Every finding on record at Vivo Healthcare Laurellwood

Based on interviews and record review the facility neglected to adequately supervise residents to prevent sexual abuse for two residents (#2 and #3) out of two residents reviewed, resulting in resident-to-resident sexual abuse.Findings included: An interview was conducted on 03/16/2026 at 10:15 AM with Staff A, Certified Nursing Assistant (CNA). Staff A stated on 03/08/2026 she was a witness to abuse in the facility. Staff A, CNA stated during breakfast tray pass, she walked into the room of Resident #3, after noticing that the resident's door was closed which was unusual for that resident. She stated the room was dark and Resident #2 was in their wheelchair at the bedside of Resident #3. Staff A revealed they immediately noticed Resident #3 was lying on their side in a fetal position with their brief pulled down and Resident #2 had their hand in a clenched fist against Resident #3's vagina. Staff A immediately separated the residents. Staff A, CNA noticed Resident #2 had their other hand on their penis which had been pulled out. She stated having pulled Resident #2 out of the room in their wheelchair and moved them out of the room. Staff A stated having worked with both Resident #2 and Resident #3 many times prior to the incident. She said Resident #2 was frequently going into Resident #3's room, was always smiling and seemed very friendly with Resident #3. Staff A, CNA stated she did not know anything about Resident #2 having any behavioral diagnoses until after the incident. She said if she knew about their behaviors they would have kept a closer eye on the resident. Staff A stated there was one previous inappropriate incident between Resident #2 and Resident #3 back in late November of 2025, they could not remember the exact date. Staff C said they witnessed an interaction between the two residents in the dining room. Staff A stated they saw Resident #2 at the table of Resident #3 smiling at them and then when he moved away from the table. Resident #3 turned towards Resident #2, opened their legs wide, and started to open one side of their incontinence brief. Staff A stated at that point they quickly approached the table, telling Resident #3 to close her legs and redirecting her to the meal at the table. Staff A CNA stated she did not report the incident when it occurred because she did not known about Resident #2's diagnosed behaviors. Staff C stated she did not think anything the incident was serious at the time. An interview conducted on 03/16/2026 at 10:34 AM with Staff B, Licensed Practical Nurse (LPN) revealed the LPN came to the facility on the date of the alleged abuse, 03/08/2026 right after the event occurred. Staff B stated their shift started after the residents had been separated so they did not witness the abuse but was told that Resident #2 was found in Resident #3's room with their hand on the other resident's private area and was masturbating with the other hand. Staff B stated that they did not know of Resident #2 having any inappropriate behaviors prior to the incident, however, it was known the resident frequently masturbated in their room which is a shared room with three other residents.An interview was conducted on 03/16/2026 at 3:55 AM with Resident #3 who was observed in the dining room. Resident #3 stated she liked it at this facility stating, Oh very much so. Resident #3 was unaware of the reported incident and stated not knowing who Resident #2 was. The resident said she was doing great and expressed no concerns.A review of the medical record for Resident #3 shows the resident was admitted to the facility in June of 2023 with diagnoses of unspecified sequelae of cerebral infarction, chronic obstructive pulmonary disease, unspecified, primary insomnia, major depressive disorder, recurrent, mild, unspecified dementia, unspecified severity, with other behavioral disturbance, essential (primary) hypertension, cognitive communication deficit, unsteadiness on feet. A review of Resident #3's quarterly Minimum Data Set (MDS) dated [DATE], Section C, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 05 indicating significantly impaired cognition. A review of Resident#3's care plan showed a focus of the resident having had impaired cognitive function/dementia or impaired thought processes related to dementia, long term memory loss, and short-term memory loss with goals of resident maintaining current level of cognitive function. Interventions showed the resident would be able to communicate basic needs on daily basis, develop skills to cope with cognitive decline and maintain safety using interventions of staff to administer medications as ordered while they monitored or documented side effects and effectiveness, staff to communicate with the resident/family/caregivers regarding resident capabilities and needs, staff to cue, reorient, and supervise the resident as necessary, and staff to keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. A review of the facility's assessment [Facility Name] Capacity for Sexual Consent dated 03/08/2026 revealed Resident #3 lacked capacity to consent to sexual activity. A review of Resident #3's progress notes show the following:On 03/08/2026 at 2:45 PM Care Plan Progress Note: Resident was being molested by another resident while lying bed. Resident has no injuries visible at this time noted. Remains in bed at this time. Skin check done. Call light is within reach. Will continue to monitor.On 03/08/2026 at 3:56 PM Social Service Note: Resident does not acknowledge situations that are identified to contribute to a diagnosis of PTSD (Post Traumatic Stress Disorder) or have a history of PTSD.On 03/09/2026 3:05 PM Care Plan Progress Note: Addendum/Clarification on said date 3/8/2026 at approximately 0830 this writer entered 21-P as she was laying in her bed with her gown raised, in the fetal position on her right side. It shall be noted I did not witness any penetration/molestation completed head to toe skin check with no negative findings and resident was noted, not to be in distress and denied knowing. anything occurred.On 03/09/2026 01:25 PM Nurses Note: Resident returned back to facility via gurney. No new orders, resident alert and responsive to verbal/physical stimuli. Safety measures in place.On 03/09/2026 3:23 PM: Psychiatry Progress Note: The patient was seen today at the request of staff following a reported incident in which a male resident of the facility was attempting to touch the patient. Due to advancing dementia, the patient was unable to recall the incident during the evaluation. The patient shows no signs or symptoms of abuse or neglect. No psychosocial distress or injuries were noted during the assessment. In an interview on 03/16/2026 at 11:31 AM with Resident #3's representative, the Resident Representative (RR) stated they were frustrated about the situation after the facility notified them of Resident #2 being found in Resident#3's room with the door shut. The RR stated they knew Resident #3 was, mentally not with it and was unable to remember much. The RR stated they felt there was no way to tell whether or not she knew what was happening. The RR stated in the last few months they saw Resident #2 in the room of Resident #3 with the door shut on three separate times, once having their hand on the resident's arm and another on the resident's arm. The RR stated that they let staff by the entrance know all three times, with the staff responding that they would separate the residents and keep an eye on them closer. The RR stated they felt like no one was taking that seriously and they were not watching them closer for the incident to have occurred with no one knowing and no one knowing how long they were in there together before they were found.An interview was conducted on 03/16/2026 at 5:00 PM with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The NHA stated she was notified by the DON on 03/16/2026 at 8:59 AM that Staff A, CNA, found Resident #2 in the room of Resident #3 when passing breakfast trays. Staff A stated they found Resident #3 laying sideways in their bed with their brief pulled down and Resident #2 at the bedside in their wheelchair with a clenched fist against Resident #3's vagina. The NHA reported Staff A stated that Resident #2's other hand was holding their penis which had been taken out. The NHA stated that when interviewing the staff after the incident, staff told them Resident #2 liked to go visit other residents and sometimes needed to be redirected. The NHA stated being unaware of the resident's hypersexual behavior diagnosis and was not concerned of any behavioral issues with the resident. The NHA stated both residents were immediately separated, they assessed by their doctors and also seen by psych. There were no outcomes. The NHA said Resident #2 was placed on 1:1 for increased supervision and was moved further from Resident #3's room. The NHA stated they educated all their staff on their policies.On 03/16/2026 at 1:03 PM an interview was conducted with the Nurse Practitioner (NP) for Resident #3. He stated being on-call and being notified of the sexual encounter. He stated he was told there was no penetration and both residents had cognitive decline. He stated both residents were assessed by psych as well as medical assessments. He stated he could not speak of prior behavioral concerns.On 03/16/2026 at 6:43 PM an interview was conducted with the facility's Medical Director (MD). The MD stated he was notified the morning the incident happened. He was then notified the next day to come and assess Resident #3. He stated she was confused, but at baseline and had no signs of distress or not being okay. The MD stated not having any concerns at the time of his visit. He stated the residents are monitored more closely and staff were educated.Review of the facility's policy titled, Abuse, Neglect and exploitation, dated 1/1/2026, 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 resident property.Definitions: Sexual Abuse is non-consensual sexual contact of any type with a resident.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:A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship;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.Protection of ResidentThe facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to:A. Responding immediately to protect the alleged victim and integrity of the investigation;B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed;C. Increased supervision of the alleged victim and residents;D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator;E. Protection from retaliation;F. Providing emotional support and counseling to the resident during and after the investigation, as needed;G. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse.

Based on interviews and record review, the facility failed to implement care plan interventions related to hypersexual behaviors for one resident (#2) of two residents reviewed.Findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses of dementia and behavioral disturbances, psychotic disturbance and mood disturbance. Resident #2 was diagnosed with high-risk heterosexual behavior on 09/09/2017.A review of Resident #2 care plan showed a focus of potential for behaviors related to depression, dementia and hypersexual behaviors; date initiated: 01/05/2026. The goal showed Resident #2 will have no evidence of behavior problems by review date. Interventions included: Anticipate and meet the residents needs. Assist the resident to develop more appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately. Can you give us to provide opportunity for positive interaction attention stop and talk with him/he as passing by. Intervene as necessary to protect the rights and safety of others. Remove from situation and to take to alternate location as needed. Monitor behavior episodes and attempt to determine underlying cause. Consider time of day, persons involved, and situations. Document behaviors and potential causes.Review of a primary physician note dated 3/11/2026 revealed . patient seen today for follow -up post behavioral incident with review of consults and new lab results. Per nursing report over the weekend on 3/8/2026, staff entered room and observed patient attempting to touch a female resident. Patient is non-verbal with a history of impulsive behaviors. Review of a psychiatry progress note dated 3/12/26 revealed Patient was seen today for follow up visit. Patient was last evaluated on 3/8/2026. Patient was seen in his room remaining on one-to-one supervision for safety and behavior monitoring. During the encounter the patient appeared calm and comfortable. He responded to questions using a thumbs up gesture and remained pleasant throughout the visit. No sign of distress was observed. Per nursing report behavioral concerns continue involving inappropriate gestures towards staff and other residents. When discussed the patient responded by laughing suggesting limited awareness of their behavior. An interview was conducted on 03/16/2026 at 10:15 AM with Staff A, Certified Nursing Assistant (CNA). Staff A stated on 03/08/2026 she was a witness to abuse in the facility. Staff A, CNA stated during breakfast tray pass, she walked into the room of Resident #3, after noticing that the resident's door was closed which was unusual for that resident. She stated the room was dark and Resident #2 was in their wheelchair at the bedside of Resident #3. Staff A revealed they immediately noticed Resident #3 was lying on their side in a fetal position with their brief pulled down and Resident #2 had their hand in a clenched fist against Resident #3's vagina. Staff A immediately separated the residents. Staff A, CNA noticed Resident #2 had their other hand on their penis which had been pulled out. She stated having pulled Resident #2 out of the room in their wheelchair and moved them out of the room. Staff A stated having worked with both Resident #2 and Resident #3 many times prior to the incident. She said Resident #2 was frequently going into Resident #3's room, was always smiling and seemed very friendly with Resident #3. Staff A, CNA stated she did not know anything about Resident #2 having any behavioral diagnoses until after the incident. She said if she knew about their behaviors they would have kept a closer eye on the resident. Staff A stated there was one previous inappropriate incident between Resident #2 and Resident #3 back in late November of 2025, they could not remember the exact date. Staff C said they witnessed an interaction between the two residents in the dining room. Staff A stated they saw Resident #2 at the table of Resident #3 smiling at them and then when he moved away from the table. Resident #3 turned towards Resident #2, opened their legs wide, and started to open one side of their incontinence brief. Staff A stated at that point they quickly approached the table, telling Resident #3 to close her legs and redirecting her to the meal at the table. Staff A CNA stated she did not report the incident when it occurred because she did not known about Resident #2's diagnosed behaviors. Staff C stated she did not think anything the incident was serious at the time. An interview was conducted on 03/16/2026 at 3:00 PM with Director of Nursing (DON). The DON stated that she had not read the treatment plan for Resident #2 and was unaware of Resident #2's diagnosis for hypersexual behaviors. An interview was conducted on 03/16/2026 at 10:34 AM with Staff B, Licensed Practical Nurse (LPN). Staff B stated they had taken care of Resident #2 before. Staff B, LPN stated they did not know of the hypersexuality diagnosis or behaviors for Resident #2, however they knew the resident was known to frequently masturbate in their room which is shared with other residents. An interview was conducted on 03/16/2026 at 10:55 AM with Staff D, CNA. Staff D had the assignment of one-to-one supervision with Resident #2. Staff D, CNA stated not being aware of what specific behaviors they were to be watching for or the reason the resident was placed on one-to-one supervision. An observation was made on 03/16/2026 at 5:11 PM of Resident #2 and Resident #3 sitting in the dining area waiting for dinner tray pass. Resident #3 was sitting at a table against the back wall of the dining area with two other residents at the table. Resident #2 was at a table across the room from Resident#3 with one other resident at the same table. No staff member was observed at the table, or anywhere in the dining room. There was no staff member observed to be providing one to one supervision for approximately 5 minutes. At 5:14 PM Staff C, CNA walked down the hallway with the behavior monitoring form and went to sit next to Resident #2 at their table. Staff C confirmed they left to get the hourly monitoring form and stated another staff member should have been sitting with the resident while they went to get the form. During an interview conducted on 03/16/2026 at 5:00 PM with the Nursing Home Administrator (NHA), the NHA stated when interviewing the staff after the incident, staff said Resident #2 liked to go visit other residents and sometimes needed to be redirected. The NHA stated being unaware of the resident's hypersexual behavior diagnosis and was not concerned of any behavioral issues with the resident. Review of a facility policy titled Comprehensive Care Plans, revised 01/2025 showed: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident 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. 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.

Based on observations, record review and interviews, the facility did not ensure food service safety standards were followed in the kitchen and in one of one nourishment rooms.Findings included: On 8/18/25 at 10:04 a.m., a tour of the kitchen was conducted with the Certified Dietary Manager. An observation of the window, above the three-compartment sink, revealed kitchen items were hanging to include pans, pots, and a long grater with a handle. Further observations of the top part of the window, where the kitchen items were hanging, had multiple black particles and debris throughout the surfaces. Another observation of that area revealed a circular kitchen item that had sharp, metal pieces inside and appeared to be for chopping food, which had dust particles throughout the surface. The CDM said it had never been used. The CDM was observed telling Staff G, Dietary Assistant (DA) to clean that area. On 8/18/25 at 10:06 a.m., an observation of the walk-in refrigerator revealed a 20-ounce Gatorade bottle, on the top shelf, behind a box of bananas. The CDM confirmed the bottle should not be there and was observed asking the dietary staff if it belonged to them. The CDM stated personal items should not be stored in there. On 8/18/25 at 10:10 a.m., an observation of inside the walk-in freezer revealed ice buildup along the top and sides of the door, as well as on top of boxes containing food items. A small mound of ice buildup was observed on the floor next to the door. The CDM said she put a work order in and has told the maintenance staff about the issue. She said the work order placed in the work order system can determine when she identified the issue. The CDM said she thinks the door does not close properly. An observation of the top part of the walk-in freezer door revealed the latch was off center compared to the walk-in refrigerator door. On 8/18/25 at 10:21 a.m., an observation of the refrigerator in the nourishment rooms revealed a 12-ounce plant-based protein shake which did not have a resident’s name or date labeled. An observation of the freezer revealed a pint of vanilla ice cream, a frozen plastic water bottle, and a 20-ounce Gatorade bottle. The CDM said she checked the refrigerator and freezer in the nourishment room on 8/15/25, and those items were not there. She said the Certified Nursing Assistants (CNAs) should have labeled the items with the resident’s name. The CDM was observed asking Staff B, Licensed Practical Nurse (LPN) who the items belonged to. Staff B, LPN answered she didn’t know and was instructed to discard the items. On 8/20/25 at 11:15 a.m., an observation of the lunch tray line was conducted. Staff G, DA was observed washing her hands in the handwashing sink area. After washing her hands, Staff G, DA was observed lifting the lid of the garbage can then went to a storage rack with clean items to retrieve a cup. At 11:25 a.m., Staff I, DA was observed touching the lid of a garbage can then putting on gloves. He was not observed performing hand hygiene before putting on gloves. Staff I, DA was observed going to the dry storage area and came back with another box of gloves that he put into the glove holder by the kitchen door. Staff I, DA was observed putting a new pair of gloves on, then went to the tray line to put beverages on the meal trays. He was not observed performing hand hygiene before placing the beverages on the meal trays. Staff I, DA was observed touching his right check while he was completing the task of putting individual bottles of milk on the meal trays. At 11:29 a.m., Staff I, DA was observed washing his hands in the handwashing sink. He was observed touching his forehand, shortly after washing his hands, and while putting items on the meal trays. At 11:36 a.m., Staff I, DA washed his hands and left the kitchen area after having touched the trays. A review of completed work orders revealed documentation for the walk-in freezer door created on 7/31/25. The notes on the work order documentation revealed the following, “Walk-in Freezer door is not closing properly … Door not closing properly and leading to ice buildup around door frame.” 2. On 8/18/2025 at 10:02 a.m., an observation of the kitchen stove revealed food was caked on the sides of the stove and on the floor of the stove. On 8/18/2025 at 10:09 a.m., an observation of the dry storage revealed an opened, half-full lemon juice bottle with no open date written on it and an expiration date of 6/27/25. The CDM confirmed that it was opened and not labeled. She said she’s not sure why the lemon-juice bottle was not stored in the refrigerator, but it should have been. On 8/20/2025 at 11:17 a.m., an observation of Staff H, [NAME] revealed she was wearing two dangling bracelets, with multiple charms on them, hanging outside of her gloved hand. Further observations of Staff H, [NAME] revealed she was stacking plates on a cart, away from the tray line, with gloves on. She was observed going to the food tray line, with the cart and plates, without completing hand hygiene and a glove change in between changing tasks. On 8/21/25 at 9:06 a.m., an interview was conducted with the Regional Director of Maintenance (DOM). He said he learned about the issue with the walk-in freezer door on Monday, 8/18/25, and has the part to fix it. He said the former maintenance staff did not make him aware of the issue. The Regional DOM said he did not expect the previous maintenance staff to notify him as he may have tried to fix the door himself and didn’t require replacement of a door, or something of that nature. On 8/21/25 at 10:08 a.m., a follow-up interview was conducted with the CDM. The CDM said when audits are conducted food item expiration dates are to be checked. Regarding the bottle of lemon juice observed in the dry storage on 8/18/25, she said if anything is expired it should be thrown out, or if an item is opened it needed to be refrigerated after use. The CDM explained the dietary staff are responsible for stocking and storing items, while the cooks check the storage areas daily. She stated she checked the stored food when she is completing orders and kitchen checks which are conducted, “About once a week.” When asked about glove and hand hygiene, the CDM explained that hands are to be washed in-between tasks and when there is a change of tasks. The CDM explained when there is a change of task, current gloves are to be disposed, hands need to be washed, then new gloves can be put on for the start of a new task. Regarding storage of staff’s personal items, the CDM said the dietary staff can have a cup with a lid and can store them in an area they are not working in. The CDM said dietary staff cannot store personal beverages in the kitchen refrigerator or freezer, as they contain items for the residents. She said staff have an area to store personal food and beverages. Regarding the freezer work order from 7/31/25, the CDM stated, “Nothing was done, to my knowledge.” She said she had been removing the ice buildup with a hammer and checking the temperature to make sure the walk-in freezer was cooling properly. The CDM stated, “When I put something in [work order system], that’s the extent of my knowledge.” She said she does not know what happens with the work order after she puts it in the work order system. For storage of resident’s food and beverage items in the nourishment room, she said the CNA or nurse should have labeled with the date and resident’s name. She said if it’s not labeled or dated, the item should be discarded. The CDM said she does not know who reviewed the nourishment refrigerator and freezer when she is not present. In regard to the food build-up on the stove and surrounding floor area, the CDM stated the cooking area is to be wiped up and cleaned daily. She said major equipment like the stove are cleaned weekly. The CDM stated that staff are to wear minimal jewelry while on shift, and “I don’t believe that hand jewelry is permitted.” On 8/21/25 at 10:29 a.m., an interview was conducted with the Director of Nursing (DON). She said the expectation for storage of resident’s items is to make sure they are in a proper container, as well as dated and labeled. She said any staff member can accept the food or beverage and put it in refrigerator/freezer. The DON said staff have been provided education on the storage of resident’s food and beverages; and it is something they reiterate. She said the kitchen manager, the night shift nurse, and CNAs should be checking the nourishment room refrigerator and freezer for proper storage to include labeling and dating of resident items. A review of the facilities Food Safety Requirements revealed the following, “Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. “Contamination” means the unintended presence of potentially harmful substances including, but not limited to microorganisms, chemicals, or physical objects. “Food service safety” refers to handling, preparing, and storing food in ways that prevent foodborne illness. 1. Food safety practices shall be followed throughout the facility’s entire food handling process. This process begins when food is received from the vendor and ends with the delivery of the food to the resident. Elements of the process include the following: . B. Storage of food in a manner that helps prevent deterioration or contamination of the food, including growth of microorganisms. C. Preparation of food, including thawing, cooking, cooling, holding, and reheating. E. Equipment used in the handling of food, including dishes, utensils, mixers, grinders, and other equipment that comes in contact with food. F. Employee hygienic practices. 3. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon deliver/receipt and ensure timely and proper storage. Refrigerated storage – foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer, whichever is applicable. Practices to maintain safe refrigerated storage include: . IV. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by-date, or frozen (Where applicable)/discarded . 5. Foods and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature and out of the Danger Zone. Strategies include but are not limited to: . C. Washing hands properly before distributing trays. 7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. A. Staff shall wash hands in according to facility procedures. G. Staff shall keep jewelry to a minimum and cover hand or wrist jewelry with gloves when handling food.” A review of the facilities Handwashing Guidelines for Dietary Employees revealed the following, “Handwashing is necessary to prevent the spread of bacteria that may cause foodborne illnesses. Dietary employees shall clean their hands in a handwashing sink or approved automatic handwashing facility . Dietary employees shall keep their hands and exposed portions of their arms clean. Dietary employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single use articles and also in the following situations: . B. After hands have touched anything unsanitary i.e., garbage, soiled utensils/equipment, dirty dishes, etc. C. After hands have touched bare human body parts other than clean hands (such as face, nose, hair, etc.) . F. While preparing food, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. J. After engaging in any activity that may contaminate the hands.” A review of the facility’s Dietary Employee Personal Hygiene Policy revealed the following, “Gloves are to be worn and changed appropriately to reduce the spread of infection. Employees are to keep jewelry to a minimum. Hand or wrist jewelry must be covered with gloves while handling food.” (Photographic Evidence Obtained)

Based on record review and staff interviews, the facility failed to complete/update the Pre-admission Screening and Resident Reviews (PASARRs) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnoses for one resident (#4) of two residents reviewed for PASARRs. Findings included: A review of Resident #4‘s admission Record revealed an original admission date of 9/13/2018, and a re-admission date of 8/10/2025 with diagnoses to include psychoactive substance abuse, primary insomnia, post-traumatic stress disorder (PTSD) - 2/7/2024, major depressive disorder, and generalized anxiety disorder. A review of Resident #4‘s Active Orders revealed the following: Antianxiety Medication-every shift. Start date 3/13/2025. Antidepressant Medication-every shift. Start date 3/13/2025. Sedative/Hypnotic Medication-every shift. Start date 3/13/2025. Zolpidem Tartrate Tablet 10 mg (milligrams) give 1 tablet by mouth at bedtime for difficulty sleeping. Start date 8/18/2025 A Review of Resident #4‘s Level I PASRR, dated 6/22/2020, under Section I-Part A MI (Mental Illness) or suspected MI, indicated anxiety disorder and depressive disorder. A review of Section IV: PASRR Screen Completion revealed the following was marked, No diagnosis or suspicion of Serious Mental Illness or intellectual Disability indicated. Level II PASRR evaluation not required. A review of Resident #4's Quarterly Minimum Data Set (MDS), dated [DATE], Section N - Medications, revealed the following to include: antianxiety, hypnotic and opioid. Further review of the Quarterly MDS, dated [DATE], Section C - Cognitive Patterns, revealed a Brief Interview Mental Status (BIMS) score of 15, cognitively intact. A review of Resident #4's current care plan included the following, [Resident name] uses anti-anxiety medications r/t (related to) Her diagnosis of anxiety & muscle spasms. [Resident name] has experienced trauma R/T (related to) adjustment issues affecting the following (specify areas) Feeling tense all the time, Anxiety attacks - Having trouble breathing, flash backs, spacing out, Feeling that things are unreal, Memory problems, bad car accidents, bad accident at work, natural disasters, physical abuse as a child/spousal abuse, forced sexual contact as a child/husband, attacked by gun by husband, sudden death of a family member, sudden loss of home/possessions, death of a close friend. 2/19/25 current triggers for physical abuse is arguing, loud noises, nightmares' due to being awakened out of deep sleep 2/19/25 Care plan reviewed and is current. Psycho-social Well Being Care Plan revealed [Resident name] has the Potential for alteration in psycho-social well being related to major depressive disorder and anxiety disorder On 8/20/2025 at 2:36 p.m., an interview with the DON (Director of Nursing) revealed that it is the her responsibility to check resident's diagnoses to compare the PASARR's with the medical records. She said the Admissions Director will ensure that the PASARR's are in the system. The DON explained that her process involves checking the resident's medications, and the type of diagnoses to determine if a Level II is needed. The DON revealed the previous administrator took on the role of checking PASARR's when an admission came in. The DON stated a resident review is completed when the resident has a change of condition. She stated a, New schizophrenia or PTSD diagnosis, qualifies a resident for a Level II PASRR. The DON revealed that she would have submitted for a Level II PASRR for Resident #4's specific diagnoses. The DON confirmed that Resident #4 does not have a Level II PASRR. She said Resident #4 needed one and she never thought about or recognized that PTSD was not on Resident #4‘s PASARR. A review of the facility's policy titled, Resident Assessment-Coordination with PASARR Program, dated 9/1/2023, revealed the following, The facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs.9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include:a. A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis).b. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR.

Based on record review, and interviews, the facility failed to implement care plan interventions related to falls/accidents for one resident (#14) of three residents sampled.Findings included: On 08/18/2025 at 09:47 A. M., an interview was conducted with Resident #14. During the interview, the resident explained having experienced a fall in the cafeteria on 08/16/2025. The resident reported going out for a smoke break and fell backwards on their walker.Review of a progress note dated 08/18/2025 with a time stamp of 08:20 A. M., showed: staff observed resident sitting on the floor on buttock in front of the sink. [NAME] was behind Resident unlocked. Resident had on slide on thong sandal shoes.A progress note dated 08/16/2025 with a time stamp of 06:50 P. M., revealed: staff heard a noise. Upon checking, Resident was sitting on the floor in the dining room on buttock between a dining table & the wall. Resident's back was against the wall. [NAME] was about two feet away, unlocked. Slide on thong sandals on Resident's feet.Review of the admission record for Resident #14 revealed the resident was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, bipolar type medical, major depressive disorder, muscle weakness, unsteadiness on feet, and essential (primary) hypertension. Review of an annual Minimum Data Set (MDS), with a target date of 07/24/2024, revealed in section C - the resident had a Brief Interview Mental Status (BIMS) of 12, which meant the resident's cognition was intact. Section GG of the MDS showed the resident had the capability to walk at least 150 feet independently. Review of the resident's physician orders dated 8/20/2025 revealed mood stabilizing medication Depakote, trazodone, and furosemide for edema. Review of an undated fall risk evaluation showed last dates of falls to include 08/16, 08/05, and 03/12 of 2025, with a fall risk score of 15, which indicated a fall risk.Review of Resident #14's care plan, revealed a focus of fall prevention initiated on 08/05/2022 and revised on 03/26/2025. It showed Resident #14 is at risk for falls. Resident #14 is on anti-psychotropic medications daily. The care plan showed the resident had falls as follows: 08/05/24, 03/12/2025, and 03/25/2025. The goal showed the resident will not experience injury from falls through the next review date. Interventions included: Resident to wear prior footwear, initiated 03/25/2025 and Educate Resident #14 to have proper shoes on when ambulating, initiated on 08/05/2024.On 08/21/2025 at 10:25 A. M., an interview was conducted with Staff A Registered Nurse (RN). Staff A,RN stated the resident was observed with legs in the air on 08/15. Staff A, RN stated the resident was wearing thong shoes. Staff A, RN stated the resident mentioned some back pain. On 08/20/2025 at 03:40 P. M., an interview was conducted with Staff B Licensed Practical Nurse (LPN). Staff B, LPN stated on 08/16 the resident was found in the cafeteria on the floor between a wall and table. Staff B, LPN stated the resident had thong sandals on. Staff B LPN stated Staff B LPN was unaware of the resident's care plan regarding shoes.On 08/20/2025 at 03:23 P. M., an interview was conducted with the Director of Therapy (DOT) and Staff C, Physical Therapist (PT). The DOT stated proper shoes are closed toed shoes like sneakers. The DOT stated thong sandals would not be appropriate for Resident #14. The DOT stated having attended a meeting on 08/15/2025, related to Resident #14, and the resident's shoes was not a topic of the meeting. The DOT and Staff C, PT were not aware of Resident #14's fall on 08/16.On 08/20/2025 at 02:36 P. M., an interview was conducted with the Director of Nursing (DON). The DON stated the resident had two falls, one on 08/15 and one on 08/16 of 2025. The DON stated the fall on 08/15 was unwitnessed and the resident was observed sitting on the floor. The DON stated the resident was educated to lock walker and to sit while washing hands. The DON Stated the resident had lower back pain. The DON stated the resident had on thong slide on shoes and a change of condition was not completed for the fall on 08/15. The DON stated the fall on 08/16 was unwitnessed and the resident was found sitting on the floor of the cafeteria with thong shoes on. The DON stated an IDT meeting was not completed for the resident and the care plan interventions were not reviewed or updated after the resident's falls. The DON stated thong shoes are not proper walking shoes for Resident #14.Review of a policy titled Accidents and Supervision, revised 04/01/2024 showed: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary. Policy Explanation and Compliance Guidelines showed:3. Implementation of Interventions- using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: Communicating the interventions to all relevant staff b. Assigning responsibility C. Providing training as needed. d. Documenting interventions (e.g., plans of action developed by the Quality Assurance Committee or care plans for the individual resident) e. Ensuring that the interventions are put into action. f. Interventions are based on the results of the evaluation and analysis of information about hazards and risks and are consistent with relevant standards, including evidence-based practice. g. Development of interim safety measures may be necessary if interventions cannot immediately be implemented fully. h. Facility-based interventions may include, but are not limited to: i. Educating staff iii. ii. Repairing the device/equipment. Developing or revising policies and procedures i. Resident-directed approaches may include: i. Implementing specific interventions as part of the plan of care ii. Supervising staff and residents, etc. iii. Facility records document the implementation of these interventions. 4. Monitoring and Modification- Monitoring is the process of evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks. Monitoring and modification processes include: a. Ensuring that interventions are implemented correctly and consistently. b. Evaluating the effectiveness of interventions d. c. Modifying or replacing interventions as needed. Evaluating the effectiveness of new interventions 5. Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: a. Defined by type and frequency. b. Based on the individual resident's assessed needs and identified hazards in the resident environment.Review of a facility policy titled Comprehensive Care Plans, revised 01/2025 showed: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident 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. 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.

