resident #10 in the videos. The NHA had no knowledge of these videos being posted, and no staff had informed her. The NHA reported staff may have thought Staff I, Admissions Coordinator was filming for activities. The NHA was unaware of other residents posted on social media sites until identified on 2/24/2025. The NHA stated Staff I was suspended and would be terminated on 2/24/2025. Review of the facility's policy titled Social Media Use, implemented 9/1/23 and revised 9/1/24 showed: It is the policy of this company to avoid inappropriate use of social media and to protect the residents, staff, visitors, volunteers and practitioners of this facility against misuse of social media content. Taking, keeping, or distributing unauthorized photographs or recordings of residents through multimedia messages or on social media networks is a violation of a resident's right to privacy and confidentiality. Staff members must recognize that they have an ethical and legal obligation to maintain resident privacy and confidentiality at all times. Policy Explanation and Compliance guidelines: 1. Employees are strictly prohibited from transmitting by way of any electronic media any resident-related image or information that may be reasonably anticipated to violate resident rights to confidentiality or privacy. This includes information that could degrade or embarrass the resident. 2. Photographs or recordings of a resident and/or his or her private space without the residents' or designated representatives; written consent, is prohibited. Examples include taking unauthorized photographs/videos of: a. A resident's room or furnishings (which may or may not include the resident). b. A resident eating in the dining room. c. A resident participating in an activity in the common area. d. Taking unauthorized photographs or recordings of residents in any state of dress or undress using any type of equipment. 3. Employees will not post or share posts that would disseminate any personal or medical record information regarding a resident. This would include medical, social, fund accounts, automated electronic or other types of personal resident information, as well as gender identity and sexual orientation. 4. Employees will maintain professional boundaries in the use of social media. 5. Employees are not to share company data or information on social media. 6. Employees will refrain from making offensive remarks on social media about their employer, coworkers, visitors, volunteers or practitioners. This includes making threats, harassing, and using profane, obscene, sexually explicit, racially derogatory, or homophobic comments. 7. Employees will not post content or otherwise speak on behalf of the employer unless authorized to do so. Any employee who violates this policy may be subject to disciplinary action, up to and including termination. Video and photographic evidence was obtained.

Based on interview and policy review the facility failed to ensure an allegations of neglect were reported related to a fall with major injury due to the facility's failure to ensure a safe environment, free from flooring hazards for one resident (#6) of 19 ambulatory residents in the facility's memory care unit. Findings included: Review of a progress note dated 1/20/25 at 12:43 p.m. revealed the resident had an unwitnessed fall in the hallway this A.M. Resident (#6) was observed lying on right side and crying out in pain to lower back and right leg. On 1/20/25 Resident #6 was ambulating in the hallway outside her room and suffered a fall significantly impairing the ability to walk and complete Activity of Daily Living (ADLs) independently. Resident #6 suffered a significant change due to a fractured right femoral head fracture requiring a surgical intervention. The fall which could have resulted in death, caused Resident #6 permanent physical impairment. Review of the Reportable Event Log, dated 1/2024, revealed events on 1/12/25 and 1/24/25 however neither of the reported incidents included Resident #6's fall with a major injury. During an interview with the Director of Nursing (DON) on 2/25/25 at 2:15 p.m., the DON stated they did not report the incident because Resident #6's fall was not an adverse as the plan of care was followed. She reported the resident who had dementia, was alert and confused, had poor safety awareness, was a long-term care resident residing in the memory care unit. Review of Resident #6's care plan initiated on 8/21/2024 showed a Focus -Resident #6 was at risk for falls related to history of falls, poor safety awareness, incontinence, dementia, psychotropic medication use and neuropathy. An intervention initiated on 8/21/24 showed to Ensure resident has a safe environment: (specify: even floors free from spills and/or clutter; adequate, glare- free light; a working and reachable call light, the bed in low position; hand rails on walls, personal items within reach). Review of Resident #6's admission record revealed the resident was [AGE] years old, originally admitted to the facility on [DATE], with a recent hospital stay from 1/20/25 to 1/26/25. The record showed diagnoses to include a displaced fracture of base of neck of right femur subsequent encounter for closed fracture with routine healing, aftercare following joint replacement surgery, difficulty in walking, presence of right artificial hip joint, and dementia and other diseases classified elsewhere unspecified severity with agitation. A review of the Situation, Background, Appearance, and Review (SBAR) evaluation for Resident #6, dated 1/20/25, showed the resident tripped and fell in the hallway, complaining of lower back and right leg pain. The evaluation revealed new pain in the right thigh, lower back and right leg with an intensity score of 9 of 10. The documentation revealed the resident was left in place due to pain on movement, and the primary physician placed an order to send the resident to the emergency room (ER) for evaluation on 1/20/25 at 8:40 a.m. An interview was conducted on 2/27/25 at 9:57 a.m. with Staff E, Licensed Practical Nurse, (LPN). Staff E stated she did not see the resident fall but heard her scream. She stated the resident had suffered a change, she does no walk anymore, does a lot more crying, doesn't eat as much as she used to. Review of the operative report for Resident #6 on 1/21/25 at 9:08 a.m., showed Resident #6 had undergone a right hip hemiarthroplasty. The post-operative X-ray results showed the prosthesis was well-seated with no evidence of hardware loosening or failure. During a facility tour on 2/24/25 at 10:30 a.m. an area of rough and uneven concrete approximately 3ft (feet) x 2 ft in the middle of the corridor of the 200-hall located inside the memory care unit. The uneven concrete area had a drain cap located near the middle that was raised. The concrete area was a known high-traffic area, outside of the secured memory care dining room, the nurses' station, and just outside of Resident #6's room. Review of the Completed Work Order #13601 showed it was created on 12/18/24 at 6:31 p.m. for a 200-hallway clean out cover missing. The order asked, please repair as soon as possible (asap). Please repair drain on 200 hallway asap. The update status on 12/27/24 at 2:49 p.m. showed the Director of Maintenance (DOM) had noted the area set to completed. On 2/25/25 at 9:45 a.m. an interview was conducted with the DOM. He stated on 200-hall, the memory care unit, a resident had pulled the clean-out cap off on 12/18/24. The DOM reported roping the area off and cutting a metal piece to fit on top of the missing cap. He stated this was done after Resident #6 had fallen. The DOM stated the facility had plumbers come in on 1/24/25. The DOM stated from 12/18/24 to 1/24/25, he had put several patches on the area, and went back every day to make sure it was secure and safe. The plumbers removed the tile all the way around the clean out cap, leaving a cemented patch. On 2/27/25 at 2:04 p.m., the Regional DOM reported not being aware of the flooring issue. The Regional DOM stated depending on severity, if something could not be handled in-house the facility contacted vendors for repairs. The Regional DOM expected something to be implemented promptly, within one to two weeks for the safety of the residents. An interview was conducted with the Director of Nursing (DON) on 2/25/25 at 2:15 p.m. She stated Resident #6 had been ambulating in the hallway with a family member (FM) and her foot kind of got stuck on tape. The DON reported the FM grabbed the resident had pulled her, then the resident lost her balance and fell . The DON stated the resident had a history of osteopenia and because of right hip pain the resident was left on floor. The DON stated she interviewed Staff B/CNA, Staff C/CNA, and Staff E, Licensed Practical Nurse (LPN). The DON stated Staff E, LPN was sitting at the desk and did not witness the fall, but heard the resident call out and saw her lying on the right side. The DON confirmed Resident #6 suffered a fall, was transferred out to the hospital, had surgery and came back to the facility. The DON stated Resident #6 had suffered a previous fall on 10/25/24. She stated the resident had a big chair in her room at the time so the family decluttered the room and when the resident started ambulating, the facility ensured the environment was free of clutter and slip hazards to prevent additional falls. An interview was conducted on 2/26/25 at 12:00 p.m. with Staff J, Licensed Practical Nurse/Unit Manager (LPN/UM). The staff member described the area of concrete as similar to other drains on unit, showing a circular drain with a square metal outer plate. The staff member stated the residents on the unit like to pick at it and had pulled the square metal plate up. Staff J stated the facility had covered the area with an approximately same size metal square and had attached it to floor with yellow and black striped industrial tape so it would be recognized as a caution area. Staff J stated she doubted the residents in the memory care unit, with their BIMS (Brief Interview for Mental Status) scores, would have recognized it as a caution area. The staff member stated the concrete area was a high-traffic area as it was between the dining room, Resident #6's room, and the nursing station. She stated due to it being a dementia unit, they had a lot of residents wandering up and down the hallways. She stated she could only report it to maintenance. Staff J stated the metal and tape were a hazard, and during the repair period the area had become bigger. An interview was conducted on 2/26/25 at 9:38 a.m. with the DON. She reported the findings of the Root Cause Analysis was the resident was ambulating in the hallway, she twisted, the family member took her arm, and her foot was caught on tape, causing the resident to fall. The DON stated she was not sure why the tape was on the floor. On 2/28/25 at 2:55 p.m. an interview was conducted with the NHA. She stated she did a QAPI (Quality Assurance Performance Improvement) on 1/25/25 for December 2024. The NHA reported they initiated a PIP (Plan in Place) on 12/20/24 due to there were 41 falls in December 2024, and one fall with fracture. She stated she did not do QA (Quality analysis) on it. Review of the Job Description for the Administrator, signed on 1/9/24 showed the Position Purpose was Leads, guides, and directs the operations of the health care facility in accordance with local, state, and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents. The Major Duties and Responsibilities included: Ensures resident incidents and concerns that rise to a reportable event such as alleged abuse neglect, mistreatment, misappropriation, etc. (etcetera) are reported to the correct entity within the stated regulatory requirement. Review of the job description of Director of Nursing, signed by the DON on 10/25/24. The description showed the DON was to participate in daily or weekly management team meetings to discuss census changes, resident changes in status, complaints, or concerns. The description included: Monitors for allegations of potential abuse or neglect, or misappropriation of resident property, and participates in the investigative process. Review of the policy - Abuse, Neglect, and Exploitation, reviewed 4/2024, revealed It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of the resident property. The policy defined Serious Bodily Injury as an injury involving extreme physical pain; Involving substantial risk of death; Involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; requiring medical interventions such as surgery, hospitalization , or physical rehabilitation; or an injury resulting from criminal sexual abuse. Neglect was defined as failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy revealed the facility will have written procedures that include: reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: (a.) Immediately, but not later than two hours after the allegation is made, if the events that caused the allegation involved abuse or result in a serious bodily injury.

Based on interview and record review the facility failed to ensure documentation was accurate and complete for one (#4) of one resident related to the documentation of a change in condition resulting in cardio-pulmonary resuscitation (CPR) being administered. Findings included: Review of Resident #4's Admission Record revealed the resident was most recently admitted to the facility on [DATE]. The record included diagnoses of idiopathic hypotension, acute respiratory failure with hypoxia, unspecified pulmonary hypertension, paroxysmal atrial fibrillation, unspecified heart failure, and dependence on supplemental oxygen. Review of Resident #4's clinical record showed a Hospital Transfer Form, dated [DATE] at 1:40 p.m. showed the resident was a Full Code. Review of a Situation, Background, Appearance, and Review/Notify (SBAR) assessment dated [DATE] at 9:37 a.m. showed notification to the provider of resident change in condition related to food and/or fluid intake (decreased or unable to eat and/or drink adequate amounts). Review of Resident #4's progress note, dated [DATE] at 1:56 p.m. showed the resident was transferred from one room to another at 1:30 p.m., and the resident was found unresponsive. Emergency Medical Transport (EMT) was called, and the physician and family were notified. An interview was conducted on [DATE] at 3:22 p.m. with the Director of Nursing (DON). The DON reported Resident #4 was transferred on [DATE], and stated the resident had CPR initiated in the facility, and the physician present in the facility assisted. She stated the expectation was for staff to document CPR was initiated and EMT was called in the clinical record. A follow-up interview with the DON on [DATE] at 3:58 p.m. confirmed the clinical record and transfer form did not reveal the resident had received CPR. Review of the policy - Documentation in Medical Record, implemented ,d+[DATE], showed Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. The compliance guidelines included: 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. 3c. Documentation shall be timely and in chronological order.

Based on record review and interview, the facility failed to provide one (Resident #3) of one family-requested medical record in a timely manner. Findings included: Review of Resident #3's medical record showed the resident was admitted on [DATE] with diagnoses not limited to unspecified Alzheimer's disease, unspecified peripheral vascular disease, atherosclerotic heart disease of native coronary artery without angina pectoris, and unspecified edema. An interview was conducted on 6/4/23 at 12:30 p.m. with the Medical Records Director (MRD). The MRD reported only one family member had requested medical records and the request had been made on July 28, 2023. The staff member reported sending the attorneys Resident #3's face sheet and death certificate and did not get a response from them for two or three months. The MRD reported speaking to the Business Office Manager about general matters and had been informed the attorneys had not been getting paid (the facility was sold at the end of June 2023). She stated the new company [name of company] had told her to hold off on legal cases, hold off on sending charts, and to follow company procedures, which was to contact company attorneys. The MRD stated at that time the facility did not have attorneys. The MRD admitted to speaking with Resident #3's family member regarding the medical records but she did not want to just give the family member the records and had informed the family she was waiting for the attorneys. The MRD stated the family member had informed her that the family attorney would request the records but had not heard from the attorney of the family since October 2023. The MRD reviewed the Authorization to Release Protected Health Information, dated July 28, 2023, confirming the request was made approximately 11 months ago. During the continued interview with the MRD on 6/4/23 at 1:05 p.m., the staff member reported the facility did have attorneys and there was no outstanding requests for records. She reported there was one other request from a resident that was requesting from another facility and all others were attorney requests. Review of the Authorization to Release Protected Health Information signed by Resident #3's Power of Attorney on July 28, 2023, showed the family member had requested clinical summaries, lab and diagnostics, and entire medical record. Review of policy, Release of Information, revised November 2009, revealed Our facility maintains the confidentiality of each resident's personal and protected health information. The policy interpretation and implementation showed: 3. All information contained in the resident's medical record is confidential and may only be released by the written consent of the resident or his/her legal representative(sponsor), consistent with state laws and regulations. 7. Closed or thinned medical records are maintained in the Medical Records Department and are available only to authorized personnel. Authorized personnel include, but are not necessarily limited to: a. Nursing Personnel; b. Physicians; c. Consultants; d. Support Services (i.e., Dietary, Activities, Social, etc.); e. Administration f. Government Agencies; and/or g. Resident/Representative (sponsor). 8. The resident may initiate a request to release such information contained in his/her records and charts to anyone he/she wishes. Such requests will be honored only upon the receipt of a written, signed, and dated request from the resident or representative (sponsor). 9. A resident may have access to his or her records within (blank) hours (excluding weekends or holidays) of the resident's written or oral request. 10. A resident may obtain photocopies of his or her records by providing the facility with at least forty-eight (48) hour (excluding weekends and holidays) advance notice of such request. A fee may be charted for copying services.