Based on record review, and interviews, the facility failed to ensure residents received Activities of Daily living (ADL) care related to showers for one resident (#16) of three residents sampled.On 08/18/2025 at 09:48 A. M., an interview was conducted with Resident #16. The resident stated showers were not being provided by the facility staff. The resident stated showers were desired and requested from facility staff and the resident stated the facility staff refused to provide the showers.Review of a Certified Nursing Assistant (CNA) Kardex (a care documentation sheet showing individual resident's care needs), showed question 3 asked the type of bathing preferred. The response to type of bathing, revealed the resident was not provided preferred showers on 07/30, 08/06, 08/10, and 08/13 of 2025.Review of the admission record for Resident #16, revealed the resident was re-admitted to the facility on [DATE] with diagnoses to include muscle weakness, need for assistance with personal care, contracture right hand, and unspecified sequelae of cerebral infarctions acute neurologic.Review of a quarterly Minimum Data Set (MDS), with a target date of 06/12/2025, revealed in section C the resident had a Brief Interview Mental Status (BIMS) score of 14 out of 15, which meant the resident's cognition was intact. Section GG of the MDS showed the resident required maximal assistance with ADLs, including washing, rinsing, and drying self.Review of the resident's physician orders, dated 07/15/2025 showed skilled occupational therapy eval and treatment for 4 times a week for 60 days with focus on weakness and increased need for assistance towards ADLs.Review of Resident #16's care plan revised 09/09/2024, revealed: a focus of Resident #16 having a self-care deficit with dressing, grooming, bathing and toilet needs related to (r/t): cerebrovascular accident (CVA), Human immunodeficiency Viruses (HIV), impaired vision, generalized weakness & debility. Resident #16 participates in ADLs with cues from staff. Resident #16 chooses to use double brief for incontinence, initiated on 09/28/2020 and revised on 09/09/2024. The interventions included: provide hands on assistance with dressing, grooming, bathing as needed. A focus initiated on 09/28/2020 and revised on 06/13/2025 showed Resident #16 is at risk for complications r/t alteration in health maintenance with a diagnosis (dx), of Anemia. Interventions included: Provide increased assist with ADLs as needed for complaints of (c/o) increased fatigue/weakness, initiated on 01/07/2022.On 08/20/2025 at 11:30 A. M., an interview was conducted with Staff F, Certified Nursing Assistant (CNA). Staff F, CNA explained not knowing what N/A in Resident #16's Kardex chart meant.On 08/20/2025, at 11:59 A. M., an interview was conducted with Staff D, CNA. Staff D, CNA stated residents are scheduled to receive showers two times a week, according to the shower schedule in a book at nursing stations and in resident charts. Staff D, CNA stated residents can receive more showers than the scheduled showers and they can receive showers on different days than scheduled. Staff D, CNA reviewed the shower logs at each nursing station and stated shower sheets for dates 07/30, 08/06, 08/10, and 08/13 of 2025 could not be found for Resident #16. For the same dates, the CNA Kardex chart for Resident #16 showed N/A. Staff D, CNA stated N/A, in the resident's chart, meant the showers did not happen. On 08/20/2025 at 02:36 P. M., an interview was conducted with the Director of Nursing (DON). The DON stated residents are scheduled to receive showers on two or more days a week and residents can request more showers. The DON stated if a resident received a shower, it should be documented in the resident's chart and the shower log book. The DON stated if a shower isn't documented anywhere, it can't be stated the shower took place. The DON stated Resident #16 should receive showers on Sundays and Wednesdays. The DON stated not applicable means the resident did not receive a shower.Review of a policy titled Activities of Daily Living (ADL), implemented on 09/01/2023 showed: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care.Policy Explanation and Compliance Guidelines: 2. The facility will provide a maintenance and restorative program to assist the resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment. 3. 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 observation, interview, and record review the facility failed to ensure effective pain management was provided consistent with professional standards of practice and the comprehensive person-centered care plan for one resident (#7) out of 14 residents on a pain management program. Findings included: An interview was conducted on 9/11/23 at 11:07 a.m. with Resident #7. Resident #7 was in her bed and stated she was new to the facility, and she will most likely be a permanent resident. Resident #7 was formerly living in an assisted living facility (ALF) prior to multiple surgeries on her right hip secondary to a fall sustained at her former ALF. Resident #7 stated she had her final surgery in August (2023) and was transferred four days later from the hospital to the current facility for physical therapy. Resident #7 said she was unable to fully cooperate with her therapy because her pain is too bad. The resident said because the pain is so bad she felt she would never leave this facility and go to another ALF or even home. The resident verbalized her short- acting pain medication had been discontinued, but she was still receiving her long-acting pain management regimen. Resident #7 stated she will get a nine o'clock dose in the morning and then a nine o'clock dose at night. Resident #7 said, The pain is so bad, and no one cares. A review of the Admission Record, dated 8/16/23, for Resident #7 included a primary diagnosis of recurrent right hip dislocation and secondary diagnoses included anxiety disorder, major depressive disorder, schizoaffective disorder, bipolar disorder, HFpEf (Heart failure), PVD (peripheral vascular disease), opioid and tobacco dependence, chronic embolism, and thrombosis of right tibial vein, age-related osteoporosis without current pathological fracture. A review of Section C-Cognitive Patterns of the Admission Minimum Date Set (MDS), dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) score of 11, indicating she had moderately impaired cognition. Section G - Functional Status for Activities of Daily Living (ADL) showed Resident #7 was a one to two person assist with transfer, bathing, dressing, bed mobility, eating, toileting and personal hygiene. Section J - Health Conditions/Pain Management showed Resident #7 was currently receiving a pain medication regimen and confirmed pain over the last five days with pain affecting sleep. The resident average verbal response to pain scale was eight (on a scale of 1-10 with 10 being the highest in severity) over the past five days and the pain was described as constant. Review of Resident #7's hospital discharge summary, dated 8/16/23, showed the resident was discharged with the following pain regimen: Oxycodone-Acetaminophen 10-325 mg (milligrams) oral tablet every six hours interval as needed for pain and Oxycodone 20 mg tablet twice a day for pain. Additional medication for pain included Gabapentin 100 mg oral capsule with the following instructions, two capsules by mouth three times a day. Further review of Resident #7's hospital records showed the resident sustained an injury to her right hip after a fall. Resident #7 had surgery to repair the initial injury but subsequently encountered, on three separate occasions, dislocations of the right hip post repair. A [NAME] procedure [procedure involves removing part of the ball of the thigh bone or femur, allowing it to fuse with the hip socket in the straight position] was performed on 8/12/23 based on the numerous dislocations Resident #7 incurred and failed attempts by the orthopedic surgeon to reduce the dislocation. A review of Resident #7's active physician orders for September 2023 for pain management included: *Oxycontin oral tablet ER 12-Hour Abuse Deterrent, give one tablet by mouth every twelve hours for Pain, and to observe for any adverse effect, dated 8/25/23, *Evaluate resident for pain by using the appropriate scale: 0: No pain; 1-3 Mild Pain; 4-6 Moderate Pain; 7-10 Severe Pain, dated 8/17/23, *Weight-bearing as Tolerated (WBAT) continuing from her discharge summary orders post operatively from the hospital, * Physical Therapy and Occupational Therapy (PT/OT) to evaluate and treat, dated 8/17/23. A review of Resident #7's discontinued physician orders for pain showed an order, dated 8/16/23, for Oxycodone-Acetaminophen 10-325 mg oral tablets to give one tablet every six hours as needed for pain until discontinued on 8/22/23. A new order was placed on 8/22/23 for Acetaminophen 10-325 mg oral tablets to give one tablet every six hours as needed for pain until 8/23/23. Review of the Resident #7's electronic Medication Administration Record (eMAR) for August 2023, between the dates of 8/17/23 to 8/22/23, showed the resident was administered eight doses out of a possible twenty doses of her as needed pain medication. A review of the as needed pain medication administration between 8/23/23 to 8/24/23 showed two doses were received out of a possibility of eight doses. The as needed for pain medication physician orders were discontinued on 8/23/22 at midnight. Review of a provider note from the Pain Management ARNP (Advanced Registered Nurse Practitioner), dated 9/11/23, noted there were no signs and symptoms of abuse with medications. The note documented the patient reported her OxyContin continues to help with pain that is generalized. Her pain level during the visit was noted as 8 out of 10 on the pain scale. The ARNP noted the resident continues to ask for increases in pain medication and has had an increase in medication over the past six months. A follow- up interview was conducted on 9/11/23 at 12:25 p.m. with Resident #7 regarding her pain management. The resident stated she had three surgeries on her right hip in a short time span with the most recent surgery being last month. The decision was made not to repair her hip anymore due to frequent dislocations. Resident #7 claimed to be able to place weight on the left side, but the pain is too bad from the right side. The resident stated she receives long-acting Oxycodone at nine o'clock in the morning and nine o'clock in the evening. The resident stated she is not asked everyday how her pain is and stated, If they were to ask me, I would say 13-14 out of the 10 on that pain scale they ask. The resident said the staff told her there is nothing they can do about her pain. She would like to talk to someone about better pain management. Resident #7 stated she would like to participate in therapy to gain strength and mobility, but the pain is too bad to achieve that goal. An interview was conducted on 9/11/23 at 12:40 p.m. with Staff F, Certified Nursing Assistant (CNA). Staff F, CNA confirmed Resident #7 had at times refused to go to the shower because she was in pain. An interview was conducted on 9/12/23 at 10:15 a.m. with Staff I, Physical Therapy Assistant (PTA). Staff I, PTA stated Resident #7 is receiving therapy on Monday, Tuesday, and Thursday. Staff I, PTA stated Resident #7 tries to participate in the physical therapy regimen, but the pain is too severe. Staff I, PTA stated the best they have been able to do is sit on the edge of the bed and then utilize a mechanical lift to get her out of bed to her personal wheelchair. Staff I, PTA stated the resident does get pain medication, but it is not strong enough for her pain and maybe a pain medication prior to therapy would benefit the resident. Staff I, PTA stated this was relayed to the resident's nursing staff. Review of the most recent Physical Therapy Progress Report, dated 9/10/23, showed despite the resident's constant pain all over her body limiting her range of motion of bilateral lower extremities and activity tolerance, she was able to improve bed mobility and sitting balance endurance during this period. Review of the Physical Therapy section of the medical record showed a diagrammatic graph titled Outcomes. In this graph there was a bar graph titled Section GG mobility with one bar representing the admission evaluation and the next bar named recent. The initial evaluation for Section GG mobility was given a twenty-one value for and the recent evaluation had a value significantly lower for the mobility score and shown as a twelve. Review of Physical Therapy Treatment Encounter Note, dated 9/11/23, showed Resident #7's response to treatment was limited mobility due to right LE (lower extremity) constant pain. Complexities/barriers Impacting session were pain levels. Review of Physical Therapy Treatment Encounter Note, dated 9/12/23, showed Resident #7's pain at rest was 7 out of 10 and her pain with movement was 10 out of 10 both constant pain in her right hip. An observation on 9/13/23 at 8:35 a.m. during medication administration for Resident #7 by Staff J, Licensed Practical Nurse (LPN) revealed the resident received her Oxycontin 20 mg tablet ER (extended release) as prescribed. Staff J, LPN administered the medication and returned to the medication cart to document the medication Resident #7 received. The eMAR had a hard stop that required Staff J, LPN for pain assessment score. Staff J, LPN returned to Resident #7 and inquired of her current pain level. The resident stated her pain was 8 out of 10. According to physician orders, the pain level response is asked from a scale of 1-10 with 10 being the highest in severity for pain. No additional interventions were provided. A follow-up interview was conducted on 9/13/23 at 10:42 a.m. with Resident #7 regarding her pain after receiving her morning dose of pain medication. Resident #7 stated the pain medication had added some relief, but the pain is still an 8. When asked if the nursing staff had followed up with a pain assessment post administration, the resident replied, No and they never do. The resident stated she felt the staff do not care about her pain and this causes an increase in her anxiety. Resident #7 stated psych has seen her twice since she has been admitted but would like to have someone to talk to regarding her feelings that overwhelm her anxiety and the pain makes it worse. She said, I get locked up and can't relax. A record review of the eMAR on Resident #7 for pain assessment based on the physician's orders from 8/17/23 to 9/13/23 revealed eighty-four entries made by the nursing staff with the following documented for pain on a scale of 1-10 with 10 being the worst: twenty-one entries were for a pain of 7-10, nine entries were for a pain of 4-6, two entries were for a pain scale of 1-3, and forty-two entries were for no pain. Review of Resident #7's progress notes from 8/17/23 to 9/13/23 did not include any documentation showing a provider was notified of the resident's complaints of uncontrolled pain or ineffective pain management regimen. There were no documented attempts at non-pharmacological pain management interventions. Review of Resident #7's care plan, dated 8/17/23, showed: Resident #7 was identified and care planned for pain management with the following interventions: -Anticipate the resident's need for pain relief and respond immediately to any complaint of pain; -Notify the physician if the interventions are unsuccessful or if current complaint is a significant change from resident's experience of pain; -Report to Nurse any change in usual activity attendance patterns or refusal to attend activities related to signs and symptoms or complaint of pain or discomfort; -Administer analgesia / opioids as per orders. Give 1/2 hour before treatments or care; -Resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. An interview was conducted on 9/13/23 at 11:30 a.m. with the Director of Nursing (DON). The DON stated the Pain Management team is following this resident and makes their facility rounds every Monday. chart and The DON was informed of the events from this morning's medication pass in which the nursing staff provided medication for pain but did not ask about the resident's level of pain until after medication was provided and the eMAR prompted a response for pain. A discussion occurred with the DON regarding the lack of pain follow- up from the nursing staff, continued resident's complaints of severe pain, the resident's willingness to participate in therapy, and physical therapy staff stating the resident is unable to participate due to constant pain. The DON stated the care plan for pain could have been better executed for this resident. The DON stated she would personally contact the physician. A phone interview was conducted on 9/13/23 at 2:15 p.m. with the Pain Management ARNP. The ARNP stated she was familiar with Resident #7 from another facility and knows the resident has a history of alcohol and opioid addiction. The ARNP expressed she was concerned the resident would not participate in therapy. The ARNP said she would be monitoring the resident's participation in therapy. 46234 A review of a facility policy titled, Pain Management, revised 9/07/2022, showed the following: Policy: The facility must ensure pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goal and preferences. Policy Explanation and Compliance Guidelines: The facility will utilize a systematic approach for recognition, assessment, treatment, and monitoring of pain. Recognition: 1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental, and psychosocial well-being and to prevent or manage pain, the facility will: a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. b. Evaluate the resident for pain and the causes upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs. c. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and their residence goal and preferences. Pain Evaluation: 1. The facility will use a pain evaluation tool, which is appropriate for the resident's cognitive status, to assist staff in consistent evaluation of a resident's pain. 2. Based on professional standards of practice, and assessment or evaluation of pain by the appropriate members of the interdisciplinary team may necessitate gathering the following information as applicable to the resident Pain Management and Treatment: 1. Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/ or the resident's representative will develop, implement, monitor, and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission . 3. The interdisciplinary team and the resident and/ or the resident's representative will collaborate to arrive at pertinent, realistic, and measurable goals for treatment . 5. For residents with an addiction history or opioid use disorder (OUD) the facility should use strategies to relieve pain while also considering the OUD or addiction history. These strategies may include continuation of medication assisted treatment (MAT), if appropriate, non-opioid pain medications, and non-pharmacological approaches . 7. Pharmacological interventions will follow a systematic approach for selecting medications and doses to treat pain. The interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain or has the potential for pain. The following are general principles the facility will utilize for prescribing analgesics: . i. Facility staff will notify the practitioner if the resident's pain is not controlled by the current treatment regimen.

Based on observations, interviews, and policy reviews the facility failed to ensure a clean and homelike environment on two units (Unit 1 and Unit 2) out of two units related to cleanliness of resident areas, cluttered halls and dining room, linen supply, and an unkempt courtyard for three days (9/11/23, 9/12/23 and 9/13/23) of three days of the survey. Findings included: An observation was made on 9/11/23 at 6:37 a.m. of the Unit 2 resident hallway and revealed it to be cluttered with medical equipment to include mechanical lifts, wheelchairs, and shower chairs. An observation was made on 9/11/23 at 7:09 a.m. of the linen closest on Unit 1 and Unit 2 having no supply of linen. An observation was made on 9/11/23 at 7:15 a.m. of floors being dirty in Resident Rooms 6, 11, 15, 18, 17, and 20. The floors in these rooms were observed to remain in this condition during the survey from 9/11/23 to 9/13/23. An observation was made on 9/11/23 at 7:10 a.m. in the dining room of weight scales in the corner, boxes and a bag of clothes on the countertop, and the front of the cabinet having drip stains down the front. The top of the ice machine in the dining room was covered in dust and there was a dirty cup and glove behind the ice machine. An observation was made on 9/11/23 at 7:24 a.m. of the trash can overflowing onto the floor in Resident room [ROOM NUMBER]. An observation was made on 9/11/23 at 8:31 a.m. in Resident room [ROOM NUMBER]. The sheets on the window bed had dark stains on them, and the toilet had a brown liquid running down the front and splattered on the floor. On 9/13/23 at 5:51 p.m. the toilet and floor had not yet been cleaned in Resident room [ROOM NUMBER]. An observation was made on 9/11/23 at 8:34 a.m. of a circular fan attached to the wall at the Unit 2 Nurses' Station covered in dust. The fan remained covered in dust on 9/13/23 at 5:45 p.m. An observation was made on 9/11/23 at 12:21 p.m. in Resident room [ROOM NUMBER] of the closet door off the track. The air conditioning in the room was also broken and half the room was missing baseboards. At this time, an interview was conducted with a Resident who resided in Resident room [ROOM NUMBER]. The resident said the doors had been that way and she was unable to open the closet doors. An interview was conducted on 9/13/23 at 9:15 a.m. with the Maintenance Director. He said the facility did not have a computer tracking system for maintenance requests, but they are working on setting one up. When asked if he had a log or list of items that need to be repaired, he said he did not. The Maintenance Director said people just tell him when things need to be fixed. A follow-up interview was conducted on 9/13/23 at 6:06 p.m. with the Maintenance Director. He said he knows there are a lot of issues, and they are getting to them. He said the floors are dirty because the hallways were stripped and waxed about a month ago and that left a build up at the doors to the resident rooms. He said they haven't had a chance to do the resident rooms yet. The Division Plan Operations Director said there had been no room audits or anything in place at the facility. 48441 An observation on 9/11/23 at 9:20 a.m. was conducted of the hallway on Unit Two (back hallway) and two ceiling tiles in front of Resident rooms [ROOM NUMBERS] were observed with dried large brown spots. (Photographic Evidence Obtained) An observation 9/11/23 at 8:37 a.m. of Resident room [ROOM NUMBER] revealed missing baseboards at the entrance to the room and visualized from the hallway. (Photographic Evidence Obtained) An observation on 9/11/23 at 9:15 a.m. of Resident room [ROOM NUMBER] revealed the floor baseboard and headboard were either missing or deteriorated, and the nightstand had a wood strip loose and curled up and sticking out. (Photographic Evidence Obtained) On 9/13/23 at 5:30 p.m. the Director of Nursing (DON) was observed entering Resident room [ROOM NUMBER] and inspected the nightstand with the strip sticking out and headboard with rotting wood and stated to the resident he will be getting a new nightstand and headboard. The DON confirmed this was not acceptable. 48223 An observation made on 9/11/23 at 6:33 a.m. and on 9/12/23 at 4:00 p.m. of the middle hallway between Resident rooms [ROOM NUMBERS] and revealed a metal cover was loose and made a clang when someone walked over it. The metal cover was soiled with what appeared to be grease and dirt. A screw was protruding from the middle of the metal cover. (Photographic Evidence Obtained) An observation made on 9/11/23 at 6:40 a.m. and 12:30 p.m. of the hallway outside of Resident room [ROOM NUMBER] and revealed shower chairs being stored and underneath a shower chair was a dirty washcloth. (Photographic Evidence Obtained) Additional observations made on 9/11/23 at 6:41 a.m. and 9/12/23 at 12:31 p.m. of the hallway outside of Resident room [ROOM NUMBER] revealed a portable air conditioner unit and next to this unit the floor had buildup of dirt and what appeared to be food particles. In the alcove where resident lifts were stored, a medication cup and tissue were on the floor. Outside of Resident room [ROOM NUMBER] in the middle of the hallway was what appeared to be a dried-up lizard. On the floor in front of Nurse Station 2, a brownish, sticky substance was visible on the floor. (Photographic Evidence Obtained) The bathroom between Resident rooms [ROOM NUMBERS] was observed on 9/11/23 at 7:30 a.m., 9/12/23 at 2:30 p.m., and 9/13/23 at 11:00 a.m. with yellow and brown liquid setting on the ceramic of the toilet base behind the toilet seat. At the base of the toilet was a black and brown substance surrounding it, a space between the base of the toilet and the floor was visible. (Photographic Evidence Obtained) The bathroom between Resident rooms [ROOM NUMBERS] was observed on 9/11/23 at 7:25 a.m., 9/12/23 at 2:25 p.m., and 9/13/23 at 10:45 a.m. with a brown substance at the base of the toilet, a buildup of dirt on the floor surrounding the front of the toilet. The pipes on the toilet, directly behind the toilet seat, were observed to be corroded. (Photographic Evidence Obtained) An observation made on 9/11/23 at 7:35 a.m. in Resident room [ROOM NUMBER] and Resident beds B, C, and D all had sheets that were threadbare. (Photographic Evidence Obtained) An interview was conducted with Staff D, Certified Nursing Assistant (CNA) on 9/11/23 at 7:30 a.m. in Resident room [ROOM NUMBER]. Staff D, CNA stated there are many sheets which are threadbare. Staff D, CNA stated, I should exchange and throw the threadbare linen out but there are not enough in the mornings to accomplish this. Staff D, CNA confirmed the toilet stains around the toilet in the bathroom between Resident rooms [ROOM NUMBERS]. Staff D, CNA stated many of the floors and toilets are stained. When I notice stains like this, I let the housekeeper know. I don't think they can do anything about it. An interview was conducted on 9/11/23 at 12:40 p.m. with Resident #13. Resident #13 stated the housekeeping in the facility is not very good. There seems to always be dirt and trash on the floor. Resident #13 stated it does not do much good to say anything. Resident #13 stated it would be better if the facility was cleaner. An interview was conducted on 9/11/23 at 9:40 a.m. with a Resident in room [ROOM NUMBER]. The Resident stated the floor has had black looking spots next to the bed for quite some time. An interview was conducted on 9/13/23 at 12:05 p.m. with Staff E, Housekeeping (Hkg). Staff E, Hkg confirmed the resident bathroom floors in between rooms19/20 and rooms 17/18 appeared dirty. Staff E, Hkg stated when an issue arises the staff notify the Maintenance Director (MD). I try to remind the MD although the MD is very busy. Staff E, Hkg confirmed the floors in the hallways and Resident room [ROOM NUMBER] were dirty. Staff E, Hkg stated she was not sure why the floors remain dirty they are supposed to be mopped at least one time per day. An interview was conducted on 9/13/23 at 12:15 p.m. with the Maintenance Director (MD). The MD confirmed responsibility of overseeing Maintenance and Housekeeping. The MD confirmed the staining of floors and toilets in resident bathrooms between rooms 19/20 and rooms 17/18. The MD stated there are several toilets that should be repaired. An interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on 9/13/23 at 5:56 p.m. The NHA and the DON both stated the environment was being worked on since July 2023. They were not able to produce any documented evidence of an ongoing plan. The NHA stated his expectation was for the Maintenance Director to have been working on all these concerns and did not understand why they had not been completed. A facility policy titled, ROUTINE CLEANING AND DISINFECTION, dated 2/2023, showed: Policy: it is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Definitions: Cleaning refers to the removal of visible soil from objects and surfaces and is normally accomplished manually or mechanically using water and detergents or enzymatic products. Policy Explanation and Compliance Guidelines: 1. Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas comma resident rooms comma and at the time of discharge. 4. Routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces and high touch areas to include, but not limited to: -a. Toilet flush handles -g. Toilet seats -l. Sinks and faucets. A facility policy titled, PREVENTATIVE MAINTENANCE PROGRAM, dated 2/2023 showed: Policy: A preventative maintenance program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Policy Explanation and Compliance Guidelines: 1. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 2. The Maintenance Director shall assess all aspects of the physical plant to determine if preventative maintenance (PM) is required. Required PM may be determined from manufacturers recommendations, maintenance requests, grand rounds, life safety requirements, or experience. 3. If preventive maintenance is required, the maintenance director shall decide what tasks need to be completed and how often to complete them. 4. The maintenance director shall develop a calendar to assist with keeping track of all tasks. 5. Documentation shall be completed for all tasks and kept in the maintenance director 's office for at least 3 years.

Based on observations, interviews, and policy review the facility failed to ensure residents were free from accident hazards related to: 1. hot water temperatures were not maintained at a safe temperature in two community shower sinks (located near room [ROOM NUMBER] and room [ROOM NUMBER]) and two resident bathroom sinks (room [ROOM NUMBER] and room [ROOM NUMBER]), 2. a storage room and supply room being unlocked with multiple housekeeping and nursing supplies, 3. emergency cords missing or unable to be used in three resident bathrooms (Rooms15/16, room [ROOM NUMBER] and room [ROOM NUMBER]), 4. a bathroom light not working in one resident shared bathroom (Rooms 15/16) and 5. an air conditioning unit in disrepair and leaking in one resident room (20) for a period of three days (9/11/23, 9/12/23 and 9/13/23) of a three day survey. Findings included: On 9/11/23 at 7:45 a.m., during the initial tour it was revealed the temperature of the water in the shower room sink near Resident room [ROOM NUMBER] was hot. The Maintenance Director (MD) tried to take the temperature of the water coming from this sink with his digital thermometers (2) and both of the thermometers were not in working order. The MD left to get a different thermometer and did not return. On 9/11/23 at 8:30 a.m. two surveyors entered the shower room next to Resident room [ROOM NUMBER], after obtaining a facility digital thermometer from Staff B, Dietary Manager. The hot water was left to run in the sink for approximately 2 minutes. The thermometer was then placed in the stream of water coming from the sink faucet. The water had a temperature of 121-degree Fahrenheit. (Photographic Evidence Obtained) On 9/11/23 at 8:40 a.m. two surveyors entered the community shower room next to Resident room [ROOM NUMBER]. The hot water was left to run in the sink for approximately 2 minutes. The thermometer was then placed in the stream of water coming from the sink faucet and the temperature of 121-degree Fahrenheit displayed on the thermometer. (Photographic Evidence Obtained) On 9/11/23 at 8:45 a.m. two surveyors entered Resident room [ROOM NUMBER], and the hot water was left to run for approximately two minutes from the bathroom sink. The thermometer was then placed in the stream of water coming from the sink faucet and the temperature of 120-degree Fahrenheit displayed on the thermometer. (Photographic Evidence Obtained) On 9/11/23 at 8:50 a.m., two surveyors entered Resident room [ROOM NUMBER], and the hot water was left to run for approximately two minutes from the bathroom sink. The thermometer was then placed in the stream of water coming from the sink faucet and the temperature of 120-degrees Fahrenheit displayed on the thermometer. (Photographic Evidence Obtained) On 9/11/23 at 9:00 a.m. an interview was conducted with Staff B, Dietary Manager (DM). Staff B, DM confirmed the digital thermometer that was being utilized for hot water temperatures had been calibrated earlier in the morning. Staff B, DM calibrated the digital thermometer again, and confirmed all was within parameters. (Photographic Evidence Obtained) On 9/11/23 at 9:10 a.m. an observation of the facility's one resident hot water heater, occurred with the MD. At the bottom of the hot water heater was a dial. The dial was labeled with the letters A, B, C, and VERY HOT. The observation showed the dial to be set with an arrow pointing between the letters B and C. (Photographic Evidence Obtained) On 9/11/23 at 9:55 a.m. an interview was conducted with the MD. The MD stated water temperatures should not be greater than 115 degrees Fahrenheit. The MD stated, we like them to be between 110-115 degrees Fahrenheit. The MD stated he did not know what the temperature setting was for letters A, B, C and Very Hot on the resident hot water heater. He stated he knew that Very Hot was hot and the temperature should not be on that setting. The MD stated the temperatures were audited regularly, and stated the current temperature logs were currently unavailable for review. On 9/11/23 at 10:00 a.m. an interview was conducted with Staff G, Registered Nurse (RN). Staff G, RN stated the water does get quite hot at times. The temperatures come and go. An interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on 9/13/23 at 5:56 p.m. The NHA stated the expectation was the water temperature to the resident locations should be between 105 to 115 degrees Fahrenheit. The NHA stated 120-degree Fahrenheit is too high. On 9/11/23 at 7:25 a.m. and at 1:40 p.m., an observation of the shared bathroom for Resident rooms [ROOM NUMBERS] revealed a sharps container hanging on the wall over the sink, with a syringe sitting in the disposal opening. The emergency call cord for the bathroom was wrapped around the grab bar next to toilet, preventing the cord from being pulled. (Photographic Evidence Obtained) On 9/11/23 at 12:30 p.m. a resident was observed in Resident room [ROOM NUMBER] self-propelling in the wheelchair and the resident confirmed she was able to utilize bathroom. An interview was conducted with the NHA and the DON on 9/13/23 at 5:56 p.m. The NHA and the DON both stated the emergency call cord should be available in all resident bathrooms and the call cords should not be wrapped around the grab bars. The residents should be able to pull the cord easily if needed. The DON stated the expectation was for sharps to be fully disposed of, not left exposed. The DON did not know why someone would not have properly disposed of the syringe, especially if the container was not full. On 9/11/23 at 8:30 a.m. an observation of the housekeeping/nursing supply closet by Resident room [ROOM NUMBER] revealed it was open. The housekeeping/nursing supply closet had bifold doors (two doors one handle that would lock and one door with no handle with locking mechanism at the top, which when not engaged both doors open). When pulling on the handle both doors opened. When opened, the housekeeping/nursing supply closet revealed bleach wipes sitting on the counter at eye level. (Photographic Evidence Obtained) An interview was conducted on 9/13/23 at 12:15 p.m. with the MD. The MD confirmed the housekeeping/nursing supply closet door should be locked. The MD continued to state the lock was working properly but the staff have removed the locking mechanism off the door without the handle. An interview was conducted with the NHA and the DON on 9/13/23 at 5:56 p.m. The NHA stated the expectation of supply closets is they all should be locked, except when in use. An observation was made on 9/11/23 at 7:40 a.m., 9/12/23 at 2:30 p.m., and 9/13/23 at 11:00 a.m. of Resident room [ROOM NUMBER]'s, air conditioner (a/c) wall unit and the wall surrounding the a/c was wet, brown, and crumbling. A lizard was seen in the blankets then ran under the wall. When looking down at the top of the a/c you could see the outside as a gap was between the unit and wall. (Photographic Evidence Obtained) An additional observation was made on 9/11/23 at 7:40 a.m. of Resident room [ROOM NUMBER]'s air conditioner (a/c) wall unit and underneath the a/c unit were two blankets that were wet. The resident in room [ROOM NUMBER] stated the a/c has been broken for over a week. I am worried about my roommate who walks to the bathroom with a walker and has a bad back, so I placed the blankets on the floor to clean up the water that had puddled on the floor, past the bathroom door. I was afraid my roommate would slip and fall. (Photographic Evidence Obtained) An interview was conducted on 9/13/23 at 12:15 p.m. with the MD. The MD stated the a/c in Resident room [ROOM NUMBER] needed to be repaired although the repair had to be completed from the outside. The MD confirmed the a/c was dripping water. An interview was conducted with the NHA and the DON on 9/13/23 at 5:56 p.m. The NHA stated the a/c should have been fixed immediately and did not know why this had not been completed. A facility policy titled, SAFE WATER TEMPERATURES, dated 3/2023, showed: Policy: it is the policy of this facility to maintain appropriate water temperatures in resident care areas. Policy explanation and compliance guidelines: 3. Thermometers will be available as needed for use by all staff period 4. Staff will report abnormal findings, such as complaints of water too cold or hot, burns or redness, or any problems with water temperatures (ex. water is painful to touch or causes redness) to the supervisor and/or maintenance staff. 5. Water temperatures will be set to a temperature of no more than 115-degree Fahrenheit, or the states allowable maximum water temperature. 6. Maintenance staff will check water heater temperature controls and the temperatures of tap water in all hot water circuits weekly and as needed. 7. Documentation of testing will be maintained for 3 years and kept in the maintenance office. 46234 An observation was made on 9/11/23 at 7:11 a.m. of a storage room on Unit 2. The door had a keypad lock, but the door was not closed all the way, allowing it to be opened by anyone. This storage room had shelves containing hand sanitizer, boxes of razors, gallon jugs of shampoo and body wash. This storage room opened to a resident hall and several residents were observed walking or self-propelling past the door. No staff were in sight of the room at that time. On 9/11/23 at 10:51 a.m. the door to the storage room on Unit 2 was observed to be partially opened. On 9/13/23 at 8:55 a.m. the door to the storage room was again observed to not be closed all the way, allowing easy access. No staff were in sight of the room. An interview was conducted on 9/11/23 at 8:53 a.m. with a resident who resided in room [ROOM NUMBER]. This resident stated the light in her bathroom had not been working and no one could see to use it at night. This bathroom was observed to be shared with the residents in room [ROOM NUMBER]. An interview was conducted on 9/11/23 at 8:55 a.m. with a resident who resided in room [ROOM NUMBER]. The resident stated there is no light in the bathroom and it hasn't worked consistently for months. She said maintenance knows and tried to fix it but it did not work. She stated staff have done nothing. She said the residents that use that bathroom have to hold it at night or they go to the bathroom in the dark. She said it is only a matter of time before someone falls. An observation was made on 9/11/23 at 8:57 a.m. of the shared bathroom for rooms [ROOM NUMBERS]. The light switch outside the door was flipped multiple times and the light in the bathroom did not come on. It was also observed that the emergency pull cord in that bathroom was missing. Review of the census showed seven residents shared the bathroom with no light and no emergency pull cord. A facility policy titled, PREVENTATIVE MAINTENANCE PROGRAM, dated 2/2023, showed: Policy: A preventative maintenance program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Policy Explanation and Compliance Guidelines: 1. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 2. The Maintenance Director shall assess all aspects of the physical plant to determine if preventative maintenance (PM) is required. Required PM may be determined from manufacturers recommendations, maintenance requests, grand rounds, life safety requirements, or experience. 3. If preventive maintenance is required, the maintenance director shall decide what tasks need to be completed and how often to complete them. 4. The maintenance director shall develop a calendar to assist with keeping track of all tasks. 5. Documentation shall be completed for all tasks and kept in the maintenance director 's office for at least 3 years.

Based on observation, interview, record review and policy review the facility failed to ensure storage and labeling of drugs and biologicals in accordance with professional standards, and failed to ensure medications were secured and not accessible to residents, visitors and/or unauthorized staff for one medication cart (Station Two) of two medication carts, and for one of one treatment carts located in an unlocked medical supply room for two days ([DATE] and [DATE]) out of three days of the survey. Findings included: An observation was made upon entering the facility on [DATE] at 7:10 a.m. of an unlocked medical supply room opened to a resident hallway. (Photographic Evidence Obtained) There were no staff around this area at this time. Inside the medical supply room was an unlocked treatment cart. The first drawer of this treatment cart contained a pair of sharp scissors and a pair of blunted trauma shears (Photographic Evidence Obtained.) The second drawer contained residents' prescription medication. On [DATE] at 2:45 p.m. a column was observed with a key hanging from a nail in Nurses Station Two. An interview was conducted with Staff K, Registered Nurse (RN) at this time. Staff K, RN stated the hanging key was utilized for the medical supply room. The height of the key could be obtained from a standing adult. An observation on [DATE] at 8:53 a.m. revealed the medical supply room was opened to the resident hallway with a treatment cart unlocked. No staff were present during this observation. An observation was made of the Medication Cart for Station Two on [DATE] at 3:08 p.m. with Staff K, RN. An observation of each individual drawer in the medication cart revealed: seven loose tablets either whole or in pieces, three hearing aid cases, one metallic chain, two keys, one denture cup, one hearing aid battery, three entire pharmaceutical bubble packs in the back of the cart behind the bottom drawer, and a white bottle with no commercial label marked in a permanent marker as Fe Iron on the side and on top of the cap. Staff K, RN confirmed the bottle should have been labeled better than how it currently was presented. Staff K, RN stated the night shift usually cleans the medication cart. An interview and observation were conducted with the Director of Nursing (DON) on [DATE] at 3:47 p.m. of the medication cart for Station Two. The DON confirmed personal items for residents should not be in the medication cart and should be locked elsewhere on behalf of the residents. The DON confirmed the white bottle with only Fe Iron should have been removed, disposed of, and replaced with a new bottle from their medication room by Nurse Station Two. The bottom drawer was brought out and the three pharmaceutical dispense cards were removed. Two of the three medication bubble packs were for Baclofen for the same resident with a current up to date expiration date and the third medication bubble pack was for Benztropine with one pill remaining. The DON said the night shift will clean the carts but the expectation is that all nurses maintain their own cart. A phone interview was conducted on [DATE] at 1:40 p.m. with the Consultant Pharmacist. The Consultant Pharmacist said she conducts monthly medication cart audits and medication room inventory as well as Quality Assurance. A monthly report is provided to the DON regarding the pharmacist's findings. The pharmacist stated expiration of medication storage has been an ongoing issue and has placed that concern in her monthly reports. The Consultant Pharmacist stated she will immediately notify staff and the DON of any concerns regarding her findings. The Consultant Pharmacist stated education is provided when the incident is found and will also provide monthly in-services as well. A review of the Consultant Pharmacist Summaries, dated [DATE], and [DATE], showed: Top Three Areas of Opportunity for medication carts with undated and expired insulin pens and undated eye drops. 41015 An observation on [DATE] at 7:40 a.m., showed the medication cart near Nurses Station One was unlocked and unattended. (Photographic Evidence Obtained) During an interview on [DATE] at 7:45 a.m., Staff A, Licensed Practical Nurse (LPN) stated she was responsible for the medication cart near Nurses Station One and the medication cart should have been locked before walking away. 46234 During an observation made on [DATE] at 7:09 a.m. of the open door to the medical supply room on Unit 2 and the following was revealed: shelves containing wound cleanser, nail polish remover, anti-fungal powder, and safety pin needles. No staff were in sight of the room at that time. On [DATE] at 10:50 a.m. the medical supply room door was observed open directly to a resident hall and several residents were observed walking or self-propelling past the open door. On [DATE] at 8:53 a.m. an observation revealed the medical supply room had the door open with access to supplies. No staff were in sight of the room. An observation was made on [DATE] at 12:23 p.m. of two pills on the floor behind the door in room [ROOM NUMBER]. Staff K, RN came and picked up the pills. One of the pills was identified as Buspirone, a medication used to treat anxiety disorders, and the second pill was not identified. Staff K, RN said she didn't know how the pills got there and confirmed they should not be there. A review of a facility policy titled, Storage of Medications, revised 11/ 2020, showed the following: Policy The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls only persons authorized to prepare and administer medications have access to locked medications. . 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. Drug containers that have missing incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. . 6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended.

Based on observation, record review and interview the facility failed to serve food that was palatable and at an appetizing temperature for six residents (#12, #16, #38, #40, #41 and #343) of 17 residents reviewed for food services. Findings included: During an interview on 09/11/23 at 8:43 a.m., Resident #41 stated the food was cold. Resident #41 stated she talked to the lady in the kitchen about the cold food but nothing changed. Review of Resident #41's Admission Record showed Resident #41 was admitted to the facility on [DATE] with the diagnoses to include type two diabetes mellitus, chronic obstructive pulmonary disease. The Quarterly Minimum Data Set (MDS), dated [DATE], showed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 13 (cognitively intact). During an interview on 09/11/23 at 8:45 a.m. Resident #40 stated being unhappy about the breakfast this morning and stated the eggs, sausage and toast was always served cold. Review of Resident #40's Admission Record showed Resident #40 was admitted to the facility on [DATE] with diagnoses to include type two diabetes and hyperlipidemia. The Quarterly MDS, dated [DATE], showed Resident #40 had a BIMS score of 15 (cognitively intact). During an interview on 09/11/23 at 8:56 a.m., Resident #12 stated she had just finished breakfast and breakfast was cold. Resident #12 stated the eggs and sausage were always cold. Review of Resident #12's Admission Record showed Resident #12 was admitted to the facility on [DATE] with diagnoses to include anemia, and adult failure to thrive. The nursing comprehensive MDS, dated [DATE], showed Resident #12 had a BIMS score of 15 (cognitively intact). During an interview on 09/11/23 at 9:07 a.m., Resident #38 stated the facility seemed to always serve the same thing over and over again and the food comes out cold. Review of Resident #38's Admission Record showed Resident #38 was admitted to the facility on [DATE] with diagnoses to include encephalopathy, and major depressive disorder. The Quarterly MDS, dated [DATE], showed Resident #38 had a BIMS score of 14 (cognitively intact). During an interview on 09/11/23 at 9:17 a.m., Resident #16 stated, The food is cold, it is always cold. Review of Resident #16's Admission Record showed Resident #16 was admitted to the facility on [DATE] with diagnoses to include diverticulosis of intestines. The nursing comprehensive MDS, dated [DATE], showed Resident #16 had a BIMS score of 14 (cognitively intact). During an interview on 09/11/23 at 10:04 a.m., Resident #343 stated the food could be a little warmer. Review of Resident #343's Admission Record showed Resident #343 was admitted to the facility on [DATE] with diagnoses to include type two diabetes mellitus, hyperlipidemia, and anemia. The comprehensive MDS, dated [DATE], showed Resident #343 had a BIMS score of 13 (cognitively intact). Review of the facility's grievance log showed food concerns related to temperatures for the following dates: June 2023 - 06/07/23, and August 2023 - 08/22/23. The grievance on 06/07/23 showed two former residents of the facility stated the food was being served cold. The actions taken by the facility showed, Education done with dietary. to let staff know when trays are on the floor. Resolution of the grievance showed concern was resolved and now being served in a timely manner and is still warm. The grievance on 08/22/23 showed Resident #41 stated, food was cold. The actions taken by the facility showed, temp (temperature) check done on food trays. Resolution of the grievance showed concern was resolved as meals being delivered warmer. A lunch tray temperature check on 09/12/23 at 12:25 p.m. was conducted with Staff B, Cook/Dietary Manger (DM). The temperatures for the lunch tray for a mechanical soft diet showed: - Mechanical Salisbury Steak- 114.2 degrees Fahrenheit (F) - Mashed potatoes with gravy- 130.8 F - Carrots- 114.9 F - strawberries with whip cream- 63.2 F During an interview on 09/12/23 at 12:25 p.m., Staff B, DM stated hot foods should be above 135 degrees for hot foods and 40 degrees for cold foods. Staff B, DM stated, I am only in trouble when the kitchen serves food under 102 degrees so I would say that today's lunch was in a fair state. During an interview on 09/12/23 at 1:20 p.m., the Regional Registered Dietitian (RRD) stated the food at service was not about the temperatures at delivery, it is about palatability. During an additional interview on 09/13/23 at 11:00 a.m., Resident #41 stated she wrote grievances before on cold food but also had a problem with cold food being hot. Resident #41 said for example ice cream was always melted before it gets served and also [gelatin dessert] was melted. Resident #41 stated she worked in the health care field in the past and she knew the food should come out appetizing and it was not. Resident #41 stated the hot food comes out cold and the cold food comes out hot. During an additional interview on 09/13/23 at 11:12 a.m., Resident #343 stated he gets ice cold eggs so he had a box a cereal he will eat when the food wasn't good. Resident #343 also stated another complaint was he liked cold milk but the milk served was never cold it is always pretty warm. An additional observation of the tray line on 09/13/23 at 11:27 a.m. showed trays were prepped with hydration and condiments first. Milk and juices were observed on the trays at 11:27 a.m., with the first trays served to residents in the dining room was at 12:00 p.m. The second tray temperature at delivery with Staff B, DM on 09/13/23 at 12:18 p.m., showed: - Mechanical soft BBQ chicken- 114.1 F - Mechanical soft corn- 116.4 F - Baked Beans- 110.4 F - Orange juice- 70.4 F During an interview on 09/13/23 at 12:19 p.m., Staff B, DM stated the tray line prep starts with desserts, then juices are added and milk to go on the tray last before the plate of food, since milk was stored by the door. Staff B, DM stated the tray prep starts around 11:30 a.m. and the trays go out of the kitchen at 12:00 p.m. Staff B, DM was asked if orange juice served at 70.4 degrees (room temperature) was a reasonable temperature for palatability. Staff B, DM stated the food was appetizing to her and she stated again the food was above 102 degrees. During an interview on 09/13/23 at 1:19 p.m., the facility's Registered Dietitian (RD) stated she would expect the juice to be cold. The RD stated, Temperatures do not matter, it is all based on palatability and if residents like and eat the food. A review of the facility's policy, Record of Food Temperature, revised date 10/19/22 showed, 2. Hot foods will be held at 135 degrees Fahrenheit or greater. 4. Potentially hazardous cold food temperatures will be kept at or below 41 degrees Fahrenheit. 8. If the food temperature falls into an unsafe range, immediately follow procedure for reheating cooked food. 10. Ready to eat foods that require heating before consumption should be taken directly from a sealed container or an intact package from an approved food processing source and heated to at least 135 degree Fahrenheit for holding for hot service.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed on two of two units, in the dining room, and in the laundry room, related to used medical gloves being left on the floor and ground, staff wearing gloves in the hall, laundry not being sanitized, dirty laundry being left hanging in shared resident bathrooms, and soiled linen being left in rooms. Findings included: An observation was made on 9/11/23 at 7:15 a.m. of a used medical glove on the floor outside of Resident room [ROOM NUMBER]. An observation was made on 9/11/23 at 7:19 a.m. of a used medical glove on the ground in the smoking courtyard. The glove remained on the ground on 9/12/23 at 1:19 p.m. An observation was made on 9/11/23 at 7:24 a.m. of a trash can overflowing in Resident room [ROOM NUMBER] with two used medical gloves on the floor near the sink. An observation was made on 9/11/23 at 8:31 a.m. of feces on the toilet and floor in the bathroom of Resident room [ROOM NUMBER]. On 9/13/23 at 6:13 p.m. the feces remained on the toilet and floor. An observation was made on 9/12/23 at 1:23 p.m. of a soiled washcloth in the dining room on a shelf by the television. An observation was made on 9/13/23 at 2:57 p.m., of a nurse at the Unit 1 medication cart with medical gloves on. The nurse was handling things on the cart then picked up a bag of trash, tied it up and carried it to the soiled utility room. The nurse continued to wear the gloves coming back into the hall then proceeded to enter a resident's room and came out with the same pair of gloves on. The nurse then removed the gloves and disposed of them. On 9/13/23 at 3:00 p.m., an interview was conducted with Staff L, Licensed Practical Nurse (LPN). When asked about wearing gloves in the hall, Staff L said I threw them away. When asked about putting trash away then going into a resident room Staff L added, it was just trash and regarding when he went in the resident's room, Staff L said I didn't touch anything. On 9/13/23 at 2:47 p.m., a tour of the laundry room was completed with Staff H, Certified Nursing Assistant (CNA). Upon entering the laundry room there was one commercial washing machine and one personal model washing machine. The personal model machine had dirt, hair, and debris around the opening and inside the lid. Staff H said the personal model machine was used for washing tablecloths, clothing protectors, and mops. She said staff used detergent and softener only in the machine. She confirmed no sanitizer was used in the machine. The personal model washing machine was being run on hot water, heavy soil level, normal cycle and two rinses. It was also observed there was nothing separating the soiled laundry from the clean laundry side. The plastic strips that were in place to be used as a divider were tucked behind clothing racks, so they were not covering the door opening. Staff H confirmed the plastic dividers should be down covering the door opening. When Staff H pulled the dividers down, they were stuck together and folded up. In the clean laundry side, there were two commercial dryers running. The lint filters in each were full. Staff H provided the sign off sheet saying the lint filters were cleaned hourly by the laundry manager. The lint filter sign off was completed every hour including 9/13/23 at 3:00 p.m. and 4:00 p.m., time that had not passed yet. An observation was also made of a rack of clean clothing that was not covered. The cover for the cart that should be used was folded on top with blankets piled on top of it. An interview was conducted on 9/13/23 at 3:15 p.m. with the Maintenance Director, who oversees laundry services. The Maintenance Director said he had not checked the temperature of the personal model washing machine. He was observed getting a thermometer and going to the laundry room. He disconnected the water hose and checked the temperature of the hot water running to the machine and the highest temperature reading was 145.6 degrees Fahrenheit. The Maintenance Director confirmed the personal model washing machine was used to wash table clothes, clothing protectors for residents, and mops. He stated no sanitizer was used in the machine. An interview was conducted on 9/13/23 at 3:20 p.m. with the Laundry Manager. She said she cleaned the lint traps on the dryers. She looked at how full the lint traps were and said they probably had not been cleaned since at least lunch. When asked why the sign off sheet was completed for every hour for the entire day, she said she, accidently signed them off yesterday. A follow-up interview was conducted on 9/13/23 at 6:06 p.m. with the Maintenance Director. He confirmed the hot water to the laundry was set too low and should be turned up to 165 degrees Fahrenheit. 41015 2. An observation on 09/11/23 at 7:47 a.m., showed blue underwear hanging on a towel rack in the shared bathroom between Resident rooms [ROOM NUMBERS]. (Photographic Evidence Obtained) During an interview on 09/11/23 at 7:47 a.m., Resident #344 stated the underwear belonged to Resident #8. Resident #344 stated, Resident #8 washed them in the sink and was letting the underwear hang dry. During an interview on 09/11/23 at 8:50 a.m., Resident #8 stated the blue underwear was hers and she washed them out in the sink and left them to dry. Resident #8 stated she was being discharged tomorrow and wanted them clean for when she got discharged tomorrow. An observation on 09/11/23 at 9:17 a.m., showed a pair of used gloves on the corner of bed B in Resident room [ROOM NUMBER]. (Photographic Evidence Obtained) 48223 3. The community shower room outside of Resident room [ROOM NUMBER] was observed on 9/11/23 at 7:50 a.m. and 1:00 p.m. The shower room had several dirty towels piled on the sink edge, dirty towels, lying on the floor between the sink and toilet, a basin was under the sink, half in a plastic bag. The basin had dirt and trash inside of it. A roll of toilet paper was sitting on the grab bar above the toilet. There was a pink/brownish color on the sink edge, where the sink attached to the wall. (Photographic Evidence Obtained) The community shower room outside of Resident room [ROOM NUMBER] was observed on 9/11/23 at 8:00 a.m. and 12:55 p.m. The shower room had dirty towels hanging from a pipe between the sink and the shower. (Photographic Evidence Obtained) An interview was conducted on 9/11/23 at 9:00 a.m. with Staff F, CNA. Staff F confirmed the towels in both community shower rooms should not have been there. Staff F stated each CNA was responsible for cleaning up after they were done using the shower for a resident. An observation was made on 9/13/23 at 10:30 a.m. of Staff C, CNA exiting Resident room [ROOM NUMBER] with gloves on. Staff C proceeded to remove the gloves in the middle of hallway as Staff C walked towards Nurse Station #2. Staff C disposed of the gloves in the trash and proceeded to complete hand hygiene. An interview was conducted on 9/13/23 at 10:55 a.m. with Staff C. Staff C confirmed exiting Resident room [ROOM NUMBER] with gloves on. Staff C stated this should not have happened, and gloves were not to be worn in the hallways. An interview was conducted on 9/13/23 at 5:45 p.m. with the Director of Nursing (DON)/Infection Preventionist (IP). She looked at pictures of the used medical gloves around the facility and confirmed it was not okay, and gloves should be thrown in a trash can. When asked about dirty under garments being washed by a resident in the bathroom sink and being left in a shared bathroom she said, Oh my, and agreed it was an infection concern. The DON/IP also confirmed staff should not be wearing gloves in the hall, especially coming in and out of a resident room. She stated that was unacceptable. The DON/IP reviewed pictures of the resident bathroom toilet that has been soiled with feces for three days, she said it is definitely an infection problem. The DON/IP said soiled linen should be bagged up and taken to the soiled laundry immediately and should never be left in a room or on the floor. The DON/IP was unaware of the laundry water temperature not being high enough. Review of a facility policy titled, Laundry, implemented 6/2023, showed the following: Policy: The facility launders linens and clothing in accordance with current CDC guidelines to prevent transmission of pathogens. Policy Explanation and Compliance Guidelines: 3. Soiled laundry shall be kept separate form clean laundry at all times . 5. Laundry equipment will be used and maintained according to manufacturer's instructions . 7. The facility should use the fabric manufacturer's recommended laundry cycles, water temperatures and chemical detergent products: a. Wash with detergent in a water temperature of 160 (71 C)[Celsius] for at least 25 minutes. b. For laundry that is not hot water compatible, low temperature washing at 71 to 77 F [Fahrenheit] (22-25 C) plus chlorine or oxygen-activated bleach can reduce microbial contamination. 14. Items that can be used for another resident after an individual resident's use must be cleaned and disinfected between use for different residents or replaced or discarded. Review of a facility policy titled, Hand Hygiene, implemented 9/7/22, showed the following: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice . 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Review of a facility policy titled, Infection Prevention and Control Program, reviewed 7/13/23, showed the following; Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: 2. All staff are responsible for following all policies and procedures related to the program . 4. Standard Precautions: b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE . e. Environmental cleaning and disinfection shall be performed according to facility policy. All staff have responsibilities related to the cleanliness of the facility and are to report problems outside of their scope to the appropriate department. 11. Linens: e. Soiled linen shall be collected at the bedside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in the soil utility room. Soiled linens shall not be kept in the residents' room or bathroom. 15. Staff Education: b. All staff shall demonstrate competence in relevant infection control practices. c. Direct care staff shall demonstrate competence in resident care procedures established by our facility.