Based on observation, resident and staff interviews, clinical record reviews and facility policy review, it was determined that the facility failed to protect four (#46, #24, #34 and #33) of six female residents reviewed for sexual abuse perpetrated by Resident # 48, a male resident. On 06/18/19, Resident #48 was witnessed by facility staff to sexually abuse Resident #46 by placing his hand under her shirt and touching her breast. Resident #46 was a vulnerable female adult with cognitive impairment and no ability to consent to contact with Resident #48. The facility failed to provide the necessary interventions to protect additional female residents from Resident #48 following this event. On 08/09/19, Resident #24, an alert and oriented resident, reported to staff that Resident #48 entered her room and exposed his penis. Resident #24, an alert and oriented resident, exhibited distress, depression, and was tearful following this event. The facility failed to put meaningful interventions in place to protect residents from Resident #48, despite two allegations of sexual abuse in less than 2 months. On 09/07/19, Staff T, C.N.[NAME], observed Resident #48 sitting next to Resident #34, rubbing her hand and shoulder and leaning in to kiss the cognitively impaired female resident who lacked the ability to consent to Resident #48's actions. Staff T took Resident #48 back to his unit and reported the event to the Licensed Practical Nurse (LPN), Staff [NAME] Staff A took no actions to prevent continued sexually abusive behaviors by Resident #48 towards other vulnerable residents. On 9/11/19, the total extent of sexual abuse perpetrated by Resident #48 could not be determined as Resident # 33 stated that Resident #48 came into her room in (MONTH) of (YEAR) and was stroking her leg while she was sleeping. Resident #33, an alert and oriented resident, indicated that she reported this event at the time of occurrence, but nothing was done about it. Resident #33 expressed fear and concern at the actions taken by Resident #48 who lives near her room. The failure to prevent access by Resident # 48 to vulnerable residents, and the failure to ensure freedom from abuse resulted in findings of immediate jeopardy on 9/16/19 at 9:08 p.m. Review of the facility's corrective action plan revealed that the Immediate Jeopardy was removed on 9/16/19 and the scope and severity reduced to an E. Findings Included: 1. Review of Resident # 48's record revealed a Behavioral Medicine note, dated 6/19/19 and signed by a Psychiatrist, which stated, Reason for Visit: Seen today for psychiatric evaluation due to inappropriate behavior. Interim History of Present Illness: (description of Resident # 48) was reportedly seen by staff groping a female peer under her blouse. They were easily re-directed and when asked, he did not recall the event 'but wished he did.' He had the same response today, denying any recall of the event. No recurrence of behavior and not seeking out any female residents. No other changes in mood/ behaviors. Risk to others: checked as no evidence. Clinical Status and Impressions: Dx (diagnoses) [MEDICAL CONDITION] late onset; Dementia (Alzheimer's type) with Behavioral Disturbances. It appears this event is a one -time thing, and I see no clear pattern of recurrence. He is not seeking out this female peer, nor any other females on the unit. No pharmacologic interventions, as staff will continue to redirect as needed. There was no additional documentation in Resident# 48's record regarding this occurrence. An interview with the 200/300 Unit Manager on 9/12/19 at 4:36 p.m. revealed that she believed the resident whose breast was touched by Resident # 48 was Resident # 46. She stated the intervention for Resident # 46 was to redirect her when she comes up the hill by herself (referring to the slope coming out of the 400 unit to the rest of the facility). The 200/300 Unit Manager did not state that there were any interventions that were being utilized to keep Resident # 48 from repeating this behavior with other residents. Review of the record for Resident # 46 revealed the only documentation related to this incident of sexual abuse was a Behavioral Medicine note, written by a Psychiatrist and dated 6/19/19. Review of this note revealed Reason for Visit: Seen today for psychiatric evaluation after being found in an inappropriate situation with a peer. Interim History of Present Illness: She is confused and was found by staff with a male resident's hands inside her blouse. They were easily separated. Today, I asked her about the event, and she denied the event but later on said 'It's none of my business.' (Resident #46) wanders all around the facility, self-propelling her chair, gets angry when redirected . She is not observed to be seeking out this male peer and vice versa. Clinical Status and Impression: Dx [MEDICAL CONDITION] late onset, Dementia (Alzheimer's Type) with behavioral disturbance. Continue current medications. I see no reason to make adjustments in her meds. Staff will continue to reorient and redirect. She appears to have not been traumatized by any event, and this situation did not appear to be unpleasant to her. The Behavioral Medicine Note from the Psychiatrist indicated that Resident # 46 was Unreliable/ Unable to participate due to condition/ dementia. Poor historian due to dementia. Orientation: person; Fund of Knowledge: Limited/ Impaired; Insight/ Judgement: Poor. Review of the record for Resident # 46 revealed [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment revealed it was a quarterly assessment dated [DATE]. Resident #46 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment. A score of 3 indicated severe cognitive impairment. A care plan initiated 7/11/18 and revised 7/30/18 revealed Resident # 46 had impaired cognitive function as evidenced by impaired decision-making skills. She was oriented to person, had short term, long term memory impairment related to dementia. Resident #46 utilized a wheelchair and was able to propel herself throughout the facility. Resident # 46 had a care plan, initiated 7/11/18 and revised 7/30/18, with a focus of potential for elopement due to: cognitive impairment, has periods of increased confusion, was exit seeking, wandered the unit and wandered near exit doors. There was no additional documentation in Resident # 46's record regarding this 6/18/19 incident of sexual abuse. Observation of Resident # 46, on 9/14/19 at 11:50 a.m. revealed a petite frail female resident, seated at a table in the dining room in her wheelchair eating lunch. An attempt was made to interview Resident #46, she was pleasantly confused and was unable to recall. On 9/12/19 at 5: 30 p.m., an interview was conducted with the Director of Social Services (DSS). She stated that in (MONTH) 2019 she was the Abuse Coordinator. She stated, she was not aware of this incident between Resident # 48 and Resident # 46, and she had not investigated. On 9/13/19, the Director of Nursing (DON) provided a folder with an investigation conducted by the DSS on 6/18/19 regarding the alleged sexual abuse of Resident #46 by Resident #48. Included in the folder was a statement by the Unit Manager of 200/300. Review of the statement, dated 6/18/19, revealed: As I was coming down the back hall going towards 300 from the nursing office, I saw (Resident # 48) and (Resident # 46) sitting at the corner of the hall next to the ramp going towards 400. When I got closer to them, I noted that (Resident # 48) had his hand up (Resident # 46's) shirt. I walked over to them and let (Resident #48) know he couldn't do that, and he immediately removed his hand. (Resident # 46) then said I 'm a grown woman and can do what I want.' I asked (Resident # 48) if he would come with me and he agreed to go back to 300 unit. I immediately let Social Services know and was told to call the daughter. I called the daughter and let her know. She voiced no concerns. Review of the DSS documented interview with Resident #46 dated 6/18/19 revealed, SW (Social Worker) was asked to speak with resident regarding alleged inappropriate behaviors with another male resident. Information from nurse was male resident was seen with his hand under resident's shirt. Per nurse, both residents were immediately separated from the area. Both residents were redirected back towards their own halls. Resident was up in wheelchair propelling towards Activities room. SW spoke with resident on screened porch. SW asked resident if she has any concerns or complaints. Resident (#46) responded no, only you stopping me and asking me stuff. SW attempted to ask resident about the alleged incident with male resident. (Resident # 46) denied any event occurring with another male resident. She then went on to state, 'I am an adult and can do as I want.' She then became frustrated and began propelling herself towards the door. SW attempted to re- direct back to conversation. Resident stated, ' We are done.' SW assisted resident back to unit. Continued review of the investigation folder for the 6/18/19 event between Resident #48 and Resident #46 revealed a note written by DSS on 6/18/19, which revealed, Discussed statements from residents with DON and Interim Administrator. No need to report. Will keep soft file. Review of the investigation file revealed the only resident interviews that were conducted were with Resident # 48 and Resident # 46. There was no documentation that other residents had been interviewed to determine if any similar occurrences had happened to them with Resident # 48. There was no documentation of any staff interviews, besides the 200/300 Unit Manager's written statement, related to any knowledge of Resident # 48's sexual abuse toward Resident # 46 or any awareness of any other concerns with the behavior of Resident # 48. A follow-up interview was conducted with the 200/ 300 Unit Manager, on 9/12/19 at approximately 12:15 p.m. She stated that Resident # 48 and Resident # 46 were sitting beside each other. Resident #48's hand was under her (Resident # 46's) armrest and under her shirt near her breast. She stated Resident # 48's hand was not moving, just kind of sitting there. She stated she asked Resident #48 to come with her and as she was walking towards him, he took his hand out. She stated she told him he could not do that. She stated she had not spoken to Resident #46 but she (Resident # 46) said, I am a grown woman. She stated she let social services know what had occurred. On 9/13/19 at 8:30 a.m., the DON stated that when she was reading the investigation, there was no statement from her. She stated, I would not say not to report something if someone puts someone's hand up someone's shirt. I heard he was touching himself and offered privacy. To my recollection he was touching himself, not someone else. She stated she was going to report this now. On 9/12/19 at 5: 17 p.m., the current Nursing Home Administrator (NHA) stated, I wish I could speak to it, but I was not here. The NHA stated she was not aware of this incident. A review of the employee roster revealed the current NHA began employment at the facility on 07/24/19. The facility was asked to provide an abuse log on 9/12/19. Review of the book provided titled 2019 reportable incidents revealed no entry or information related to this 6/18/19 sexual abuse allegation. Review of the incident log/occurrence log from (MONTH) 2019 to (MONTH) 2019 revealed no entry for this 6/18/19 sexual abuse allegation. Interview with the Assistant Director of Nursing (ADON), on 9/16/19 at 8: 51 a.m., revealed that if it was a resident to resident incident it would be on the occurrence log. She stated if the staff had filled out an occurrence log it would be on the occurrence report. She reviewed the occurrence log and stated that she did not see an occurrence report or an entry on the occurrence log for this incident. The facility could not provide any additional evidence to demonstrate any actions taken as a result of this 06/18/19 event. 2. Review of the facility grievance log revealed an entry for 8/9/19 for a grievance filed by the Social Service Assistant on behalf of Resident #24. The nature of the grievance was documented as wandering resident exposing in common areas and the grievance was noted to be resolved on 8/9/19. Review of a form titled Investigation of Concern or Grievance dated 8/9/19 for Resident #24 revealed under specifics of concern or grievance, See Attachment. Attached to this form was a note, dated 8/9/19, written by the Social Services Assistant. Review of the note revealed, The Social Services Assistant was pulled to the side by (Staff L, LPN) along with (the 200/300 Unit Manager) regarding an incident involving (Resident #24 and Resident #48). (Staff L) stated that (Resident #24) approached him and stated that (Resident #48) showed her his penis. Social Services approached (Resident #24) in her room and shut the door. Social Services asked (Resident # 24) what happened. She stated she was sitting in her wheelchair facing her television. She stated (Resident #48) came to her doorway and had his penis out. She stated she was shocked and yelled at him to leave her room. She stated he continued to sit there staring at her. She stated she continued to tell him to leave her room. She stated he finally left her room and positioned himself in front of the window at the end of the hallway. She stated she was shocked because she has always seen him as a nice guy. She stated everyone in that area are friends and she did not expect it. Social Services asked (Resident # 24) if anyone else had seen him do it and she stated no. She stated she told (another male resident ) after it happened. She stated she no longer wants him anywhere near her. She stated she is disgusted and unhappy that it happened. Social Services stated they will reach out to (Resident # 48) in regard to the situation. She stated thank you and retreated back into her room. Continued review of the Grievance form indicated under findings of investigative process - spoke with resident regarding incident. The recommendations and corrective actions section included: fabric stop sign placed across door of resident (Resident #24). Resident agreeable and happy. Roommate and Health Care Proxy notified and agreeable. Guardian notified. The findings were noted to be reported to Resident # 24 and her family member on 8/9/19 ( the date of the sexual abuse incident). Review of the record for Resident #24 revealed diagnoses, which included cerebral infarction due to embolism of left middle cerebral artery, dysphagia following cerebral infarction, [MEDICAL CONDITION] unspecified affecting right dominant side, anxiety disorder, major [MEDICAL CONDITION], and muscle weakness. Review of a quarterly MDS assessment, dated 8/22/19, revealed a score of 13, cognitively intact, on the Brief Interview for Mental Status. Locomotion on the unit (including her room) and off unit was noted to be an extensive assist of one personal physical assist. A care plan for communication, dated 6/19/19, indicated Resident #24 had strength in communication as evidenced by able to hear at normal tones, speech was clear and easily understood and communicated needs to staff. Review of the record for Resident # 24 revealed a progress note, dated 8/13/19 and written by the Social Service Assistant (SSA). The progress note stated, Late entry: S.S. (Social Services) conducted the first F/U ( Follow Up) regarding the incident reported on 8/9/19 on 8/12/19. Resident stated she was okay. Resident appeared to become teary-eyed. Resident continued to state she was doing okay. She stated she sees him, but he does not bother her. S.S reached out to (family member) and informed him of the incident. S.S made a referral for Psych services. S.S conducted second F/U on resident. She was organizing her belongings. She stated she is doing just fine. She stated she is still disgusted by what happened, but he has not come by her room. S.S will conduct a third F/U on 8/14/19. An additional progress note dated 8/14/19 by the SSA for Resident # 24, stated, Day 3 F/U. Resident was seen by Psychiatry. Resident informed the psychiatrist that resident attempted to approach residents' room but was re-directed by staff. Resident stated she is okay, just disgusted by resident and would like him to stay away from her or change units. There was no documentation in the medical record other than the Social Service Follow Up notes to indicate what had occurred as stated in the 8/9/19 grievance. Review of a Behavioral Medicine Note dated 8/14/19 revealed, She is upset after an incident with a male resident, but appreciates staff assistance in keeping him away from her room. She is depressed with tearful episodes, no clear reason. Review of a nursing progress note found in Resident #24's record, dated 9/7/19 at 12:50 p.m. revealed On Saturday 9/7/19, I was informed by activities CNA that resident had c/o (complained of) male resident housed in adjacent room (Resident # 48's room number) was coming into room and exposing private part to female resident on numerous occasions. Supervisor addressed nurse on duty about matter and made arrangements to move female resident to a different part of hall. Resident stated that she was fine and did not want to move from current room. Resident stated to nurse that 'I can handle it, I'm okay. I don't need to be moved.' There was a Stop sign on female resident's door to alert male resident that entering is not allowed. Will continue to monitor resident for recurrent behavior and will continue to redirect. Will monitor for any changes in condition. Review of a nursing progress note dated 9/7/19 at 14:36 p.m. (2:36 p.m.) revealed Resident approached by this nurse asking if she would like to move her room down the hall so she could feel more comfortable due to the occurrence last week. Resident states she is fine with all the residents, no c/o (complaints) of being near any certain residents, does not want to move rooms. Resident states she would like to stay in her room so she can watch over her roommate. Resident was instructed to let a nurse or any other employee know if she feels uncomfortable. An interview was conducted with the 200/300 Unit Manager, on 9/12/19 at 4: 27 p.m. She stated she was not aware of any further incidents with Resident # 48 and # 24. She stated, I can only assume it was him (referring to Resident #48) that the 9/7/19 note was referring to. An interview was conducted with Resident # 24 , on 9/11/19 at 12:30 p.m. She stated that she was sitting in her room watching TV when Resident #48 came in her room and exposed his genital area to her. She stated she was shocked and asked him what he thought he was doing. She stated she went down the hall and told everyone, nurses and CNAs (Certified Nursing Assistants) both. She stated she was distressed by this, It was terrible, and he shouldn't be doing that. Resident # 24 appeared traumatized from the event and repeatedly stated she was shocked, and this was terrible. Review of Resident #48's clinical record revealed a nursing progress note, dated 8/12/19 at 11:28 a.m., which stated, Called daughter . to speak to her about resident's behaviors, message left for return call. Another nursing progress note, dated 8/12/19 15:23 (3:23 p.m.), which stated resident's daughter returned call. Spoke with her about his behaviors. Daughter stated she would speak with him about it. Continued review of Resident #48's clinical record revealed a Medication Management Assessment on 8/14/19 by the psychiatrist. Chief complaint was documented as Other - inappropriate behavior. Context- He reportedly exposed his private parts to a female peer, wheeling himself to her room. He reports not knowing what happened. Under the section for Assessment and Recommendations the psychiatrist documented Patient with disinhibited behavior on the unit, denies recall of the event. Explained to him that exposing himself to others is illegal and witnesses have the option to file a complaint with the police. He said he won't do it again. No medication changes were recommended. There was no documentation in the 2019 [MEDICATION NAME] book/abuse log and no documentation in the incident/occurrence log related to Resident #24's allegations of sexual abuse. An interview was conducted with the 200/300 Unit Manager on 9/12/19 at 4:27 p.m. She stated that Resident # 48 was independent with everything, refuses showers, does his own thing. She stated he sits at the end of the hall and watches traffic or sits with other Spanish speaking residents. Regarding the allegation of exposing himself to Resident # 24 she stated, Apparently that happened, but I have not seen him do it. No residents have expressed concern about him other than (Resident #24). She stated she (referring to Resident # 24) said he exposed himself, both residents were confused with mental status that comes and goes. She stated no one saw it. An interview was conducted with the Administrator, on 9/12/19 at 1:28 p.m. and again on 9/15/19 at 12:50 p.m. She stated that the incident on 8/9/19 of Resident # 48 exposing himself to Resident #24 was not a reportable event and this was a behavior. The Administrator also stated on 9/15/19 at 12:50 p.m. that she had been the abuse coordinator since 8/1/19. During an interview with the Administrator and the DON, on 9/13/19 at 10:18 a.m., the Administrator stated that she was still investigating as to whether there was another incident with Resident #48 and Resident #24 in (MONTH) 2019. The DON stated she had spoken briefly to Resident #24 the day before and Resident #24 referred to Resident #48 as that terrible man and stated he had not bothered her in a long time. On 9/14/19 at 12:15 p.m. The Administrator stated she had not yet spoken to the activities assistant who reported to the nurse on 9/7/19 and had not yet spoken to the nurse who wrote the note. Review of Resident #48's clinical record revealed a nursing note, dated 8/21/19 at 10:44 p.m., written by Staff O, an LPN stated, Resident alert and responsive, able to make needs known. Resident remains on one to one with staff member, resident has tried to touch staff member inappropriately, will continue to monitor. Review of Resident #48's record revealed a Therapy Assessment, conducted by a Psychologist, on 8/27/19 . Review of the assessment indicated Chief Complaint was other - Inappropriate behavior. The assessment and recommendation documented: Patient has been presenting with inappropriate sexual behavior; however, he denies remembering these events. Patient appears calm and with stable mood. No stress symptoms evident. Clinician explained in Spanish consequences of inappropriate touching. Patient demonstrated an understanding. Daily repetition may be needed due to memory issues. Recommendations: Have daily routine for patient and encourage participation in different activities in order to keep patient distracted. When patient approaches other residents remind him the need to keep his distance from other residents. There was no documentation found in Resident #48's record as to daily repetition of consequences or reminders to keep his distance from other residents. An interview was conducted with Staff O, on 9/12/19 at 5:00 p.m. She stated she did not know why Resident # 48 was placed on one to one on 8/21/19 and thought it was only for one day. Interview with the DON and Administrator, on 9/12/19 at 1:28 pm. revealed that they were both unaware of Resident #48 being placed on one to one on 8/21/19. The Administrator stated that there appeared to be more going on with Resident #48 then she was aware of and she would investigate. 3. Due to the allegations related to Resident #48, additional resident interviews were conducted on the unit where Resident #48 resided. On 9/12/19 at 8:30 a.m., Resident # 33 reported that in (MONTH) of (YEAR), Resident # 48 came in her room in the middle of the night and put his chair up next to her bed. She stated he was stroking her leg through her nightgown. She stated she told a nurse at the time. She did not state who this nurse was. Resident #33 appeared anxious and distressed stating she no longer feels comfortable wearing a nightgown, keeps her door shut now and does not want him anywhere near her. She referred to Resident #48 as a pervert. Resident # 33 also reported that the CNAs had told her that a couple of weeks ago Resident # 48 had grabbed a female resident's breasts. Review of the clinical record for Resident #33 revealed diagnoses, which included major [MEDICAL CONDITION], recurrent, moderate, generalized anxiety disorder, muscle weakness, and chronic pai[DIAGNOSES REDACTED]. Review of an 8/6/19 quarterly MDS revealed a BIMS score of 15, cognitively intact. Review of a quarterly Nursing Comprehensive Evaluation dated 9/3/19 and completed by the 200/300 Unit Manager, revealed that the resident was alert and oriented times 3, with adequate vision, adequate hearing and speech that was clear and easily understood, calm mood and no behaviors. A review of the grievance log, Resident #33's clinical record, and the abuse/reportable log for (YEAR) revealed no information related to this allegation of sexual abuse. An interview was conducted with the 200/300 Unit Manager, on 9/12/19 at 4:43 p.m. She stated she was not aware of this allegation from (MONTH) (YEAR) and that Resident # 33 would have told her as she was alert and oriented. On 9/15/19 at 12:15 p.m., the Administrator, Assistant Director of Nursing (ADON), and DON, stated they were not aware of this allegation of sexual abuse from (YEAR) from Resident #33 until 9/12/19. 