Based on observations, interviews and record review, the facility failed to provide equal access to quality care related to a dignified meal service for two (#2 and #3) of four residents sampled for dependence on staff during dining. Findings included: On 11/02/23 at approximately 11:50 a.m., Resident #2 and #3 were observed in the dining room. Resident #2 was in his wheelchair sharing a table with another resident. Resident #2's tray was observed in front of him. The resident was observed not able to feed himself. Resident #3 was observed in specialized chair sharing a table with two other residents. All the residents had trays in front of them. The other two residents were observed being assisted with their meals. Resident #3 was observed not eating or drinking while the other residents ate. Review of record showed Resident #2 was admitted to the facility on [DATE] with diagnoses to include encephalopathy, other specified disorders of the brain, hemiplegia and hemiparesis affecting left non-dominant side and Dysphagia following cerebral infarction. Review of physician orders for Resident #2 dated 11/02/23 showed the resident required a mechanical soft texture, thin liquid consistency diet. A quarterly Minimum Data Set (MDS) dated , 08/08/23 showed under Section C, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. Section G showed the resident required extensive assistance for eating, with one-person physical assistance. Section K showed Resident #2 required a mechanically altered diet. Review of a care plan for Resident #2 dated 05/11/23, showed an Activities of Daily Living (ADL) related to memory loss, encephalopathy, anxiety, status post CVA (Cerebral Vascular Accident) affecting left side Interventions included provide assistance as needed with ADL task. Review of record showed Resident #3 was admitted to the facility on [DATE] with diagnoses to include unspecified fracture of shaft of humerus left arm, subsequent encounter for fracture with routine healing, unspecified dementia with unspecified severity, with other behavioral disturbance, displaced fracture of body of scapular, left shoulder, unspecified protein calorie malnutrition, epilepsy, cerebral palsy, unspecified intellectual disabilities and age-related osteoporosis with current pathological fracture. Review of physician orders for Resident #3 dated 11/02/23 showed the resident required a mechanical soft texture with thin liquid consistency for nutrition. An annual MDS dated , 06/19/23 showed under section C, Resident #3 had a BIMS score of 99, indicating significant cognitive impairment. Section G showed the resident required extensive assistance for eating, with one-person physical assistance. Section K showed Resident #2 required a mechanically altered diet. Review of a care plan for Resident #3 revised 04/15/23, showed the resident had a self-care deficit due to contractures on BLE (bilateral lower extremities), (ROM) Range of Motion that impact ADL activities. Resident #3 will feed self at times and may assist with simple tasks. Resident #3 is never understood and does not understand others. The goals showed the resident will allow staff to assist with ADLs as deemed necessary and will maintain current level of ADL functioning through the next review date. Interventions included to encourage/cue resident to participate in ADL task, to observe for decline in ADL function and report to the physician as indicated, and to provide hands on assistance as needed. On 11/02/23 at 12:10 p.m., an observation was made of Resident #2 and #3 sitting at dining room tables with other residents. Some residents in the dining room were observed to have finished eating their meals during approximately the 20-30-minute period. These two residents were waiting to be assisted with their meal. On 11/02/23 at 12:10 p.m., an interview was conducted with Staff A, Certified Nursing Assistant (CNA) who was assisting another Resident sharing a table with Resident #3. Staff A stated there were two CNAs assigned dining duty. She stated she would assist Resident #3 once she was done with the resident she was feeding. Staff A confirmed Resident #3 was dependent on staff for eating. Staff A stated, I know, they should not wait. The nurses are supposed to help. Staff A stated it was not okay with her that Resident #2 and #3 were waiting to be assisted with their meals while all the other residents were eating. On 11/02/23 at 12:13 p.m., an interview was conducted with Staff B, Registered Nurse (RN). Staff B walked into the dining room and sat next to Resident #2. She stated she was about to assist the resident with his meal. Staff B said, I understand how having the residents wait for their meal while everyone is eating is uncomfortable. She stated she did not think it was fair to the residents who were dependent on staff. She stated she did not know the residents had been waiting. On 11/02/23 at 2:51 p.m., an interview was conducted with the Director of Nursing (DON). She stated she would expect all residents to be served at the same time and if they need assistance, it should be provided at the same time. The DON stated she would expect the CNA to ask for assistance if they needed additional help. The DON said, It is not dignified to smell the food while others are eating, and one is not. I would not want that. A follow-up interview was conducted on 11/02/23 at 5:10 p.m., with the Nursing Home Administrator (NHA). The NHA stated he would expect residents who are sitting together to be served and assisted together. He said, right is right and wrong is wrong. That was wrong. The residents should not have been waiting when the others were eating. We will fix that. Review of a facility policy titled, Promoting/Maintaining Resident Dignity, dated 09/07/22, showed it is the policy 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. Under compliance guidelines the policy showed 1.) All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. 5.) When interacting with a resident, pay attention to the resident as an individual. 6.) Respond to requests for assistance in a timely manner. 13.) Assist residents to participate in activities of choice. 14.) Each resident will be provided equal access to quality care regardless of diagnosis, severity of condition or payment source.

Based on observations, interviews and record review, the facility failed to provide equal access to quality care related to a dignified meal service for two (#2 and #3) of four residents sampled for dependence on staff during dining. Findings included: On 11/02/23 at approximately 11:50 a.m., Resident #2 and #3 were observed in the dining room. Resident #2 was in his wheelchair sharing a table with another resident. Resident #2's tray was observed in front of him. The resident was observed not able to feed himself. Resident #3 was observed in specialized chair sharing a table with two other residents. All the residents had trays in front of them. The other two residents were observed being assisted with their meals. Resident #3 was observed not eating or drinking while the other residents ate. Review of record showed Resident #2 was admitted to the facility on [DATE] with diagnoses to include encephalopathy, other specified disorders of the brain, hemiplegia and hemiparesis affecting left non-dominant side and Dysphagia following cerebral infarction. Review of physician orders for Resident #2 dated 11/02/23 showed the resident required a mechanical soft texture, thin liquid consistency diet. A quarterly Minimum Data Set (MDS) dated , 08/08/23 showed under Section C, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. Section G showed the resident required extensive assistance for eating, with one-person physical assistance. Section K showed Resident #2 required a mechanically altered diet. Review of a care plan for Resident #2 dated 05/11/23, showed an Activities of Daily Living (ADL) related to memory loss, encephalopathy, anxiety, status post CVA (Cerebral Vascular Accident) affecting left side Interventions included provide assistance as needed with ADL task. Review of record showed Resident #3 was admitted to the facility on [DATE] with diagnoses to include unspecified fracture of shaft of humerus left arm, subsequent encounter for fracture with routine healing, unspecified dementia with unspecified severity, with other behavioral disturbance, displaced fracture of body of scapular, left shoulder, unspecified protein calorie malnutrition, epilepsy, cerebral palsy, unspecified intellectual disabilities and age-related osteoporosis with current pathological fracture. Review of physician orders for Resident #3 dated 11/02/23 showed the resident required a mechanical soft texture with thin liquid consistency for nutrition. An annual MDS dated , 06/19/23 showed under section C, Resident #3 had a BIMS score of 99, indicating significant cognitive impairment. Section G showed the resident required extensive assistance for eating, with one-person physical assistance. Section K showed Resident #2 required a mechanically altered diet. Review of a care plan for Resident #3 revised 04/15/23, showed the resident had a self-care deficit due to contractures on BLE (bilateral lower extremities), (ROM) Range of Motion that impact ADL activities. Resident #3 will feed self at times and may assist with simple tasks. Resident #3 is never understood and does not understand others. The goals showed the resident will allow staff to assist with ADLs as deemed necessary and will maintain current level of ADL functioning through the next review date. Interventions included to encourage/cue resident to participate in ADL task, to observe for decline in ADL function and report to the physician as indicated, and to provide hands on assistance as needed. On 11/02/23 at 12:10 p.m., an observation was made of Resident #2 and #3 sitting at dining room tables with other residents. Some residents in the dining room were observed to have finished eating their meals during approximately the 20-30-minute period. These two residents were waiting to be assisted with their meal. On 11/02/23 at 12:10 p.m., an interview was conducted with Staff A, Certified Nursing Assistant (CNA) who was assisting another Resident sharing a table with Resident #3. Staff A stated there were two CNAs assigned dining duty. She stated she would assist Resident #3 once she was done with the resident she was feeding. Staff A confirmed Resident #3 was dependent on staff for eating. Staff A stated, I know, they should not wait. The nurses are supposed to help. Staff A stated it was not okay with her that Resident #2 and #3 were waiting to be assisted with their meals while all the other residents were eating. On 11/02/23 at 12:13 p.m., an interview was conducted with Staff B, Registered Nurse (RN). Staff B walked into the dining room and sat next to Resident #2. She stated she was about to assist the resident with his meal. Staff B said, I understand how having the residents wait for their meal while everyone is eating is uncomfortable. She stated she did not think it was fair to the residents who were dependent on staff. She stated she did not know the residents had been waiting. On 11/02/23 at 2:51 p.m., an interview was conducted with the Director of Nursing (DON). She stated she would expect all residents to be served at the same time and if they need assistance, it should be provided at the same time. The DON stated she would expect the CNA to ask for assistance if they needed additional help. The DON said, It is not dignified to smell the food while others are eating, and one is not. I would not want that. A follow-up interview was conducted on 11/02/23 at 5:10 p.m., with the Nursing Home Administrator (NHA). The NHA stated he would expect residents who are sitting together to be served and assisted together. He said, right is right and wrong is wrong. That was wrong. The residents should not have been waiting when the others were eating. We will fix that. Review of a facility policy titled, Promoting/Maintaining Resident Dignity, dated 09/07/22, showed it is the policy 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. Under compliance guidelines the policy showed 1.) All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. 5.) When interacting with a resident, pay attention to the resident as an individual. 6.) Respond to requests for assistance in a timely manner. 13.) Assist residents to participate in activities of choice. 14.) Each resident will be provided equal access to quality care regardless of diagnosis, severity of condition or payment source.

Based on record review and interview the facility failed to request a Level II Pre-Admission Screening and Resident Review (PASARR) for one resident (#16) with a newly diagnosed mental illness out of 14 sampled residents. Findings included: A review of Resident #16's Admission Record showed Resident #16 was admitted to the facility on [DATE] with diagnoses to include cerebral palsy and paraplegia. Resident #16 was diagnosed with schizophrenia, unspecified on 01/16/23. A review of a psychiatric note dated 01/16/23 showed, Reason for today's evaluation: Consult for psychiatric evaluation for schizophrenia disorder. Results: Patient has schizophrenia start Risperdal 1 mg (milligram) PO (by mouth) BID (two times a day) for schizophrenia. A review of the physician orders for September 2023 showed: Risperidone Oral Tablet 1 MG (Risperidone) Give one tablet by mouth two times a day for Schizophrenia. A review of the care plan showed Resident #16 had a Focus Area for Antipsychotic Care Plan, initiated on 1/16/23, that showed: [Resident #16] is at risk of adverse side effects related to use of antipsychotic medications. He has a dx. (diagnosis) of Schizophrenia . A review of the Quarterly Minimum Data Set (MDS), dated [DATE], showed the use of antipsychotic medication and a diagnosis of schizophrenia. Further review of Resident #16's medical record showed the PASARR, dated 04/26/2020, documented a diagnosis of cerebral palsy. There was no other PASARR available in the medical record to show the new diagnosis of schizophrenia on 01/16/23. During an interview on 09/13/23 at 12:49 p.m., the Director of Nursing (DON) stated when a resident gets a new diagnosis like schizophrenia, after admission, it was expected for a PASARR Level II to be submitted. The DON stated she was responsible for all PASARR information in the facility. The DON stated she was on leave during the time the Level II was required to be submitted however she would have expected the staff member covering during her leave of absence would have submitted the new diagnosis for a Level II. Review of the facility's policy titled, Resident Assessment- Coordination with PASARR Program, implemented 09/07/2022, showed, Any resident who exhibits a newly evident or possible serious mental illness, intellectual disorder, or a related condition with be referred promptly to the state mental heal or intellectual disability authority for a level II resident review.

Based on observation, record review and interview the facility failed to monitor and record temperatures for the one nourishment refrigerator used for residents located at one nurses station (Nurses Station Two) of two nurses stations. Findings included: An observation on 09/13/23 at 1:30 p.m., showed a RESIDENTS ONLY refrigerator located at Nurses Station Two. The refrigerator contained food and drink for multiple residents. On the refrigerator was a temperature log for September 2023 that showed missing temperatures. The dates missing temperature checks for the month of September 2023 were as follows: (Photographic Evidence Obtained) - 09/01/23 - 09/03/23 - 09/04/23. Behind the September 2023 refrigerator temperature log was the August 2023 refrigerator temperature log. The dates missing temperature checks for the month of August 2023 were as follows: (Photographic Evidence Obtained) -08/18/23 -08/19/23 -08/20/23 -08/21/23 -08/22/23 -08/23/23 -08/24/23 -08/25/23 -08/26/23 -08/27/23 -08/28/23. During an interview on 09/13/23 at 1:36 p.m. the Assistant Director of Nursing (ADON) stated the night shift should have completed the refrigerator temperature logs nightly. The ADON confirmed the refrigerator temperature logs for August 2023 and September 2023 were incomplete. The ADON stated she would expect the temperature logs to be completed nightly and education will need to be provided to the staff. A review of the facility's policy, Resident Refrigerators, revised date 02/2023 showed Staff shall record refrigerator temperatures weekly on a temperature log attached to the refrigerator.

Based on record review and interview, the facility failed to ensure the binding arbitration agreement was understood by two residents (#13 and #34) of three residents sampled. Findings included: 1. On 9/11/2023 at 10:36 a.m., an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated all residents review and sign arbitration agreements upon admission. The NHA stated no one has declined to sign the arbitration agreement. The NHA provided a facility document titled, Facility Admission Agreement, State: FLORIDA printed in the middle of the page and on the bottom left corner, Admission Agreement, August 2022 version. Review of Resident #13's Admission Record revealed Resident #13 was admitted on [DATE]., with diagnoses that included sepsis, chronic obstructive pulmonary disease, type 2 diabetes, hypertension encephalopathy. Review of the Minimum Data Set (MDS), dated [DATE], Section C - Cognitive Patterns revealed the Brief Interview for Mental Status (BIMS) score was 03 out of 15, indicating the resident had severe cognitive impairment. Review Resident #13's Facility Admission Agreement - Facility Admission Agreement, August 2022 version, and Attachments Section G & H revealed it was signed by Resident #13 and dated 6/1/2023. An interview with Resident #13 occurred on 9/13/2023 at 1:20 p.m. Resident #13 stated, I somewhat recall signing paperwork, but I was very out of it when admitted . I don't really recall anything specific. Review of Resident #13's medical record showed no evidence the resident's representative was contacted for assistance during this time. 2. Review of Resident #34's Admission Record revealed Resident #34 was admitted on [DATE], with diagnoses that included type 2 diabetes, hypertension, unsteadiness on feet, other abnormalities of gait and mobility. Review of the MDS, dated [DATE], Section C - Cognitive Patterns revealed the BIMS score was 13 out of 15, indicating the resident was cognitively intact. Review of Resident #34's Facility Admission Agreement, August 2022 version revealed it was signed by Resident #34 and dated 9/7/2023. An interview with Resident #34 was conducted on 9/13/2023 at 1:30 p.m. Resident #34 stated her admittance was very recent and recalls discussing the admission paperwork with the Admission Director (AD). Resident #34 continued to state, no arbitration, mediation or dispute resolution was mentioned. I did not sign that. I know there was a bunch of paperwork they had me sign for treatment, etc. nothing about court or disputes. On 9/13/2023 at 1:52 p.m. an interview was conducted with the AD. The AD stated the admission paperwork included the arbitration agreement. The AD stated she explains to the resident they are waiving their rights and can decline if they want to, and their admission is not affected if they choose not to sign. The AD continued and explained how they determine if a resident can understand the agreement or not, and stated everyone is able to sign the admission agreement. The only residents that are not able to sign themselves in are those a physician has deemed incapacitated. All other residents can sign themselves. On 9/13/2023 at 5:56 p.m. an interview was conducted with the NHA and the Director of Nursing (DON). The NHA stated he would expect the residents to be given an opportunity to ask questions, and to ensure they understand they are waiving the right to go to court and instead go through arbitration. The DON stated the cognitive status of the resident should be considered to determine if the resident is able to understand the agreement. A facility policy titled, BINDING ARBITRATION AGREEMENTS, dated 2/2023, showed: Policy: this facility asks all residents to enter into an agreement for binding arbitration. We do not require binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, this facility. Policy explanation and compliance guidelines: 1. When explaining the arbitration agreement, the facility shall: b. Explain to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands. c. Ensure the resident or his or her representative acknowledges that he or she understands the agreement.

Based on observation, record review, interviews, policy review, and the Plan of Correction review, the facility failed to ensure that it had a functioning Quality Assurance Committee. The facility was actively involved in the creation, implementation and monitoring of the plan of correction for deficient practice identified during a recertification survey that was conducted [DATE] to [DATE] and was cited F761 and F880. On [DATE] a revisit survey was conducted, and the facility was recited F761 and F880. The facility had developed a Plan of Correction with a completion date of [DATE]. Findings included: 1. The facility developed a plan of correction that included: Quality review was conducted on [DATE], by the Assistant Director of Nursing (ADON) of medication carts and supply rooms to ensure medications were labeled and stored appropriately. The facility developed a plan of correction that identified measures to be put into place or made systemic changes to ensure the practice did not recur included: Licensed nurses re-educated by the Director of Nursing (DON) regarding ensuring storage and labeling of drugs and biologicals in accordance with professional standards on [DATE]. The plan identified newly hired licensed nurses would receive education as part of the orientation process. The Director of Nursing or designee, will conduct a quality review of medication carts and supply rooms to ensure medications are labeled, stored appropriately twice weekly x 4 weeks, then twice monthly x 2 months. The findings of these reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 3 or until the committee determines substantial compliance has been met. During the revisit survey conducted [DATE] the facility failed to ensure the medications were stored appropriately when unattended on one (#2) of two medication carts and medications with a shortened expiration life was opened were labeled with an open date on two of two medication carts. On [DATE] at 8:59 a.m., Staff D, Registered Nurse (RN) was observed walking away from a medication cart parked outside of Nursing Station #2, two residents were observed standing in the hallway near the cart. The medication cart was left unlocked with a bottle of Lactulose on top of it while the staff member ambulated to the vendor/employee entrance at the end of the hallway to let a visitor out the key-coded door. Staff D returned to the cart, confirmed the cart was unlocked and the bottle of Lactulose was left on top. The staff member stated I'll be sure not to do that again. On [DATE] at 10:28 a.m. an observation was conducted with Staff C, Licensed Practical Nurse (LPN) of Medication Cart #1. The observation revealed the following: - Opened bottle of Liquid Protein - Medical Food, dated [DATE]. The manufacturer instructed Discard 3 months after opening. Staff C had turned bottle over to read the unopened expiration date, unaware of the shortened shelf life once opened. - One (1) vial of opened Humalog insulin, the medication's attached label did not identify the date the vial was opened. - One (1) opened vial of Levemir, the vial's attached label did not identify when it was opened. - One (1) unopened vial of Levemir. The packaging instructed to Refrigerate and had a handwritten date of [DATE]. - One (1) Humalog Kwik pen, the medication's attached label did not identify the date opened. The packaging identified Refrigerate and did not identify an open date on the available sticker. The printed packaging label included a handwritten date of [DATE]. - One (1) Lantus Solostar insulin pen was opened and did not identify an open date on the medications attached label. The packaging identified an open date of [DATE] and the printed packaging label indicated Once opened store at room temperature for 28 days. The pen was not labeled with an expiration date. - One (1) Lantus Solostar insulin pen, which did not identify an open date on the available attached label and did not identify the date of expiration. The clear plastic bag containing the pen was labeled with an open date of [DATE], and the pharmacy had printed storage instructions, Once opened store a room temperature for 28 days. Neither the pens label or the the packaging label identified an expiration date. - One (1) Novolog Flexpen (insulin) undated per the medication's attached label. A packaging sticker identified the pen had been opened on [DATE]. The pharmacy label on packaging identified Once opened store at room temp for up to 28 days. The pen did not identify an expiration date. (Photographic Evidence Obtained) Immediately following Medication Cart #1's observation, Staff C confirmed the Liquid Protein was to be discarded after 3 months and the plastic bag packaging could be destroyed leaving the insulin pens with unknown open dates. The staff member identified 3 insulin pens and one (1) vial of insulin had arrived to the facility on [DATE] (same day as observation). On [DATE] at 2:17 p.m., Staff C reported just taking the insulin from the refrigerator and the pens and vial, dated [DATE], were still cold during the observation (they were room temperature) and the package bags had been dated (with [DATE]) due to habit. On [DATE] at 11:00 a.m. an observation was conducted with Staff D, Registered Nurse (RN) of Medication Cart #2. The observation revealed the following: - In the small top drawer, located under multiple insulin pens were 2 blister packages containing Azithromycin 250 milligram (mg) tablets. The packaging was worn and did not identify a residents' name. - An Insulin Lispro KwikPen was located in a plastic bag, the medication's attached label did not identify a date the medication was opened. The packaging did not identify an open date and the pharmacy label revealed Refrigerate until opened. - A Lantus Solostar insulin pen without a resident identifier on the medication and the pen was not labeled with an open or expiration date. - An opened Lantus Solostar insulin pen did not identify an open date on the medication's attached label. The packaging identified a pen was opened on [DATE] but did not identify an expiration date. The pharmacy label revealed Once opened store at room temperature for 28 days. - An opened bottle of Latanoprost 0.005% ophthamolic solution that was not dated. The plastic bag containing the medication identified an open date of [DATE] but did not reveal an expiration date. The pharmacy label identified Store opened room temp., Discard after 6 weeks (wk). - A Humalog insulin pen did not identify an opened date on the medication's attached pharmacy label. The packaging did not identify an open date however did reveal Refrigerate until opened. Once opened store at room temperature for 28 days. - A Levemir insulin pen, that was not contained in plastic bag. The medication's attached label did not identify an open date or any specific prescribing instructions. - An opened vial of Novolog. The medication's attached label did not include an open date. - An opened vial of Levemir whose attached label did not identify an open date. The packaging bottle identified an open date of [DATE]. According to https://www.mynovoinsulin.com/insulin-products/levemir/home.html, after use the Levemir FlexPen and vial should be disposed of after 42 days, even if there is insulin left in the pen or vial. The vial of Levemir expired on [DATE]. - An opened Novolog FlexPen. The medication's attached label did not identify an open date. The pharmacy label revealed Once opened store at room temp for 28 days. The sticker attached to the plastic bag containing the insulin pen identified an open date of [DATE] but did not reveal an expiration date. - The attached medication label of one (1) Lantus Solostar insulin pen did not identify an open date. The plastic bag containing the pen identified an open date of [DATE]. The pharmacy label indicted Once opened store at room temperature for 28 days. The pen or the packaging did not identify an expiration date. - The pharmacy label attached to a Lantus Solostar pen did not reveal an open date. The plastic bag containing the pen identified an open date of [DATE]. The pharmacy label revealed once opened the pen could be stored for 28 days at room temperature. The packaging stickers or the medication label did not reveal an expiration date. - The attached medication label for a Basaglar insulin Kwikpen identified an open date. The plastic bag containing the Kwikpen identified an open date of [DATE]. - A box containing an open bottle of Artificial Tears Lubricant Eye Drops was located in the med cart #2. Staff C confirmed neither the box or the bottle were labeled with an open date. According to Cleveland Clinic, (https://my.clevelandclinic.org/health/drugs/18710-artificial-tears-eye-solution) Once the product is opened, most experts recommend discarding the product (Artificial Tears) after 30 days. Immediately following the observation, Staff C confirmed the findings of several insulin pens not being dated, the Artificial Tears not being dated, and the unopened bottle of Calcitonin should have been refrigerated. On [DATE] at 11:44 a.m., Staff C was standing at Medication Cart #2, parked in front of the nursing station, with Staff G counting narcotics located in the cart. A medication cup, containing several tablets and a large beige-colored geltab was observed sitting on the nursing station counter to the side of medication cart where Staff G was standing. Staff C noted the observation and moved around Staff G to the location, grabbed the cup, and said, those are mine. Staff C placed them on the medication cart in front of where she was standing (the opposite side of the cart). On [DATE] at 12:45 p.m., the Director of Nursing (DON) stated the expectation was to label the medications not just the baggies. The DON stated medications should not be stored with cleaners, medications carts should be locked when unattended, and medications should not be left on the cart when unattended. The DON reported education had been done regarding locking medication carts, the consultant pharmacist reviewed and it has been hectic week due to having a new pharmacy. The policy - Medication Storage, implemented [DATE], read It is the policy of this facility to ensure all medications housed on a premises will be stored in the pharmacy and or medication rooms according to the manufacturers recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. The policy explanations and compliance guidelines identified: - All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls.- - During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/ cart. - All medications requiring refrigeration are stored in refrigerators located in the pharmacy and at each medication room. 2. The facility developed a plan of correction that included: Quality review completed by DON/designee on [DATE] - [DATE] of resident rooms, resident bathrooms, shower rooms, hallways, laundry and dining room to ensure appropriate infection control practices were being utilized to include proper hand hygiene/wearing gloves, gloves discarded appropriately, bathrooms are clean, linen was stored appropriately, washing machine is clean and proper disinfecting is utilized, clean and dirty linen areas are separate, lint filters for dryers are clean, and linen in laundry is properly covered. The facility developed a plan of correction that identified measures to be put into place or made systemic changes to ensure the practice did not recur included: The Infection Preventionist/DON/designee provided educated to staff on [DATE]. Staff were reeducated on Infection prevention protocols including proper hand hygiene/wearing gloves, gloves discarded appropriately, bathrooms are clean, linen is stored appropriately, washing machine is clean and proper disinfecting is utilized, clean and dirty linen areas are separate, lint filters for dryers are clean, and linen in laundry is properly covered. During the revisit survey conducted [DATE] the facility failed to ensure clean laundry was handled in a sanitary manner and failed to ensure the clean laundry area was free from staff's personal items. On [DATE], beginning at 9:00 a.m., observations were made of two staff members (E and F) performing housekeeping duties throughout the facility, including resident rooms. On [DATE] at 2:10 p.m., Staff F was asked by other staff members to show this writer the facility's laundry area. The staff member maneuvered the housekeeping cart that was being used to outside the building to the laundry area. Staff E was observed in the clean laundry side of the area. The window of the one commercial-sized washer was full of linens and resident gowns. Staff F removed the laundry from the washer and placed it into a large gray rolling tote and Staff E rolled it into the clean laundry area. The area contained another tote with a large amount of linens in it. Staff E, with bare hands, placed the wet laundry into the dryer. The observation identified a clear container of store-bakery cookies and a paper take-out cup on top of the folding counter. Staff E identified the items belonged to her and Staff F questioned whether they could have the items there or not. Staff E folded a pink-back pad in half then tucked the end of it under her chin and folded the item. The staff member reached for another pink-back pad and repeated the process of holding the item under her chin and against personal clothing, the same gray sweatshirt with red lettering that she was wearing during housekeeping duties. Staff E and F reported the laundry aide works 5 a.m. to 1 p.m., they work from 7 a.m. to 3 p.m., and after their housekeeping duties they come back to the laundry area to finish up (with laundry). The staff members stated the facility is able to finish all the laundry during working hours. (Photographic evidence was obtained) On [DATE] at approximately 2:30 p.m., the Maintenance/Laundry/Housekeeping Director reported the facility has 3 laundry/housekeeping staff, the laundry aide works from 5 a.m. to 1 p.m., two housekeepers work from 7 a.m. to 3 p.m., and before the two housekeepers leave from the day they assist with laundry: folding and getting things (linens) to the carts. The M/L/H director reviewed the photo taken of the washer and stated it was normally like that (full) and confirmed it looked really full. The director reported not being trained in laundry and/or housekeeping and confirmed supervising staff in areas he had not been trained. The M/L/H director confirmed staff should not putting (clean) clothes into the washer with bare hands and stated it was not appropriate for the staff member to fold laundry while holding it up against herself. During an interview on [DATE] after 2:30 p.m., the Director of Nursing (DON) reviewed the photo of the washer and stated it looked full and confirmed the staff member (E) had cross-contaminated the laundry. On [DATE] at 5:20 p.m., the DON stated the M/L/H director and Regional Maintenance Director had educated the (laundry/housekeeping) staff. The facility policy - Handling Clean Linen, copyrighted 2023, revealed It is the policy of this facility to handle, store, process, and transport clean linen in a safe and sanitary method to prevent contamination of the linen, which can lead to infection. The policy identified the following: - Facility linen is considered hygienically clean. The policy defined hygienically clean as rendered free of vegetative pathogens through disinfection during the laundering process. - Linens can become contaminated with pathogens from contact with intact skin or body substances, or from environmental contaminants or contaminated hands. - Do not place clean linen on the floor or other contaminated surfaces. 3. On [DATE] at 9:05 a.m., an observation was made of Resident #1 sitting in a specialized wheelchair in the hallway outside of nursing station #1. The resident's urinary drainage bag and tubing was observed lying on the floor under the wheelchair. The privacy bag for the urinary bag was improperly placed and allowed other residents and visitors to visualize the contents of the bags. The Admission Record revealed Resident #1 was admitted on [DATE] and included diagnoses not limited to spastic quadriplegic cerebral palsy, unspecified scoliosis, and benign prostatic hyperplasia (BPH) with lower urinary tract symptoms. The care plan for Resident #1 identified the resident had a urinary catheter related to neurogenic bladder and had a diagnosis of BPH. The interventions instructed staff to provide privacy bag to drainage bag at all times and provide catheter care to prevent Urinary Tract Infection (UTI). During an interview on [DATE] at 4:34 p.m., the Director of Nursing (DON) reported Resident #1 had one of one urinary catheters in the facility. The DON stated catheters should be stored in a privacy bag and off the floor. She reported she was the one who corrected (the location) of Resident #1's catheter this morning. The Centers of Disease Control and Prevention (CDC) - Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009), last reviewed: [DATE], identified the proper technique of Urinary Catheter Maintenance was Do not rest the bag on the floor. This information was located at https://www.cdc.gov/infectioncontrol/guidelines/cauti/recommendations.html. According to the Cleveland Clinic, (https://my.clevelandclinic.org/health/articles/14832-urine-drainage-bag-and-leg-bag-care), Do not place the urine bag on the floor. The policy - Infection Prevention and Control Program, reviewed/revised on [DATE], identified This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections as per accepted national standards and guidelines. - 2. All staff are responsible for following all policies and procedures related to the program. - 11a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection. The facility policy - QAPI with QA and Risk Management Program, implemented [DATE], revealed Center should implement a specific Quality Assurance and Risk Management Program that includes collecting data under a written QAPI plan to coordinate and evaluate activities under the QAPI program meeting including the development of Performance Improvement Projects (PIPs) under the QAPI plan if necessary. The policy identified the purpose was To provide a structured process by which customer care and organizational functions are continually and systematically reviewed in the context of a quality improvement model. And so during, organizational compliance with regulatory requirements and professional standards of care should be enhanced in the achievement of center goals and objectives realized, thereby providing the foundation for positive customer outcomes.