4. On 9/14/19 at 8:00 a.m., Resident # 33 reported she had heard about another incident with Resident #48 that occurred this week and again expressed concern for female residents in the facility related to Resident # 48's actions. On 9/14/19 at approximately 10:17 a.m. the Administrator and DON were asked if there had been another incident involving Resident #48 that they were aware of and had not reported to the survey team. The Administrator stated yes, they were notified yesterday (9/13/19) from a CNA ,Staff T, that Resident #48 tried to kiss Resident #34 on 9/7/19. She stated that the CNA, Staff T, reported it to the nurse (Staff A, LPN) at the time it occurred and (Staff A) did not report it. She stated an investigation was initiated and it was reported to the abuse hotline, law enforcement and the State survey agency on 9/13/19. She stated Staff A was suspended for not reporting. A telephone interview was conducted with Staff T, on 9/14/19 at 10: 20 a.m. She stated she was working on the 200 Unit, on 9/7/19 and she saw Resident #48 (who resided on the 300 unit) and Resident # 34 ( who resided on the 200 unit) sitting together in the hallway. Resident #34 was seated in a geriatric chair and Resident #48 was next to her in his wheelchair. She stated she saw Resident #48 rubbing Resident #34's hand and shoulder, and then he moved toward Resident #34's face like he was going to kiss her. She stated, He acted like he was going to kiss her. This was not okay for him to do. She stated she distracted him by saying he needed to go back to his hall to eat his lunch. She took him back to his unit and reported it to the nurse, Staff [NAME] Staff T stated that on Friday, 9/13/19, she was getting an abuse inservice from a nurse and during the in-service she asked the nurse if she had heard about what happened last weekend. She stated the nurse told her no, and she explained what she saw with Resident # 48 and Resident #34. The nurse told her to go report it to the Administrator, which she did. Review of the Statement written by Staff T revealed, I witnessed (Resident # 48) trying to kiss (Resident #34) on 200 hall. He was also rubbing on her shoulder and hands. I reported it to the 300 hall nurse (Staff A). After that I asked (Resident # 48) to go to his room and eat lunch. 9/7/19. Statements were also obtained by the Administrator from Staff A and two CNA's on the 200 unit. One CNA stated she did not see Resident #48 doing anything inappropriate, only holding Resident # 34's hand. The second CNA stated that she only saw Resident # 34 holding Resident #48's hand. Staff A's statement revealed that she Saw (Resident # 34) in her chair and (Resident #48) next to her. They seemed comfortable, both smiling and talking. The statements by Nurse A and two additional C.N.[NAME]'s revealed no attempts were made to redirect Resident #48 from holding the hand of Resident #34, an incapacitated resident. The DON, on 9/14/19 at approximately 12:15 p.m., stated that the staff seemed to indicate that the two residents were friends and she gets a hold of his hand. She stated they have frequent visits where they are sitting next to each other. She stated from her interactions with Resident # 34, if she doesn't want you around her, she will let you know. The Administrator, on 9/14/19 at approximately 12:15 p.m. stated, She (referring to Resident #34) is incapacitated, as is he (referring to Resident #48). They are both incapacitated. Review of the record for Resident # 34 revealed [DIAGNOSES REDACTED]. Review of a Significant Change in Condition MDS assessment dated [DATE] revealed that the Brief Interview for Mental Status was not conducted as the resident was rarely/never understood. The section for mental status indicated short and long-term memory problems. Cognitive skills for daily decision making were documented as moderately impaired. Functional status indicated Resident # 34 required extensive assist of one for bed mobility and transfer, and total dependence for locomotion on and off the unit. Functional limitations in range of motion indicated impairment on both sides of upper and lower extremities. A care plan dated 11/3/17 with a revision date of 9/12/19 indicated (Resident # 34) has impaired short and long- term memory loss. Sometimes understood and sometimes understands others. She does have impaired decision- making skills due to Dx: Dementia, [MEDICAL CONDITION] with Paranoia and [MEDICAL CONDITION]. At risk for further fluctuations and changes in cognition. On 09/10/19 at 11:56 a.m., Resident #34 was observed in bed. The resident was observed swinging her arms in the air. The resident was frail and not interviewable as she could not answer simple questions. Despite this occurring and being reported by a CNA, on 9/7/19, nothing was done to protect this resident and other residents from sexual abuse from Resident #48 until 9/13/19. Review of the record for Resident # 48 revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/18/2018, a care plan focus of . is independently capable of pursuing their own activities without staff intervention, was initiated. Review of care plans for Resident # 48 revealed a care plan, initiated 6/18/19, by the Director of Social Services for a focus of (Resident # 48) exhibits the following behaviors: Socially Inappropriate AEB (As Evidenced By) touching residents inappropriately, feeding residents etc. The goal stated, Resident will exhibit a decrease in the number of behavior episodes by the next reviewed date. Interventions were documented as: Anticipate care needs and provide them before resident becomes overly stressed. Approach resident in a calm manner and explain actions. Re-approach resident if agitation is noted. Invite to and encourage activity programs consistent with resident's interests. Intervene as needed to protect the rights and safety of residents and others: remove from situation as able. Request psychiatric consult as needed. Update physician of increase in presence or severity of behaviors as indicated. A care plan revision was dated 8/9/19 with the addition under Focus of exposes himself

Based on interviews with the Nursing Home Administrator/Abuse Coordinator, Director of Nursing, Director of Social Services, nursing staff, residents, observations, record review of residents' medical record, abuse and incident/occurrence logs. grievances and the review of the facility's policies and procedures, it was determined that the facility failed to report allegations of sexual abuse after allegations were made related to resident to resident sexual abuse perpetrated by Resident #48, a male resident, against three female residents ( #46, #24, #34) of six female residents reviewed for abuse. On 6/18/19, the Director of Social Services who was the Abuse Coordinator at the time of the first alleged sexual abuse incident, failed to report an allegation of sexual abuse perpetrated by Resident #48 against Resident #46 to the State Survey Agency and Adult Protective Services. On 8/9/19, the Director of Social Services failed to report an allegation of sexual abuse perpetrated by Resident #48 against Resident #24 to the Administrator, the State Survey Agency, and Adult Protective Services. On 9/7/19, facility staff failed to report an allegation of sexual abuse perpetrated by Resident #48 against Resident #24 to the Administrator, the State Survey Agency and Adult Protective Services. When the Administrator was made aware of this allegation, she did not report the allegation to the State Survey Agency and Adult Protective Services. Resident #24 was a physically vulnerable resident requiring extensive one-person physical assistance. On 9/7/19, facility staff did not report an allegation of alleged sexual abuse perpetrated by Resident #48 against Resident #34 to the Administrator, the State Survey Agency and Adult Protective Services. Failure of the facility to follow the facility's policy and procedure on abuse reporting demonstrated a lack of commitment by the facility to protect residents from multiple incidents of sexual abuse. Failure to report the first and subsequent allegations of sexual abuse perpetrated by Resident #48 on vulnerable female residents in the facility resulted in findings of immediate jeopardy on 9/16/19 at 9:08 p.m. Review of the facility's corrective action plan revealed that the Immediate Jeopardy was removed on 9/16/19 and the scope and severity reduced to an E. Findings included: 1. A review of the facility's policy and procedure titled, Abuse Protection and Response Policy, identified by the Administrator as dated (YEAR), revealed: Policy : Abuse, as hereafter defined , will not be tolerated by anyone including staff, patients, volunteers, family members or legal guardians, friends or any other individuals. The health center Administrator is responsible for assuring that patient safety, including freedom from risk of abuse, holds the highest priority. Definitions: Abuse : the willful infliction of injury , unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by any individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental and psychosocial well- being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, physical abuse and mental including abuse facilitated or enabled through the use of technology. Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm Mental Abuse: Includes , but is not limited to , humiliation, harassment, threats of punishment or deprivation. Sexual Abuse: is non - consensual sexual contact of any type with a resident . .VII. Reporting and Response: Policy: All allegations involving abuse, neglect, exploitation, sexual abuse, mistreatment, injuries of unknown sources and misappropriation of resident property will be reported immediately but not later than ( 2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than (24) hours if the events that cause the allegation do not involve abuse or result in serious bodily injury to the Administrator of the facility and to other officials (including to the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long term care facilities) in accordance with State law through established procedures. Procedure: Any investigation that substantiates abuse, neglect or exploitation will be reported immediately to the Administrator and/or the Abuse Prevention Coordinator. It will also be reported to other officials , in accordance with State and Federal Law. [NAME] The Immediate Report : All allegations of abuse, neglect, exploitation, or misappropriation of property, including injuries of unknown source, must be reported immediately or practicable. This allegation must be reported to the Abuse Hotline ( Adult Protective Services) within immediately or practicable whenever an is allegation made. The Abuse Prevention Coordinator will also submit The Agency for Health Care Administration AHCA Federal Immediate/ 5-day Report and send it to: B. The report of Investigation (Five Day Report) The facility Abuse Prevention Coordinator will send the result of facility investigations to the State Survey Agency within five working days of the incident. This will be completed using the same AHCA Federal/ Five Day Report. The facility will report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of or is receiving care from the facility. The facility shall report not later than (2) hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than (24) hours if the events that cause the suspicion do not result in serious bodily injury. Review of a Policy and Procedure , entitled Reporting Abuse to Facility Management, undated, revealed : Policy Statement: It is the responsibility of our employees, facility consultants, Attending Physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management. Policy Interpretation and Implementation: 1. Our facility does not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends or other individuals. 3. All personnel, residents, family members, visitors, etc., are encouraged to report incidents of resident abuse or suspected incidents of abuse. Such reports may be made without fear of retaliation from the facility or its staff. 4. Employees, facility consultants and /or Attending Physicians must immediately report any suspected abuse or incidents of abuse to the Director of Nursing Services. In the absence of the Director of Nursing services such reports may be made to the Nurse Supervisor on duty. 5. Any individual observing an incident or resident abuse of suspecting resident abuse must immediately report such incident to the Administrator, Director of Nursing Services, or Charge Nurse. The following information should be reported: a. the name(s) of the resident(s) to which the abuse or suspected abuse occurred; b. the date and time the incident occurred; c. Where the incident took place; d. The name(s) of the person(s) allegedly committing the incident, if known; e. The name(s) of any witnesses to the incident; f. The type of abuse that was committed ( i.e., verbal, physical, sexual, neglect, etc.); and g. Any other information that may be required by management. 6. Any staff member or person affiliated with this facility who has witnessed or who believes that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense shall immediately report, or cause a report to be made of, the mistreatment or offense. Failure to report such an incident may result in legal/criminal action being filed against the individual(s) withholding such information. 7. Staff members and persons affiliated with this facility shall not knowingly: a. Attempt, with or without threats or promises of benefit, to induce another to fail to report an incident of mistreatment or other offense; b. Fail to report an incident or mistreatment or other offense; c. Alter, change without authorization, destroy or render unavailable a report made by another ; and / or d. Screen reports or withhold information to reporting agencies. 8. The Administrator or Director of Nursing Services must be immediately notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator and Director of Nursing Services must be called at home or must be paged and informed of such incident. 9. When an incident or resident abuse is suspected or confirmed, the incident must be immediately reported to facility management regardless of the time lapse since the incident occurred. Reporting procedures should be followed as outlined in the policy . 17. Inquiries concerning abuse reporting and investigations should be referred to the Administrator and/ or to the Director of Nursing Services. 2. On 9/12/19 at 5: 30 p.m., an interview was conducted with the Director of Social Services (DSS). She stated that in (MONTH) 2019 she was the Abuse Coordinator. She stated, she was not aware of the 6/18/19 incident between Resident # 48 and Resident # 46, and she had not investigated. On 9/13/19, the Director of Nursing (DON) provided a folder with an investigation conducted by the DSS on 6/18/19 regarding the alleged sexual abuse of Resident #46 by Resident #48. Included in the folder was a statement by the Unit Manager of 200/300. Review of the statement, dated 6/18/19, revealed: As I was coming down the back hall going towards 300 from the nursing office, I saw (Resident #48) and (Resident #46) sitting at the corner of the hall next to the ramp going towards 400. When I got closer to them, I noted that (Resident #48) had his hand up (Resident #46's) shirt. I walked over to them and let (Resident #48) know he couldn't do that, and he immediately removed his hand. (Resident #46) then said I'm a grown woman and can do what I want.' I asked (Resident #48) if he would come with me and he agreed to go back to 300 unit. I immediately let Social Services know and was told to call the daughter. I called the daughter and let her know. She voiced no concerns. An interview with the 200/300 Unit Manager on 9/12/19 at approximately 12:15 p.m. confirmed the documented investigation findings. She stated that Resident #48 and Resident #46 were sitting beside each other. Resident #48's hand was under her (Resident #46's) arm rest and under her shirt near her breast. She stated Resident #48's hand was not moving, just kind of sitting there. She stated she asked Resident #48 to come with her and as she was walking towards him, he took his hand out. She stated she told him he could not do that. She stated she had not spoken to Resident #46 but she (Resident #46) said, I am a grown woman. She stated she let Social Services know what had occurred. Review of the DSS documented interview with Resident #46 dated 6/18/19 revealed, SW (Social Worker) was asked to speak with resident regarding alleged inappropriate behaviors with another male resident. Information from nurse was male resident was seen with his hand under resident's shirt. Per nurse, both residents were immediately separated from the area. Both residents were redirected back towards their own halls. Resident was up in wheelchair propelling towards Activities room. SW spoke with resident on screened porch. SW asked resident if she has any concerns or complaints. Resident (#46) responded no, only you stopping me and asking me stuff. SW attempted to ask resident about the alleged incident with male resident. (Resident # 46) denied any event occurring with another male resident. She then went on to state, 'I am an adult and can do as I want.' She then became frustrated and began propelling herself towards the door. SW attempted to re- direct back to conversation. Resident stated, ' We are done.' SW assisted resident back to unit. Continued review of the investigation folder for the 6/18/19 event between Resident #48 and Resident #46 revealed a note written by DSS on 6/18/19, which revealed, Discussed statements from residents with DON and Interim Administrator. No need to report. Will keep soft file. Review of the record for Resident # 46 revealed [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment revealed it was a quarterly assessment dated [DATE]. Resident #46 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment. A score of 3 indicated severe cognitive impairment. A care plan initiated 7/11/18 and revised 7/30/18 revealed Resident #46 had impaired cognitive function as evidenced by impaired decision-making skills. She was oriented to person, had short term, long term memory impairment related to dementia. A care plan initiated 7/11/18 and revised 7/30/18 revealed, (Resident #46) has impaired cognitive function as evidenced by has impaired decision making skills. Is oriented to person. Has short term, long term memory impairment reference to dx (diagnosis) of Dementia . Observation of Resident #46, on 9/14/19 at 11:50 a.m. revealed a petite frail female resident, seated at a table in the dining room in her wheelchair eating lunch. An attempt was made to interview Resident #46, she was pleasantly confused and was unable to recall. Review of the Director of Social Services documented interview with Resident #48, on 6/18/19, revealed, SW was asked to speak with resident regarding alleged inappropriate behaviors with another female resident (#46). Information from the nurse (200/300 Unit Manager) was, resident was seen with his hand under another resident's shirt. Per nurse, both residents were immediately separated from the area. Both residents were redirected back towards their own halls. Resident was up in wheelchair near nurse's station. SW assisted resident back to his room. SW attempted to ask resident about the alleged incident with female resident. (Resident #48) denied any event occurring with female resident but stated, I wish I could remember. Resident was pleasant during conversation but had no recall of alleged event. The facility was asked to provide an abuse log, on 9/12/19. Review of a book titled, 2019 Reportable Incidents, which was the facility's abuse log, revealed no entry or information related to the 6/18/19 sexual abuse allegation between Resident #48 and Resident #46. Review of the occurrence log/incident log from (MONTH) 2019 to (MONTH) 2019 revealed no entry for the 6/18/19 sexual abuse allegation. Interview with the Assistant Director of Nursing (ADON), on 9/16/19 at 8:51 a.m., revealed that if it was a resident to resident incident it would be on the occurrence log. She stated if the staff had filled out an occurrence report it would be on the occurrence log. She reviewed the occurrence log and stated that she did not seen an occurrence report or an entry on the occurrence log for this incident (6/18/19). Review of Resident # 48's record revealed a Behavioral Medicine note, dated 6/19/19 and signed by a Psychiatrist, which stated, Reason for Visit: Seen today for psychiatric evaluation due to inappropriate behavior. Interim History of Present Illness: (description of Resident #48) was reportedly seen by staff groping a female peer under her blouse. They were easily re-directed and when asked, he did not recall the event 'but wished he did.' He had the same response today, denying any recall of the event. No recurrence of behavior and not seeking out any female residents. No other changes in mood/behaviors. On 9/13/19 at 8:30 a.m., the DON stated that when she was reading the investigation, there was no statement from her. She stated, I would not say not to report something if someone puts someone's hand up someone's shirt. I heard he was touching himself and offered privacy. To my recollection he was touching himself, not someone else. She stated she was going to report this now. The Administrator was not the Interim Administrator at the time of this incident. She stated, on 9/12/19 at 5:17 p.m. I wish I could speak to it, but I was not here. She stated she was not aware of this incident. The facility could not provide any additional evidence to demonstrate any actions taken as a result of this 06/18/19 event. 3. Review of the facility's grievance log revealed an entry for 8/9/19 for a grievance filed by the Social Service Assistant on behalf of Resident #24. The nature of the grievance was documented as wandering resident exposing in common areas, and the grievance was noted to be resolved on 8/9/19. Review of a form titled Investigation of Concern or Grievance dated 8/9/19 for Resident #24 revealed under specifics of concern or grievance See Attachment. Attached to this form was a note dated 8/9/19 written by the Social Services Assistant. Review of the note revealed, The Social Services Assistant was pulled to the side by (Staff L, LPN) along with (the 200/300 Unit Manager) regarding an incident involving (Resident #24 and Resident #48). (Staff L) stated that (Resident #24) approached him and stated that (Resident #48) showed her his penis. Social Services approached (Resident #24) in her room and shut the door. Social Services asked (Resident #24) what happened. She stated she was sitting in her wheelchair facing her television. She stated (Resident #48) came to her doorway and had his penis out. She stated she was shocked and yelled at him to leave her room. She stated he continued to sit there staring at her. She stated she continued to tell him to leave her room. She stated he finally left her room and positioned himself in front of the window at the end of the hallway. She stated she was shocked because she has always seen him as a nice guy. She stated everyone in that area are friends and she did not expect it. Social Services asked (Resident # 24) if anyone else had seen him do it and she stated no. She stated she told (another male resident ) after it happened. She stated she no longer wants him anywhere near her. She stated she is disgusted and unhappy that it happened. Social Services stated they will reach out to (Resident #48) in regard to the situation. She stated thank you and retreated back into her room. Continued review of the Grievance form indicated under findings of investigative process - spoke with resident regarding incident. The recommendations and corrective actions section included: fabric stop sign placed across door of resident (Resident #24). Resident agreeable and happy. Roommate and Health Care Proxy notified and agreeable. Guardian notified. The findings were noted to be reported to Resident #24 and her family member on 8/9/19 (the date of the sexual abuse incident). Review of a Behavioral Medicine Note dated 8/14/19 revealed, She is upset after an incident with a male resident, but appreciates staff assistance in keeping him away from her room. She is depressed with tearful episodes, no clear reason. Review of the record for Resident #24 revealed diagnoses, which included cerebral infarction due to embolism of left middle cerebral artery, dysphagia following cerebral infarction, [MEDICAL CONDITION] unspecified affecting right dominant side, anxiety disorder, major [MEDICAL CONDITION], and muscle weakness. Review of a quarterly MDS assessment, dated 8/22/19, revealed a score of 13, cognitively intact, on the Brief Interview for Mental Status. Locomotion on the unit (including her room) and off unit was noted to be an extensive assist of one personal physical assist. A care plan for communication, dated 6/19/19, indicated Resident #24 had strength in communication as evidenced by able to hear at normal tones, speech was clear and easily understood and communicated needs to staff. A care plan initiated 6/26/19 indicated, has a potential for alteration in thought process reference to has periods of forgetfulness. An interview was conducted with Resident #24 , on 9/11/19 at 12:30 p.m. She stated that she was sitting in her room watching TV when Resident #48 came in her room and exposed his genital area to her. She stated she was shocked and asked him what he thought he was doing. She stated she went down the hall and told everyone, nurses and CNAs (Certified Nursing Assistants) both. She stated she was distressed by this, It was terrible, and he shouldn't be doing that. Resident #24 appeared traumatized from the event and repeatedly stated she was shocked, and this was terrible. Continued review of Resident #48's clinical record revealed a Medication Management Assessment on 8/14/19 by the psychiatrist. Chief complaint was documented as Other - inappropriate behavior. Context- He reportedly exposed his private parts to a female peer, wheeling himself to her room. He reports not knowing what happened. Under the section for Assessment and Recommendations the psychiatrist documented Patient with disinhibited behavior on the unit, denies recall of the event. Explained to him that exposing himself to others is illegal and witnesses have the option to file a complaint with the police. He said he won't do it again. No medication changes were recommended. There was no documentation in the 2019 [MEDICATION NAME] book/abuse log and no documentation in the incident/occurrence log related to Resident #24's allegations of sexual abuse. An interview was conducted with the Administrator, on 9/12/19 at 1:28 p.m. and again on 9/15/19 at 12:50 p.m. She stated that the incident on 8/9/19 of Resident # 48 exposing himself to Resident #24 was not a reportable event and this was a behavior. The Administrator also stated on 9/15/19 at 12:50 p.m. that she had been the abuse coordinator since 8/1/19. Review of a nursing progress note found in Resident #24's record, that was dated 9/7/19 at 12:50 p.m., revealed On Saturday 9/7/19, I was informed by activities CNA that resident had c/o (complained of) male resident housed in adjacent room (Resident # 48's room number) was coming into room and exposing private part to female resident on numerous occasions. Supervisor addressed nurse on duty about matter and made arrangements to move female resident to a different part of hall. Resident stated that she was fine and did not want to move from current room. Resident stated to nurse that 'I can handle it, I'm okay. I don't need to be moved.' There was a Stop sign on female resident's door to alert male resident that entering is not allowed. Will continue to monitor resident for recurrent behavior and will continue to redirect. Will monitor for any changes in condition. During an interview with the Administrator and the DON, on 9/13/19 at 10:18 a.m., the Administrator stated that she was still investigating as to whether there was another incident with Resident #48 and Resident #24 in (MONTH) 2019. The DON stated she had spoken briefly to Resident #24 the day before and Resident #24 referred to Resident #48 as that terrible man and stated he had not bothered her in a long time. 4. On 9/14/19 at approximately 10:17 a.m. the Administrator and DON were asked if there had been another incident involving Resident #48 that they were aware of and had not reported to the survey team. The Administrator stated yes, they were notified yesterday (9/13/19) from a CNA, Staff T, that Resident #48 tried to kiss Resident #34 on 9/7/19. She stated that the CNA, Staff T, reported it to the nurse (Staff A, LPN) at the time it occurred and (Staff A) did not report it. She stated an investigation was initiated and it was reported to the abuse hotline, law enforcement and the State survey agency on 9/13/19. She stated Staff A was suspended for not reporting. A telephone interview was conducted with Staff T, on 9/14/19 at 10:20 a.m. She stated she was working on the 200 Unit, on 9/7/19 and she saw Resident #48 (who resided on the 300 unit) and Resident #34 (who resided on the 200 unit) sitting together in the hallway. Resident #34 was seated in a geriatric chair and Resident #48 was next to her in his wheelchair. She stated she saw Resident #48 rubbing Resident #34's hand and shoulder, and then he moved toward Resident #34's face like he was going to kiss her. She stated, He acted like he was going to kiss her. This was not okay for him to do. She stated she distracted him by saying he needed to go back to his hall to eat his lunch. She took him back to his unit and reported it to the nurse, Staff [NAME] Staff T stated that on Friday, 9/13/19, she was getting an abuse in-service from a nurse and during the in-service she asked the nurse if she had heard about what happened last weekend. She stated the nurse told her no, and she explained what she saw with Resident #48 and Resident #34. The nurse told her to go report it to the Administrator, which she did. Review of the Statement written by Staff T revealed, I witnessed (Resident #48) trying to kiss (Resident #34) on 200 hall. He was also rubbing on her shoulder and hands. I reported it to the 300 hall nurse (Staff A). After that I asked (Resident #48) to go to his room and eat lunch. 9/7/19. Statements were also obtained by the Administrator from Staff A and two CNA's on the 200 unit. One CNA stated she did not see Resident #48 doing anything inappropriate, only holding Resident #34's hand. The second CNA stated that she only saw Resident #34 holding Resident #48's hand. Staff A's statement revealed that she Saw (Resident # 34) in her chair and (Resident #48) next to her. They seemed comfortable, both smiling and talking. The statements by Nurse A and two additional C.N.[NAME]'s revealed no attempts were made to redirect Resident #48 from holding the hand of Resident #34, an incapacitated resident. The DON, on 9/14/19 at approximately 12:15 p.m., stated that the staff seemed to indicate that the two residents were friends and she gets a hold of his hand. She stated they have frequent visits where they are sitting next to each other. She stated from her interactions with Resident #34, if she doesn't want you around her, she will let you know. The Administrator, on 9/14/19 at approximately 12:15 p.m. stated, She (referring to Resident #34) is incapacitated, as is he (referring to Resident #48). They are both incapacitated. Review of the record for Resident #34 revealed [DIAGNOSES REDACTED]. Review of a Significant Change in Condition MDS assessment dated [DATE] revealed that the Brief Interview for Mental Status was not conducted as the resident was rarely/never understood. The section for mental status indicated short and long-term memory problems. Cognitive skills for daily decision making were documented as moderately impaired. Functional status indicated Resident #34 required extensive assist of one for bed mobility and transfer, and total dependence for locomotion on and off the unit. Functional limitations in range of motion indicated impairment on both sides of upper and lower extremities. A care plan dated 11/3/17 with a revision date of 9/12/19 indicated (Resident # 34) has impaired short and long- term memory loss. Sometimes understood and sometimes understands others. She does have impaired decision- making skills due to Dx: Dementia, [MEDICAL CONDITION] with Paranoia and [MEDICAL CONDITION]. At risk for further fluctuations and changes in cognition. On 09/10/19 at 11:56 a.m., Resident #34 was observed in bed. The resident was observed swinging her arms in the air. The resident was frail and unable to answer simple questions. On 9/14/19, the DON stated that the Director of Social Services was suspended for not reporting the allegation of sexual abuse perpetrated on Resident #46 by Resident #48 on 6/18/19. On 9/14/19, the Administrator reported that Staff A, LPN was suspended for not reporting the allegation of sexual abuse on Resident #34 by Resident #48 reported to her by Staff T, CNA on 9/7/19. On 9/13/19, the Administrator provided documentation that she had notified the abuse hotline, law enforcement, and the State survey agency regarding the alleged sexual abuse by Resident #48 on Resident #46 and #34. On 9/16/19 at 8:51 a.m., the interview with the Administrator, DON, 200/300 Unit Manager, and ADON, was continued. The ADON, who was the Risk Manager prior to the DON, stated that if there was a resident to resident incident it would be on the occurrence log. She stated if the nurse filled out an occurrence report, now called an incident report, she would put the occurrence on the occurrence log. The ADON was asked to review the incident/occurrence log to determine if any of the sexual abuse by Resident # 48 towards Resident's #46, #24, and #34 was on the log. She stated that she did not see that an occurrence report was done. The ADON was asked if there were any resident to resident incidents reflected on the log and she stated no. She stated there would be no tracking if they were not on the incident/ occurrence log. The administrator stated, We don't have a system in place to monitor what occurs. Facility administration was asked if any of the allegations of sexual abuse perpetrated by Resident # 48 were in the abuse log/2019 [MEDICATION NAME] book. The Administrator stated they were not as they had not been reported to the authorities prior to 9/13/19. 5. The facility implemented the following action plan to remove the immediate jeopardy: 1. Resident #48 was placed on continuous one to one supervision as of 9/13/19 at 10:30 a.m. 2. He was seen by the Psych ARNP on 9/13/19 who suggested medication and involvement in activities that would keep his hands occupied. 3. On 9/13/19 the facility began retraining staff on abuse identification and reporting. As of 9/16/19 all licensed nurses and CNAs who worked from 9/13/19 to 9/16/19 have received the training. The facility has a plan to get all remaining staff via telephone or through meetings at the time clock to ensure all staff receive the training prior to working on the floor. Verification interviews were conducted on 9/16/19 with 29 staff who work across all 3 shifts. No concerns were identified related to staff knowledge of the abuse training. 4. On 9/16/19, a meeting was held with the Administrator, DON, the psychiatrist, and Resident #48's Power of Attorney (POA) to discuss immediate plans to include possible medication changes and appropriateness of this placement. [MEDICATION NAME] 125 milligrams twice daily was added to Resident #48's medication regimen and one to one observation was ordered to continue. Medication will be adjusted based on the resident's response. 5. In-service training for 1:1 staff was initiated on 9/16/19 for how to redirect Resident #48 when exhibiting inappropriate behaviors. This will be continued as each new staff comes on shift for 1:1. This training was verified through staff interviews and sign-in sheets. 6. On 9/16/19 facility administration provided the following additional Plan for Supervision of Residents which was started on 09/16/19. a. Immediate training of all staff regarding supervision of residents commencing 9/16/19 with plans to ensure all licensed nurses and C.N.[NAME]'s received the training before their next shift. b. Immediate training of all staff regarding behavior of (Resident

Based on observations, interviews with the Nursing Home Administrator/Abuse Coordinator, Director of Nursing, Director of Social Services, nursing staff, residents, record review of residents' medical record, abuse and incident/occurrence logs. grievances and the review of the facility's policies and procedures, it was determined that the facility failed to fully investigate allegations of sexual abuse related to resident to resident sexual abuse perpetrated by Resident #48, a male resident, against three (#46, #24 and #34) of six female residents reviewed for abuse for nearly a 3 month period (6/18/19 to 9/7/19). The facility failed to put measures in place to prevent further sexual abuse of the female residents by Resident #48. The Director of Social Services, who was the Abuse Coordinator at the time of the first alleged sexual abuse incident on 6/18/19, failed to conduct a thorough investigation of an allegation of sexual abuse perpetrated by Resident #48 against Resident #46 and observed by the 200/300 Unit Manager. Resident #46 was a vulnerable adult that had impaired cognitive function related to dementia. The Administrator, who was the Abuse Coordinator at the time of the second allegation of sexual abuse on 8/9/19, failed to conduct a thorough investigation of this allegation, perpetrated by Resident #48 against Resident #24, and referred to the allegation as a behavior for Resident #48 and not sexual abuse. Resident #48 had exposed his penis to Resident #24 who was cognitively intact, physically vulnerable, and required extensive assistance by one person. On 9/7/19, facility staff documented an additional allegation of sexual abuse related to a resident exposing his penis to Resident #24. When the Administrator was made aware of the allegation, she did not report the additional allegation to the State Survey Agency and Adult Protective Services, and as of 9/14/19, had not completed the investigation. On 9/7/19, facility staff did not initiate an investigation of a new allegation of sexual abuse perpetrated by Resident #48 against Resident #34. Resident #34 was mentally incapacitated and functionally limited with impairment on both sides of upper and lower extremities. The facility failed to prevent sexual abuse by failing to fully investigate the allegations of sexual abuse perpetrated by Resident #48 and failure to put corrective measures in place. The facility failed to implement its policy and procedure related to the investigation of all allegations of sexual abuse. Failure of the facility to implement the policy and procedure on abuse investigation, protection, and taking corrective actions placed all vulnerable residents at risk and resulted in findings of immediate jeopardy on 9/16/19 at 9:08 p.m. Review of the facility's corrective action plan revealed that the Immediate Jeopardy was removed on 9/16/19 and the scope and severity reduced to an E. Findings included: 1. Review of a policy and procedure titled, Abuse Protection and Response Policy, identified by the Administrator as dated (YEAR), revealed: Policy : Abuse, as hereafter defined , will not be tolerated by anyone including staff, patients, volunteers, family members or legal guardians, friends or any other individuals. The health center Administrator is responsible for assuring that patient safety, including freedom from risk of abuse, holds the highest priority. Definitions: Abuse: the willful infliction of injury , unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by any individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental and psychosocial well- being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, physical abuse and mental including abuse facilitated or enabled through the use of technology. Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm Mental Abuse: Includes , but is not limited to , humiliation, harassment, threats of punishment or deprivation. Sexual Abuse: is non-consensual sexual contact of any type with a resident . IV. Identification: Policy: Any resident event that is reported to any staff by patient, family, other staff or any other person will be considered as a possible abuse if it meets any of the following criteria: c. Any patient or family complaint of physical harm, pain or mental anguish resulting from the actions of others, f. Any complaint of sexual harassment, sexual coercion or sexual assault. Procedure: Any and all staff observing or hearing about such events will report the event immediately to the ABUSE HOTLINE (number listed). The event will also be reported immediately to the Social Worker (Abuse Prevention Coordinator), Director of Nursing , or Administrator. Any and all employees are empowered to initiate immediate action as appropriate to protect a resident. V. Investigation: Policy: Any employee having either direct or indirect knowledge of any event that might constitute abuse must report the event immediately. Procedure: Any and all staff observing or hearing about such events must report the event immediate to the Abuse Prevention Coordinator or the Administrator. Policy: All events reported as possible abuse will be investigated to determine whether abuse did not take place. The facility will have evidence to demonstrate that a thorough investigation has been completed. Procedure: The Abuse Prevention Coordinator will initiate investigative action. The social services manager (abuse prevention coordinator) will be responsible for initiating the abuse reporting. Investigation of alleged violations and reporting results to the state agency or other agencies. The person(s) investigating the allegation will review documentation forms, interview persons reporting the incident and witnesses to the incident, interview other staff members working during the time frame of the incident, interview other residents, family members, and visitors. Review events leading up to the event. Statements and finding of the investigation will be documented. VI. Protection: Policy - In instances where residents are suspected of initiating the abuse behavior toward other residents they will be immediately separated from any suspected victim or victims. The specific approach employed to separate victim and perpetrator and to ensure the protection of all potential victims will vary on a case specific basis. In all cases, every appropriate effort will be made to ensure the protection of our residents. The resident's attending physician should be contacted promptly to determine the most appropriate interventions. These may include but are not limited to: One on one assignment of staff to protect resident victims, Involvement of law enforcement, Review of medication regimen, Review of the resident's care plan interventions, Involuntary Discharge. Sexual Abuse: is non - consensual sexual contact of any type with a resident . .VII. Reporting and Response: Policy: All allegations involving abuse, neglect, exploitation, sexual abuse, mistreatment, injuries of unknown sources and misappropriation of resident property will be reported immediately but not later than ( 2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than (24) hours if the events that cause the allegation do not involve abuse or result in serious bodily injury to the Administrator of the facility and to other officials (including to the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long term care facilities) in accordance with State law through established procedures. Procedure: Any investigation that substantiates abuse, neglect or exploitation will be reported immediately to the Administrator and/or the Abuse Prevention Coordinator. It will also be reported to other officials , in accordance with State and Federal Law. [NAME] The Immediate Report : All allegations of abuse, neglect, exploitation, or misappropriation of property, including injuries of unknown source, must be reported immediately or practicable. This allegation must be reported to the Abuse Hotline ( Adult Protective Services) within immediately or practicable whenever an is allegation made. The Abuse Prevention Coordinator will also submit The Agency for Health Care Administration AHCA Federal Immediate/ 5-day Report and send it to: B. The report of Investigation (Five Day Report) The facility Abuse Prevention Coordinator will send the result of facility investigations to the State Survey Agency within five working days of the incident. This will be completed using the same AHCA Federal/ Five Day Report. The facility will report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of or is receiving care from the facility. The facility shall report not later than (2) hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than (24) hours if the events that cause the suspicion do not result in serious bodily injury. Policy: Trends of investigative findings will be analyzed and addressed by the QA and Risk Management committee process. Procedure: An accurate summary reporting of all investigations conducted by the center will be maintained as a working document of the Quality Assessment and Risk Management Committees. QA and RM will review and analyze investigations to track and determine presence of any trends. 2. Review of the record for Resident # 46 revealed [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment revealed it was a quarterly assessment dated [DATE]. Resident #46 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment. A score of 3 indicated severe cognitive impairment. A care plan initiated 7/11/18 and revised 7/30/18 revealed Resident #46 had impaired cognitive function as evidenced by impaired decision-making skills. She was oriented to person, had short term, long term memory impairment related to dementia. A care plan initiated 7/11/18 and revised 7/30/18 revealed, (Resident #46) has impaired cognitive function as evidenced by has impaired decision making skills. Is oriented to person. Has short term, long term memory impairment reference to dx (diagnosis) of Dementia . Observation of Resident #46, on 9/14/19 at 11:50 a.m. revealed a petite frail female resident, seated at a table in the dining room in her wheelchair eating lunch. An attempt was made to interview Resident #46. She was pleasantly confused and was unable to recall. Review of the record for Resident # 46 revealed the only documentation related to this incident of sexual abuse was a Behavioral Medicine note, written by a Psychiatrist and dated 6/19/19. Review of this note revealed Reason for Visit: Seen today for psychiatric evaluation after being found in an inappropriate situation with a peer. Interim History of Present Illness: She is confused and was found by staff with a male resident's hands inside her blouse. They were easily separated. Today, I asked her about the event, and she denied the event but later on said 'It's none of my business.' (Resident #46) wanders all around the facility, self-propelling her chair, gets angry when redirected . She is not observed to be seeking out this male peer and vice versa. Clinical Status and Impression: Dx [MEDICAL CONDITION] late onset, Dementia (Alzheimer's Type) with behavioral disturbance. Continue current medications. I see no reason to make adjustments in her meds. Staff will continue to reorient and redirect. She appears to have not been traumatized by any event, and this situation did not appear to be unpleasant to her. The Behavioral Medicine Note from the Psychiatrist indicated that Resident # 46 was Unreliable/ Unable to participate due to condition/ dementia. Poor historian due to dementia. Orientation: person; Fund of Knowledge: Limited/ Impaired; Insight/ Judgement: Poor. On 9/12/19 at 5: 30 p.m., an interview was conducted with the Director of Social Services (DSS). She stated that in (MONTH) 2019 she was the Abuse Coordinator. She stated, she was not aware of this incident between Resident # 48 and Resident # 46, and she had not investigated. On 9/13/19, the Director of Nursing (DON) provided a folder with an investigation conducted by the DSS on 6/18/19 regarding the alleged sexual abuse of Resident #46 by Resident #48. Included in the folder was a statement by the Unit Manager of 200/300. Review of the statement, dated 6/18/19, revealed: As I was coming down the back hall going towards 300 from the nursing office, I saw (Resident # 48) and (Resident # 46) sitting at the corner of the hall next to the ramp going towards 400. When I got closer to them, I noted that (Resident # 48) had his hand up (Resident # 46's) shirt. I walked over to them and let (Resident #48) know he couldn't do that, and he immediately removed his hand. (Resident # 46) then said I 'm a grown woman and can do what I want.' I asked (Resident # 48) if he would come with me and he agreed to go back to 300 unit. I immediately let Social Services know and was told to call the daughter. I called the daughter and let her know. She voiced no concerns. A follow-up interview was conducted with the 200/ 300 Unit Manager, on 9/12/19 at approximately 12:15 p.m. She stated that Resident # 48 and Resident # 46 were sitting beside each other. Resident #48's hand was under her (Resident # 46's) armrest and under her shirt near her breast. She stated Resident # 48's hand was not moving, just kind of sitting there. She stated she asked Resident #48 to come with her and as she was walking towards him, he took his hand out. She stated she told him he could not do that. She stated she had not spoken to Resident #46 but she (Resident # 46) said, I am a grown woman. She stated she let social services know what had occurred. Review of the DSS documented interview with Resident #46 dated 6/18/19 revealed, SW (Social Worker) was asked to speak with resident regarding alleged inappropriate behaviors with another male resident. Information from nurse was male resident was seen with his hand under resident's shirt. Per nurse, both residents were immediately separated from the area. Both residents were redirected back towards their own halls. Resident was up in wheelchair propelling towards Activities room. SW spoke with resident on screened porch. SW asked resident if she has any concerns or complaints. Resident (#46) responded no, only you stopping me and asking me stuff. SW attempted to ask resident about the alleged incident with male resident. (Resident # 46) denied any event occurring with another male resident. She then went on to state, 'I am an adult and can do as I want.' She then became frustrated and began propelling herself towards the door. SW attempted to re- direct back to conversation. Resident stated, ' We are done.' SW assisted resident back to unit. Review of the investigation file revealed the only resident interviews that were conducted were with Resident # 48 and Resident # 46. There was no documentation that other residents had been interviewed to determine if any similar occurrences had happened to them with Resident # 48. There was no documentation of any staff interviews, besides the 200/300 Unit Manager's written statement, related to any knowledge of Resident #48's sexual abuse toward Resident # 46 or any awareness of any other concerns with the behavior of Resident # 48. Continued review of the investigation folder for the 6/18/19 event between Resident #48 and Resident #46 revealed a note written by DSS on 6/18/19, which revealed, Discussed statements from residents with DON and Interim Administrator. No need to report. Will keep soft file. On 9/12/19 at 5:17 p.m., the current Nursing Home Administrator (NHA) stated, I wish I could speak to it, but I was not here. The NHA stated she was not aware of this incident. A review of the employee roster revealed the current NHA began employment at the facility on 07/24/19. The facility was asked to provide an abuse log on 9/12/19. Review of the book provided titled 2019 reportable incidents revealed no entry or information related to this 6/18/19 sexual abuse allegation. Review of the incident log/occurrence log from (MONTH) 2019 to (MONTH) 2019 revealed no entry for this 6/18/19 sexual abuse allegation. Interview with the Administrator, on 9/15/19 at 12:15 pm. , revealed that she became the Abuse Coordinator about (MONTH) 1, 2019. Prior to (MONTH) 1, 2019, the Social Service Director (SSD) had been the Abuse Coordinator. Interview with the Director of Nursing (DON) on 9/15/19 at approximately 12:15 p.m., revealed that she became the Risk Manager 2 to 3 weeks ago. The DON stated the ADON was the Risk Manager prior to her assuming the role. Interview with the Assistant Director of Nursing (ADON), on 9/16/19 at 8: 51 a.m., revealed that if it was a resident to resident incident it would be on the occurrence log. She stated if the staff had filled out an occurrence log it would be on the occurrence report. She reviewed the occurrence log and stated that she did not see an occurrence report or an entry on the occurrence log for this incident. The facility could not provide any additional evidence to demonstrate any actions taken as a result of this 06/18/19 event. 