Based on observation, record review, interviews, policy review, and the Plan of Correction review, the facility failed to ensure that it had a functioning Quality Assurance Committee. The facility was actively involved in the creation, implementation and monitoring of the plan of correction for deficient practice identified during a recertification survey that was conducted 9/11/23 to 9/13/23 and was cited F761 and F880. On 11/2/23 a revisit survey was conducted, and the facility was recited F761 and F880. The facility had developed a Plan of Correction with a completion date of 10/13/23. Findings included: 1. The facility developed a plan of correction that included: Quality review was conducted on 9/14/23, by the Assistant Director of Nursing (ADON) of medication carts and supply rooms to ensure medications were labeled and stored appropriately. The facility developed a plan of correction that identified measures to be put into place or made systemic changes to ensure the practice did not recur included: Licensed nurses re-educated by the Director of Nursing (DON) regarding ensuring storage and labeling of drugs and biologicals in accordance with professional standards on 9/25/23. The plan identified newly hired licensed nurses would receive education as part of the orientation process. The Director of Nursing or designee, will conduct a quality review of medication carts and supply rooms to ensure medications are labeled, stored appropriately twice weekly x 4 weeks, then twice monthly x 2 months. The findings of these reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 3 or until the committee determines substantial compliance has been met. During the revisit survey conducted 11/2/23 the facility failed to ensure the medications were stored appropriately when unattended on one (#2) of two medication carts and medications with a shortened expiration life was opened were labeled with an open date on two of two medication carts. On 11/2/23 at 8:59 a.m., Staff D, Registered Nurse (RN) was observed walking away from a medication cart parked outside of Nursing Station #2, two residents were observed standing in the hallway near the cart. The medication cart was left unlocked with a bottle of Lactulose on top of it while the staff member ambulated to the vendor/employee entrance at the end of the hallway to let a visitor out the key-coded door. Staff D returned to the cart, confirmed the cart was unlocked and the bottle of Lactulose was left on top. The staff member stated I'll be sure not to do that again. On 11/2/23 at 10:28 a.m. an observation was conducted with Staff C, Licensed Practical Nurse (LPN) of Medication Cart #1. The observation revealed the following: - Opened bottle of Liquid Protein - Medical Food, dated 7/6/2023. The manufacturer instructed Discard 3 months after opening. Staff C had turned bottle over to read the unopened expiration date, unaware of the shortened shelf life once opened. - One (1) vial of opened Humalog insulin, the medication's attached label did not identify the date the vial was opened. - One (1) opened vial of Levemir, the vial's attached label did not identify when it was opened. - One (1) unopened vial of Levemir. The packaging instructed to Refrigerate and had a handwritten date of 11/2/23. - One (1) Humalog Kwik pen, the medication's attached label did not identify the date opened. The packaging identified Refrigerate and did not identify an open date on the available sticker. The printed packaging label included a handwritten date of 11/2/23. - One (1) Lantus Solostar insulin pen was opened and did not identify an open date on the medications attached label. The packaging identified an open date of 10/10/23 and the printed packaging label indicated Once opened store at room temperature for 28 days. The pen was not labeled with an expiration date. - One (1) Lantus Solostar insulin pen, which did not identify an open date on the available attached label and did not identify the date of expiration. The clear plastic bag containing the pen was labeled with an open date of 11/2/23, and the pharmacy had printed storage instructions, Once opened store a room temperature for 28 days. Neither the pens label or the the packaging label identified an expiration date. - One (1) Novolog Flexpen (insulin) undated per the medication's attached label. A packaging sticker identified the pen had been opened on 11/2/23. The pharmacy label on packaging identified Once opened store at room temp for up to 28 days. The pen did not identify an expiration date. (Photographic Evidence Obtained) Immediately following Medication Cart #1's observation, Staff C confirmed the Liquid Protein was to be discarded after 3 months and the plastic bag packaging could be destroyed leaving the insulin pens with unknown open dates. The staff member identified 3 insulin pens and one (1) vial of insulin had arrived to the facility on [DATE] (same day as observation). On 11/2/23 at 2:17 p.m., Staff C reported just taking the insulin from the refrigerator and the pens and vial, dated 11/2/23, were still cold during the observation (they were room temperature) and the package bags had been dated (with 11/2/23) due to habit. On 11/2/23 at 11:00 a.m. an observation was conducted with Staff D, Registered Nurse (RN) of Medication Cart #2. The observation revealed the following: - In the small top drawer, located under multiple insulin pens were 2 blister packages containing Azithromycin 250 milligram (mg) tablets. The packaging was worn and did not identify a residents' name. - An Insulin Lispro KwikPen was located in a plastic bag, the medication's attached label did not identify a date the medication was opened. The packaging did not identify an open date and the pharmacy label revealed Refrigerate until opened. - A Lantus Solostar insulin pen without a resident identifier on the medication and the pen was not labeled with an open or expiration date. - An opened Lantus Solostar insulin pen did not identify an open date on the medication's attached label. The packaging identified a pen was opened on 10/6/23 but did not identify an expiration date. The pharmacy label revealed Once opened store at room temperature for 28 days. - An opened bottle of Latanoprost 0.005% ophthamolic solution that was not dated. The plastic bag containing the medication identified an open date of 10/27/23 but did not reveal an expiration date. The pharmacy label identified Store opened room temp., Discard after 6 weeks (wk). - A Humalog insulin pen did not identify an opened date on the medication's attached pharmacy label. The packaging did not identify an open date however did reveal Refrigerate until opened. Once opened store at room temperature for 28 days. - A Levemir insulin pen, that was not contained in plastic bag. The medication's attached label did not identify an open date or any specific prescribing instructions. - An opened vial of Novolog. The medication's attached label did not include an open date. - An opened vial of Levemir whose attached label did not identify an open date. The packaging bottle identified an open date of 9/17/23. According to https://www.mynovoinsulin.com/insulin-products/levemir/home.html, after use the Levemir FlexPen and vial should be disposed of after 42 days, even if there is insulin left in the pen or vial. The vial of Levemir expired on 10/29/23. - An opened Novolog FlexPen. The medication's attached label did not identify an open date. The pharmacy label revealed Once opened store at room temp for 28 days. The sticker attached to the plastic bag containing the insulin pen identified an open date of 10/21/23 but did not reveal an expiration date. - The attached medication label of one (1) Lantus Solostar insulin pen did not identify an open date. The plastic bag containing the pen identified an open date of 10/31/23. The pharmacy label indicted Once opened store at room temperature for 28 days. The pen or the packaging did not identify an expiration date. - The pharmacy label attached to a Lantus Solostar pen did not reveal an open date. The plastic bag containing the pen identified an open date of 10/8/23. The pharmacy label revealed once opened the pen could be stored for 28 days at room temperature. The packaging stickers or the medication label did not reveal an expiration date. - The attached medication label for a Basaglar insulin Kwikpen identified an open date. The plastic bag containing the Kwikpen identified an open date of 10/27/23. - A box containing an open bottle of Artificial Tears Lubricant Eye Drops was located in the med cart #2. Staff C confirmed neither the box or the bottle were labeled with an open date. According to Cleveland Clinic, (https://my.clevelandclinic.org/health/drugs/18710-artificial-tears-eye-solution) Once the product is opened, most experts recommend discarding the product (Artificial Tears) after 30 days. Immediately following the observation, Staff C confirmed the findings of several insulin pens not being dated, the Artificial Tears not being dated, and the unopened bottle of Calcitonin should have been refrigerated. On 11/2/23 at 11:44 a.m., Staff C was standing at Medication Cart #2, parked in front of the nursing station, with Staff G counting narcotics located in the cart. A medication cup, containing several tablets and a large beige-colored geltab was observed sitting on the nursing station counter to the side of medication cart where Staff G was standing. Staff C noted the observation and moved around Staff G to the location, grabbed the cup, and said, those are mine. Staff C placed them on the medication cart in front of where she was standing (the opposite side of the cart). On 11/2/23 at 12:45 p.m., the Director of Nursing (DON) stated the expectation was to label the medications not just the baggies. The DON stated medications should not be stored with cleaners, medications carts should be locked when unattended, and medications should not be left on the cart when unattended. The DON reported education had been done regarding locking medication carts, the consultant pharmacist reviewed and it has been hectic week due to having a new pharmacy. The policy - Medication Storage, implemented 8/25/22, read It is the policy of this facility to ensure all medications housed on a premises will be stored in the pharmacy and or medication rooms according to the manufacturers recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. The policy explanations and compliance guidelines identified: - All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls.- - During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/ cart. - All medications requiring refrigeration are stored in refrigerators located in the pharmacy and at each medication room. 2. The facility developed a plan of correction that included: Quality review completed by DON/designee on 9/14/23 - 9/25/23 of resident rooms, resident bathrooms, shower rooms, hallways, laundry and dining room to ensure appropriate infection control practices were being utilized to include proper hand hygiene/wearing gloves, gloves discarded appropriately, bathrooms are clean, linen was stored appropriately, washing machine is clean and proper disinfecting is utilized, clean and dirty linen areas are separate, lint filters for dryers are clean, and linen in laundry is properly covered. The facility developed a plan of correction that identified measures to be put into place or made systemic changes to ensure the practice did not recur included: The Infection Preventionist/DON/designee provided educated to staff on 9/25/23. Staff were reeducated on Infection prevention protocols including proper hand hygiene/wearing gloves, gloves discarded appropriately, bathrooms are clean, linen is stored appropriately, washing machine is clean and proper disinfecting is utilized, clean and dirty linen areas are separate, lint filters for dryers are clean, and linen in laundry is properly covered. During the revisit survey conducted 11/2/23 the facility failed to ensure clean laundry was handled in a sanitary manner and failed to ensure the clean laundry area was free from staff's personal items. On 11/2/23, beginning at 9:00 a.m., observations were made of two staff members (E and F) performing housekeeping duties throughout the facility, including resident rooms. On 11/2/23 at 2:10 p.m., Staff F was asked by other staff members to show this writer the facility's laundry area. The staff member maneuvered the housekeeping cart that was being used to outside the building to the laundry area. Staff E was observed in the clean laundry side of the area. The window of the one commercial-sized washer was full of linens and resident gowns. Staff F removed the laundry from the washer and placed it into a large gray rolling tote and Staff E rolled it into the clean laundry area. The area contained another tote with a large amount of linens in it. Staff E, with bare hands, placed the wet laundry into the dryer. The observation identified a clear container of store-bakery cookies and a paper take-out cup on top of the folding counter. Staff E identified the items belonged to her and Staff F questioned whether they could have the items there or not. Staff E folded a pink-back pad in half then tucked the end of it under her chin and folded the item. The staff member reached for another pink-back pad and repeated the process of holding the item under her chin and against personal clothing, the same gray sweatshirt with red lettering that she was wearing during housekeeping duties. Staff E and F reported the laundry aide works 5 a.m. to 1 p.m., they work from 7 a.m. to 3 p.m., and after their housekeeping duties they come back to the laundry area to finish up (with laundry). The staff members stated the facility is able to finish all the laundry during working hours. (Photographic evidence was obtained) On 11/2/23 at approximately 2:30 p.m., the Maintenance/Laundry/Housekeeping Director reported the facility has 3 laundry/housekeeping staff, the laundry aide works from 5 a.m. to 1 p.m., two housekeepers work from 7 a.m. to 3 p.m., and before the two housekeepers leave from the day they assist with laundry: folding and getting things (linens) to the carts. The M/L/H director reviewed the photo taken of the washer and stated it was normally like that (full) and confirmed it looked really full. The director reported not being trained in laundry and/or housekeeping and confirmed supervising staff in areas he had not been trained. The M/L/H director confirmed staff should not putting (clean) clothes into the washer with bare hands and stated it was not appropriate for the staff member to fold laundry while holding it up against herself. During an interview on 11/2/23 after 2:30 p.m., the Director of Nursing (DON) reviewed the photo of the washer and stated it looked full and confirmed the staff member (E) had cross-contaminated the laundry. On 11/2/23 at 5:20 p.m., the DON stated the M/L/H director and Regional Maintenance Director had educated the (laundry/housekeeping) staff. The facility policy - Handling Clean Linen, copyrighted 2023, revealed It is the policy of this facility to handle, store, process, and transport clean linen in a safe and sanitary method to prevent contamination of the linen, which can lead to infection. The policy identified the following: - Facility linen is considered hygienically clean. The policy defined hygienically clean as rendered free of vegetative pathogens through disinfection during the laundering process. - Linens can become contaminated with pathogens from contact with intact skin or body substances, or from environmental contaminants or contaminated hands. - Do not place clean linen on the floor or other contaminated surfaces. 3. On 11/2/23 at 9:05 a.m., an observation was made of Resident #1 sitting in a specialized wheelchair in the hallway outside of nursing station #1. The resident's urinary drainage bag and tubing was observed lying on the floor under the wheelchair. The privacy bag for the urinary bag was improperly placed and allowed other residents and visitors to visualize the contents of the bags. The admission Record revealed Resident #1 was admitted on [DATE] and included diagnoses not limited to spastic quadriplegic cerebral palsy, unspecified scoliosis, and benign prostatic hyperplasia (BPH) with lower urinary tract symptoms. The care plan for Resident #1 identified the resident had a urinary catheter related to neurogenic bladder and had a diagnosis of BPH. The interventions instructed staff to provide privacy bag to drainage bag at all times and provide catheter care to prevent Urinary Tract Infection (UTI). During an interview on 11/2/23 at 4:34 p.m., the Director of Nursing (DON) reported Resident #1 had one of one urinary catheters in the facility. The DON stated catheters should be stored in a privacy bag and off the floor. She reported she was the one who corrected (the location) of Resident #1's catheter this morning. The Centers of Disease Control and Prevention (CDC) - Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009), last reviewed: November 5, 2015, identified the proper technique of Urinary Catheter Maintenance was Do not rest the bag on the floor. This information was located at https://www.cdc.gov/infectioncontrol/guidelines/cauti/recommendations.html. According to the Cleveland Clinic, (https://my.clevelandclinic.org/health/articles/14832-urine-drainage-bag-and-leg-bag-care), Do not place the urine bag on the floor. The policy - Infection Prevention and Control Program, reviewed/revised on 7/13/23, identified This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections as per accepted national standards and guidelines. - 2. All staff are responsible for following all policies and procedures related to the program. - 11a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection. The facility policy - QAPI with QA and Risk Management Program, implemented 9/7/22, revealed Center should implement a specific Quality Assurance and Risk Management Program that includes collecting data under a written QAPI plan to coordinate and evaluate activities under the QAPI program meeting including the development of Performance Improvement Projects (PIPs) under the QAPI plan if necessary. The policy identified the purpose was To provide a structured process by which customer care and organizational functions are continually and systematically reviewed in the context of a quality improvement model. And so during, organizational compliance with regulatory requirements and professional standards of care should be enhanced in the achievement of center goals and objectives realized, thereby providing the foundation for positive customer outcomes.

Based on interview and medical record review, the facility failed to notify the Physician in a timely manner of abnormal laboratory results for two (#2 and #3) of three residents sampled for urinary tract infections. Findings include: 1. Review of Resident #2 Admission Record form indicated she was admitted to the facility in early February 2022 for short term rehabilitation. Her primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Continued record review revealed a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Discontinue after completion. Nursing Notes were reviewed dated 04/01/2022 at 09:22 Situation, Background, Assessment, Recommendation (SBAR) indicating a change in condition: Primary Care Provider Feedback recommendations: for labs new testing orders: Urinalysis or culture Nursing notes dated 04/02/2022 at 06:56 a.m. U/A C&S; may straight Cath every shift to Rule out [CONDITION(S)] Discontinue after completion. Documentation stated, Unable to collect specimen. Nursing notes dated 04/02/2022 at 10:44 a.m. U/A C&S; may straight Cath every shift to Rule out [CONDITION(S)] Discontinue after completion. Documentation stated, Unable to obtain. Nursing notes dated 04/03/2022 at 4:18 a.m. U/A C& S; may straight Cath every shift to Rule out [CONDITION(S)] Discontinue after completion. Documentation stated, specimen not collected. Nursing notes dated 04/04/2022 at 1:25 p.m. (13:25) U/A C& S; may straight Cath every shift to Rule out [CONDITION(S)] Discontinue after completion. Documentation stated, already done. Review of laboratory Results Report dated 04/06/2022 at 11:37 a.m. contained results that indicted a urinary tract infection. Further review of nursing notes dated on 04/07/2022 at 11:33 a.m. communicated with the Physician regarding recent labs reported 04/06/2022. New order received & documented. Resident & family notified. On 05/10/2022 at 2:30 p.m. the Director of Nursing (DON) confirmed Resident #2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She additionally confirmed the Physician was not notified in a timely manner of the abnormal laboratory results that resulted in the delay of proving appropriate treatment. 2. On 05/10/2022 at 2:15 p.m. the DON stated Resident #3 was currently being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Record form for Resident #3 indicated she has resided at the facility for four years. Review of the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nursing Notes dated on 05/05/22 at 2: 56 p.m. (14:56). Labs reviewed for urinalysis (UA). Medical Doctor (MD) notified. No new orders at this time. Will continue to monitor. Power of Attorney (POA) notified. Review of the urine culture dated on 05/07/22 at 12:16 p.m. revealed the urine was positive for extended spectrum beta-lactamase (ESBL). Further review of nursing notes dated 05/09/22 revealed urine culture reviewed. MD notified. New orders received. Resident POA notified and will continue to monitor. Review of Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . ESBL-producing Enterobacterales are a concern in healthcare settings and the community. They can spread rapidly and cause or complicate infections in healthy people. ESBLs (extended-spectrum beta-lactamase) are enzymes that make commonly used antibiotics ineffective. Accessed at https://www.cdc.gov/drugresistance/biggest-threats.html#extend on 5/10/22. On 05/10/2022 at 2:30 p.m. the DON confirmed the urinary culture for Resident #3 had been received on 05/07/22, and the Physician was not notified of the results until 05/09/2022. She confirmed there was a two-day delay in notification and treatment. The DON confirmed it is her expectation the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] On 05/10/22 at 3:06 p.m. a phone interview was conducted with Advanced Registered Nurse Practitioner who confirmed she knew Resident #3. She said the MD should be notified in a timely manner of abnormal lab results and indicate when the facility receives the results.

Based on observations, interviews, and clinical record review, the facility failed to ensure professional standards of nursing care were adhered to regarding pressure ulcer care for one (Resident #68) of two residents sampled for pressure ulcers. Findings included: 1. The Florida Department of Health, Florida Board of Nursing Nurse Practice Act, Chapter 64B9, F.A.C, 464.003 Definitions state: According to the Nurse Practice Act, 3) (a) Practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. 3. The supervision and teaching of other personnel in the theory and performance of any of the above acts. (b) Practice of practical nursing means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. The professional nurse and the practical nurse shall be responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing. 464.002 Purpose-The sole legislative purpose in enacting this part is to ensure that every nurse [MEDICATION NAME] in this state meets minimum requirements for safe practice. It is the legislative intent that nurses who fall below minimum competency or who otherwise present a danger to the public shall be prohibited from [MEDICATION NAME] in this state. 2. A clinical record review revealed Resident #68 was originally admitted to the facility on [DATE], and, most recently, readmitted after a 14 day hospitalization on [DATE]. His medical [DIAGNOSES REDACTED]. A review of the MDS assessments revealed a discharge assessment, dated 6/3/16, that indicated Resident #68 had two stage III pressure ulcers when he went to the hospital. When he returned on 6/17/16, a review of wound care measurements, dated 6/28/16, revealed one of the stage III pressure ulcers was a right buttock wound. Further review revealed no physician's order [REDACTED]. A Care Plan, dated 6/27/16, indicated the resident had two stage III pressure ulcers at that time, and approaches included, Update MD with ineffectiveness of treatments or any further skin issues. On 8/12/16 at approximately 11:45 a.m., a clinical record review was conducted with the Director of Nursing (DON). She reviewed the measurements that included the stage III ulcer to Resident #68 ' s right buttock and could not explain why there was an assessment of the wound, but also a note that stated the wound was not actually assessed. She reviewed the physician's order [REDACTED]. She confirmed that for 22 days there was no documentation that wound care was provided for this stage III pressure ulcer. The DON confirmed the wound care measurements, dated 7/11/15, indicated the wound was 8 weeks old at that time, and had tripled in size to 5x4.8x0.1 The tissue had deteriorated to 60% slough and 40% granulation. Additional review revealed the measurements and description of the wound stayed approximately the same until the last wound care assessment dated [DATE]. There was no documentation of the thick green yellow exudate and drainage that had been observed, no documentation of the foul odor, and no documentation in the nurses' notes when this appeared. There was no documentation that the physician had been notified of the appearance of these signs and symptoms of infection. The DON confirmed that a clarification order for wound care to the right buttock had been written on 7/7/16, 20 days after he had returned from the hospital. She confirmed that there were still two more days until there was documentation that wound care had been initiated on 7/9/16. The DON had no explanation for why the resident went 22 days without wound care for a stage III pressure ulcer, and confirmed that this was unacceptable and could cause further deterioration and infection. On 8/11/16 at 2:40 p.m. Employee C, a registered nurse, was observed as she provided wound care to Resident #68. Resident #68 was lying on his right side, and both of his feet were absent of the soft boot skin protectors that had been present the day before. Employee D, a certified nurse assistant (CNA) assisted to reposition the resident. Employee D stated that she did not know where the skin protectors were for the resident, and confirmed that he was supposed to have them in place to prevent further skin breakdown. Employee C stated the facility did not have tongue depressors or applicators that were needed for wound care, so she would be using a plastic spoon. Employee C removed Resident #68 ' s dressing to his right buttock that was saturated with thick, green-yellow drainage and had a foul smelling odor to reveal a stage III pressure ulcer that had a wound bed also thick with green exudate and a foul odor. During the course of the wound care, she cleansed the wound with normal saline and gauze sponges, removed her gloves, and then immediately re-applied another pair of gloves without washing or sanitizing her hands. She applied the Santyl to the wound bed using a plastic spoon. Upon completion of the wound care, the surveyor accompanied Employee D as she tried to locate the resident's soft boots. She found them in a plastic bag in the top of the therapy room closet. She stated that she would label them so they wouldn ' t get lost again. On 8/12/16 at approximately 4:30 p.m. Resident #68 ' s record was reviewed with his physician and the DON. There was no documentation that the physician had been notified of the omission in care for 22 days, and no documentation of the appearance of green-yellow exudate. Resident #68 ' s physician confirmed that stage III pressure ulcers that were not treated can lead to systemic infection and one symptom of this could be a high white blood cell count. A review of Resident #68 ' s lab results revealed he had a high white blood cell count on 8/8/16 of 16.5 (normal 4.5-11.0). The physician stated that he depended upon the nurses to call him and get orders for wound care, and if he had known the stage III ulcer to the resident ' s right buttock did not have orders, he would have provided them immediately for the proper care, and prevention of further deterioration and infection.

Based on clinical record review, observations and interviews, the facility failed to care for and treat a pressure ulcer for one (Resident #68) of two residents sampled for pressure ulcers. Resident #68 went 22 days without the proper care and treatment of [REDACTED]. Findings included: On 8/11/16 at 2:40 p.m. Employee C, a registered nurse, was observed as she provided wound care to Resident #68. Resident #68 was lying on his right side, and both of his feet were absent of the soft boot skin protectors that had been present the day before. Employee D, a certified nurse assistant (CNA) assisted to reposition the resident. Employee D stated that she did not know where the soft boot skin protectors were for the resident, and confirmed that he was supposed to have them in place to prevent further skin breakdown. Employee C stated the facility did not have sterile tongue depressors or applicators that were needed for wound care, so she would be using a plastic spoon. Employee C removed Resident #68 ' s dressing to his right buttock that was saturated with thick, green-yellow drainage and had a foul smelling odor to reveal a stage III pressure ulcer that had a wound bed also thick with green exudate and a foul odor. Employee C commented on the foul odor. During the course of the wound care, she cleansed the wound with normal saline and gauze sponges, removed her gloves, and then immediately re-applied another pair of gloves without washing or sanitizing her hands. She applied the Santyl to the wound bed using the plastic spoon. Upon completion of the wound care, the surveyor accompanied Employee D as she tried to locate the Resident #68 ' s soft boots. She found them in a plastic bag in the top of the therapy room closet. She stated that she would label them so they wouldn ' t get lost again. A clinical record review revealed Resident #68 was originally admitted to the facility on [DATE], and most recently readmitted after a 14 day hospitalization on [DATE]. His medical [DIAGNOSES REDACTED]. A review of the MDS assessments revealed a discharge assessment, dated 6/3/16, that indicated Resident #68 had two stage III pressure ulcers when he went to the hospital. When he returned, a review of his wound care measurements revealed one of the stage III pressure ulcers was the right buttock wound that was observed by the surveyor during wound care. The measurements of this wound were documented on 6/28/16, and 7/4/16 as exactly the same: 1.5x1x0.1. There was moderate drainage that was serous (clear/pale without symptoms of infection), there was no odor and there was 80% granulation tissue (healing tissue/pink) and 20% slough. Although these measurements and descriptions were documented, there was also a note that stated, Only the elbow was assessed today. A review of the physician's order [REDACTED]. Further review of the physician's order [REDACTED]. There was no documentation that any wound care had been provided for Resident #68 ' s stage III ulcer to his right buttock between 6/17-7/9/16 and 8/12/16. On 8/12/16 at approximately 11:45 a.m. a clinical record review was conducted with the Director of Nursing (DON). She reviewed the measurements that included the stage III ulcer to Resident #68 ' s right buttock and could not explain why there was an apparent assessment of the wound, but also a note that stated the wound was not actually assessed. She reviewed the physician's order [REDACTED]. She confirmed that for 22 days there was no documentation that wound care was provided for this stage III pressure ulcer. The DON confirmed wound care measurements dated 7/11/15 indicated the wound was 8 weeks old at that time, and had tripled in size to 5x4.8x0.1 The tissue had deteriorated to 60% slough and 40% granulation. There was no documentation of the thick green yellow exudate and drainage that had been observed, no documentation of the foul odor, and no documentation in the nurses' notes when this appeared. There was no documentation that the physician had been notified of the appearance of these signs and symptoms of infection. The DON confirmed that a clarification order for wound care to the right buttock had been written on 7/7/16, 20 days after he had returned from the hospital. She confirmed that there were still two more days until there was documentation that wound care had been initiated on 7/9/16. The DON had no explanation for why the resident went 22 days without wound care for a stage III pressure ulcer, and confirmed that this was unacceptable and could cause further deterioration and infection. A Care Plan, dated 6/27/16, indicated the resident had two stage III pressure ulcers at that time, and approaches included Update MD with ineffectiveness of treatments or any further skin issues. On 8/12/16 at approximately 4:30 p.m. Resident #68 ' s record was reviewed with his physician and the DON. There was no documentation that the physician had been notified of the omission in care for 22 days, and no documentation of the appearance of green-yellow exudate. Resident #68 ' s physician confirmed that stage III pressure ulcers that were not treated can lead to systemic infection and one symptom of this could be a high white blood cell count. A review of Resident #68 ' s lab results revealed he had a high white blood cell count on 8/8/16 of 16.5 (normal 4.5-11.0). The physician stated that he depended upon the nurses to call him and get orders for wound care, and if he had known the stage III ulcer to the resident ' s right buttock did not have orders, he would have provided them immediately for the proper care, and prevention of further deterioration and infection.

Based on resident record review and resident and staff interview, it was determined that the facility failed to ensure measures were in place to prevent unwanted sexual advances from a known sexual offender (Resident #1) for one of 20 sampled residents for abuse (Resident #2). The facility failed to afford Resident #2 with an environment free from abuse. The facility Administration had knowledge that Resident #1 was a registered sexual offender yet failed to relay this information to facility staff. The facility allowed Resident #1 to self-propel throughout the facility in his wheelchair at his own free will with no special supervision or monitoring plan in place. By failing to protect Resident #2, a mentally and intellectually disabled female, from Resident #1, a registered sexual offender, the facility allowed a sexual abuse to occur. The facility's lack of action and commitment to protect residents from a known risk resulted in findings of immediate jeopardy which was removed on April 23, 2014 at 11:00 p.m. and the severity and scope was reduced to a D. Findings include: 1. Review of the Florida Department of Law Enforcement website (<http://offender.fdle.state.fl.us/>) on 4/21/2014 revealed Resident #1 was listed as a known sexual offender with an adjudication of guilty/convicted on 4/5/1991 of Lewd, Lascivious Act on a Child Under 16 (F.S. 800.04), gender unknown. The resident's address listed on the website was that of this nursing facility. 2. On 4/21/14 at 12:30 p.m. an interview was conducted with Employee "N", a licensed practical nurse (LPN), who has worked at the facility since July of 2013 with a full time assignment normally on Station One for the 3:00 p.m. - 11:00 p.m. shift. Employee "N" stated she was familiar with Resident #1 and described Resident #1 as friendly and nice. She stated he would self-propel in his wheelchair throughout the building talking to everyone. She stated Resident #1 was known to have a little bit of an aggression issue and could be mean at times, over react, and escalate. Resident #1 was not on her assignment, but she had worked with him in the past and stated she did his admission so she knew a little bit more about him. Employee "N" stated she did not see anything upon admission that said Resident #1 was a sexual offender, but she was told this by an unknown employee a few days after his admission. Employee "N" stated she witnessed Resident #1 a few times in the hall with one of his hands on Resident #23's legs. She would ask him what he was doing and he would just say he was trying to move her. Employee "N" would tell him it's inappropriate to touch other residents and to please move along. She would tell him if he needs help moving someone to call the staff and we would move the resident for him. Employee "N" stated she would report these incidents to the nurse assigned to Resident #1 but was unsure what was done with this information. In addition to her observing Resident #1's hand on the legs of Resident #23, Employee "N" reported that about a month or two ago Resident #20 reported to her that Resident #1 had promised Resident #2 a cigarette if she would lift up her shirt. Resident #20 reported that Resident #2 had lifted her shirt and Resident #1 had touched her. Employee "N" stated that Resident #20 could not speak but she wrote this to her on a piece of paper. In response to this allegation, Employee "N" stated she immediately headed outside to the smoking area where the alleged incident was said to have occurred. As Employee "N" headed to this area, Resident #2 was already observed back inside the facility. Employee "N" stated she reported this to the Director of Nursing (DON) and in turn, the Administrator had viewed the surveillance tapes for the outside area. Employee "N" did not know if anything was found on the tapes and she thought an incident report had been completed but was unsure. Continued interview with Employee "N" revealed she had a recent incident on 04/06/2014 involving Resident #1 and Resident #2. In this instance, Employee "N" stated she was sitting at her nurses' station when she overheard Resident #2, a female resident, saying "Stop, don't touch me, leave me alone." Employee "N" said Resident #2 was not usually that vocal so she went to see what was going on. When she entered the area, she saw that Resident #1's back was to her. She walked up to see what he was doing, and she witnessed Resident #1's arm under the dressing gown of Resident #2 about "mid forearm deep." Employee "N" went in front of Resident #2 and said "What are you doing? Leave that woman alone." Resident #1 told her he was just trying to move Resident #2. Employee "N" stated she immediately moved Resident #2 away from Resident #1 and reported this to the LPN, Employee "T" assigned to both Resident #1 and Resident #2. Employee "N" and "T" then placed Resident #1 on 1:1 supervision and the DON was called. Employee "N" spoke to the DON who told her to call the abuse hotline and the police which she did. The report was accepted by the hotline and the police came out later that night to see Resident #1. When the police arrived, Resident #1 was in bed with staff outside of his door as the resident was unable to get out of bed on his own. The police spoke to Resident #1 and took a statement from Employee "N." The police said they would be working with the State to investigate this further and they wanted to know if Resident #2's guardian wanted to press charges. Employee "N" thinks that the family of Resident #2 did want to press charges; however, she thought there was some questions about Resident #2's mental status and was unsure if they were able to press charges. Employee "N" stated "Unfortunately, we are not a big staff on 3:00 p.m. - 11:00 p.m. so it is hard to keep track of everyone. We try to continuously monitor the outside but it was late and the aides were busy putting residents to bed." Both Resident #1 and Resident #2 are all over the facility and there were no special parameters for monitoring Resident #1. However, he was placed on 1:1 after the incident and by the time she returned to work the following Wednesday, he had been discharged . Employee "N" stated she was also familiar with Resident #2 and described her as fun with a very hyper personality. She stated she loved cigarettes, soda, and Doritos. Resident #2 was not on her regular assignment but she knew the resident because she self-propelled throughout the building in her wheelchair (w/c) and she talked a lot. 3. An interview with Employee "T" revealed he was an LPN, had worked at the facility for about four and a half months and currently worked on the 3:00 p.m. - 11:00 p.m. He stated he was familiar with Resident #2 as he took care of her. He described Resident #2 as confused, uses a w/c but can also walk but not steady. He stated staff constantly redirect her and tell her to sit back in the chair. Occasionally, Resident #2 gets agitated because she always wants a soda or Doritos. She is compliant with medications and is not combative, but can be disruptive at times. Employee "T" stated he was also familiar with Resident #1. He described Resident #1 as compliant with medications, self-propelling in his w/c and sometimes needing to be re-directed. Employee "T" stated he had never witnessed Resident #1 touching other residents or staff inappropriately, but he was told about an incident by Employee "N." When Employee "T" was asked by the surveyor if he knew that Resident #1 was a sexual offender he stated "No, I was not aware of this. Is that true? I was not aware of that. Nobody told me that." Employee "T" stated Resident #1 was supervised "just like any other resident." Employee T stated he did rounds every one to two hours on his residents and the aides do the same. There was no special monitoring for Resident #1 prior to the incident on 4/6/2014, but after that he immediately checked Resident #2 to see if she had any issues and spoke with her. She said something but Employee "T" could not understand what she said. Resident #2 had no physical markings and she seemed her usual self. He also checked Resident #1 with Employee "N." Employee "T" stated "I was not happy with him. I said ... what did you do?" Resident #1 said he did nothing; he was just touching her w/c. Resident #1 denied it. Resident #1 had no physical injuries. Employee "T" stated he called Resident #2's sister and reported the incident to her. He stated the sister said she was going to press charges. Employee "T" stated the police came in that night and spoke to Resident #1 and immediately following the incident he was placed on 1:1 supervision. Follow up interview with Employee "T" on 4/22/2014 at 3:24 p.m. revealed that he called the psychiatric nurse on either 4/6/2014 or 4/7/2014 to see Resident #1; however, he did not call or get any orders for psychological or psychiatric services for Resident #2, at that time. 4. An interview with Resident #20 was conducted on 4/22/2014 at 3:20 p.m. Resident #20 was able to answer yes and no questions by nodding her head/gesturing; however, she could not be understood verbally for detailed answers. Resident #20 was provided with pen and paper to write her answers. Resident #20 gestured she had never been touched inappropriately while residing in the facility. However, she wrote a statement that she witnessed Resident #1 pull Resident #2's "blouse down and he pulled her breast. I told a nurse." Resident #20 thought this event had occurred in December. Review of Resident #20's clinical record revealed she was [AGE] years old and originally admitted to the facility on [DATE]. The face sheet revealed this resident was her own responsible party and listed the following relevant Diagnoses: [REDACTED]. Review of Resident #20's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a score of 15 out of a possible 15 on the brief interview for mental status (BIMS). Review of her active care plans revealed no care plan was in place to indicate that she confabulates. 5. An interview with Resident #9 was conducted on 4/21/14 at 1:15 p.m. Resident #9 stated he remembered Resident #1, "He was a pervert." Resident #9 said he had witnessed Resident #1 "put his hands up the dress of about four female residents." Resident #9 stated he had reported it to the nurses, but, he did not know if anything was done about it. He stated this "mostly happened in the little hallway to the dining room." Resident #9 did not know if anyone watched Resident #1 and stated "I don't have anything more to say about it." Review of Resident #9's clinical record revealed he was [AGE] years old and admitted to the facility on [DATE]. Review of his face sheet revealed he was his own responsible party and had the following relevant Diagnoses: [REDACTED]. Review of the most recent MDS dated [DATE] revealed a BIMS score of 14 out of a possible 15. Review of the active care plans revealed no care plan was in place to indicate that he confabulates. 6. Review of the clinical record for Resident #2 revealed a face sheet indicating this female resident was [AGE] years old, and was admitted to the facility on [DATE]. The resident had a level one Pre-Admission Screen and Record Review (PASRR) dated 2/18/10. Review of this screening revealed the resident had a primary [DIAGNOSES REDACTED]. The resident had a determination of incapacity signed by a physician on 10/29/2009 which documented that this resident lacked the capacity to give informed consent to make medical decisions and did not have reasonable medical probability of recovering mental and physical capacity to directly exercise her rights. Review of Resident #2's most recent minimum data set assessment ((MDS) dated [DATE] revealed a score of 9 out of 15 on the brief interview for mental status (BIMS). The resident displayed the following signs of [MEDICAL CONDITION]: Inattention (behavior present fluctuates; comes and goes; changes in severity) Disorganized thinking (behavior continuously present, does not fluctuate) The resident's mood interview revealed she felt down, depressed, and was having trouble sleeping (2-6 days; several days). The resident required limited assistance/one person physical assistance with transfers and dressing, extensive assistance/one person physical assistance with personal hygiene, bathing, and toilet use, and was independent with no physical help needed for locomotion on and off the unit. Review of nurses' notes revealed the following relevant entries: 4/6/2014 8:20 p.m. A male resident was found by 3-11 nurse (station 1) stroking resident's thigh. And also the resident was saying to him: Stop it! Stop it! Immediately, the staff separated both residents, re-direct and spoke firmly with the male resident on the issue. (The male resident was warned by me, the nurse at 3:00 p.m. to avoid female resident. (He admitted ). Resident was checked thoroughly. Apparently has no injuries at all. Resident is intellectually disabled. Director of Nursing (DON), Assistant Director of Nursing (ADON) were called. DON instructed to call the police. Resident's proxy was called (sister was informed, Medical Doctor (MD) was called). Message left. Male resident is on 1:1 out of bed. Being checked every 15 minutes. This note was signed by LPN, Employee "T." 4/8/2014 ....easily distracted. Does not recall incident of 4/6/14 and no apparent injury. Sister proxy aware of situation. Social services (SS) will contact sister today who request exploring relocating resident to be closer to sister. No additional nurses' notes or social service notes addressing Resident #2's physical and emotional well-being post incident were found. In addition, review of all nurse's notes and social service notes from November 2013 to April 22, 2014 revealed no information related to the allegation made by Resident #20 in which Resident #2 was said to have lifted her shirt and been touched by Resident #1. Continued review of the record revealed Resident #2 was seen by the psychiatric Advanced Registered Nurse Practitioner (ARNP) on 4/15/2014. This assessment noted the resident to have [DIAGNOSES REDACTED]. The resident was noted to be agitated, verbal, hi-pitched, mood "good" she says. Frequently asking for items and interrupting nurse all shift. Plan: add [MEDICATION NAME] 50 mg twice a day for agitation and increase [MEDICATION NAME] to 6 caps 125 mg 9:00 a.m. and 9:00 p.m. This assessment made no mention of the sexual abuse which had occurred on 4/6/2014. Observation of Resident #2 revealed the following information: 4/21/2014 at 6:00 a.m.: Resident #2 was a well-nourished female resident observed sitting upright on the side of the bed in a four bed ward. The resident was clean, well groomed and did not appear to be in any distress. 4/21/2014 at 12:20 p.m.: Resident #2 was seated in the main dining room with three tablemates. Resident was observed to socialize with her tablemates but was difficult to understand. An interview was conducted with Resident #2 on 4/21/2014 at 1:13 p.m. She revealed that she did not think anybody in the facility had ever touched her inappropriately or sexually. She did not recall knowing Resident #1. She did not recall anyone ever putting their hand on her leg and stated she did not think this had occurred. She stated she felt safe in the facility and liked living there. A telephone interview was attempted with Resident #2's sister on 4/21/14 at 11:31 and 4/22/2014 at 8:31 a.m. but she was not available to talk and stated she would call this surveyor back. As of 4/25/2014 no return call had been received. 7. Review of the clinical record for Resident #1 revealed this [AGE] year old male resident was admitted [DATE] discharged to the hospital on [DATE]; readmitted on [DATE] and discharged on [DATE] with return not anticipated. Review of the face sheet revealed this resident was his own responsible party and had relevant [DIAGNOSES REDACTED]. Review of the Florida PASRR Mental Illness Level II Determination Summary Report dated 9/2/2011 revealed the following relevant information: ...The patient was residing in another nursing home owned by the same corporation. The patient was released from prison on 6/1/2007 and was convicted of Lewd and Lascivious indecent abuse on a child under 16 on 5/21/1990 ...According to public record, this patient has a history of Lewd, Lascivious Child U/16; F.S. 800.04 (Principal) and is a registered sexual offender. Due to these circumstances, special consideration should be given with regards to local ordinances, placement in a facility that does not accept minor patients (under the age of 18), or a facility in which he will not be in close proximity to visiting children. It should be noted that residents in nursing care facilities are typically vulnerable to the actions of others and should there be a significant change in his mental status or orientation, it is recommended that an additional resident review be conducted ... Review of the most recent MDS dated [DATE] revealed Resident #1 had a BIMS of 13 out of a possible 15. The resident had trouble with sleep nearly every day according to his mood interview. He was independent with locomotion on and off the unit with setup help only. He required extensive assistance/one person physical assistance with bed mobility, transfers, dressing, toileting and bathing. Review of nurses' notes for the duration of the resident's stay from 10/18/2013 - 4/7/2014 revealed the following relevant entries: 4/6/2014 8:20 p.m. Resident was watched (by nurses' station one) stroking another female resident's thigh while that female resident was saying to him: Stop it! Stop it! Immediately residents were separated and spoke to him about the issue. He stated he was trying to move her chair. We told him that when another resident needs help he has to call us, not touch female residents. And also he admitted in front of the nurse that he was warned at 3:00 p.m. by me and female resident that he was stroking now to avoid her and not ever to talk to her. DON, ADON informed. DON asked to call the police also. The police came to gather information about the issue. Signed by Employee "T." 4/7/2014 Resident in bed resting post incident no signs and symptoms of distress. Will continue to monitor. 4/7/2014 2:00 p.m. Resident remains 1:1 with staff member. Will continue to monitor. 4/7/2014 8:38 p.m. Transported via Sheriff's office to hospital under a Baker Act 52 per psychiatric ARNP. Doctor and ARNP notified. Review of the Certificate of Professional Initiating involuntary Examination at 7:20 p.m. on 4/7/2014 completed by the psychiatric ARNP revealed a [DIAGNOSES REDACTED]. This document noted the Resident was unable to determine for himself whether examination was necessary AND There was substantial likelihood that without care or treatment the person will cause serious bodily harm to others in the near future as evidenced by recent behaviors. Supporting evidence: Patient found with his hand up a female patients gown between knee and peri- area yesterday eve. This was discovered when nurse went to find out why a female patient yelled "help ...stop it ... let go of me." Patient denies behavior and is currently on 1:1. Review of the entire clinical record to include physician progress notes [REDACTED]. This resident's criminal history/sexual offense was not addressed anywhere in the clinical record and no care plan was developed to address the resident's behavior problems or potential to abuse others. 8. Review of the clinical record for Resident #23 (the resident mentioned by Employee "N" to have been seen with Resident #1's hand on her legs a few times) revealed this female resident was [AGE] years old and was admitted to the facility on [DATE]. The resident's face sheet revealed the following relevant Diagnoses: [REDACTED]. The resident's most recent MDS dated [DATE] revealed she was not a candidate for the BIMS and had short term and long term memory problems. The resident had unclear speech, was rarely/never understood and rarely/never understands. She required extensive assistance/one person physical assistance with bed mobility, transfers, locomotion on/off unit, and was totally dependent/one person physical assistance with dressing, eating, toileting, personal hygiene, and bathing. Review of her nurses' notes and social service notes from 12/16/2013 - 4/21/2014 revealed no mention of her ever being touched by Resident #1 a known sexual offender. Observation of Resident #23 on 4/21/2014 at 1:00 p.m. revealed a young female resident slowly propelling herself around in a w/c with a lap tray in place. The resident was observed to make sounds but did not formulate any meaningful words or sentences. An attempt was made to interview this resident but she was unable to answer simple yes/no questions and just smiled at this surveyor. 9. An interview was conducted with the Administrator and DON on 4/21/2014 at 10:56 p.m. The Administrator revealed the facility has an outside marketing person who typically visits with a potential resident prior to admission and gathers all applicable information. After that, a nurse to nurse report is done, and then the admissions coordinator will run financial's and a background check to see if the resident is on the Florida sexual offender website. The Administrator stated "typically" if a resident is on that website we don't "typically" accept them. We knew Resident #1 was on there, but he had an issue which was not sexually related at a sister facility, and he needed placement. We were concerned that he was on the sexual offender listing, but from the reports we got from his previous facility he had not shown any inappropriate sexual behavior and at the first sign of it here we removed him from this facility. The Administrator stated he had been with the company for 6 years and stated he knew the former council had put in to place as a pseudo policy and procedure to not accept sexual offenders for the last 3 years. He stated the policy is "typically" we do not accept them. We look at the people individually and on a case by case basis, but "typically" we do not accept sexual offenders. The Administrator stated that the facility had no sexual offenders residing in the facility at this time and that he was aware that Resident #1 was a sexual offender from the time he was originally admitted in October of 2013. The Administrator stated Resident #1 was treated as any other resident was. The facility did not provide any special one on one or "anything like that." Resident #1 was monitored through observation to ensure nothing was happening. The Administrator said "this was the first instance that we heard of it and we took what action we thought was appropriate." The Administrator stated this first instance involved Employee "N" hearing a commotion in the dining room. Employee "N" saw Resident #1 with his hand up Resident #2's skirt. The Administrator stated the staff was "somewhat aware" that Resident #1 was a sexual offender. He stated some of the nurses were aware but he did not have a sit down with his staff to inform them that Resident #1 was a registered sexual offender. The Administrator stated "any time a resident has an issue [MEDICAL CONDITION] something we don't want to infringe on the resident's dignity. We don't want them to be treated any different than anyone else as far as ADL care. Typically, we don't accept sexual offenders so it is not an issue." The Administrator stated residents and family members were not notified that a registered sexual offender was residing in the facility. "We didn't send out a notice about it. I am not aware of having a policy and procedure that says I need to send out a public notice to residents and family members informing them of this." The Administrator did verify that the abuse hotline, the police, and the State Survey and Certification agency had been notified using the federal immediate/5 day report of the alleged incident on 4/6/2014. The Administrator confirmed that the federal reports did not make any mention that Resident #1 was a registered sexual offender. The Administrator stated Resident #1 had a challenge at one of our sister facilities, and we were trying to help them out of that situation and again "we don't typically accept these residents." The DON stated she had spoken to a couple of staff members about Resident #1 being a sexual offender after the resident's sister came to visit after a recent hospitalization for aggressive behavior. According to the DON, the resident's sister told staff that he was a sexual predator, but he wasn't on the list because he had been grandfathered in. The DON said the staff was not concerned about it, and it was more a topic for the rumor mill. Subsequent interview with the DON on 4/22/14 at 10:17 a.m. revealed she wanted to let it be known that she was not aware that Resident #1 was a sexual offender during his stay at the facility. The DON stated she started working at the facility in January of 2014 and the first time she found out about this was when another State agency came in and showed her the flyer on their computer. This was after Resident #1 had been discharged from the facility. The nurses had reported to her in the past that he would stroke the hand of female residents and give the female residents attention. The staff would divert him. The DON was not overly concerned about this behavior because she did not know he was a sexual offender. Her awareness was more heightened to watch him around female residents based on the nurses' reports, but she had no reason with the knowledge she had at the time to believe the behavior would escalate. The DON stated had she known, she would have been more aggressive in monitoring, more aggressive in trying to find alternative placement, and she would have made the staff aware so they could monitor him. Continued investigation and interview with the DON on 4/22/14 at 6:25 p.m. revealed she recalled being told about the allegation made by Resident #20 related to Resident #2 lifting her shirt and Resident #1 touching her. The DON confirmed that Employee "N" did report this to her in March 2014 before daylight savings time, and she thinks it occurred on a Sunday evening. The DON stated I believe that the staff said it was still light out, but it was after dinner and before smoke break at 7:00 p.m. As a result of the allegation, the DON stated she and the Administrator reviewed the surveillance tapes of the outside smoking area extensively for several hours before the time of the allegation through several hours after that. The DON stated we never did see that happen but we did see that a couple of days earlier Resident #2 had lifted her shirt and Resident #1 motioned her away with his hand and shook his head no. There was no audio on the tape so the exact exchange was unknown but the body language was a no. The DON stated the interdisciplinary team met about this and came up with an approach to ensure Resident #2 wore a tight fitting undergarment or a bra as she did not have anything on underneath her shirt at the time of the event. The DON stated the activities director went out and purchased a bra or bras as a result of this. Review of Resident #2's record by the DON revealed no documentation could be found related to the resident's behavior of lifting her shirt in a public area and no care plan was located in her clinical record which had an approach related to the wearing of undergarments. The Administrator joined this interview at 6:40 p.m. on 4/22/2014 and stated there was nothing substantiated in this allegation. He stated Resident #2 has a behavior of lifting her shirt and that she has done this to him in the past, yet the behavior was not directed at any particular person. The Administrator said the event was reported as having had occurred in the memory garden (smoking area). "We viewed the tapes and there was no event." The Administrator stated that based on the tapes, we did not report the allegation as we looked at all of our data and nothing showed us abuse had occurred. The Administrator stated no occurrence report was done for this and no documentation of the investigation was maintained. 10. An interview was conducted via telephone on 4/22/2014 at 10:46 a.m. with the physician for both Resident #1 and Resident #2. The physician stated she was very familiar with Resident #1 as she had taken care of him for years at the sister nursing facility. She was aware that he was a registered sexual offender and stated she had never discussed the resident's sexual /criminal history with him just the fact that he needed to keep his hands to himself. The physician stated he was not totally 100% there. She stated the resident was on medications because he had been baker acted for violent behavior several times in the past and he was followed routinely by psych. The doctor said that while the resident resided at the sister facility he would wheel himself into women's rooms and when they would remove him he would get mad and throw things. The physician stated that everyone at this facility knew the resident's sexual offender history and everyone was watching him closely. "I don't know what else you could possibly do other than staff watching him. You can't put him on 1:1 forever. He was fairly limited because he had right [MEDICAL CONDITION] and could not scooch really fast in his w/c." The physician stated she was notified of the event on 4/6/2014 when Resident #1 was found with his hand up the dress of Resident #2. She could not recall if she gave any orders at that time because she receives a lot of phone calls every day. She thought psych was coming out right away to see both residents. The physician stated that she had not seen or examined either resident since the 4/6/2014 incident and stated it was an unfortunate episode. We knew he had the predisposition to do this, but Resident #1 was not totally competent and Resident #2 was far from competent. 11. An interview was conducted via telephone on 4/22/2014 at 11:06 a.m. with the psychiatric ARNP for Resident #1 and Resident #2. The psych nurse stated she thought she had started seeing Resident #1 in January 2014 for routine psych services. She stated she was aware that Resident #1 was a sexual offender as an unknown staff person had informed her of this on an unknown date. The psych nurse stated she thought she had put this in her notes but was not positive. (Review of Resident #1's psychiatric notes revealed no mention of Resident #1 being a registered sexual offender). The ARNP stated nobody seemed to think Resident #1 was at risk of sexually abusing residents as there wasn't anything going on that would be viewed as an issue. She stated she had never spoken to Resident #1 about his sexual history until the day he was baker acted (4/7/2014) and he denied that the behavior of 4/6/2014 had occurred. The psych nurse had not recommended any special supervision or monitoring of Resident #1 because she wasn't aware there was a need for that since he was in a "psychiatric facility that cares for people." The psych ARNP stated she was also familiar with Resident #2 as she was on routine psych services. The ARNP stated she did see Resident #2 after the alleged sexual abuse on 4/15/2014. She did not discuss the inci