3. Review of the record for Resident #24 revealed diagnoses, which included cerebral infarction due to embolism of left middle cerebral artery, dysphagia following cerebral infarction, [MEDICAL CONDITION] unspecified affecting right dominant side, anxiety disorder, major [MEDICAL CONDITION], and muscle weakness. Review of a quarterly MDS assessment, dated 8/22/19, revealed a score of 13, cognitively intact, on the Brief Interview for Mental Status. Locomotion on the unit (including her room) and off unit was noted to be an extensive assist of one personal physical assist. A care plan for communication, dated 6/19/19, indicated Resident #24 had strength in communication as evidenced by able to hear at normal tones, speech was clear and easily understood and communicated needs to staff. Review of the facility grievance log revealed an entry for 8/9/19 for a grievance filed by the Social Service Assistant on behalf of Resident #24. The nature of the grievance was documented as wandering resident exposing in common areas and the grievance was noted to be resolved on 8/9/19. Review of a form titled Investigation of Concern or Grievance dated 8/9/19 for Resident #24 revealed under specifics of concern or grievance, See Attachment. Attached to this form was a note, dated 8/9/19, written by the Social Services Assistant. Review of the note revealed, The Social Services Assistant was pulled to the side by (Staff L, LPN) along with (the 200/300 Unit Manager) regarding an incident involving (Resident #24 and Resident #48). (Staff L) stated that (Resident #24) approached him and stated that (Resident #48) showed her his penis. Social Services approached (Resident #24) in her room and shut the door. Social Services asked (Resident # 24) what happened. She stated she was sitting in her wheelchair facing her television. She stated (Resident #48) came to her doorway and had his penis out. She stated she was shocked and yelled at him to leave her room. She stated he continued to sit there staring at her. She stated she continued to tell him to leave her room. She stated he finally left her room and positioned himself in front of the window at the end of the hallway. She stated she was shocked because she has always seen him as a nice guy. She stated everyone in that area are friends and she did not expect it. Social Services asked (Resident # 24) if anyone else had seen him do it and she stated no. She stated she told (another male resident ) after it happened. She stated she no longer wants him anywhere near her. She stated she is disgusted and unhappy that it happened. Social Services stated they will reach out to (Resident # 48) in regard to the situation. She stated thank you and retreated back into her room. Continued review of the Grievance form indicated under findings of investigative process - spoke with resident regarding incident. The recommendations and corrective actions section included: fabric stop sign placed across door of resident (Resident #24). Resident agreeable and happy. Roommate and Health Care Proxy notified and agreeable. Guardian notified. The findings were noted to be reported to Resident # 24 and her family member on 8/9/19 ( the date of the sexual abuse incident). Review of a Behavioral Medicine Note dated 8/14/19 revealed, She is upset after an incident with a male resident but appreciates staff assistance in keeping him away from her room. She is depressed with tearful episodes, no clear reason. An interview was conducted with Resident # 24 , on 9/11/19 at 12:30 p.m. She stated that she was sitting in her room watching TV when Resident #48 came in her room and exposed his genital area to her. She stated she was shocked and asked him what he thought he was doing. She stated she went down the hall and told everyone, nurses and CNAs (Certified Nursing Assistants) both. She stated she was distressed by this, It was terrible, and he shouldn't be doing that. Resident # 24 appeared traumatized from the event and repeatedly stated she was shocked, and this was terrible. Regarding the allegation of exposing himself to Resident # 24 the Unit Manager stated on 9-12-19 at 12:15 p.m., Apparently that happened, but I have not seen him do it. No residents have expressed concern about him other than (Resident #24). She stated she (referring to Resident # 24) said he exposed himself, both residents were confused with mental status that comes and goes. She stated no one saw it. There was no documentation in the 2019 [MEDICATION NAME] book/abuse log and no documentation in the incident/occurrence log related to Resident #24's allegations of sexual abuse. An interview was conducted with the Administrator, on 9/12/19 at 1:28 p.m. and again on 9/15/19 at 12:50 p.m. She stated that the incident on 8/9/19 of Resident # 48 exposing himself to Resident #24 was not a reportable event and this was a behavior. The Administrator also stated on 9/15/19 at 12:50 p.m. that she had been the abuse coordinator since 8/1/19. The facility could not provide any additional evidence to demonstrate any further investigative actions taken as a result of this allegation of sexual abuse. The only statement obtained from Resident #24 was in the form of a grievance. There was no documentation of any staff interviews, related to any knowledge of Resident # 48's sexual abuse towards Resident #24 or any awareness of any other concerns with the behavior of Resident #48. There was no documentation that other residents had been interviewed to determine if any similar occurrences had happened to them with Resident #48. Review of a nursing progress note found in Resident #24's record, dated 9/7/19 at 12:50 p.m. revealed On Saturday 9/7/19, I was informed by activities CNA that resident had c/o (complained of) male resident housed in adjacent room (Resident # 48's room number) was coming into room and exposing private part to female resident on numerous occasions. Supervisor addressed nurse on duty about matter and made arrangements to move female resident to a different part of hall. Resident stated that she was fine and did not want to move from current room. Resident stated to nurse that 'I can handle it, I'm okay. I don't need to be moved.' There was a Stop sign on female resident's door to alert male resident that entering is not allowed. Will continue to monitor resident for recurrent behavior and will continue to redirect. Will monitor for any changes in condition. Review of a nursing progress note dated 9/7/19 at 14:36 p.m. (2:36 p.m.) revealed Resident approached by this nurse asking if she would like to move her room down the hall so she could feel more comfortable due to the occurrence last week. Resident states she is fine with all the residents, no c/o (complaints) of being near any certain residents, does not want to move rooms. Resident states she would like to stay in her room so she can watch over her roommate. Resident was instructed to let a nurse or any other employee know if she feels uncomfortable. An interview was conducted with the 200/300 Unit Manager, on 9/12/19 at 4: 27 p.m. She stated she was not aware of any further incidents with Resident # 48 and # 24. She stated, I can only assume it was him (referring to Resident #48) that the 9/7/19 note was referring to. There was no documentation in the 2019 [MEDICATION NAME] book/abuse log and no documentation in the incident/occurrence log related to Resident #24's allegations of sexual abuse documented in the nursing progress note of 9/7/19. During an interview with the Administrator and the DON, on 9/13/19 at 10:18 a.m., the Administrator stated that she was still investigating as to whether there was another incident with Resident #48 and Resident #24 in (MONTH) 2019. The DON stated she had spoken briefly to Resident #24 the day before and Resident #24 referred to Resident #48 as that terrible man and stated he had not bothered her in a long time. On 9/14/19 at 12: 15 p.m. The Administrator stated she had not yet spoken to the activities assistant who reported to the nurse on 9/7/19 and had not yet spoken to the nurse who wrote the note. Despite the allegation documented in Resident # 24's record on 9/7/19, the allegation as of 9/14/19, had not been fully investigated. 4. Review of the record for Resident # 34 revealed [DIAGNOSES REDACTED]. Review of a Significant Change in Condition MDS assessment dated [DATE] revealed that the Brief Interview for Mental Status was not conducted as the resident was rarely/never understood. The section for mental status indicated short and long-term memory problems. Cognitive skills for daily decision making were documented as moderately impaired. Functional status indicated Resident # 34 required extensive assist of one for bed mobility and transfer, and total dependence for locomotion on and off the unit. Functional limitations in range of motion indicated impairment on both sides of upper and lower extremities. A care plan dated 11/3/17 with a revision date of 9/12/19 indicated (Resident # 34) has impaired short and long- term memory loss. Sometimes understood and sometimes understands others. She does have impaired decision- making skills due to Dx: Dementia, [MEDICAL CONDITION] with Paranoia and [MEDICAL CONDITION]. At risk for further fluctuations and changes in cognition. On 09/10/19 at 11:56 a.m., Resident #34 was observed in bed. The resident was observed swinging her arms in the air. The resident was frail and could not answer simple questions. An allegation of sexual abuse was reported from a CNA, Staff T, on 9/7/19 to Staff A, Licensed Practical Nurse (LPN) , per Staff T's report. Neither Staff T or Staff A reported this to the Administrator (Abuse Coordinator) on 9/7/19, therefore an investigation of this allegation was not initiated until 9/13/19 when Staff T reported it again. On 9/14/19 at approximately 10:17 a.m. the Administrator and DON were asked if there had been another incident involving Resident #48 that they were aware of and had not reported to the survey team. The Administrator stated yes, they were notified yesterday (9/13/19) from a CNA ,Staff T, that Resident #48 tried to kiss Resident #34 on 9/7/19. She stated that the CNA, Staff T, reported it to the nurse (Staff A, LPN) at the time it occurred and (Staff A) did not report it. She stated an investigation was initiated and it was reported to the abuse hotline, law enforcement and the State survey agency on 9/13/19. She stated Staff A was suspended for not reporting. A telephone interview was conducted with Staff T, on 9/14/19 at 10: 20 a.m. She stated she was working on the 200 Unit, on 9/7/19 and she saw Resident #48 (who resided on the 300 unit) and Resident # 34 ( who resided on the 200 unit) sitting together in the hallway. Resident #34 was seated in a geriatric chair and Resident #48 was next to her in his wheelchair. She stated she saw Resident #48 rubbing Resident #34's hand and shoulder, and then he moved toward Resident #34's face like he was going to kiss her. She stated, He acted like he was going to kiss her. This was not okay for him to do. She stated she distracted him by saying he needed to go back to his hall to eat his lunch. She took him back to his unit and reported it to the nurse, Staff [NAME] Staff T stated that on Friday, 9/13/19, she was getting an abuse in-service from a nurse and during the in-service she asked the nurse if she had heard about what happened last weekend. She stated the nurse told her no, and she explained what she saw with Resident # 48 and Resident #34. The nurse told her to go report it to the Administrator, which she did. Review of the Statement written by Staff T revealed, I witnessed (Resident # 48) trying to kiss (Resident #34) on 200 hall. He was also rubbing on her shoulder and hands. I reported it to the 300 hall nurse (Staff A). After that I asked (Resident # 48) to go to his room and eat lunch. 9/7/19. The Administrator, on 9/14/19 at approximately 12:15 p.m. stated, She (referring to Resident #34) is incapacitated, as is he (referring to Resident #48). They are both incapacitated. Despite this sexual abuse being observed and reported by a CNA (Staff T), on 9/7/19, nothing was done to protect this resident (Resident #34) and other residents from sexual abuse from Resident #48 until 9/13/19. On 9/13/19, the Administrator provided documentation that she had notified the abuse hotline, law enforcement, and the State survey agency regarding the alleged sexual abuse by Resident #48 on Resident #46 and #34. A review of Resident #48's clinical record revealed a Behavioral Medicine note by the Psychiatrist, dated 6/19/19 related to the incident with Resident #46. and signed by a Psychiatrist, which stated, Reason for Visit: Seen today for psychiatric evaluation due to inappropriate behavior. Interim History of Present Illness: (description of Resident # 48) was reportedly seen by staff groping a female peer under her blouse. They were easily re-directed and when asked, he did not recall the event 'but wished he did.' He had the same response today, denying any recall of the event. No recurrence of behavior and not seeking out any female residents. No other changes in mood/ behaviors. Risk to others: checked as no evidence. Clinical Status and Impressions: Dx (diagnoses) [MEDICAL CONDITION] late onset; Dementia (Alzheimer's type) with Behavioral Disturbances. It appears this event is a one -time thing, and I see no clear pattern of recurrence. He is not seeking out this female peer, nor any other females on the unit. No pharmacologic interventions, as staff will continue to redirect as needed. Continued review of Resident #48's clinical record revealed a Medication Management Assessment on 8/14/19 by the psychiatrist related to the 8/9/19 incident involving Resident #24. Chief complaint was documented as Other - inappropriate behavior. Context- He reportedly exposed his private parts to a female peer, wheeling himself to her room. He reports not knowing what happened. Under the section for Assessment and Recommendations the psychiatrist documented Patient with disinhibited behavior on the unit, denies recall of the event. Explaine

Based on observation, resident and staff interviews, clinical record review and facility policy review it was determined that the facility failed to provide supervision to Resident #48, who was known to the facility staff as having committed unsafe and sexually inappropriate behaviors toward one (#47) of six residents sampled for accidents and three (#46, #24, #34) of six female residents reviewed for abuse. The facility failed to ensure behavioral medicine recommendations were implemented and failed to develop and implement meaningful care plan interventions related to behaviors and sexually inappropriate behaviors for Resident #48. The facility failed to alert and educate staff on specific interventions to prevent continued unsafe and sexually inappropriate behaviors by Resident #48. On 5/8/19, Resident #48 was witnessed by staff trying to feed Resident #47, a cognitively impaired resident with physician orders [REDACTED]. On 6/18/19, Resident # 48 was witnessed to sexually abuse Resident #46 by placing his hand under her shirt and touching her breast. Resident #46 was a vulnerable female adult with cognitive impairment with no ability to consent to physical contact by Resident #48. On 8/9/19, Resident #24, an alert and oriented resident, reported to staff that Resident #48 entered her room and exposed his penis. Resident #24, exhibited distress, depression, and was tearful following this event. On 9/7/19, Staff T, Certified Nursing Assistant (C.N.[NAME]) observed Resident #48 sitting next to Resident #34, rubbing her hand and shoulder and leaning in to kiss the cognitively impaired female resident who lacked the ability to consent to Resident #48's actions. Staff T took Resident #48 back to his unit and reported the event to the nurse, Staff A, Licensed Practical Nurse (LPN). Staff A took no action following this report. The continuous failure to implement and develop interventions, provide monitoring supervision and staff training related to the repeated actions of Resident #48 placed all vulnerable residents in the facility at risk and resulted in findings of Immediate Jeopardy on 9/16/19 at 9:08 p.m. Review of the facility's corrective action plan revealed that the Immediate Jeopardy was removed on 9/16/19 and the scope and severity reduced to a E. Findings included: 1. Review of the record for Resident # 48 revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment for Resident #48, dated 6/11/19 revealed a score of 7 on the Brief Interview for Mental Status (BIMS) assessment (severe cognitive impairment). Functional Status for Activities of Daily Living included supervision with one-person physical assist for bed mobility, transfer, walk in room, walk in corridor, dressing, toilet use and personal hygiene. Resident #48 was noted to be independent with locomotion on and off unit eating. He utilized a cane for ambulation and a wheelchair. Observations of Resident #48 revealed: 9/12/19 at 4:30 p.m., Resident #48 was observed seated in his wheelchair in the door way of his room, watching all who passed by in the hall. 9/13/19 at 9:30 a.m., Resident #48 was observed wheeling himself down the hall on the 300 unit towards the nursing station. 9/13/19 at 10: 00 a.m., Resident #48 was observed seated in the dining/activity room between the 200 and 300 units. He appeared to be watching the activity. 9/14/19 at 9:28 a.m., Resident #48 was observed laying on his bed. One to One staff member was observed seated in a chair outside of his room. 9/15/19 at 10: 36 a.m., Resident #48 was observed ambulating in hall with his cane while holding the arm of a family member. Family member had just signed him out to take him to church. Resident #48 and the family member were observed ambulating through the halls, exited through the front door, and Resident #48 waited under the covered entrance while the family member brought the car around. Review of a nursing progress note found in Resident #48's clinical record, written by the MDS Coordinator, on 5/8/19 at 14:06 p.m. (2:06 p.m.) revealed, I was asked by nurse to translate to resident, nurse observed resident trying to feed cookies to another resident who is NPO (nothing by mouth). When I spoke with res (resident) he said God can lift the dead. I explained that the res is not dead and that he could not feed her. Res insisted God will take care of her. Other res moved away again from res. Social Services will contact family to reinforce to res about not feeding another res. A subsequent note, dated 5/8/19 and signed by the Social Service Assistant (SSA), revealed, SSA contacted daughter . at . SSA informed ( family member) that her father was caught giving a cookie to a resident. She stated he did the same thing in the past because he lives to share his food, but she will remember to tell him again. An interview was conducted with Staff L, a Licensed Practical Nurse (LPN) on 9/12/19 at 4:53 p.m. Staff L stated that he was the nurse who stopped him from going to her with a cookie. He stated he doesn't remember if Resident #48 fed the cookie to the resident or if the resident was attempting to feed the cookie. He remembered him going over to her and going up towards her with it. He identified the female resident as Resident #47. Review of the record for Resident #47 revealed [DIAGNOSES REDACTED]. Review of a 5/7/19 nutrition/ dietary progress note revealed, She is totally dependent on TF ( Tube Feed) for nutritional intake at this time. Review of a 5/16/19 nutrition/dietary note revealed, Resident #47 receives 100% nutrition hydration needs via enteral delivery reference to TBI ([MEDICAL CONDITION]) with inability to consume adequate nutrition/hydration. There was no documentation found in Resident #47's record related to this incident on 5/8/19, no notification to the family and there was no documentation of this incident on the occurrence/ incident reporting log. On 9/15/19 at 12:15 p.m., an interview was conducted with the Administrator, Director of Nursing (DON), 200/300 Unit Manager, Assistant Director of Nursing (ADON) and the Social Service Assistant (SSA). The SSA stated that she was notified by Staff L, LPN that (Resident #48) had fed a cookie to one of the residents, and she reached out to Resident # 48's daughter about it. The 200/300 Unit Manager stated that she remembered it being reported to her, but she was not aware of the specifics. She stated she let the SSA so that she (SSA) could update the care plan and reach out to psych services if needed. She stated that if it was on the 24 hours report she would have reviewed it and the incident would have been reviewed at the morning meeting. She stated, I do remember knowing about it, I just can't remember what was done. The 200/300 Unit Manager, the ADON, and the Social Service Assistant do not remember if it was discussed at a morning meeting. The Administrator stated she had reached out to the former Administrator, but he did not keep morning meeting minutes. A care plan, initiated 11/15/17 and revised on 6/28/19, revealed a focus of The resident has potential to demonstrate physical behaviors toward staff r/t (related to) Dementia, non-compliant with showering. 5/8/19 Observed by staff attempting to feed NPO (Nothing by Mouth ) pt (patient). The goal was: The resident will not harm self or others through the review date. Interventions included: Analyze key times, places, circumstances, triggers and what de-escalates behavior and document. Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc. Monitor/document report to MD (Medical Doctor) of danger to self and others. Psychiatric/Psychogeriatric consult as indicated. Re-educate resident as needed to not feed other residents. When the resident becomes agitated: Intervene before agitation escalates. Guide away from source of distress. Engage calmly in conversation; if response is aggressive, staff to walk calmly away and approach later. On 9/15/19 at 12:15 p.m., the 200/300 Unit Manager stated, We would have just directed him away from her. She confirmed there was no other documentation or specific plan to ensure Resident #48 would not feed this resident or another resident. There was no documentation provided by the facility of any specific education or training provided to staff on supervision and monitoring of Resident #48 after this incident. In addition, there was no documentation of any increased supervision for Resident #48 following this initial incident of unsafe behavior towards a vulnerable resident. Review of Resident # 48's record revealed a Behavioral Medicine note, dated 6/19/19 and signed by a Psychiatrist, which stated, Reason for Visit: Seen today for psychiatric evaluation due to inappropriate behavior. Interim History of Present Illness: (description of Resident # 48) was reportedly seen by staff groping a female peer under her blouse. They were easily re-directed and when asked, he did not recall the event 'but wished he did.' He had the same response today, denying any recall of the event. No recurrence of behavior and not seeking out any female residents. No other changes in mood/ behaviors. Risk to others: checked as no evidence. Clinical Status and Impressions: Dx (diagnoses) [MEDICAL CONDITION] late onset; Dementia (Alzheimer's type) with Behavioral Disturbances. It appears this event is a one -time thing, and I see no clear pattern of recurrence. He is not seeking out this female peer, nor any other females on the unit. No pharmacologic interventions, as staff will continue to redirect as needed. There was no additional documentation in Resident# 48's record regarding this occurrence. 