Based on staff interviews, resident record review, facility file review, the facility's policy for "elopement leave of absence", and observations, the facility failed to provide services necessary to ensure the safety of two (#5 and #3) out of twenty-eight sampled residents who were assessed as elopement risk. The facility did not have knowledge of Resident #3 and Resident #5's whereabouts on more than one occasion (3/5/2014, 3/20/2014 and 4/19/2014), nor did they provide adequate supervision to meet the needs of these residents known to have exit seeking behaviors. Resident #3, who is a sixty year old, climbed out from his bathroom window two times (3/5/2014 and 4/19/2014) into an area that had a large amount of hazardous materials, broken equipment, used bed frames, toilets, large rusted and sharp objects, and tools. Resident #3 climbed over a wooden fence that was not secured to the building and made his way down a back dirt alley way and approximately twenty feet from where transient people routinely hang out and approximately fifteen feet from a single lane road street that was used by heavy operating equipment such as eighteen wheeled trucks, cement mixing trucks and vehicles that drive by fast. Further, Resident #5, who is a fifty-eight year old, displayed, since her admission, exit seeking behaviors by banging on the windows and exit doors. Resident #5 got out from the facility's back smoking porch on (3/20/2014) unnoticed and walked around to the front of the building and banged on the door to be let back in. The facility placed residents at risk as evidenced by the failure to provide adequate close supervision for two residents that showed ongoing exit seeking behaviors. The facility demonstrated a lack of action and commitment to protect and supervise Residents #3 and #5, who based on the facility's own documented observations and assessments, were known to require close supervision which resulted in the findings of immediate jeopardy. The immediate jeopardy was found to be removed on April 23, 2014 at 11:00 p.m. and the severity and scope was reduced to a D. Findings include: 1. On 4/21/2014 at approximately 10:00 a.m. the Administrator provided the facility's "Elopement, Leave of Absence" policy dated and revised on February, 2014. The policy indicated, "The facility strives to prevent resident elopement", and that "the facility Elopement Overview & Prevention Policy will enable the resident to safely attain or maintain their highest practicable physical, mental and psychosocial well being." The policy further read definitions as follows: - Elopement: Elopement occurs when a cognitively impaired resident leaves the premises or a safe area without authorization (i.e., an order for [REDACTED]. - Refer to Discharge/or Leave of Absence policies for the cognitively intact resident who leaves the facility grounds unattended and without staff knowledge. - Refer to Discharge Against Medical Advice policy for when a cognitively intact resident or responsible party wished to discharge from the facility against medical advice. The policy also referred its purpose is to: - To identify residents at risk for unsafe wandering and exit seeking behavior. - To develop individualized prevention and management interventions based on evaluation. Also, the facility team will assess the environment to identify potential risks associated with elopement. Facility interventions will be developed and implemented to reduce the risk of elopement and/ or hazards associated with elopement. The policy's procedure revealed: I. Evaluations A. A review of the resident's elopement risk is completed upon admission, quarterly, with a significant change or if an elopement occurs. B. Collect Risk Factor Data on the Elopement Risk Evaluation form for the cognitively impaired residents physically capable of eloping unassisted. C. Determine if the resident is at risk for elopement. D. Include resident and family in development of the Plan of Care. E. Present at the next-scheduled Interdisciplinary Plan of Care meeting. II. Prevention A. Develop individualized interventions which may include, but are not limited to, the following: 1. Electronic monitoring/alarm systems where applicable. 2. Environmental modifications 3. Protected list of names and photographs of those at risk for elopement. 4. Psychosocial interventions 5. Regular rounds 6. Resident and family education 7. Staff interventions 8. Structured group activities B. Communicate risk and interventions to the care giving team C. Discuss interdisciplinary interventions with the resident and family and provide education as needed. D. Provide staff training as needed E. Review and revise Plan of Care as needed. III. Physical Plant Preventions A. Assess the security of potential internal risk factors including, but not limited to, the following: 1. Elevators 2. Exit doors 3. Screens 4. Stairwells 5. Windows B. If applicable, ensure door alarms and wander control systems is proper working order. C. Identify and manage potential external environmental risk factors including, but not limited to: 1. Bodies of water 2. Busy streets/highways 3. Health threatening weather 4. Railroad crossing D. Review and correct deficiencies in practices as they relate to the following, including, but not limited to: 1. Cueing devices/monitors 2. Resident identification systems 3. Response to alarms 4. Testing of alarms E. Maintain a current protected list of names and photographs of residents identified at risk for elopement. 1. Use form Elopement Identification Information form. Assure document contains the following information: a. Name b. Description c. Height d. Weight e. Age f. Pertinent medical information F. Identify residents at risk for elopement on assignment sheets, pocket care plans and/or kardex. G. Present high risk areas of concern at the Safety/Risk Management meeting for discussion during the QAPI meetings. Interview with the Administrator on 4/22/2014 at approximately 10:00 a.m. revealed the facility's interpretation of "safe areas" would be areas where Resident's usually frequent to include their rooms, bathrooms, dining room, hallways, activities rooms, therapy gym, courtyard, and shower rooms. The Administrator further clarified that the outside Maintenance equipment storage area, the alley way behind the facility and behind the smoking area/courtyard are not "safe areas." Resident #3's medical record did not contain an elopement risk assessment upon admission. Review of the only elopement risk assessment, which was dated 2/27/2014 (seven days after admission), revealed he had behaviors of exit seeking, and had wandering tendencies in the past. On 4/21/2014 review of Resident #3's medical record including the demographic sheet (undated) indicated he is a sixty year old who was admitted to the facility on [DATE] and was at the facility for long term care. Further review of the admission cumulative [DIAGNOSES REDACTED]. The medical record revealed a signed and dated incapacity statement on 3/18/2014, by the physician. As per review of the advanced directives, Resident #3's wife served as the health care surrogate as of 3/18/2014. Review of the following nurse notes revealed: On 2/25/2014 (no time) Resident was noted to be at door with bag. Will place on elopement risk. On 3/4/2014 at 9:00 p.m. Resident actively gets out of wheelchair and tries to walk around. Staff has tried to redirect with no success and to monitor condition. On 3/5/2014 at 3:30 a.m. Resident observed resting quietly with eyes closed. On 3/5/2014 at 5:40 a.m. Resident not in bed. Discovered outside with back pack sitting on ground. Was brought back to nursing station for observation and found with a superficial scrape to Right forearm and Left knee. Physician and Spouse notified. On 3/5/2013 (Interdisciplinary Team note) Resident is on elopement risk. Exited building earlier this a.m. as above (previous nurse note). Interventions include 30 minute rounds for 24 hours, with contact alarms on window and possible room change to be closer to nurse station. On 3/13/2014 (no time) continues to monitor for exit seeking behaviors. On 3/14/2014 at 10:00 p.m. observed Resident trying to open bathroom window with a knife from his dinner tray, redirected Resident and started a 15 minute check sheet. Resident resting in bed and writer recommends plastic silverware. Note further indicated to continue to monitor. On 3/15/2014 at 1:00 a.m. Resident on 15 minute checks with no signs of distress. On 4/18/2014 at 7:50 p.m. Resident is in room and remains on 1:1 with staff member. On 4/18/2014 at 10:00 p.m. window on bathroom has an alarm to alert to alert staff if resident is trying to open it. Alarm went off once this shift and staff immediately went to room where resident was seen walking out of the bathroom. Staff explained to the resident not to open windows. Resident nodded in understanding. Will continue to monitor. On 4/19/2014 at 4:45 p.m. Resident observed ambulating outside by laundry room carrying shoulder bag with belongings. Assisted to wheelchair and to room. Body assessment completed. Placed on 1:1 staff. Observed Resident had turned off window alarm in bathroom and climbed out then pushed through gate on outside of property. Resident, previously at 3:30 p.m. was visually observed in room with feet up on his bed. And then was observed outside at 4:10 p.m. Director of Nursing (DON), physician and spouse were all notified. On 4/19/2014 at 10:00 p.m. Resident on 1:1 no attempt to elope after 4:00 p.m. elopement. Will continue 1:1 and monitor for elopement risk. On 4/20/2014 at 1:45 p.m. remains on 1:1 supervision. On 4/21/2014 at 5:00 a.m. remains on 1:1 supervision. Review of the current care plans revealed the following: Risk for falls and wandering/exit seeking (thinks he can go home) initiated on day of admission 2/20/2014 through to 6/10/2014 with interventions to include but not limited to: Monitor transfers; Monitor changes in resident's condition that may warrant increased supervision; Monitor location offering diversion as needed if attempting to exit. Resident #3 wanders in unsafe situations as he has made attempts to leave facility. This was initiated, on 2/20/2014, day of admission, through to 6/10/2014. Interventions include: Place resident in an area where frequent observation is possible; Alert staff of resident's wandering behaviors, Provide with diversional activities, If resident is wandering away, instruct staff to stay with him; Monitor behavior. None of Resident #3's care plans revealed anything related to a specific "elopement protocol" or "elopement program." Interview with the Administrator revealed they follow their elopement policy, in relation to "Review of the resident's elopement risk completed upon admission", "Environmental modifications", and "Staff Training" (as part of elopement leave of absence policy dated February 2014). However, the Administrator and Director of Nursing confirmed there was no evidence or documentation that staff were ever trained and in-serviced after the 3/5/2014 incident when Resident #3 exited the building. They also indicated there was not an elopement assessment completed upon Resident #3's. The Administrator and Maintenance Director did not evaluate all the environmental areas to include the maintenance equipment storage areas, located behind resident room windows, in a manner to prevent further exits. Review of Resident #3's Minimum Data Set (MDS) admission assessment signed and dated for 2/27/2014, revealed under section "C" that he had short term and long term memory loss with moderately impaired decision making. Section "E" revealed the Resident did not present with elopement behaviors during the assessment period. Section "G" indicated the Resident needed one person physical assistance with transfers and extensive assistance with locomotion. Section "G" further indicated that during the time of the assessment, Resident #3 was not steady with balance. Review of the "8 hour shift frequent observation worksheets" revealed the Resident was only provided with 15 minute checks on 3/5/2014, 3/6/2014, 3/7/2014 and 3/8/2014 after exiting the building through the bathroom window on 3/5/2014 also 3/14/2014 and 3/15/2014 after being observed trying to get out from the bathroom window on 3/14/2014. It was not clear when Resident #3 was taken off 15 minute checks after the 3/14/2014 incident. However, it was noted that Resident #3, again, exhibited exit seeking behaviors from his alarmed window on 3/12/2014. In an interview with the Administrator and the DON indicated that there was no documentation of Resident #3 being placed on 15 minute checks after the 3/14/2014 observation and it was further confirmed that he was only verbally educated not to lift up the window. Both the Administrator and Director of Nursing (DON) were asked on 4/21/2014 why Resident #3 was not placed on 1:1 supervision on 4/18/2014, after he was noted lifting up the bathroom window where he had made multiple attempts of exiting, once successfully, they both indicated that they were unaware of the incident on 4/18/2014 as it was late at night. They were asked if Resident #3 was placed on an elopement protocol and indicated that yes, he was and that supervision included checks on an hourly basis and throughout the shift to see where he was. Per Administrator and DON interview, it was determined that Resident #3 exited his window the very next day on 4/19/2014 and was not on any type of 1:1 or 15 minute checks supervision. Record review determined that Resident #3 was placed on "8 hour shift frequent observations checks/worksheet" only, dating from 4/20/2014, 4/21/2014, 4/23/2014 and onward. In an interview with the Administrator on 4/21/2014 indicated that Resident #3 would be placed on 24 hour 1:1 supervision until the Interdisciplinary team and family made a decision for discharge planning to another facility that could meet his needs. Interview and observations with the Nursing Home Administrator (NHA) and Maintenance Director on 4/21/2014 at approximately 10:00 a.m., confirmed the areas where Resident #3 exited the building. On 3/5/2014, the Administrator and Maintenance Director indicated he was at that time residing in room [ROOM NUMBER], which had a bathroom that was shared with room [ROOM NUMBER]. The perimeter of the building was toured with the NHA and Maintenance Director down the "East" street and to the back alley. The "East" street was observed on 4/21/2014, 4/22/2014 and 4/23/2014 at approximately 7:00 a.m., 10:00 a.m., 1:00 p.m. and 5:00 p.m. with very heavy traffic to include cars/trucks driving very fast. Eighteen wheeled diesel trucks and large concrete mixer trucks were also observed at this time. The Maintenance Director further indicated that the area between the back of resident rooms/walls and the laundry/maintenance building was used to store broken equipment, tools, chemicals, beds, toilets, air conditioner units, etc. and had a "build-up" of discarded equipment for over three years. The Administrator indicated again that this area would be interpreted as an "unsafe" area for residents. The Administrator and Maintenance Director both indicated that this area was where Resident #3 exited twice from his room. On 4/21/2014 at approximately 10:45 a.m. an interview with the Administrator and Maintenance Director revealed after 3/5/2014, Resident #3 was moved to another room, closer to the nurse's station. The new room was observed and noted to be room [ROOM NUMBER]. It was observed that the room's windows and shared bathroom window led to the same maintenance and laundry area where all the "discarded" equipment and other hazard items were located. It was observed that the areas, directly outside and below room [ROOM NUMBER]'s windows and bathroom window, had a massive amount of equipment that was stacked and strewn all the way to both windows. It was determined through interviews with the Maintenance Director that the equipment was in the same place, when Resident #3 climbed out of the bathroom window. The Administrator indicated that Resident #3 on 4/19/2014 went to his bathroom, turned off the alarm switch attached to the side of the window, lifted the window up and punched/tore the screen to make a hole and then proceeded to climb out through the window and negotiated his way down the hazardous equipment to the ground and then walked to the wooden fence and this time instead of climbing the fence, Resident #3 pushed through it by breaking the rusted hinges. The Administrator indicated that the resident then walked approximately twenty feet down the alley and stepped up to a sidewalk/ramp between the dirt alley and the back of the facility wall, which was still defined as facility property. The Administrator confirmed that the area outside resident room [ROOM NUMBER] and the area at the alley was "unsafe." The Administrator indicated Resident #3 was seen by a dietary worker and reported it and at the same time nursing had already found out he was not in the building. He indicated that Resident #3 was found by nursing and brought back to his room where he was assessed with [REDACTED]. In an Interview with Employee R, a kitchen aide/cook that works in the kitchen during the day and night shift, on 4/23/2014 at approximately 10:00 a.m., he indicated that he was now aware of Resident #3 and his exit seeking behaviors. He did now know where information of who was an elopement risk was kept and did not know who was at risk. Employee R indicated that he was here at the facility on 4/19/2014 and he and employee U were outside the kitchen in the back. Employee R explained that employee U spotted a person who appeared to be a female down the alley near the road and was drinking milk. Employee R then looked and told employee U that that person was not a female and that it was Resident #3. Employee R indicated he told employee U to stand there and watch while he ran in to tell a nurse. Employee R indicated that by the time he reached the nurse station, the staff had just found out he was missing from the facility and he told them where Resident #3 was at. At this point, Employee R stated that Resident #3 was already found. He indicated it happened really fast. Employee R was also aware of resident #5 with exit seeking behaviors and saw her banging on windows and doors at times, trying to get out. He has not seen Resident #5 out of the building before but heard she had found a way out and came to the front door to be let back in. Employee R indicated he has not had any elopement training since he had been an employee here approximately three months and did not know how to identify a resident who was an elopement risk. He had not been part of an elopement drill since his hire date. During the time of the survey 4/21/2014 through 4/23/2014, employee U could not be contacted for interview. Interview on 4/21/2014 at approximately 8:00 a.m. with employee I, who was a Licensed Practical Nurse (LPN), revealed that on Saturday 4/19/2014, during the 3-11 shift, Resident #3 was found outside back behind the building and in the alleyway. She further revealed she was off-going shift and noticed Resident #3 was in his room and with his feet propped up on the bed at 3:30 p.m. She further revealed that when nurse (Employee N) went to Resident #3's room, she did not see him and asked where he was. Employee I indicated that she had just seen him in his room and an aide, who is unknown, indicated that Resident #3 was outside in the alley, as seen by a Laundry worker. When Employee I and N figured out that Resident #3 was not outside in the smoking area, another aide indicated that a Laundry worker seen someone out in the alley that may be a resident. Employee I indicated that she and employee N immediately went out to the back and brought Resident #3 back into the facility without difficulty. Employee I confirmed that Resident #3 was at the time not on 1:1 supervision, and was also not on 15 minute checks. Employee I does not remember when Resident #3 was taken off 15 minute checks the previous day. Interview on 4/22/2014 at approximately 4:15 p.m. with employee N, who was a Licensed Practical Nurse (LPN), revealed that on Saturday 4/19/2014, during the 3-11 shift, Resident #3, who was on her assignment at that time, was found not in his room when she was passing medication at 4:00 p.m. She indicated that Employee I was asked where he was at and she was told that he had just seen in his room with his feet propped up on the bed at 3:30 p.m. Employee N indicated just as she had asked Employee I where Resident #3 was at, another aide, whose name was unknown, indicated that Resident #3 is outside. Employee N indicated that Employee I checked the closed circuit monitors that lead to the smoking area and found Resident #3 was not outside in that area. Employee N also indicated at around the same time a Laundry Aide had noticed a person outside the building in the alley way. She indicated that at that time, she and Employee I went outside to get him and brought him back inside without any problems or injuries. Employee N was not sure when Resident #3 was taken off 1:1 or 15 minute checks the day before and was also not told he was on 15 minute checks during the prior shift. She confirmed that she later found out Resident #3 was not on 15 minute checks during the time he exited the building. Employee H, a Licensed Practical Nurse (LPN) that works the 11-7 shift was interviewed on 4/21/2014 at approximately 5:15 a.m. and revealed she was aware that Resident #3 had exited the facility a couple of times but was not sure as to when, but believed the last time was a couple of days ago. She indicated that he was now on 1:1 24 hour supervision. She indicated she believed she had not been in-serviced or trained with subject matter regarding elopement and risk within the past few months (to include 3/2014 and 4/2014). Employee O, a Certified Nursing Assistant (CNA) that works the 11-7 shift was interviewed on 4/21/2014 at approximately 5:20 a.m. and revealed she was aware of Resident #3's exit seeking behaviors, but had not had any in-services or training related to elopement or risks during or after the last two incidents or upon her orientation, which was approximately one month ago. Upon further interview, employee O was now aware of an "Elopement book" or book that shows what residents are on elopement risk. Employee F and J, both CNAs and work the 11-7 shift were interviewed at the same time on 4/21/2014 at approximately 5:25 a.m. Both employee F and J confirmed they were aware of Resident #3 and his exit seeking behaviors, but have not had any in-services or training since his last two exits (3/5/2014 and 4/19/2014). They further revealed they have been working at the facility for about one year and did not know of any book that indicated residents who are assessed as elopement risk. Both felt they could use more training in the area of elopements. Employee E, a CNA that works the 11-7 shift was interviewed on 4/21/2014 at 6:45 a.m. and indicated Resident #3 has had multiple attempts of eloping during this shift. She further indicated approximately one month ago the resident got out of his room and was found in the back alley that was not enclosed. She also indicated that he was noted to be still on the property to the best of her knowledge. She also indicated that she believed he had not eloped since and has been on 1:1 supervision. When asked, Employee E indicated she has not received any in-services or training related to elopement within the past few months (to include 3/2014 and 4/2014). She also was unaware of exactly where the elopement book was kept and that there should be one somewhere. Employee A, a CNA that works the 7-3 shift and had been employed eight years, was interviewed on 4/21/2014 at approximately 7:45 a.m. Employee A indicated she was aware of Resident #3 and his exit seeking behaviors and had been scheduled to monitor him for 1:1 supervision. She indicated she had heard of both instances when Resident #3 exited the building and knew they received training and in-services but could not remember the last time they had it. She was aware of the elopement book and where it was located. Employee A indicated that she knew that Resident #3 was moved from room [ROOM NUMBER] to the current room [ROOM NUMBER], and staff had placed an alarm on the window as an intervention. She further explained that Resident #3 found out how to turn off the alarm and turned it off and lifted the window up in the bathroom and exited into the alley. She did not know why he was not on 1:1 supervision at the time. Employee D, the lead CNA that works the 7-3 shift and had been employed approximately one year and a half, was interviewed on 4/21/2014 at approximately 9:50 a.m. Employee D explained that he was aware Resident #3 had exited the building twice and has been put on 1:1 24 hour supervision and had had a room change after the first incident on 3/5/2014. He indicated that he had not signed or attended any in-services or training related to elopement within the past two months to include (3/2014 and 4/2014). He further indicated he did not recall any elopement drills during his shift the past few months. Employee L, an LPN that works primarily 7-3 shift but had worked 3-11 shifts recently, was interviewed on 4/21/2014 at approximately 9:00 a.m. and revealed she knew of Resident #3 and his exit seeking behaviors and that he had exited his room twice. She indicated Resident #3 was placed on 1:1 supervision and moved to another room after the first incident (3/5/2014) and also an alarm was placed on the window. Employee L also indicated that Resident #3 was noted to have been lifted off 1:1 supervision the day or night before his last exit incident (4/19/2014). She also indicated he had been noted to have behaviors of playing with the alarm on the window and somehow turned the alarm off and went out the window again. She believed there had been in-services and training but did not know when. She indicated she could use more training when it comes to elopement and those who are at risk. Employee G, a CNA that works 3-11 shift and 7-3 shift, was interviewed on 4/21/2014 at approximately 9:30 a.m. Employee G indicated that he has been employed at the facility about four months. He was aware Resident #3 is on 1:1 supervision and that he has exited the facility twice within the past month or so. He indicated he did not know where the elopement book was kept or any information as to who is considered an elopement risk was kept. He did not believe he had been in-serviced or trained the past two months to include (3/2014 and 4/2014) with regards to elopement or those who are at risk. He had not been part of an elopement drill and indicated he could use more training on the matter. Employee K, a CNA that works the 7-3 shift, was interviewed on 4/21/2014 at approximately 9:50 a.m. She indicated that she was aware of Resident #3's elopement behaviors and did not know of where information regarding who was elopement risk was kept. She was not aware of an "elopement book" with resident pictures. She further explained she believed she has had training on the matter, but does not know when. Employee Q, a Housekeeper that works different shifts, was interviewed on 4/23/2014 at 9:55 a.m. Employee Q indicated she did not know what residents are on elopement risk and would not know where the elopement book or book where resident information related to elopement risk was kept. Employee Q was aware that Resident (#3) was found outside the building and on the alleyway. It was determined that of the seventeen employees interviewed, thirteen (H, P, O, F, E, B, A, D, N, G, K, Q and R) were not aware of an elopement book and had not been in-serviced related to elopement and elopement risks for the months 3/2014 and 4/2014. Interview on 4/21/2014 with care staff during the 11-7 shift at 6:45 a.m. and 7-3 shift at approximately 1: 00 p.m., to include employees P, O, E, I, M, L, N all indicated that they were aware of Resident #3's wandering and exit seeking behaviors and further indicated that Administration would place him on 24 hour 15 minute checks for a day or two and then he would be lifted off those checks. The staff also confirmed that Resident #3 was very "sneaky" and during their care with him presented some days he would "act" like he needed assistance with ADLs and when left alone, he would get up, walk around and attempt to exit the facility. They all indicated he had been doing this and showing the same type of behavior since his admission. They all confirmed that he would be supervised and as soon as that supervision was lifted, he would plan and try to leave. On 4/21/2014 at approximately 1:00 p.m. interview with the Director of Nursing, Assistant Director of Nursing and the Administrator all provided information related to Resident #3's exit seeking behaviors. This administrative team all indicated that after the first incident, which occurred on 3/5/2014, when Resident #3 climbed out of his bathroom window and out to the alley, they, immediately put him on "elopement risk", which included 30 minute rounds every 24 hours. They reported Resident #3 was moved to another room, located near the nurse's station, for better supervision. The Administrative team indicated they also placed a contact alarm on the window to prevent the resident from getting out the window again. The Administrative team was asked if the window alarm would prevent the Resident from getting out of the window, or was it used as a deterrent and announcer to notify staff when the window was being lifted open. The Administrative team expressed that the alarm did not prevent the resident from getting out of the window, but was rather to notify staff he or someone was manipulating the window open. The Administrative team was asked if Resident #3 exhibited any exit seeking behaviors prior to 3/5/2014. They indicated he presented with exit seeking behaviors the day before on 3/4/2014. The Administrative team reported the resident was observed trying to get up out of his wheelchair and tried to walk around at exit doors. The Administrative team indicated that the only documented intervention was to continue to monitor. The Administrative team further explained that on 2/25/2014, the resident presented with exit seeking behaviors and had his bag with clothes and was sitting at the front door. They indicated the Interdisciplinary team met and placed him on "elopement risk." The Administrative team stated the elopement risk procedure was to continually monitor the resident. Also, they indicated information was kept in the elopement book, kept at each station. There were no other interventions at that time, prior to the 3/5/2014 exit from the building. The facility did not have any documentation related to 15 minute or 30 minute checks after shown behaviors dating 2/25/2014 and 3/4/2014. The Administrative team was asked if they provided any education to any of the staff after the 3/5/2014 incident of Resident #3 exiting the building. The Administrative team explained they in-serviced all their staff related to elopements and risks. However, the Administrative team did not have any documentation to that affect. The Director of Nursing provided an in-service and sign in sheet, dated 3/18/2014, but it was only titled "Dining room." It was confirmed that there was no evidence in this in-service that the elopement subject matter was discussed. The Administrative team explained that, after Resident #3 was moved to the new room (7), they placed him on 15 minute checks, placed the contact alarm on the window and conducted with monitoring. Review of the 15 minute checks sheet did indicate 15 minute checks were conducted and the checks continued until 7:15 p.m. on 3/9/2014. The Assistant Director of Nursing and Director of Nursing both indicated that the 15 minute checks should have only lasted 24 hours but they see the checks actually lasted four days unintentionally. The Administrative team confirmed there were no other inte