2. An interview was conducted with the 200/ 300 Unit Manager, on 9/12/19 at approximately 12:15 p.m. She stated that Resident #48 and Resident #46 were sitting beside each other. Resident #48's hand was under her (Resident # 46's) armrest and under her shirt near her breast. She stated Resident # 48's hand was not moving, just kind of sitting there. She stated she asked Resident #48 to come with her and as she was walking towards him, he took his hand out. She stated she told him he could not do that. She stated she had not spoken to Resident #46 but she (Resident # 46) said, I am a grown woman. She stated she let social services know what had occurred. An interview with the 200/300 Unit Manager on 9/12/19 at 4:36 p.m. revealed that she believed the resident whose breast was touched by Resident # 48 was Resident # 46. She stated the intervention for Resident #46 was to redirect her when she comes up the hill by herself (referring to the slope coming out of the 400 unit to the rest of the facility).The 200/300 Unit Manager did not state that there were any interventions or supervision being utilized for Resident #48 who exhibited the inappropriate touching. On 9/12/19 at 5: 30 p.m., an interview was conducted with the Director of Social Services (DSS) She stated that in (MONTH) 2019 she was the Abuse Coordinator. She stated she was not aware of this incident between Resident #48 and Resident #46 and had not investigated. On 9/12/19 at 5: 30 p.m., an interview was conducted with the Director of Social Services (DSS). She stated that in (MONTH) 2019 she was the Abuse Coordinator. She stated, she was not aware of this incident between Resident # 48 and Resident # 46, and she had not investigated. On 9/13/19, the Director of Nursing (DON) provided a folder with an investigation conducted by the DSS on 6/18/19 regarding the alleged sexual abuse of Resident #46 by Resident #48. Included in the folder was a statement by the Unit Manager of 200/300. Review of the statement, dated 6/18/19, revealed: As I was coming down the back hall going towards 300 from the nursing office, I saw (Resident # 48) and (Resident # 46) sitting at the corner of the hall next to the ramp going towards 400. When I got closer to them, I noted that (Resident # 48) had his hand up (Resident # 46's) shirt. I walked over to them and let (Resident #48) know he couldn't do that, and he immediately removed his hand. (Resident # 46) then said I 'm a grown woman and can do what I want.' I asked (Resident # 48) if he would come with me and he agreed to go back to 300 unit. I immediately let Social Services know and was told to call the daughter. I called the daughter and let her know. She voiced no concerns. Review of the DSS documented interview with Resident #46 dated 6/18/19 revealed, SW (Social Worker) was asked to speak with resident regarding alleged inappropriate behaviors with another male resident. Information from nurse was male resident was seen with his hand under resident's shirt. Per nurse, both residents were immediately separated from the area. Both residents were redirected back towards their own halls. Resident was up in wheelchair propelling towards Activities room. SW spoke with resident on screened porch. SW asked resident if she has any concerns or complaints. Resident (#46) responded no, only you stopping me and asking me stuff. SW attempted to ask resident about the alleged incident with male resident. (Resident # 46) denied any event occurring with another male resident. She then went on to state, 'I am an adult and can do as I want.' She then became frustrated and began propelling herself towards the door. SW attempted to re- direct back to conversation. Resident stated, ' We are done.' SW assisted resident back to unit. Continued review of the investigation folder for the 6/18/19 event between Resident #48 and Resident #46 revealed a note written by DSS on 6/18/19, which revealed, Discussed statements from residents with DON and Interim Administrator. No need to report. Will keep soft file. Review of the record for Resident # 46 revealed the only documentation related to this incident of sexual abuse was a Behavioral Medicine note, written by a Psychiatrist and dated 6/19/19. Review of this note revealed Reason for Visit: Seen today for psychiatric evaluation after being found in an inappropriate situation with a peer. Interim History of Present Illness: She is confused and was found by staff with a male resident's hands inside her blouse. They were easily separated. Today, I asked her about the event, and she denied the event but later on said 'It's none of my business.' (Resident #46) wanders all around the facility, self-propelling her chair, gets angry when redirected . She is not observed to be seeking out this male peer and vice versa. Clinical Status and Impression: Dx [MEDICAL CONDITION] late onset, Dementia (Alzheimer's Type) with behavioral disturbance. Continue current medications. I see no reason to make adjustments in her meds. Staff will continue to reorient and redirect. She appears to have not been traumatized by any event, and this situation did not appear to be unpleasant to her. The Behavioral Medicine Note from the Psychiatrist indicated that Resident #46 was Unreliable/ Unable to participate due to condition/ dementia. Poor historian due to dementia. Orientation: person; Fund of Knowledge: Limited/ Impaired; Insight/ Judgement: Poor. Review of the record for Resident # 46 revealed [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment revealed it was a quarterly assessment dated [DATE]. Resident #46 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment. A score of 3 indicated severe cognitive impairment. A care plan initiated 7/11/18 and revised 7/30/18 revealed Resident # 46 had impaired cognitive function as evidenced by impaired decision-making skills. She was oriented to person, had short term, long term memory impairment related to dementia. Resident #46 utilized a wheelchair and was able to propel herself throughout the facility. Resident # 46 had a care plan, initiated 7/11/18 and revised 7/30/18, with a focus of potential for elopement due to: cognitive impairment, has periods of increased confusion, was exit seeking, wandered the unit and wandered near exit doors. Resident #46 is at continued risk from Resident # 48 due to her cognitive impairment, poor judgement/insight, and her propensity to wander. There was no additional documentation in Resident #46's record regarding this incident of sexual abuse on 6/18/19. Observation of Resident #46, on 9/14/19 at 11: 50 a.m. revealed a petite frail female, seated at a table in the dining room in her wheelchair eating lunch. An attempt was made to interview Resident #46. She was pleasantly confused and was unable to recall the event. Review of a behavioral medicine note in Resident # 48's record, written by the psychiatrist, 6/19/19 in response to the inappropriate sexual behavior of Resident # 46 revealed staff will continue to redirect as needed. After the sexual abuse incident with Resident # 46 on 6/18/19, the following care plan was initiated for Resident #48: (Resident # 48) exhibits the following behaviors: Socially Inappropriate AEB ( As Evidenced By) touching residents inappropriately, feeding residents etc. The goal stated Resident will exhibit a decrease in the number of behavior episodes by the next reviewed date. Interventions were documented as: Anticipate care needs and provide them before resident becomes overly stressed, Approach resident in a calm manner and explain actions, Re-approach resident if agitation is noted, Invite to and encourage activity programs consistent with resident's interests, Intervene as needed to protect the rights and safety of residents and others: remove from situation as able, Request psychiatric consult as needed, Update physician of increase in presence or severity of behaviors as indicated. A phone interview on 9/16/19 at 5:02 p.m. with Resident #48's Primary Care Physician, who was the Medical Director, revealed he was contacted by the facility on Thursday (9/12/19) regarding Resident # 48's sexual behavior towards other residents. He reported he came into the facility that night to see the resident and to follow the psych recommendations. He reported that he was not aware of any other prior sexually inappropriate incidents by Resident #48. An interview on 9/16/19 at 8:51 a.m. with the 200/300 Unit Manager and the DON regarding the care plan interventions for Resident #48 related to agitation and stress revealed they had never seen him agitated or stressed. They did not know why those interventions were listed. On 9/12/19 at 4:36 p.m., the 200/300 Unit Manager was interviewed related to the incident on 6/18/19. She did not state that there were any interventions that were being utilized to keep Resident #48 from repeating this inappropriate sexual behavior with other residents or any documentation or plan to monitor Resident #48's whereabouts and offer redirection. There was no documentation provided by the facility of any specific education or training provided to staff on supervision and monitoring of Resident #48 after this second incident. In addition, there was no documentation of any increased supervision for Resident #48 following the second incident of inappropriate behavior towards a vulnerable resident. 3. Review of the facility grievance log revealed an entry for 8/9/19 for a grievance filed by the Social Service Assistant on behalf of Resident #24. The nature of the grievance was documented as wandering resident exposing in common areas and the grievance was noted to be resolved on 8/9/19. Review of a form titled Investigation of Concern or Grievance dated 8/9/19 for Resident #24 revealed under specifics of concern or grievance, See Attachment. Attached to this form was a note, dated 8/9/19, written by the Social Services Assistant. Review of the note revealed, The Social Services Assistant was pulled to the side by (Staff L, LPN) along with (the 200/300 Unit Manager) regarding an incident involving (Resident #24 and Resident #48). (Staff L) stated that (Resident #24) approached him and stated that (Resident #48) showed her his penis. Social Services approached (Resident #24) in her room and shut the door. Social Services asked (Resident # 24) what happened. She stated she was sitting in her wheelchair facing her television. She stated (Resident #48) came to her doorway and had his penis out. She stated she was shocked and yelled at him to leave her room. She stated he continued to sit there staring at her. She stated she continued to tell him to leave her room. She stated he finally left her room and positioned himself in front of the window at the end of the hallway. She stated she was shocked because she has always seen him as a nice guy. She stated everyone in that area are friends and she did not expect it. Social Services asked (Resident # 24) if anyone else had seen him do it and she stated no. She stated she told (another male resident ) after it happened. She stated she no longer wants him anywhere near her. She stated she is disgusted and unhappy that it happened. Social Services stated they will reach out to (Resident # 48) in regard to the situation. She stated thank you and retreated back into her room. Continued review of the Grievance form indicated under findings of investigative process - spoke with resident regarding incident. The recommendations and corrective actions section included: fabric stop sign placed across door of resident (Resident #24). Resident agreeable and happy. Roommate and Health Care Proxy notified and agreeable. Guardian notified. The findings were noted to be reported to Resident # 24 and her family member on 8/9/19 ( the date of the sexual abuse incident). An interview was conducted with Resident # 24 , on 9/11/19 at 12:30 p.m. She stated that she was sitting in her room watching TV when Resident #48 came in her room and exposed his genital area to her. She stated she was shocked and asked him what he thought he was doing. She stated she went down the hall and told everyone, nurses and CNAs (Certified Nursing Assistants) both. She stated she was distressed by this, It was terrible, and he shouldn't be doing that. Resident # 24 appeared traumatized from the event and repeatedly stated she was shocked, and this was terrible. Review of the record for Resident # 24 revealed a progress note, dated 8/13/19 and written by the Social Service Assistant (SSA). The progress note stated, Late entry: S.S. (Social Services) conducted the first F/U ( Follow Up) regarding the incident reported on 8/9/19 on 8/12/19. Resident stated she was okay. Resident appeared to become teary-eyed. Resident continued to state she was doing okay. She stated she sees him, but he does not bother her. S.S reached out to (family member) and informed him of the incident. S.S made a referral for Psych services. S.S conducted second F/U on resident. She was organizing her belongings. She stated she is doing just fine. She stated she is still disgusted by what happened, but he has not come by her room. S.S will conduct a third F/U on 8/14/19. An additional progress note dated 8/14/19 by the SSA for Resident #24, stated, Day 3 F/U. Resident was seen by Psychiatry. Resident informed the psychiatrist that resident attempted to approach residents' room but was re-directed by staff. Resident stated she is okay, just disgusted by resident and would like him to stay away from her or change units. There was no documentation in the medical record other than the Social Service Follow Up notes to indicate what had occurred as stated in the 8/9/19 grievance. Review of a Behavioral Medicine Note dated 8/14/19 revealed, She is upset after an incident with a male resident but appreciates staff assistance in keeping him away from her room. She is depressed with tearful episodes, no clear reason. Review of the record for Resident #24 revealed diagnoses, which included cerebral infarction due to embolism of left middle cerebral artery, dysphagia following cerebral infarction, [MEDICAL CONDITION] unspecified affecting right dominant side, anxiety disorder, major [MEDICAL CONDITION], and muscle weakness. Review of a quarterly MDS assessment, dated 8/22/19, revealed a score of 13, cognitively intact, on the Brief Interview for Mental Status. Locomotion on the unit (including her room) and off unit was noted to be an extensive assist of one personal physical assist. A care plan for communication, dated 6/19/19, indicated Resident #24 had strength in communication as evidenced by able to hear at normal tones, speech was clear and easily understood and communicated needs to staff. An interview was conducted with the 200/300 Unit Manager on 9/12/19 at 4:27 p.m. She stated that Resident #48 was independent with everything, refuses showers, does his own thing. She stated he sits at the end of the hall and watches traffic or sits with other Spanish speaking residents. Regarding the allegation of exposing himself to Resident #24 she stated, Apparently that happened, but I have not seen him do it. No residents have expressed concern about him other than (Resident #24). She stated she (referring to Resident # 24) said he exposed himself. Both residents were confused with mental status that comes and goes. She stated no one saw it. An interview was conducted with the Administrator, on 9/12/19 at 1:28 p.m. and again on 9/15/19 at 12:50 p.m. She stated that the incident on 8/9/19 of Resident #48 exposing himself to Resident #24 was not reportable as it was a behavior. Review of Resident #48's clinical record revealed a nursing progress note, dated 8/12/19 at 11:28 a.m., which stated, Called daughter . to speak to her about resident's behaviors, message left for return call. Another nursing progress note dated 8/12/19 15:23 (3:23 p.m.), which stated resident's daughter returned call. Spoke with her about his behaviors. Daughter stated she would speak with him about it. Continued review of Resident #48's clinical record revealed a Medication Management Assessment on 8/14/19 by the psychiatrist. Chief complaint was documented as Other - inappropriate behavior. Context- He reportedly exposed his private parts to a female peer, wheeling himself to her room. He reports not knowing what happened. Under the section for Assessment and Recommendations the psychiatrist documented Patient with disinhibited behavior on the unit, denies recall of the event. Explained to him that exposing himself to others is illegal and witnesses have the option to file a complaint with the police. He said he won't do it again. No medication changes were recommended. The Focus of the care plan, initiated 6/18/19, for (Resident # 48) exhibits the following behaviors: Socially Inappropriate AEB ( As Evidenced By) touching residents inappropriately, feeding residents etc. was updated on 8/9/19 to include: exposes himself in common areas. The interventions were not revised. There was no documentation provided by the facility of any specific education or training provided to staff related to supervision and monitoring of Resident #48 after this third incident. In addition, there was no documentation of any increased supervision for Resident #48 following this third incident, however, continued review of Resident #48's record revealed a nursing note dated 8/21/19 at 10:44 p.m., written by Staff O, LPN that stated, Resident alert and responsive, able to make needs known. Resident remains on one to one with staff member, resident has tried to touch staff member inappropriately, will continue to monitor. An interview was conducted with Staff O, on 9/12/19 at 4:25 p.m. She stated she did not know why Resident #48 was placed on one to one on 8/21/19 and thought it was only for one day. Interview with the 200/300 Unit Manager on 9/12/19 at 5:00 p.m. revealed that she did not know about this because she was out sick at that time and Staff L, the LPN, had worked for her. Staff L stated he was not sure why Resident #48 was on one to one. The Unit Manager stated that the decision to place someone on one to one was a decision made by more than one person and would include the Administrator and DON. Interview with the DON and Administrator, on 9/12/19 at 1:28 pm. revealed that they were both unaware of Resident #48 being placed on one to one on 8/21/19. The Administrator stated that there appeared to be more going on with Resident #48 then she was aware of and she would investigate. Continued review of Resident # 48's record revealed a Therapy Assessment, conducted by a Psychologist, on 8/27/19 . Review of the assessment indicated Chief Complaint was other - Inappropriate behavior. The assessment and recommendation documented: Patient has been presenting with inappropriate sexual behavior; however, he denies remembering these events. Patient appears calm and with stable mood. No stress symptoms evident. Clinician explained in Spanish consequences of inappropriate touching. Patient demonstrated an understanding. Daily repetition may be needed due to memory issues. Recommendations: Have daily routine for patient. and encourage participation in different activities in order to keep patient distracted. When patient approaches other residents remind him the need to keep his distance from other residents. There was no documentation found in Resident #48's record as to daily repetition of consequences or reminders to keep his distance from other residents as recommended by the Psychologist on 8/27/19. Continued investigation and review of an additional nursing progress note found in Resident #24's record, dated 9/7/19 at 12:50 p.m. revealed, On Saturday 9/7/19, I was informed by activities CNA that resident had c/o (complained of) male resident housed in adjacent room (Resident # 48's room number) was coming into room and exposing private part to female resident on numerous occasions. Supervisor addressed nurse on duty about matter and made arrangements to move female resident to a different part of hall. Resident stated that she was fine and did not want to move from current room. Resident stated to nurse that 'I can handle it, I'm okay. I don't need to be moved.' There was a Stop sign on female resident's door to alert male resident that entering is not allowed. Will continue to monitor resident for recurrent behavior and will continue to redirect. Will monitor for any changes in condition. Review of a nursing progress note dated 9/7/19 at 14:36 p.m. (2:36 p.m.) revealed, Resident approached by this nurse asking if she would like to move her room down the hall so she could feel more comfortable due to the occurrence last week. Resident states she is fine with all the residents, no c/o (complaints) of being near any certain residents, does not want to move rooms. Resident states she would like to stay in her room so she can watch over her roommate. Resident was instructed to let a nurse or any other employee know if she feels uncomfortable. There was no further documentation found in Resident # 24's record to indicate when the exposure of private parts to a female resident on numerous occasions had occurred. An interview was conducted with 200/300 Unit Manager, on 9/12/19 at 4:27 p.m. She stated she was not aware of any further incidents with Resident #48 and #24. She stated, I can only assume it was him (referring to Resident #48) that the 9/7/19 note was referring to. During an interview with the Administrator and the DON, on 9/13/19 at 10:18 a.m., the Administrator stated that she was still investigating as to whether there was another incident with Resident #48 and Resident #24 in (MONTH) of 2019. The DON stated she had spoken briefly to Resident #24 the day before and Resident #24 referred to Resident #48 as that terrible man and stated he had not bothered her in a long time. On 9/14/19 at 12: 15 p.m., the Administrator stated she had not yet spoken (TRUNCATED)

Based on a review of the facility's job description for the Administrator, Director of Nursing, and Assistant Director of Nursing, resident record reviews, resident and staff interviews, and review of facility policies it was determined the facility failed to utilize resources effectively to prevent sexual abuse perpetrated by Resident #48 against three (#46, #24, and #34) of six residents reviewed for sexual abuse. Facility administration failed to ensure all residents in the facility were protected from abuse, failed to ensure allegations of sexual abuse were fully investigated and reported, and failed to ensure staff provided the level of supervision warranted due to known behaviors and repeated allegations of sexual abuse by Resident #48. The facility administration had knowledge of Resident #48's actions and demonstrated a lack of commitment to prevent, investigate, and protect residents from sexual abuse which resulted in findings of Immediate Jeopardy on 9/16/19 at 9:08 p.m. Review of the facility's corrective action plan revealed that the Immediate Jeopardy was removed on 9/16/19 and the scope and severity reduced to an E. Findings included: 1. Review of the signed, 7/24/19, job description for the Administrator revealed : Purpose of Your Job Position The primary purpose of your position is to direct the day -to - day functions of the Facility in accordance with current federal, state and local standards, guidelines, and regulations that govern nursing facilities to assure the highest degree of quality of care can be provided to our residents at all times. Duties and Responsibilities Interpret the Facility's policies and procedures to employees, residents, family members , visitors, government agencies etc., as necessary. Ensure that all employees, residents, visitors, and the general public follow the Facility's established policies and procedures. Assume the administrative authority, responsibility, and accountability of directing the activities and programs of the Facility. Personnel Functions Schedule and participate in departmental meetings to ensure that appropriate information sharing is provided on a continuous basis. Inform the Medical Director of all suspected or known incidents of resident abuse. Safety and Sanitation Review accident and incident reports (e.g., falls, injuries of an unknown source, abuse, etc.). Monitor to determine the effectiveness of the Facility's Risk Management Program. Resident Rights Review resident complaints and grievances and make written reports of action taken. Discuss such action with resident and family as appropriate. Review complaints and grievances made by the resident and make a written or oral report to the Nurse Supervisor, LPN, or RN. Follow Facility's established procedures. Report all allegations of resident abuse and/ or misappropriation of resident property. Specific Requirements Must possess the ability to plan, organize, develop, implement, and interpret the program's goals, objective and procedures, etc., that are necessary for providing quality care and maintaining a sound operation. 2. Review of the signed, 5/26/19, job description for the Director of Nursing Services revealed : Purpose of Your Job Position The primary purpose of your position is to plan, organize, develop, and direct the overall operation of our Nursing Service Department in accordance with current federal , state and local standards, guidelines, and regulations that govern our Facility and as may be directed by the Administrator to ensure that the highest degree of quality care is maintained at all times. Duties and Responsibilities Plan, develop, organize, implement, evaluate, and direct the nursing service department, as well as its programs and activities, in accordance with current rules, regulations and guidelines that govern the nursing care facilities. Develop methods for coordination of nursing services with other resident services to ensure the continuity of the resident's total regimen of care. Develop, implement, and maintain an ongoing quality assurance program for the nursing service department. Monitor the Facility's QI, QM, and survey reports. Assist in developing plans of action to correct potential identified problem areas. Ensure that CNAs, department personnel, residents, and visitors follow the department's established policies and procedures at all times. Receive or provide the nursing report upon reporting in and ending shift duty hours. Nursing Care Functions Review nurses' notes to ensure that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to the care, and that such care is provided in accordance with the resident's wishes. Care Plan and Assessment Functions Assist in the development of preliminary and comprehensive assessments of the nursing needs of each resident. Develop a written plan of care (preliminary and comprehensive) for each resident that identifies the problems or needs of the resident, indicates the care to be given, goal to be accomplished, and which professional service is responsible for each element of care. Ensure that all personnel involved in providing care to the resident are aware of the resident's care plan. Ensure that nursing personnel refer to the resident's care plan prior to administering daily care to the resident. Review nurses' notes to determine if the care plan is being followed. Resident Rights Review complaints and grievances made by the resident and make a written or oral report to the Administrator. Follow Facility's established procedures. Maintain a written record of the resident's complaints and/or grievances that indicates the action taken to resolve the complaint and the current status of the complaint. Report all allegations of resident abuse and/or misappropriation of resident property. 3. Review of the unsigned and undated job description for the Assistant Director of Nursing revealed : Purpose of Your Job Position The primary purpose of your position is to assist the Director of Nursing Services in planning, organizing, developing, and directing the day -to-day function of the Nursing Services Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our Facility; and as may be directed by the Administrator, Medical Director, and/or the Director of Nursing Services to ensure the highest degree of quality care is maintained at all times. Duties and Responsibilities Assist the Director of Nursing Services ( the Director) in planning, developing, organizing, implementing, evaluation, and directing the day-to-day functions of the nursing service department, in accordance with current rules, regulations, and guidelines that govern the Facility. Assist in developing methods for coordinating nursing services with other resident services to ensure the continuity of the resident's total regimen of care. Participate in the development, maintenance, and implementation of the Facility's quality assurance program for the nursing service department Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary. Monitor the Facility's QI, QM and survey reports and provide the Director with recommendations that will be helpful in eliminating problem areas. Care Plan and Assessment Function Participate in the development of written preliminary and comprehensive assessments of the nursing needs of each resident. Participate in the development of a written care plan ( preliminary and comprehensive) for each resident that identifies the problems/needs of the resident, indicates the care to be given, goals to be accomplished, and which professional service is responsible for each element of care. Ensure that all personnel involved in providing care to the resident are aware of the resident's care plan. Ensure that nursing personnel refer to the resident's care plan prior to administrating daily care to the resident. Review nurses' notes to determine if the care plan is being followed. Review and revise care plans and assessments as necessary , but at least quarterly. Resident Rights Review complaints and grievances made by the resident and make a written or oral report to the Director of Nursing. Follow Facility's established procedures. Report all allegations of resident abuse and /or misappropriation of resident property. Report all allegations of resident abuse and/ or misappropriation of resident property. 4. An interview with the DON on 9/16/19 at approximately 4:00 p.m. revealed the facility did not have a job description for the Director of Social Services. 5. On 9/16/19 at 8:51 a.m., an interview with the Nursing Home Administrator (NHA), Director of Nursing (DON), 200/300 Unit Manager, and Assistant Director of Nursing (ADON), was conducted. The ADON, who was the Risk Manager, until about 2-3 weeks ago, stated that if there was a resident to resident incident, it would be on the occurrence log. She stated if the nurse filled out an occurrence report, now called an incident report, she would put the occurrence on the occurrence log. The ADON was asked to review the 2019 incident/occurrence log to determine if any sexual abuse by Resident #48 towards Residents #46, #24, and #34 was on the log. She stated that she did not see that an occurrence report was done. The ADON was asked if there were any resident to resident incidents reflected on the log and she stated no. She stated there would be no tracking if they were not on the incident/ occurrence log. The Administrator stated, We don't have a system in place to monitor what occurs. Facility administration was asked if any of the allegations of sexual abuse perpetrated by Resident #48 were in the abuse log/2019 [MEDICATION NAME] book. The Administrator stated they were not as they had not been reported to the authorities prior to 9/13/19. The administrative team was asked how Resident #48 was being monitored for inappropriate sexual behaviors prior to being placed on one to one supervision on 9/13/19. The Administrator stated that there was observation and redirection. She was asked where the documentation would be, and she stated it should be in the chart. They were asked how staff were educated on observation and monitoring of Resident #48. The 200/300 Unit Manager and the ADON stated that the education would have been shift to shift, from one staff to another passed on in report, and that it would have been verbal. The DON stated that nursing staff and unit managers should know where Resident #48 is. The DON was asked, all the time? She responded, I can't say all the time. No one was able to provide any documentation to support these statements. On 9/13/19, the Administrator provided documentation that she had notified the abuse hotline, law enforcement, and the State survey agency regarding the alleged sexual abuse by Resident #48 on Resident #46, #33, and #34. 6. Review of Resident #48's record revealed a Behavioral Medicine note, dated 6/19/19 and signed by a Psychiatrist, which stated, Reason for Visit: Seen today for psychiatric evaluation due to inappropriate behavior. Interim History of Present Illness: (description of Resident # 48) was reportedly seen by staff groping a female peer under her blouse. They were easily re-directed and when asked, he did not recall the event 'but wished he did.' He had the same response today, denying any recall of the event. No recurrence of behavior and not seeking out any female residents. No other changes in mood/ behaviors. Risk to others: checked as no evidence. Clinical Status and Impressions: Dx (diagnoses) [MEDICAL CONDITION] late onset; Dementia (Alzheimer's type) with Behavioral Disturbances. It appears this event is a one -time thing, and I see no clear pattern of recurrence. He is not seeking out this female peer, nor any other females on the unit. No pharmacologic interventions, as staff will continue to redirect as needed. There was no additional documentation in Resident# 48's record regarding this occurrence. An interview with the 200/300 Unit Manager on 9/12/19 at 4:36 p.m. revealed that she believed the resident whose breast was touched by Resident #48 was Resident # 46. She stated the intervention for Resident # 46 was to redirect her when she comes up the hill by herself (referring to the slope coming out of the 400 unit to the rest of the facility). The 200/300 Unit Manager did not state that there were any interventions that were being utilized to keep Resident # 48 from repeating this behavior with other residents. Review of the record for Resident #46 revealed the only documentation related to this incident of sexual abuse was a Behavioral Medicine note, written by a Psychiatrist and dated 6/19/19. Review of this note revealed Reason for Visit: Seen today for psychiatric evaluation after being found in an inappropriate situation with a peer. Interim History of Present Illness: She is confused and was found by staff with a male resident's hands inside her blouse. They were easily separated. Today, I asked her about the event, and she denied the event but later on said 'It's none of my business.' (Resident #46) wanders all around the facility, self-propelling her chair, gets angry when redirected . She is not observed to be seeking out this male peer and vice versa. Clinical Status and Impression: Dx [MEDICAL CONDITION] late onset, Dementia (Alzheimer's Type) with behavioral disturbance. Continue current medications. I see no reason to make adjustments in her meds. Staff will continue to reorient and redirect. She appears to have not been traumatized by any event, and this situation did not appear to be unpleasant to her. The Behavioral Medicine Note from the Psychiatrist indicated that Resident # 46 was Unreliable/ Unable to participate due to condition/ dementia. Poor historian due to dementia. Orientation: person; Fund of Knowledge: Limited/ Impaired; Insight/ Judgement: Poor. Review of the record for Resident # 46 revealed [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment revealed it was a quarterly assessment dated [DATE]. Resident #46 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment. A score of 3 indicated severe cognitive impairment. A care plan initiated 7/11/18 and revised 7/30/18 revealed Resident # 46 had impaired cognitive function as evidenced by impaired decision-making skills. She was oriented to person, had short term, long term memory impairment related to dementia. Resident #46 utilized a wheelchair and was able to propel herself throughout the facility. Resident # 46 had a care plan, initiated 7/11/18 and revised 7/30/18, with a focus of potential for elopement due to: cognitive impairment, has periods of increased confusion, was exit seeking, wandered the unit and wandered near exit doors. There was no additional documentation in Resident # 46's record regarding this 6/18/19 incident of sexual abuse. Observation of Resident #46, on 9/14/19 at 11:50 a.m. revealed a petite frail female resident, seated at a table in the dining room in her wheelchair eating lunch. An attempt was made to interview Resident #46, she was pleasantly confused and was unable to recall. On 9/12/19 at 5:30 p.m., an interview was conducted with the Director of Social Services (DSS). She stated that in (MONTH) 2019 she was the Abuse Coordinator. She stated, she was not aware of this incident between Resident # 48 and Resident # 46, and she had not investigated. On 9/13/19, the DON provided a folder with an investigation conducted by the DSS on 6/18/19 regarding the alleged sexual abuse of Resident #46 by Resident #48. Included in the folder was a statement by the Unit Manager of 200/300. Review of the statement, dated 6/18/19, revealed: As I was coming down the back hall going towards 300 from the nursing office, I saw (Resident # 48) and (Resident # 46) sitting at the corner of the hall next to the ramp going towards 400. When I got closer to them, I noted that (Resident # 48) had his hand up (Resident # 46's) shirt. I walked over to them and let (Resident #48) know he couldn't do that, and he immediately removed his hand. (Resident # 46) then said, 'I'm a grown woman and can do what I want.' I asked (Resident # 48) if he would come with me and he agreed to go back to 300 unit. I immediately let Social Services know and was told to call the daughter. I called the daughter and let her know. She voiced no concerns. Review of the DSS documented interview with Resident #46 dated 6/18/19 revealed, SW (Social Worker) was asked to speak with resident regarding alleged inappropriate behaviors with another male resident. Information from nurse was male resident was seen with his hand under resident's shirt. Per nurse, both residents were immediately separated from the area. Both residents were redirected back towards their own halls. Resident was up in wheelchair propelling towards Activities room. SW spoke with resident on screened porch. SW asked resident if she has any concerns or complaints. Resident (#46) responded no, only you stopping me and asking me stuff. SW attempted to ask resident about the alleged incident with male resident. (Resident # 46) denied any event occurring with another male resident. She then went on to state, 'I am an adult and can do as I want.' She then became frustrated and began propelling herself towards the door. SW attempted to re- direct back to conversation. Resident stated, ' We are done.' SW assisted resident back to unit. Continued review of the investigation folder for the 6/18/19 event between Resident #48 and Resident #46 revealed a note written by DSS on 6/18/19, which revealed, Discussed statements from residents with DON and Interim Administrator. No need to report. Will keep soft file. Review of the investigation file revealed the only resident interviews that were conducted were with Resident # 48 and Resident # 46. There was no documentation that other residents had been interviewed to determine if any similar occurrences had happened to them with Resident #48. There was no documentation of any staff interviews, besides the 200/300 Unit Manager's written statement, related to any knowledge of Resident # 48's sexual abuse toward Resident #46 or any awareness of any other concerns with the behavior of Resident #48. A follow-up interview was conducted with the 200/ 300 Unit Manager, on 9/12/19 at approximately 12:15 p.m. She stated that Resident # 48 and Resident # 46 were sitting beside each other. Resident #48's hand was under her (Resident # 46's) armrest and under her shirt near her breast. She stated Resident # 48's hand was not moving, just kind of sitting there. She stated she asked Resident #48 to come with her and as she was walking towards him, he took his hand out. She stated she told him he could not do that. She stated she had not spoken to Resident #46 but she (Resident # 46) said, I am a grown woman. She stated she let social services know what had occurred. On 9/13/19 at 8:30 a.m., the DON stated that when she was reading the investigation, there was no statement from her. She stated, I would not say not to report something if someone puts someone's hand up someone's shirt. I heard he was touching himself and offered privacy. To my recollection he was touching himself, not someone else. She stated she was going to report this now. On 9/12/19 at 5:17 p.m., the current NHA stated, I wish I could speak to it, but I was not here. The NHA stated she was not aware of this incident. A review of the employee roster revealed the current NHA began employment at the facility on 07/24/19. The facility was asked to provide an abuse log on 9/12/19. Review of the book provided titled 2019 reportable incidents revealed no entry or information related to this 6/18/19 sexual abuse allegation. Review of the incident log/occurrence log from (MONTH) 2019 to (MONTH) 2019 revealed no entry for this 6/18/19 sexual abuse allegation. The facility could not provide any additional evidence to demonstrate any actions taken as a result of this 06/18/19 event. 7. Review of the facility grievance log revealed an entry for 8/9/19 for a grievance filed by the Social Service Assistant on behalf of Resident #24. The nature of the grievance was documented as wandering resident exposing in common areas and the grievance was noted to be resolved on 8/9/19. Review of a form titled Investigation of Concern or Grievance dated 8/9/19 for Resident #24 revealed under specifics of concern or grievance, See Attachment. Attached to this form was a note, dated 8/9/19, written by the Social Services Assistant. Review of the note revealed, The Social Services Assistant was pulled to the side by (Staff L, LPN) along with (the 200/300 Unit Manager) regarding an incident involving (Resident #24 and Resident #48). (Staff L) stated that (Resident #24) approached him and stated that (Resident #48) showed her his penis. Social Services approached (Resident #24) in her room and shut the door. Social Services asked (Resident # 24) what happened. She stated she was sitting in her wheelchair facing her television. She stated (Resident #48) came to her doorway and had his penis out. She stated she was shocked and yelled at him to leave her room. She stated he continued to sit there staring at her. She stated she continued to tell him to leave her room. She stated he finally left her room and positioned himself in front of the window at the end of the hallway. She stated she was shocked because she has always seen him as a nice guy. She stated everyone in that area are friends and she did not expect it. Social Services asked (Resident # 24) if anyone else had seen him do it and she stated no. She stated she told (another male resident ) after it happened. She stated she no longer wants him anywhere near her. She stated she is disgusted and unhappy that it happened. Social Services stated they will reach out to (Resident # 48) in regard to the situation. She stated thank you and retreated back into her room. Continued review of the Grievance form indicated under findings of investigative process - spoke with resident regarding incident. The recommendations and corrective actions section included: fabric stop sign placed across door of resident (Resident #24). Resident agreeable and happy. Roommate and Health Care Proxy notified and agreeable. Guardian notified. The findings were noted to be reported to Resident # 24 and her family member on 8/9/19 ( the date of the sexual abuse incident). Review of the record for Resident #24 revealed diagnoses, which included cerebral infarction due to embolism of left middle cerebral artery, dysphagia following cerebral infarction, [MEDICAL CONDITION] unspecified affecting right dominant side, anxiety disorder, major [MEDICAL CONDITION], and muscle weakness. Review of a quarterly MDS assessment, dated 8/22/19, revealed a score of 13, cognitively intact, on the Brief Interview for Mental Status. Locomotion on the unit (including her room) and off unit was noted to be an extensive assist of one personal physical assist. A care plan for communication, dated 6/19/19, indicated Resident #24 had strength in communication as evidenced by able to hear at normal tones, speech was clear and easily understood and communicated needs to staff. Review of the record for Resident #24 revealed a progress note, dated 8/13/19 and written by the Social Service Assistant (SSA). The progress note stated, Late entry: S.S. (Social Services) conducted the first F/U ( Follow Up) regarding the incident reported on 8/9/19 on 8/12/19. Resident stated she was okay. Resident appeared to become teary-eyed. Resident continued to state she was doing okay. She stated she sees him, but he does not bother her. S.S reached out to (family member) and informed him of the incident. S.S made a referral for Psych services. S.S conducted second F/U on resident. She was organizing her belongings. She stated she is doing just fine. She stated she is still disgusted by what happened, but he has not come by her room. S.S will conduct a third F/U on 8/14/19. An additional progress note dated 8/14/19 by the SSA for Resident # 24, stated, Day 3 F/U. Resident was seen by Psychiatry. Resident informed the psychiatrist that resident attempted to approach residents' room but was re-directed by staff. Resident stated she is okay, just disgusted by resident and would like him to stay away from her or change units. There was no documentation in the medical record other than the Social Service Follow Up notes to indicate what had occurred as stated in the 8/9/19 grievance. Review of a Behavioral Medicine Note dated 8/14/19 revealed, She is upset after an incident with a male resident, but appreciates staff assistance in keeping him away from her room. She is depressed with tearful episodes, no clear reason. Review of a nursing progress note found in Resident #24's record, dated 9/7/19 at 12:50 p.m. revealed On Saturday 9/7/19, I was informed by activities CNA that resident had c/o (complained of) male resident housed in adjacent room (Resident # 48's room number) was coming into room and exposing private part to female resident on numerous occasions. Supervisor addressed nurse on duty about matter and made arrangements to move female resident to a different part of hall. Resident stated that she was fine and did not want to move from current room. Resident stated to nurse that 'I can handle it, I'm okay. I don't need to be moved.' There was a Stop sign on female resident's door to alert male resident that entering is not allowed. Will continue to monitor resident for recurrent behavior and will continue to redirect. Will monitor for any changes in condition. Review of a nursing progress note dated 9/7/19 at 14:36 p.m. (2:36 p.m.) revealed Resident approached by this nurse asking if she would like to move her room down the hall so she could feel more comfortable due to the occurrence last week. Resident states she is fine with all the residents, no c/o (complaints) of being near any certain residents, does not want to move rooms. Resident states she would like to stay in her room so she can watch over her roommate. Resident was instructed to let a nurse or any other employee know if she feels uncomfortable. An interview was conducted with the 200/300 Unit Manager, on 9/12/19 at 4: 27 p.m. She stated she was not aware of any further incidents with Resident # 48 and # 24. She stated, I can only assume it was him (referring to Resident #48) that the 9/7/19 note was referring to. An interview was conducted with Resident # 24 , on 9/11/19 at 12:30 p.m. She stated that she was sitting in her room watching TV when Resident #48 came in her room and exposed his genital area to her. She stated she was shocked and asked him what he thought he was doing. She stated she went down the hall and told everyone, nurses and CNAs (Certified Nursing Assistants) both. She stated she was distressed by this, It was terrible, and he shouldn't be doing that. Resident # 24 appeared traumatized from the event and repeatedly stated she was shocked, and this was terrible. Review of Resident #48's clinical record revealed a nursing progress note, dated 8/12/19 at 11:28 a.m., which stated, Called daughter . to speak to her about resident's behaviors, message left for return call. Another nursing progress note, dated 8/12/19 15:23 (3:23 p.m.), which stated resident's daughter returned call. Spoke with her about his behaviors. Daughter stated she would speak with him about it. Continued review of Resident #48's clinical record revealed a Medication Management Assessment on 8/14/19 by the psychiatrist. Chief complaint was documented as Other - inappropriate behavior. Context- He reportedly exposed his private parts to a female peer, wheeling himself to her room. He reports not knowing what happened. Under the section for Assessment and Recommendations the psychiatrist documented Patient with disinhibited behavior on the unit, denies recall of the event. Explained to him that exposing himself to others is illegal and witnesses have the option to file a complaint with the police. He said he won't do it again. No medication changes were recommended. There was no documentation in the 2019 [MEDICATION NAME] book/abuse log and no documentation in the incident/occurrence log related to Resident #24's allegations of sexual abuse. An interview was conducted with the 200/300 Unit Manager on 9/12/19 at 4:27 p.m. She stated that Resident # 48 was independent with everything, refuses showers, does his own thing. She stated he sits at the end of the hall and watches traffic or sits with other Spanish speaking residents. Regarding the allegation of exposing himself to Resident # 24 she stated, Apparently that happened, but I have not seen him do it. No residents have expressed concern about him other than (Resident #24). She stated she (referring to Resident # 24) said he exposed himself, both residents were confused with mental status that comes and goes. She stated no one saw it. An interview was conducted with the Administrator, on 9/12/19 at 1:28 p.m. and again on 9/15/19 at 12:50 p.m. She stated that the incident on 8/9/19 of Resident #48 exposing himself to Resident #24 was not a reportable event and this was a behavior. The Administrator also stated on 9/15/19 at 12:50 p.m. that she had been the abuse coordinator since 8/1/19. During an interview with the Administrator and the DON, on 9/13/19 at 10:18 a.m., the Administrator stated that she was still investigating as to whether there was another incident with Resident #48 and Resident #24 in (MONTH) 2019. The DON stated she had spoken briefly to Resident #24 the day before and Resident #24 referred to Resident #48 as that terrible man and stated he had not bothered her in a long time. On 9/14/19 at 12:15 p.m. The Administrator stated she had not yet spoken to the activities assistant who reported to the nurse on 9/7/19 and had not yet spoken to the nurse who wrote the note. Review of Resident #48's clinical record revealed a nursing note, dated 8/21/19 at 10:44 p.m., written by Staff O, an LPN stated, Resident alert and responsive, able to make needs known. Resident remains on one to one with staff member, resident has tried to touch staff member inappropriately, will continue to monitor. Review of Resident #48's record revealed a Therapy Assessment, conducted by a Psychologist, on 8/27/19 . Review of the assessment indicated Chief Complaint was other - Inappropriate behavior. The assessment and recommendation documented: Patient has been presenting with inappropriate sexual behavior; however, he denies remembering these events. Patient appears calm and with stable mood. No stress symptoms evident. Clinician explained in Spanish consequences of inappropriate touching. Patient demonstrated an understanding. Daily repetition may be needed due to memory issues. Recommendations: Have daily routine for patient and encourage participation in different activities in order to keep patient distracted. When patient approaches other residents remind him the need to keep his distance from other residents. There was no documentation found in Resident #48's record as to daily repetition of consequences or reminders to keep his distance from other residents. An interview was conducted with Staff O, on 9/12/19 at 4:25 p.m. She stated she did not know why Resident # 48 was placed on one to one on 8/21/19 and thought it was only for one day. Interview with the DON and Administrator, on 9/12/19 at 1:28 pm. revealed that they were both unaware of Resident #48 being placed on one to one on 8/21/19. The Administrator stated that there appeared to be more going on with Resident #48 then she was aware of and she would investigate. 8. On 9/14/19 at approxim

Based on observation, interview of residents and staff, and record review the facility failed to provide First Aid Treatment Medical Emergency Services for one (#2) of 7 sampled residents related to a resident on anticoagulant therapy bleeding from their access [MEDICAL TREATMENT] port for approximately 10 hours, failed to provide medications on [MEDICAL TREATMENT] treatment days for 4 of 5 sampled residents (#1, #3, #6, and #7) as well as documentation for checking [MEDICAL TREATMENT] for signs of infection and bleeding for Resident #3. Findings included: 1. Record review of Emergency Management Services Summary dated 03/02/19, arrived on scene at 5:01 a.m. showed per resident he had [MEDICAL TREATMENT] at 5:30 p.m. and his port had been bleeding since he got back from [MEDICAL TREATMENT] treatment. Upon arrival at 5:04 a.m. the resident was found lying supine in his bed with his left arm hanging off of the bed and no facility staff around. Resident was alert, normal unlabored breathing, capillary refill was less than 25 seconds. Resident's bandages were soaked through with blood and there was blood dripping into a large puddle on the floor. The resident was complaining of a wound on his right heel. Upon arrival to the 400 wing, two nurses were at the nursing station and one handed the resident information to the EMS staff. The EMS staff immediately applied direct pressure and placed an abdominal pad and roller gauze to control bleeding. The EMS staff checked the vital signs. The EMS staff never received a report from the facility nurse. The nurse never made entry to the resident's room while EMS staff was on the scene. Resident was transferred to the hospital on [DATE] at 5:40 a.m. Resident #2 was admitted on [DATE], readmission on 12/07/18, and discharged on [DATE]. Record review of admission paperwork showed [DIAGNOSES REDACTED]. Record review of the quarterly, Minimum Data Set ((MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 13 (cognitively intact). Resident required extensive assistance for bed mobility, transfers, and toileting. He had impairment in range of motion of one lower extremity. The resident was on [MEDICAL TREATMENT]. Record review of physician orders [REDACTED].-F; [MEDICATION NAME] 5 mg in the evening for [MEDICAL CONDITION] as of 2/11/19, INR 2.4, recheck on 2/19/19. Record review of nursing progress notes showed: On 03/01/19 at 8:15 p.m. the resident was up in the wheelchair when he returned from [MEDICAL TREATMENT] and was alert and oriented. No complaint of pain at this time. Some bleeding noted to [MEDICAL TREATMENT] bandage. Bandage changed and no bleeding noted at this time. Staff A, Licensed Practical Nurse (LPN) On 03/02/19 at 2:30 a.m., late entry, resident was noted to have bleeding from the left arm. The resident was alert and oriented. He answers to staff appropriately. Resident's arm bleeding through the bandage. The bandage was reinforced and the bleeding has slowed. Instructed the resident to keep his arm elevated. Resident stated understanding. Staff B, LPN On 03/02/19 at 6:32 a.m. Resident bleeding from the [MEDICAL TREATMENT] port. The site was reinforced but unsuccessful. The attending physician was called and notified with order to send to ER for evaluation and treatment. Staff B, LPN Record review of Situation / Background / Appearance / Review (SBAR) dated 03/02/19 at 4:30 a.m. by Staff B, LPN showed blood pressure of 123/77. Nursing notes section of form was blank. Record review of Nursing Home to Hospital Transfer Form dated 03/02/19, 4:49 a.m. by Staff C, LPN showed blood pressure, 167/77; pulse 61, respirations 20 and temperature 97.9. Change in Condition form dated 03/02/19 at 6:35 a.m. by, no staff member name noted on form, showed bleeding. INR was 2.1 on 02/25/19. Attending physician was called on 03/02/19 at 4:00 a.m. and family notified on 03/02/19 at 4:30 a.m. Record review of care plans showed had potential for complications related to [MEDICAL TREATMENT] for treatment of [REDACTED]. Interventions included but not limited to observe shunt site for change in skin integrity and for signs and symptoms of infection, notify physician; observe for complications such as bleeding, fluid volume overload, dehydration, hemorrhage, infection, notify physician if noted. Care plan for risk for abnormal bleeding related to use of anticoagulants for the treatment of [REDACTED]. During an interview on 03/18/19 at 11:50 p.m. Staff C, LPN stated that he worked the 11-7 shift, either as the supervisor or the floor nurse. He had been there about 2 months. He was trained on abuse and neglect reporting in orientation. He stated that he took the report from the 3-11 supervisor that night, 03/01/19. He was the supervisor but had a cart on the 400 floor, 03/02/19. He did not have Resident #2, Staff B, LPN did. He stated that the Staff B, LPN came to him and told him Resident #2 was bleeding from his [MEDICAL TREATMENT] port. He stated that he went and looked at it. He stated that Staff B, LPN had said she had applied pressure but it was not working, it was not stopping the bleeding. He told her to get the resident ready for transport and he called the attending physician for orders to send to the resident to the ER. He then called 911. He stated that he told Staff B, LPN to get an aide to help get him ready to go and to stay with him. Staff C, LPN was getting the paperwork together. When EMS arrived Staff C, LPN gave them the paperwork. He stated that EMS had put more gauze on the site and applied more pressure. He stated that the resident's vital signs were stable and the resident stated he was okay. Staff C, LPN stated that the nurse and aide were with the resident. When EMS came in they went in the resident's room and asked why there was not a nurse with the resident due to him bleeding. Staff C, LPN stated that they were in the room and they must have just walked out to get something trying to get the resident ready to go. Staff C, LPN stated that he does not know exactly when the bleeding started. He stated that EMS came in around 4 or 5 a.m. He stated that he did not know when it started bleeding just when Staff B, LPN came and got him to check the site and they started calling the doctor and EMS. He stated when he observed it, the gauze had red blood on the top portion of the gauze and the bottom portion but not in the middle. He stated that he did not observe any blood on the floor. He stated that the resident received wound care to his food on the 7-3 shift. He did not assess the foot, and did not know the resident. He stated that there was no odor that he noted in the room. He stated that the 3-11 supervisor did not report to him that the resident was bleeding from his port. During an interview on 03/19/19 at 3:05 p.m., Staff A, LPN stated that he worked the 3-11 shift and Resident #2 went out on the 11-7 shift. He stated that the resident's shunt was in his left forearm. It was a [MEDICAL TREATMENT] day. He stated that he noticed the dressing was bloody around 6ish, it was after dinner. He stated that he took the dressing off and it was pooling a little. He replaced the dressing with a heavy duty pressure dressing, gauze and abdominal pad. He stated that he put a good dressing on the arm. He stated that the blood was not pulsing, it was pooling and then it would run down his arm. He stated that he was not too concerned at that point. The resident was on [MEDICATION NAME] and ASA. He stated that he watched it until around 11 p.m. and there was no evident bleeding. He stated that he passed the information to the 11-7 nurse, Staff B, LPN, to watch it. Staff A, LPN stated that they looked at it during rounds and no blood was evident. He stated that if a resident was bleeding profusely, he would contact the supervisor, the physician and 911. During an interview on 03/20/19 at 1:51 p.m. Staff D, Certified Nursing Assistant (CNA) stated she worked the 11-7 shift. She stated that she checked on Resident #2 and his bandage was saturated with blood. She stated that she told Staff B, LPN. She stated that Staff B, LPN said she was going to put pressure on it. Staff D, aide stated that Staff B, LPN never changed the dressing. She was talking to the resident and he stated that his shunt normally does that (bleed). Staff D, aide stated that she told Staff B, LPN several times about the bleeding. Staff D, stated that she never did anything to her knowledge. She stated that about 3:30 a.m. she told the other nurse, Staff C, LPN, and he made the decision to send the resident out. The resident would not allow her to touch him, to clean him up. He went out to the hospital in his street clothes. She stated that he had blood on his other hand but would not let her clean him up. She stated that she noticed the blood on the dressing at about 11:30 p.m. when she was making her rounds. She stated that he was laying in the bed awake and oriented. Staff D, aide stated that she did not know him, that she did not normally have him as a resident. He was not willing to let her touch him. She stated that she talked to him several different times during the night. She stated again that the bandage was already saturated with blood at 11:30 p.m. Staff D, aide stated that obviously Staff B, LPN did not do much of anything, because the bandage was the same one when the ambulance took him out. Staff D stated that she went into his room probably three times and wiped up the blood on the floor. She stated that she thought the nurse would have changed the dressing on the arm, but she didn't. When EMS came she had just walked out of the room and gave the nurse his vital signs. Both Staff B, LPN and Staff C, LPN were at the nursing station getting the paperwork ready. During interview on 03/20/19 at 2:24 p.m. the Director of Nursing (DON) stated that Staff B, LPN had resigned on the spot last night with no notice. She stated that she and the ADON did the interviews and she did not speak with the aide (Staff D) involved and did not know if the ADON had or not. She stated that she would send the requested policies and grievance and any other paperwork that the NHA gave permission to send. The information was received from the facility on 03/20/19 at 3:38 p.m. During an interview on 03/20/19 at 3:40 p.m. the DON stated she spoke with the ADON and she did not interview Staff D, aide but she was coming into the facility to document a statement. Placed a call to Staff B, LPN on 03/19/19 at 2:17 p.m., on 03/19/19 at 3:18 p.m., and on 03/20/19 at 1:41 p.m., all three times left voice mail. Did not receive a return call. During an interview on 03/21/19 at 7:48 a.m. Staff B, LPN called. She stated that the facility had told her the surveyor had wanted to speak with her. She stated that she does not remember much about that night. She stated that he was bleeding out from his port and we sent him out. She stated that he had blood on the dressing but not a lot at 11 p.m. She stated that she does not remember much because it was fuzzy and 3 weeks ago. When asked she stated that she did not stay with the resident and wished she had. She again stated that she doesn't remember much about that night because it was fuzzy. Record review of the Grievance Report dated 03/08/19 showed the facility received a complaint concern regarding return to hospital, care and services for Resident #2. Employees involved included: Staff C, LPN, Staff B, LPN and Staff D, aide. Recommendation included education with nurses on bleeding and staying with the resident, and discipline as indicated. Investigation showed to see the statements. During an interview on 03/19/19 at 1:12 p.m. the ADON and Social Worker stated that they received a complaint from the family of Resident #2. On 03/07/19, they got a message from the front desk that the family wanted a call from nursing, regarding nursing and wound care. The ADON and Staff E, LPN wound care nurse called the family back. They informed her that the wound care doctor had seen the resident on the 02/28/19. They talked about the current treatment plan and that the doctor had ordered an MRI and the resident was unable to do it, and the doctor asked for a bone scan. The wound doctor had not changed treatment plans. The family was satisfied with that. They said the family discussed the concerns EMS had voiced at the hospital regarding the shunt bleeding. The ADON stated that she had interviewed the 2 nurses, Staff B, LPN and Staff C, LPN. She stated that both nurses stated that he was bleeding from the site and a pressure dressing was applied. Neither nurse remembered blood being on the floor. They could not get the bleeding stopped and called the physician and 911. They stated that 911 was called and transfer paperwork was initiated. EMS arrived. She stated that both nurses stated that the two EMS workers were rude and would not take report from them. They stated that EMS changed the dressing to the site and transported him to the hospital. Staff C, LPN stated that he tried to engage them in conversation and they walked by him. ADON stated that they in-serviced the nursing staff on making good judgement calls. ADON stated that they were instructed that one nurse should have stayed at the bedside, even if EMS was rude. ADON stated that they educated the nursing staff on the importance of bleeding precautions and first aid care for excessive bleeding especially [MEDICAL TREATMENT] catheters. When asked, the ADON stated that they saw the bleeding in the afternoon after [MEDICAL TREATMENT], around 5:30 and they applied a pressure dressing. ADON stated that she was told there was no bleeding on rounds at change of shift. The ADON reviewed the nursing documentation and verified based on it the bleeding started around 7 p.m. per the documentation of Staff A, LPN. She stated that a QAPI had been started and the two nurses involved (Staff B and Staff C) had been disciplined. They stated that the family was called back on 03/13/19 and the family thanked her for the head up, they had done the investigation and in-serviced all the nursing staff accordingly. The family was satisfied. The ADON stated that Staff D, aide was involved but only worked weekends. They stated that the incident was not reported to anyone outside the facility. Record review of a facility report dated 03/07/19 showed the ADON documented family voiced concerns about the resident's care and the night he was transferred to the hospital. The family stated that on 03/02/19, when the nurse removed the dressing and it smelled like rotting flesh and they wanted to know what kind of wound care was being done. Staff E, LPN discussed the wound care with her. The family told the ADON about EMS informing her that when they arrived to the resident's room there was a large pool of blood from his [MEDICAL TREATMENT] port and the two nurses were sitting at the nurses' station. She stated that the EMS had pictures of the resident in the room alone and the bleeding and that they were told he had been bleeding since 5 p.m. ADON read her the nurse's note from 03/01/19 at 7:15 p.m. stating that the resident had returned from [MEDICAL TREATMENT] and some bleeding was noted and that the dressing was changed and no further bleeding was noted. ADON apologized and told the family that they take this very seriously and would be investigating this and would get back to her after it was complete. Record review of the facility report dated 03/07/19 showed Staff E, LPN received notification that Resident #2's family was concerned about his wound care and wanted to speak with someone. Staff E and ADON spoke with family, stated when the resident got to the hospital that the wounds on his right leg smelled like rotting flesh and was now being treated with IV antibiotic. Staff E, LPN assured the family that the wounds were being followed by a wound care specialist on a weekly basis and that they were doing a work up on him to determine if he had osteo[DIAGNOSES REDACTED]. The resident had an MRI scheduled on 02/28 that was unsuccessful due to the resident movements, so a bone scan was to be scheduled instead and oral antibiotics were started. The wound care physician was at the facility on 02/28/19 and evaluated his wounds. The resident was sent to the hospital on [DATE]. Record review of the facility report, without a date, by Staff A, LPN showed while taking care of Resident #2 he noticed his [MEDICAL TREATMENT] site bleeding around 6 p.m. He replaced and reinforced the dressing to the site with good results noted. He then passed it on to the 11-7 on coming shift nurse (Staff B, LPN). Record review of the facility report dated 03/07/19 written by Staff C, LPN showed on 03/02/19, was the supervisor on duty and also working the medication cart on the 400 hall when the nurse assigned to 400 (2) (Staff B, LPN) came to me to see the resident in his room. Stated that he noticed the resident bleeding from the [MEDICAL TREATMENT] port. Staff B, LPN told him that she had tried to apply pressure but the bleeding continued. Staff C told her to call the aide and they should get the resident ready as he was going to call the physician for an order to send the resident to the hospital. Staff C called the physician and got an order to discharge to hospital and he also called 911 for an ambulance. He also called the family to notify them of the situation. The ambulance arrived while he was getting the documents ready for transfer to the hospital and the resident was sent to the hospital. Record review of the facility report dated 03/08/19 by Staff B, LPN showed she was told in report that the [MEDICAL TREATMENT] port was bleeding and that the 3-11 nurse had reinforced the dressing and the bleeding had stopped. Bleeding was noted by the aide so she reinforced and the bleeding stopped a while and restarted. The bleeding was noted to be bright red, noted that resident had been to [MEDICAL TREATMENT] that day and that also the INR was 2.1 which was higher than lab value. Staff B conferred with the supervisor and called the physician to have him sent out. EMS arrived at 4:00 a.m. and did not want to listen, just started talking down to us. They never asked any questions or anything. Record review of the facility's policy, First Aide Treatment, revised 2014 showed residents and employees who experience minor injuries shall be treated at the facility. If the injuries cannot be treated with basic Red Cross first aide intervention, the EMS will be activated. Basic first aid intervention includes but is not limited to interventions for the following situations: bleeding (mild and moderate). In addition to providing basic first aid interventions, contact the EMS or advanced medical personnel immediately for the following situations: severe bleeding. Record review of the facility's policy, [MEDICAL CONDITION], Care of a Resident with, revised 2014 showed staff caring for residents with [MEDICAL CONDITION], including residents receiving [MEDICAL TREATMENT] care outside the facility, shall be trained in the care and special needs of these resident. Education and training of staff included, specifically: the type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis; signs and symptoms of worsening condition and / or complication of [MEDICAL CONDITION]; how to recognize and intervene in medical emergencies such as hemorrhages and septic infections; the care of grafts and fistulas. 2. On 03/18/19 at 9:00 p.m. Resident #3 was observed in her room. She stated that she went to [MEDICAL TREATMENT] on Monday, Wednesday and Friday. An air, scoop mattress was in place. She stated that her [MEDICAL TREATMENT] access was in her chest. She stated that the facility checks on her when she gets back from [MEDICAL TREATMENT]. She stated that she has had no problem with bleeding post [MEDICAL TREATMENT]. She stated that the [MEDICAL TREATMENT] center changes her dressing and the facility looks at it when she gets back. Resident #3 was admitted on [DATE] and readmission on 03/28/18. Record review of admission paperwork showed [DIAGNOSES REDACTED]. Record review of annual, Minimum Data Set ((MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 06 (severe impairment). Resident required extensive assistance of one for bed mobility, totally dependent for transfers and toileting. Resident on [MEDICAL TREATMENT]. Record review of physician orders [REDACTED]. Carvedilol 25 mg twice a day for hypertension was not given on 03/12/19 due to away from facility without meds; Calcium Acetate (Phos Binder) 667 mg three times a day for [MEDICAL CONDITION] was not given on 03/05 and 03/07 due to away from facility without meds and not given on 03/02, 03/09, 03/12, 03/14, 03/16 due to out to [MEDICAL TREATMENT]; Check [MEDICAL TREATMENT] for signs of infection and mild bleeding from the access site can be expected for mild bleeding, reinforce pressure dressing. If there is major bleeding from the access site, apply pressure to the insertion site and contact [MEDICAL TREATMENT] center or physician for instructions lacked documentation on 03/03, 03/06, 03/08, 03/10, 03/16. Record review of care plans for potential for complications related to [MEDICAL TREATMENT] for treatment of [REDACTED]. 3. Resident #1 was admitted on [DATE] and readmitted on [DATE]. Admission paperwork showed [DIAGNOSES REDACTED]. Record review of 30-day Minimum (MDS) data set [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). Resident required extensive assistance for bed mobility, toileting and transfers. Record review of physician orders [REDACTED]. [MEDICATION NAME] Bisulfate 75 mg daily for blood thinner was not given on 03/05, 03/07, 03/12 due to away from facility without meds; Fluconazole 200 mg daily for infection was not given on 03/05, 03/07, 03/12 due to away from facility without meds; Insulin Detemir 15 units daily for [MEDICAL CONDITION] was not given on 03/07, 03/12 due to away from facility without meds; [MEDICATION NAME] Monoitrate ER 60 mg daily for [MEDICAL CONDITION] was not given on 03/05, 03/07, 03/12 due to away from facility without meds; [MEDICATION NAME] ER osmotic release extended release 24 hour 60 mg daily for hypertension was not given on 03/05, 03/07, 03/12 due to away from facility without meds; [MEDICATION NAME] 100 mg give 2 capsules every 12 hours for [MEDICAL CONDITION] was not given on 03/05, 03/07, 03/12 due to away from facility without meds; [MEDICATION NAME] HCL 50 mg give 2 tablets twice a day for hypertension was not given on 03/05, 03/07, 03/12 due to away from facility without meds; NAME] Delayed Release 40 mg twice a day for ulcer was not given on 03/05, 03/07, 03/12 due to away from facility without meds; [MEDICATION NAME] 0.25 mg three times a day for [MEDICAL CONDITION] not given on 03/01, 03/04, 03/05, 03/07, 03/08, 03/11, 03/12, 03/18 due to away from facility without meds; [MEDICATION NAME] Suspension 1 gm / 10 ml four times a day [MEDICAL CONDITION] given on 03/06, 03/07, 03/11, 03/12, 03/18 due to away from facility without meds; [MEDICATION NAME]sliding scale on 03/18 due to away from facility without meds; Apply Santyl ointment 250 unit / gm to right foot topically daily related to complete traumatic amputation of right foot on 03/06 due to out to [MEDICAL TREATMENT]. Record review of care plans for potential for complications related to [MEDICAL TREATMENT] for treatment of [REDACTED]. Care plan for potential for or has an alteration in comfort related to [MEDICAL CONDITION] initiated on 01/02/19 showed interventions included but not limited to administer medication for discomfort as ordered. Care plan for potential for complications related to alteration in cardiac function due to [DIAGNOSES REDACTED]. Resident #1 noted to have skin impairment as follows: surgical wound, right foot amputation. Interventions included but not limited to administer medications for wound healing as ordered and perform wound treatments as ordered. Resident was at risk fro complications related to diabetes, initiated 01/02/19, interventions included but not limited to administer medications and / or insulin per physician orders, obtain blood sugar levels / labs as ordered. Resident at risk for complications related to GERD, initiated on 01/02/19, interventions included but not limited to administer medications as ordered. During an interview on 03/19/19 at 11:45 a.m. Resident #1 was sitting in her wheelchair dressed and groomed for the day. No odors were noted. She stated that she had just come back from the doctor and he dressed her left foot wound, partial amputation. She stated that she was doing very well. She had oxygen in place via nasal cannula. She stated that she had [MEDICAL TREATMENT] on Monday, Wednesday, and Fridays. She stated that they check her shunt in her chest when she gets back from [MEDICAL TREATMENT] on every shift. She stated that she has never had a bleeding problem from her shunt. 4. Resident #6 was admitted on [DATE]. Review of admission paperwork showed [DIAGNOSES REDACTED]. Record review of 30-day, MDS dated [DATE] showed a BIMS score of 14 (cognitively intact). Resident required extensive assistance of 2 for bed mobility, transfers, and toileting. Resident was on [MEDICAL TREATMENT]. Record review of physician orders [REDACTED]. [MEDICATION NAME] 5 mg daily for [MEDICAL CONDITION] fib not given on 03/02, 03/09 due to away from facility without meds; Carvedilol 3.125 mg twice a day for hypertension not given on 03/09/19 due to away from facility without meds; [MEDICATION NAME] 5 mg twice a day for hypertension not given on 03/09/19 due to away from facility without meds; Calcium Acetate (Phos Binder) 667 mg give 2 capsules, with meals for [MEDICAL CONDITION] phos binder not given on 03/02, 03/04, 03/05, 03/07, 03/09, 03/12, 03/14, 03/19 due to away from facility without meds; Senna Plus 8.6-50 mg give 2 tabs twice a day for bowel management was not given on 03/09/19 due to away from facility without meds; Calcium D 600-400 three times a day for vitamin deficiency not given on 03/02, 03/05, 03/07, 03/09, 03/12, 03/14, 03/19 due to away from facility without meds; [MEDICATION NAME] HCL 25 mg every 8 hours for anxiety not given on 03/02, 03/05, 03/07, 03/09, 03/12, 03/14, 03/19 due to away from facility without meds; [MEDICATION NAME]sliding scale not performed on 03/02, 03/04, 03/05, 03/07, 03/09, 03/12, 03/14, 03/19 due to away from facility without meds; Clean left stump, surgical incision with normal saline, pat dry, apply roll gauze and secure with ace wrap daily was not documented as performed on 03/02, 03/05, 03/07, 03/12 due to away from facility without meds; on 03/01, 03/06, 03/08, 03/14, 03/15 lacked documentation. Record review of care plans for potential for complications related to [MEDICAL TREATMENT] for treatment of [REDACTED]. Resident was at risk for abnormal bleeding and increased bruising related to use of anticoagulants for treatment of [REDACTED]. Interventions included but not limited to administer medications as ordered. Resident was at risk for complications related to diabetes, initiated on 02/06/19, interventions included but not limited to administer oral medications and /or insulin per physician orders. 5. Resident #7 was admitted on [DATE] with readmission on 03/05/2019. Record review of admission paperwork showed [DIAGNOSES REDACTED].Record review of quarterly, MDS dated [DATE] showed a BIMS score of 15 (cognitively intact). Resident required extensive assistance of one for bed mobility, transfers, and toileting. Resident was on [MEDICAL TREATMENT]. Record review of physician orders [REDACTED]. Aspirin 81mg daily for hypertension was not given on 03/06, 03/08, 03/11, 03/13, 03/15 due to away from facility without meds; [MEDICATION NAME] Bisulfate 75 mg daily for [MEDICAL CONDITION] was not given on 03/06, 03/08, 03/11, 03/13, 03/15 due to away from facility without meds; [MEDICATION NAME] 80 mg daily for hypertension was not given on 03/06, 03/08, 03/11, 03/13, 03/15 due to away from facility without meds; [MEDICATION NAME] XL 60 mg for hypertension was not given on 03/06, 03/08, 03/11, 03/13, 03/15, 03/18 due to away from facility without meds; NAME] delayed release 40 mg daily [MEDICAL CONDITION] not given on 03/06, 03/08, 03/11, 03/13, 03/15, 03/18 due to away from facility without meds; [MEDICATION NAME]-[MEDICATION NAME] Aerosol 160-4.5 mcg/act 2 puffs inhale orally twice a day related to [MEDICAL CONDITION] was not given on 03/06, 03/08, 03/11, 03/13, 03/15, 03/18 due to away from facility without meds; Carvedilol 3.125 mg twice a day for [MEDICAL CONDITION] was not given on 03/06, 03/08, 03/11, 03/13, 03/15, 03/18 due to away from facility without meds; [MEDICATION NAME] HCL 50 mg twice a day for hypertension was not given on 03/06, 03/08, 03/11, 03/13, 03/15, 03/18 due to away from facility without meds; Sevelamer HCL, 800 mg give 4 tablets three times a day for [MEDICAL CONDITION] was not given on 03/06, 03/08, 03/11, 03/13, 03/15, 03/18, 03/19 due to away from facility without meds; [MEDICATION NAME] 1 gm four times a day [MEDICAL CONDITION] not given on 03/06, 03/08, 03/11, 03/13, 03/15, 03/18, 03/19 due to away from facility without meds; Record review of care plans for potential for complications related to [MEDICAL TREATMENT] for treatment of [REDACTED]. Resident was at risk for abnormal bleeding and increased bruising related to use of antiplatelet, interventions included not limited to administer medications as ordered. Resident was at risk for complication related to GERD, interventions included but not limited to administer medications as ordered. Resident was at risk for complications related to an alteration in cardiac function due to [DIAGNOSES REDACTED].