Based on resident record review, resident and staff interview, and review of facility policies and procedures, it was determined that the facility failed to implement the policies and procedures in the Abuse Manual, revised June 2012 related to prevention, identification, protection, investigation, and resident-to-resident altercations for one of 20 sampled residents for abuse (Resident #2). The facility failed to implement policies and procedures which prohibited the admission of Resident #1, a Registered Sexual Offender. The facility failed to identify, assess, care plan, and monitor Resident #1 in accordance with the abuse manual for behaviors which may lead to conflict. The facility failed to monitor Resident #1 after he was warned by staff to stay away from Resident #2 at 3:00 p.m. approximately 5 hours prior to sexually abusing this same resident. In addition, the facility failed to provide protection from harm for Resident #2 during an investigation of sexual abuse by providing "medical and emotional support immediately following any individual suffering or suspected abuse" as defined in its policy. Failure to implement the policies and procedures led to Resident #2, a mentally and intellectually disabled female, being victimized by inappropriate and unwanted sexual advances by a known sexual offender, Resident #1, who had no special monitoring or supervision in place. Facility Administration was "responsible for the overall coordination and implementation of " the "facility's abuse prevention program and policies." However, Administration knowingly withheld information from direct care staff, residents, and families related to Resident #1's sexual offender status. The failure to follow and implement abuse policies and procedures to ensure the safety and protection of residents resulted in findings of immediate jeopardy which was removed on April 23, 2014 at 11:00 p.m. and the severity and scope was reduced to a D. Findings include: Review of the facility's "Abuse Manual" revised June 2012 revealed the following relevant information: Abuse Policy Policy Statement: The purpose of this policy is to ensure resident freedom from abuse, neglect, exploitation, and misappropriation of property (ANEM). The Administrator is responsible to assure the process. ANEM as defined below will not be tolerated in the facility. This includes residents, staff, agents of the facility, family members, legal guardians, friends, or interested parties. Policy Interpretation and Implementation: Definitions: 1. "Abuse" is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. 4. " Sexual abuse" is defined as, but is not limited to, sexual harassment, sexual coercion, or sexual abuse. 6. "Mental abuse" is defined as, but is not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. Procedure: 3. Prevention Issues a. Practice: The facility will provide proper support, education, and supervision designed to reduce the likelihood of abusive behaviors. 4. Identification: a. Practice: The facility will consider any event that is reported to any staff by patient/resident, family, or any other person involving any persons (e.g., resident to resident, employee/volunteer to resident, etc.) as possible abuse if it meets any of the following criteria: Any complaint of sexual harassment, coercion, or sexual abuse. 5. Protection: a. Practice: Patients/residents will be protected from harm during any investigation. b. Steps: Any individual found in danger of injury (physical or emotional) will be: 1. Removed from the source of the suspected abusive behavior. 2. Provided with medical and emotional support immediately following any individual suffering or suspected abuse. Abuse Investigations: Statement: All reports of resident abuse, neglect, exploitation, misappropriation of property and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Interpretation and Implementation: 2. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. 3. The individual conducting the investigation will, as a minimum: b. Review the resident's medical record to determine events leading up to the incident; j. Review all events leading up to the alleged incident. Preventing Resident Abuse Statement: Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse. Interpretation and implementation: Zero Tolerance of Abuse: 1. The facility's goal is to achieve and maintain an abuse-free environment. Contents of Abuse Prevention/Intervention Program: 2. Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: a. Training all staff and practitioners how to resolve conflicts appropriately; e. Involving the resident/family group council in developing, monitoring, and evaluating the facility's abuse prevention program; g. Training staff to understand and manage a resident's verbal or physical aggression; j. Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect; k. Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues; l. Conducting background investigations to avoid hiring persons or admitting new residents who have been found guilty (by a court of law) of abusing, neglecting or mistreating individuals or those who have had a finding of such action entered into the state nurse aide registry or state sex offender registry; m. Involving Attending Physicians and the Medical Director when findings of abuse have been determined. n. Involving qualified psychiatrists and other mental health professionals to help the staff manage difficult or aggressive residents; o. Identifying areas within the facility that may make abuse and/or neglect more likely to occur (e.g. secluded areas) and monitoring these areas regularly; p. Striving to maintain adequate staffing on all shifts to ensure that the needs of each resident are met; Reporting Abuse to Facility Management: Responsibility of Person(s) Observing Incidents of Abuse: 7. Staff members and persons affiliated with this facility shall not knowingly: Screen reports or withhold information to reporting agencies. Resident-to-Resident Altercations Interpretation and Implementation: Monitoring Residents for Aggressive/Inappropriate Behavior: 1. Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or to the staff. Occurrences of such incidents shall be promptly reported to the Nurse Supervisor, Director of Nursing (DON), and to the Administrator. 2. If two residents are involved in an altercation, staff will: c. Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation; e. Review the events with the Nursing Supervisor and DON including interventions to try to prevent additional incidents; f. Consult with the Attending Physician to identify treatable conditions such as acute [MEDICAL CONDITION] that may have caused or contributed to the problem; g. Make any necessary changes in the care plan approaches to any or all of the involved individuals; h. Document in the resident's clinical record all interventions and their effectiveness; i. Consult psychiatric services as needed for assistance in assessing the resident, identifying causes and developing a care plan for intervention and management as necessary or as may be recommended by the Attending Physician or Interdisciplinary Care Planning Team; j. Complete a Report of Incident/Accident form and document the incident, findings and any corrective measures taken in the resident's medical/clinical record; k. If, after carefully evaluation the situation, it is determined that care cannot be readily given within the facility, transfer the resident; Staff Responsible for Coordinating/Implementing Abuse Prevention Program Policies and Procedures Statement: The Administrator is responsible for the overall coordination and implementation of our facility's abuse prevention program policies and procedures. 1. Review of the clinical record for Resident #1 revealed this [AGE] year old male resident was admitted [DATE] and discharged to the hospital on [DATE]; readmitted on [DATE] and discharged on [DATE] with return not anticipated. Review of the face sheet revealed this resident was his own responsible party and had relevant [DIAGNOSES REDACTED]. Review of the Florida Pre-Admission Screening and Resident Review (PASRR) Mental Illness Level II Determination Summary Report dated 9/2/2011 revealed the following relevant information: ...The patient was residing in another nursing home owned by the same corporation. The patient was released from prison on 6/1/2007 and was convicted of Lewd and Lascivious indecent abuse on a child under 16 on 5/21/1990 ...According to public record, this patient has a history of Lewd, Lascivious Child U/16; F.S. 800.04 (Principal) and is a registered sexual offender. Due to these circumstances, special consideration should be given with regards to local ordinances, placement in a facility that does not accept minor patients (under the age of 18), or a facility in which he will not be in close proximity to visiting children. It should be noted that residents in nursing care facilities are typically vulnerable to the actions of others and should there be a significant change in his mental status or orientation, it is recommended that an additional resident review be conducted ... Review of the most recent MDS dated [DATE] revealed Resident #1 had a BIMS of 13 out of a possible 15. The resident had trouble with sleep nearly every day according to his mood interview. He was independent with locomotion on and off the unit with setup help only. He required extensive assistance/one person physical assistance with bed mobility, transfers, dressing, toileting and bathing. Review of nurses' notes for the duration of the resident's stay from 10/18/2013 - 4/7/2014 revealed the following relevant entries: 4/6/2014 8:20 p.m. Resident was watched (by nurses' station one) stroking another female resident's thigh while that female resident was saying to him: Stop it! Stop it! Immediately residents were separated and spoke to him about the issue. He stated he was trying to move her chair. We told him that when another resident needs help he has to call us, not touch female residents. And also he admitted in front of the nurse that he was warned at 3:00 p.m. by me and female resident that he was stroking now to avoid her and not ever to talk to her. Director of Nursing (DON), Assistant Director of Nursing (ADON) informed. DON asked to call the police also. The police came to gather information about the issue. Signed by Employee "T." 4/7/2014 Resident in bed resting post incident no signs and symptoms of distress. Will continue to monitor. 4/7/2014 2:00 p.m. Resident remains 1:1 with staff member. Will continue to monitor. 4/7/2014 8:38 p.m. Transported via Sheriff's office to hospital under a Baker Act 52 per psychiatric Advanced Registered Nurse Practitioner (ARNP). Doctor and ARNP notified. Review of the Certificate of Professional Initiating involuntary Examination at 7:20 p.m. on 4/7/2014 completed by the psychiatric ARNP revealed a [DIAGNOSES REDACTED]. This document noted the Resident was unable to determine for himself whether examination was necessary AND There was substantial likelihood that without care or treatment the person will cause serious bodily harm to others in the near future as evidenced by recent behaviors. Supporting evidence: Patient found with his hand up a female patients gown between knee and peri-area yesterday eve. This was discovered when nurse went to find out why a female patient yelled "help ...stop it ... let go of me." Patient denies behavior and is currently on 1:1. Review of the entire clinical record to include physician progress notes [REDACTED]. This resident's criminal history/sexual offense was not addressed anywhere in the clinical record and no care plan was developed to address the resident's behavior problems or potential to abuse others. 2. Review of the Florida Department of Law Enforcement website (<http://offender.fdle.state.fl.us/>) on 4/21/2014 revealed Resident #1 was listed as a known sexual offender with an adjudication of guilty/convicted on 4/5/1991 of Lewd, Lascivious Act on a Child Under 16 (F.S. 800.04), gender unknown. The resident's address listed on the website was that of this nursing facility. 3. An interview was conducted with the Administrator and DON on 4/21/2014 at 10:56 p.m. The Administrator revealed the facility has an outside marketing person who typically visits with a potential resident prior to admission and gathers all applicable information. After that, a nurse to nurse report is done, and then the admissions coordinator will run financial's and a background check to see if the resident is on the Florida sexual offender website. The Administrator stated "typically" if a resident is on that website we don't "typically" accept them. We knew Resident #1 was on there, but he had an issue which was not sexually related at a sister facility, and he needed placement. We were concerned that he was on the sexual offender listing, but from the reports we got from his previous facility he had not shown any inappropriate sexual behavior and at the first sign of it here we removed him from this facility. The Administrator stated he had been with the company for 6 years and stated he knew the former council had put in to place as a pseudo policy and procedure to not accept sexual offenders for the last 3 years. He stated the policy is "typically" we do not accept them. We look at the people individually and on a case by case basis, but "typically" we do not accept sexual offenders. The Administrator stated that the facility had no sexual offenders residing in the facility at this time and that he was aware that Resident #1 was a sexual offender from the time he was originally admitted in October of 2013. The Administrator stated Resident #1 was treated as any other resident was. The facility did not provide any special one on one or "anything like that." Resident #1 was monitored through observation to ensure nothing was happening. The Administrator said "this was the first instance that we heard of it and we took what action we thought was appropriate." The Administrator stated this first instance involved Employee "N" hearing a commotion in the dining room. Employee "N" saw Resident #1 with his hand up Resident #2's skirt. The Administrator stated the staff was "somewhat aware" that Resident #1 was a sexual offender. He stated some of the nurses were aware but he did not have a sit down with his staff to inform them that Resident #1 was a registered sexual offender. The Administrator stated "any time a resident has an issue [MEDICAL CONDITION] something we don't want to infringe on the resident's dignity. We don't want them to be treated any different than anyone else as far as ADL care. Typically, we don't accept sexual offenders so it is not an issue." The Administrator stated residents and family members were not notified that a registered sexual offender was residing in the facility. "We didn't send out a notice about it. I am not aware of having a policy and procedure that says I need to send out a public notice to residents and family members informing them of this." The Administrator did verify that the abuse hotline, the police, and the State Survey and Certification agency had been notified using the federal immediate/5 day report of the alleged incident on 4/6/2014. The Administrator confirmed that the federal reports did not make any mention that Resident #1 was a registered sexual offender. The Administrator had no explanation for why this information was missing from the Federal Report. The Administrator stated Resident #1 had a challenge at one of our sister facilities, and we were trying to help them out of that situation and again "we don't typically accept these residents." The DON stated she had spoken to a couple of staff members about Resident #1 being a sexual offender after the resident's sister came to visit after a recent hospitalization for aggressive behavior. According to the DON, the resident's sister told staff that he was a sexual predator, but he wasn't on the list because he had been grandfathered in. The DON said the staff was not concerned about it, and it was more a topic for the rumor mill. Subsequent interview with the DON on 4/22/14 at 10:17 a.m. revealed she wanted to let it be known that she was not aware that Resident #1 was a sexual offender during his stay at the facility. The DON stated she started working at the facility in January of 2014 and the first time she found out about this was when another State agency came in and showed her the Sexual Offender flyer on their computer. This was after Resident #1 had been discharged from the facility on 4/7/2014. The nurses had reported to her in the past that he would stroke the hand of female residents and give the female residents attention. The staff would divert him. The DON was not overly concerned about this behavior because she did not know he was a sexual offender. Her awareness was more heightened to watch him around female residents based on the nurses' reports, but she had no reason with the knowledge she had at the time to believe the behavior would escalate. The DON stated had she known, she would have been more aggressive in monitoring, more aggressive in trying to find alternative placement, and she would have made the staff aware so they could monitor him. Continued investigation and interview with the DON on 4/22/14 at 6:25 p.m. revealed she recalled being told about an allegation made by Resident #20 related to Resident #2 lifting her shirt and Resident #1 touching her. The DON verified that Employee "N" had reported this to her in March 2014 before daylight savings time, and she thinks it occurred on a Sunday evening. The DON stated I believe that the staff said it was still light out, but it was after dinner and before smoke break at 7:00 p.m. As a result of the allegation, the DON stated she and the Administrator reviewed the surveillance tapes of the outside smoking area extensively for several hours before the time of the allegation through several hours after that. The DON stated we never did see that happen but we did see that a couple of days earlier Resident #2 had lifted her shirt and Resident #1 motioned her away with his hand and shook his head no. There was no audio on the tape so the exact exchange was unknown but the body language was a no. The DON stated the interdisciplinary team met about this and came up with an approach to ensure Resident #2 wore a tight fitting undergarment or a bra as she did not have anything on underneath her shirt at the time of the event. The DON stated the activities director went out and purchased a bra or bras as a result of this. Review of Resident #2's record by the DON revealed no documentation could be found related to the resident's behavior of lifting her shirt in a public area and no care plan was located in her clinical record which had an approach related to the wearing of undergarments. The Administrator joined this interview at 6:40 p.m. on 4/22/2014 and stated there was nothing substantiated in this allegation made by Resident #20 indicating that Resident #2 had lifted her shift and Resident #1 had touched her. He stated Resident #2 has a behavior of lifting her shirt and that she has done this to him in the past, yet the behavior was not directed at any particular person. The Administrator said the event was reported as having had occurred in the memory garden (smoking area). "We viewed the tapes and there was no event." The Administrator stated that based on the tapes, we did not report the allegation as we looked at all of our data and nothing showed us abuse had occurred. The Administrator stated no occurrence/incident report was done for this and no documentation of the investigation was maintained. 4. On 4/21/14 at 12:30 p.m. an interview was conducted with Employee "N", a licensed practical nurse (LPN), who has worked at the facility since July of 2013 with a full time assignment normally on Station One for the 3:00 p.m. - 11:00 p.m. shift. Employee "N" stated she was familiar with Resident #1 and described Resident #1 as friendly and nice. She stated he would self-propel in his wheelchair throughout the building talking to everyone. She stated Resident #1 was known to have a little bit of an aggression issue and could be mean at times, over react, and escalate. Resident #1 was not on her assignment, but she had worked with him in the past and stated she did his admission so she knew a little bit more about him. Employee "N" stated she did not see anything upon admission that said Resident #1 was a sexual offender, but she was told this by an unknown employee a few days after his admission. Employee "N" stated she witnessed Resident #1 a few times in the hall with one of his hands on Resident #23's legs. She would ask him what he was doing and he would just say he was trying to move her. Employee "N" would tell him it's inappropriate to touch other residents and to please move along. She would tell him if he needs help moving someone to call the staff and we would move the resident for him. Employee "N" stated she would report these incidents to the nurse assigned to Resident #1 but was unsure what was done with this information. In addition to her observing Resident #1's hand on the legs of Resident #23, Employee "N" reported that about a month or two ago Resident #20 reported to her that Resident #1 had promised Resident #2 a cigarette if she would lift up her shirt. Resident #20 reported that Resident #2 had lifted her shirt and Resident #1 had touched her. Employee "N" stated that Resident #20 could not speak but she wrote this to her on a piece of paper. In response to this allegation, Employee "N" stated she immediately headed outside to the smoking area where the alleged incident was said to have occurred. As Employee "N" headed to this area, Resident #2 was already observed back inside the facility. Employee "N" stated she reported this to the Director of Nursing (DON) and in turn, the Administrator had viewed the surveillance tapes for the outside area. Employee "N" did not know if anything was found on the tapes and she thought an incident report had been completed but was unsure. Continued interview with Employee "N" revealed she had a recent incident on 04/06/2014 involving Resident #1 and Resident #2. In this instance, Employee "N" stated she was sitting at her nurses' station when she overheard Resident #2, a female resident, saying "Stop, don't touch me, leave me alone." Employee "N" said Resident #2 was not usually that vocal so she went to see what was going on. When she entered the area, she saw that Resident #1's back was to her. She walked up to see what he was doing, and she witnessed Resident #1's arm under the dressing gown of Resident #2 about "mid forearm deep." Employee "N" went in front of Resident #2 and said "What are you doing? Leave that woman alone." Resident #1 told her he was just trying to move Resident #2. Employee "N" stated she immediately moved Resident #2 away from Resident #1 and reported this to the LPN, Employee "T" assigned to both Resident #1 and Resident #2. Employee "N" and "T" then placed Resident #1 on 1:1 supervision and the DON was called. Employee "N" spoke to the DON who told her to call the abuse hotline and the police which she did. The report was accepted by the hotline and the police came out later that night to see Resident #1. When the police arrived, Resident #1 was in bed with staff outside of his door as the resident was unable to get out of bed on his own. The police spoke to Resident #1 and took a statement from Employee "N." The police said they would be working with the State to investigate this further and they wanted to know if Resident #2's guardian wanted to press charges. Employee "N" thinks that the family of Resident #2 did want to press charges; however, she thought there was some questions about Resident #2's mental status and was unsure if they were able to press charges. Employee "N" stated "Unfortunately, we are not a big staff on 3:00 p.m. - 11:00 p.m. so it is hard to keep track of everyone. We try to continuously monitor the outside but it was late and the aides were busy putting residents to bed." Both Resident #1 and Resident #2 are all over the facility and there were no special parameters for monitoring Resident #1. However, he was placed on 1:1 after the incident and by the time she returned to work the following Wednesday, he had been discharged . Employee "N" stated she was also familiar with Resident #2 and described her as fun with a very hyper personality. She stated she loved cigarettes, soda, and Doritos. Resident #2 was not on her regular assignment but she knew the resident because she self-propelled throughout the building in her wheelchair (w/c) and she talked a lot. 5. An interview with Employee "T" revealed he was an LPN, had worked at the facility for about four and a half months and currently worked on the 3:00 p.m. - 11:00 p.m. He stated he was familiar with Resident #2 as he took care of her. He described Resident #2 as confused, uses a w/c but can also walk but not steady. He stated staff constantly redirect her and tell her to sit back in the chair. Occasionally, Resident #2 gets agitated because she always wants a soda or Doritos. She is compliant with medications and is not combative, but can be disruptive at times. Employee "T" stated he was also familiar with Resident #1. He described Resident #1 as compliant with medications, self-propelling in his w/c and sometimes needing to be re-directed. Employee "T" stated he had never witnessed Resident #1 touching other residents or staff inappropriately, but he was told about an incident by Employee "N." When Employee "T" was asked by the surveyor if he knew that Resident #1 was a sexual offender he stated "No, I was not aware of this. Is that true? I was not aware of that. Nobody told me that." Employee "T" stated Resident #1 was supervised "just like any other resident." Employee T stated he did rounds every one to two hours on his residents and the aides do the same. There was no special monitoring for Resident #1 prior to the incident on 4/6/2014, but after that he immediately checked Resident #2 to see if she had any issues and spoke with her. She said something but Employee "T" could not understand what she said. Resident #2 had no physical markings and she seemed her usual self. He also checked Resident #1 with Employee "N." Employee "T" stated "I was not happy with him. I said ... what did you do?" Resident #1 said he did nothing; he was just touching her w/c. Resident #1 denied it. Resident #1 had no physical injuries. Employee "T" stated he called Resident #2's sister and reported the incident to her. He stated the sister said she was going to press charges. Employee "T" stated the police came in that night and spoke to Resident #1 and immediately following the incident he was placed on 1:1 supervision. Follow up interview with Employee "T" on 4/22/2014 at 3:24 p.m. revealed that he called the psychiatric nurse on either 4/6/2014 or 4/7/2014 to see Resident #1; however, he did not call or get any orders for psychological or psychiatric services for Resident #2. 6. Review of the clinical record for Resident #2 revealed a face sheet indicating this female resident was [AGE] years old, and was admitted to the facility on [DATE]. The resident had a level one Pre-Admission Screen and Record Review (PASRR) dated 2/18/10. Review of this screening revealed the resident had a primary [DIAGNOSES REDACTED]. The resident had a determination of incapacity signed by a physician on 10/29/2009 which documented that this resident lacked the capacity to give informed consent to make medical decisions and did not have reasonable medical probability of recovering mental and physical capacity to directly exercise her rights. Review of Resident #2's most recent minimum data set assessment ((MDS) dated [DATE] revealed a score of 9 out of 15 on the brief interview for mental status (BIMS). The resident displayed the following signs of [MEDICAL CONDITION]: Inattention (behavior present fluctuates; comes and goes; changes in severity) Disorganized thinking (behavior continuously present, does not fluctuate) The resident's mood interview revealed she felt down, depressed, and was having trouble sleeping (2-6 days; several days). The resident required limited assistance/one person physical assistance with transfers and dressing, extensive assistance/one person physical assistance with personal hygiene, bathing, and toilet use, and was independent with no physical help needed for locomotion on and off the unit. Review of nurses' notes revealed the following relevant entries: 4/6/2014 8:20 p.m. A male resident was found by 3-11 nurse (station 1) stroking resident's thigh. And also the resident was saying to him: Stop it! Stop it! Immediately, the staff separated both residents, re-direct and spoke firmly with the male resident on the issue. (The male resident was warned by me, the nurse at 3:00 p.m. to avoid female resident. (He admitted ). Resident was checked thoroughly. Apparently has no injuries at all. Resident is intellectually disabled. DON, ADON were called. DON instructed to call the police. Resident's proxy was called (sister was informed, Medical Doctor (MD) was called). Message left. Male resident is on 1:1 out of bed. Being checked every 15 minutes. This note was signed by LPN, Employee "T." 4/8/2014 ....easily distracted. Does not recall incident of 4/6/14 and no apparent injury. Sister proxy aware of situation. Social services (SS) will contact sister today who request exploring relocating resident to be closer to sister. No additional nurses' notes or social service notes addressing Resident #2's physical and emotional well-being post incident were found. In addition, review of all nurse ' s notes and social service notes from November 2013 to April 22, 2014 revealed no information related to the allegation made by Resident #20 in which Resident #2 was said to have lifted her shirt and been touched by Resident #1. Continued review of the record revealed Resident #2 was seen by the psychiatric Advanced Registered Nurse Practitioner (ARNP) on 4/15/2014 this assessment noted the resident to have [DIAGNOSES REDACTED]. The resident was noted to be agitated, verbal, hi-pitched, mood "good" she says. Frequently asking for items and interrupting nurse all shift. Plan: add [MEDICATION NAME] 50 mg twice a day for agitation and increase [MEDICATION NAME] to 6 caps 125 mg 9:00 a.m. and 9:00 p.m. This assessment made no mention of the sexual abuse which had occurred on 4/6/2014. Observation of Resident #2 revealed the following information: 4/21/2014 at 6:00 a.m.: Resident #2 was a well-nourished female resident observed sitting upright on the side of the bed in a four bed ward. The resident was clean, well groomed and did not appear to be in any distress. 4/21

Based on observations, facility file review, resident record review, policy review and staff and resident interviews, the facility failed to ensure supervision to meet the needs and provide a safe environment free of hazards for two residents (#3 and #5) out of twenty-eight who were identified as an elopement risk. Residents #3 and #5, who had been assessed at risk for elopement, exited the building on one or more than one occasions. It was further determined that both residents exited the building in an area that was described as an "unsafe area." Resident #3, who is a sixty year old, climbed out from his bathroom window two times (3/5/2014 and 4/19/2014) into an area that had a large amount of hazardous materials, broken equipment, used bed frames, toilets, large rusted and sharp objects, and tools. Further, Resident #3 climbed over a wooden fence that was not secured to the building and made his way down the back dirt alley way and approximately twenty feet from where "transient" people routinely gathered in the alley, was approximately fifteen feet from a single lane street that was used by heavy operating equipment such as eighteen wheeled trucks, cement mixing trucks and other vehicles. Resident #5, who is a fifty-eight year old, displayed exit seeking behaviors since her admission on 8/26/2013 of banging on the windows and exit doors. On 3/20/2014, Resident #5 left the facility's back smoking porch area unnoticed and walked around to the front of the building and banged on the door to be let back in. The facility placed residents at risk due to the lack of immediate supervision for two residents that demonstrated ongoing exit seeking behaviors which resulted in findings of immediate jeopardy. The immediate jeopardy was found to be removed on April 23, 2014 at 11:00 p.m. and the severity and scope was reduced to a D. Findings include: 1. During resident record review for Resident #3 who is a sixty year old, was admitted to the facility on [DATE] from the Hospital. According to the demographic and cumulative [DIAGNOSES REDACTED].#3 was admitted with [DIAGNOSES REDACTED]. He was admitted to the facility for long term care placement and review of the advanced directives section revealed an incapacity statement signed and dated by the primary care physician on 3/18/2014. His wife served as the Health Care Surrogate and decision maker as of 2/26/2014. Upon further review of Resident #3's medical record, the facility did not complete an elopement risk assessment until 2/27/2014 (seven days after he was admitted ). The elopement risk assessment, dated 2/27/2014, indicated that Resident #3 had been exhibiting with exit seeking behaviors and had wandering tendencies in the past. Review of Resident #3's Minimum Data Set (MDS) admission assessment signed and dated for 2/27/2014, revealed under section "C" that he had short term and long term memory loss with moderately impaired decision making. Section "E" revealed resident did not present with elopement behaviors during the assessment period. Section "G" indicated resident needed one person physical assistance with Transfers and extensive assistance with locomotion. Section "G" further indicated that during the time of the assessment, Resident #3 was not steady with balance. Review of the current care plans revealed the following: - Risk for falls and wandering/exit seeking (thinks he can go home) initiated on day of admission 2/20/2014 through to 6/10/2014 with interventions to include but not limited to: Monitor transfers; Monitor changes in resident's condition that may warrant increased supervision; Monitor location offering diversion as needed if attempting to exit. - Resident #3 wanders in unsafe situations as he has made attempts to leave facility. This was initiated, on 2/20/2014, day of admission, through to 6/10/2014. Interventions include: Place resident in an area where frequent observation is possible; Alert staff of resident's wandering behaviors, Provide with diversional activities, If resident is wandering away, instruct staff to stay with him; Monitor behavior. None of Resident #3's care plans revealed anything related to a specific "elopement protocol" or "elopement program." Interview with the Administrator revealed they follow their elopement policy, in relation to "Review of the resident's elopement risk completed upon admission", "Environmental modifications", and "Staff Training" (as part of elopement leave of absence policy dated February 2014). However, the Administrator and Director of Nursing confirmed there was no evidence or documentation that staff were ever trained and in-serviced after the 3/5/2014 incident when Resident #3 exited the building. They also indicated there was not an elopement assessment completed upon Resident #3's. The Administrator and Maintenance Director did not evaluate all the environmental areas to include the maintenance equipment storage areas, located behind resident room windows, in a manner to prevent further exits. Review of the following nurse notes revealed: - 2/25/2014 (no time) Resident was noted to be at door with bag. Will place on elopement risk. - 3/4/2014 9:00 p.m. Resident actively gets out of wheelchair and tries to walk around. Staff has tried to redirect with no success and to monitor condition. - 3/5/2014 3:30 a.m. Resident observed resting quietly with eyes closed. - 3/5/2014 5:40 a.m. Resident not in bed. Discovered outside with back pack sitting on ground. Was brought back to nursing station for observation and found with a superficial scrape to Right forearm and Left knee. Physician and Spouse notified. - 3/5/2013 (Interdisciplinary Team note) Resident is on elopement risk. Exited building earlier this a.m. as above (previous nurse note). Interventions include 30 minute rounds for 24 hours, with contact alarms on window and possible room change to be closer to nurse station. - 3/13/2014 (no time) continues to monitor for exit seeking behaviors. - 3/14/2014 10:00 p.m. observed Resident trying to open bathroom window with a knife from his dinner tray, redirected Resident and started a 15 minute check sheet. Resident resting in bed and writer recommends plastic silverware. Note further indicated to continue to monitor - 3/15/2014 1:00 a.m. Resident on 15 minute checks with no signs of distress. - 4/18/2014 7:50 p.m. Resident is in room and remains on 1:1 with staff member - 4/18/2014 10:00 p.m. window on bathroom has an alarm to alert to alert staff if resident is trying to open it. Alarm went off once this shift and staff immediately went to room where R224, F323 and N201 resident was seen walking out of the bathroom. Staff explained to the resident not to open windows. Resident nodded in understanding. Will continue to monitor. - 4/19/2014 4:45 p.m. Resident observed ambulating outside by laundry room carrying shoulder bag with belongings. Assisted to wheelchair and to room. Body assessment completed. Placed on 1:1 staff. Observed Resident had turned off window alarm in bathroom and climbed out then pushed through gate on outside of property. Resident, previously at 3:30 p.m. was visually observed in room with feet up on his bed. And then was observed outside at 4:10 p.m. Director of Nursing (DON), physician and spouse were all notified. - 4/19/2014 10:00 p.m. Resident on 1:1 no attempt to elope after 4:00 p.m. elopement. Will continue 1:1 and monitor for elopement risk. - 4/20/2014 1:45 p.m. remains on 1:1 supervision. - 4/21/2014 5:00 a.m. remains on 1:1 supervision. Review of the "8 hour shift frequent observation worksheets" revealed the Resident was only provided with 15 minute checks on 3/5/2014, 3/6/2014, 3/7/2014 and 3/8/2014 after exiting the building through the bathroom window on 3/5/2014 also 3/14/2014 and 3/15/2014 after being observed trying to get out from the bathroom window on 3/14/2014. It was not clear when Resident #3 was taken off 15 minute checks after the 3/14/2014 incident. However, it was noted that Resident #3, again, exhibited exit seeking behaviors from his alarmed window on 3/15/2014. In an interview with the Administrator and the DON indicated that there was no documentation of Resident #3 being placed on 15 minute checks after the 3/14/2014 observation and it was further confirmed that he was only verbally educated not to lift up the window. When both the Administrator and Director of Nursing (DON) were asked on 4/21/2014 why Resident #3 was not placed on 1:1 supervision on 4/18/2014, after he was noted lifting up the bathroom window where he had made multiple attempts of exiting, once successfully, they both indicated that they were unaware of the incident on 4/18/2014 as it was late at night. They were asked if Resident #3 was placed on an elopement protocol and indicated that yes, he was and that supervision included checks on an hourly basis and throughout the shift to see where he was. It was determined that Resident #3 exited his window the very next day on 4/19/2014 and was not on any type of 1:1 or 15 minute checks supervision, as per DON and Administrator interview. Record review determined that Resident #3 was placed on "8 hour shift frequent observations checks/worksheet" only, dating from 4/20/2014, 4/21/2014, 4/23/2014 and onward. In an interview with the Administrator on 4/21/2014 indicated that Resident #3 would be placed on 24 hour 1:1 supervision until the Interdisciplinary team and family made a decision for discharge planning to another facility that could meet his needs. Observations and interview with the Nursing Home Administrator (NHA) and Maintenance Director on 4/21/2014 at approximately 10:00 a.m., found the areas where the Resident exited the building: On 3/5/2014, the Administrator and Maintenance Director indicated he was at that time residing in Room 19, which had a bathroom that was shared with room 20. The perimeter of the building was toured with the NHA and Maintenance Director down the "East" street and to the back alley. The "East" street was observed on 4/21/2014, 4/22/2014 and 4/23/2014 at approximately 7:00 a.m., 10:00 a.m., 1:00 p.m. and 5:00 p.m. with very heavy traffic to include cars/trucks driving very fast. Eighteen wheeled diesel trucks and large concrete mixer trucks were also observed at this time. The Maintenance Director further indicated that the area between the back of resident rooms/walls and the laundry/maintenance building was used to store broken equipment, tools, chemicals, beds, toilets, air conditioner units, etc. and had a "build-up" of said mentioned equipment for over three years. The Administrator indicated again that this area would be interpreted as an "unsafe" area for residents. The Administrator and Maintenance Director both indicated that this area was where Resident #3 exited twice from his room. Additional interview with the Administrator and Maintenance Director on 4/21/2014 at approximately 10:45 a.m. revealed after 3/5/2014, Resident #3 was moved to another room, closer to the nurse's station. The new room was observed and noted to be room 7. It was observed that the room's windows and shared bathroom window led to the same maintenance and laundry area where all the "discarded" equipment and other hazard items were located. It was observed that the areas, directly outside and below room 7's windows and bathroom window, had a massive amount of equipment that was stacked and strewn all the way to both windows. It was determined through interviews with the Maintenance Director that the equipment was in the same place when Resident #3 climbed out of the bathroom window. The Administrator indicated that Resident #3 on 4/19/2014 went to his bathroom, turned off the alarm switch attached to the side of the window, lifted the window up and punched/tore the screen to make a hole and then proceeded to climb out through the window and negotiated his way down the hazardous equipment to the ground and then walked to the wooden fence and this time instead of climbing the fence, Resident #3 pushed through it by breaking the rusted hinges. The Administrator indicated that the resident then walked approximately twenty feet down the alley and stepped up to a sidewalk/ramp between the dirt alley and the back of the facility wall, which was still defined as facility property. The Administrator confirmed that the area outside resident room 7 and the area at the alley was "unsafe." The Administrator indicated Resident #3 was seen by a dietary worker who reported it and at the same time nursing had already found out he was not in the building. He indicated that Resident #3 was found by nursing and brought back to his room where he was assessed with [REDACTED]. On 4/21/2014 at approximately 1:00 p.m. interview with the Director of Nursing, Assistant Director of Nursing and the Administrator all provided information related to Resident #3's exit seeking behaviors. This administrative team all indicated that after the first incident, which occurred on 3/5/2014, when Resident #3 climbed out of his bathroom window and out to the alley, they, immediately put him on "elopement risk", which included 30 minute rounds every 24 hours. They reported Resident #3 was moved to another room, located near the nurse's station, for better supervision. The Administrative team indicated they also placed a contact alarm on the window to prevent the resident from getting out the window again. The Administrative team was asked if the window alarm would prevent the Resident from getting out of the window, or was it used as a deterrent and announcer to notify staff when the window was being lifted open. The Administrative team expressed that the alarm did not prevent the resident from getting out of the window, but was rather to notify staff he or someone was manipulating the window open. The Administrative team was asked if Resident #3 exhibited any exit seeking behaviors prior to 3/5/2014. They indicated he presented with exit seeking behaviors the day before on 3/4/2014. The Administrative team reported the resident was observed trying to get up out of his wheelchair and tried to walk around at exit doors. The Administrative team indicated that the only documented intervention was to continue to monitor. The Administrative team further explained that on 2/25/2014, the resident presented with exit seeking behaviors and had his bag with clothes and was sitting at the front door. They indicated the Interdisciplinary team met and placed him on "elopement risk." The Administrative team stated the elopement risk procedure was to continually monitor the resident. Also, they indicated information was kept in the elopement book, kept at each station. There were no other interventions at that time, prior to the 3/5/2014 exit from the building. The facility did not have any documentation related to 15 minute or 30 minute checks after shown behaviors dating 2/25/2014 and 3/4/2014. The Administrative team was asked if they provided any education to any of the staff after the 3/5/2014 incident of Resident #3 exiting the building. The Administrative team explained they in-serviced all their staff related to elopements and risks. However, the Administrative team did not have any documentation to that affect. The Director of Nursing provided an in-service and sign in sheet, dated 3/18/2014, but it was only titled "Dining room." It was confirmed that there was no evidence in this in-service that the elopement subject matter was discussed. The Administrative team explained that, after Resident #3 was moved to the new room (7), they placed him on 15 minute checks, placed the contact alarm on the window and conducted with monitoring. Review of the 15 minute checks sheet did indicate 15 minute checks were conducted and the checks continued until 7:15 p.m. on 3/9/2014. The Assistant Director of Nursing and Director of Nursing both indicated that the 15 minute checks should have only lasted 24 hours but they see the checks actually lasted four days unintentionally. The Administrative team confirmed there were no other interventions at that time other than Resident #3 was to be monitored as per their "elopement risk" plan, and was taken off 1:1 and 15 minute checks. The Administrative team confirmed they had no documentation as to why the 15 minute check was lifted other than the 15 minute check assessment was used on a 24 hour basis. The team stated that Resident #3 started exhibiting exit seeking behaviors, again, on 3/14/2014 where he used a knife from the kitchen (butter knife) and tried to manipulate the bathroom window with it. The DON indicated that the knife was taken away and he was placed on 15 minute checks for 24 hours. The DON confirmed the nurse note dated 3/14/2014 10:00 p.m., indicated that the writer (nurse) recommended plastic silverware. The DON stated that she believed the recommendation was passed through to the Dietician but neither she, nor the Dietician, took it further and did not change to plastic silverware as recommended. She confirmed she did not have any documentation or evidence this recommendation was reviewed. The Administrative team explained that it was documented in the nurse notes dated 4/18/2014 at 7:50 p.m. that Resident #3 was on 1:1 supervision. However, there were no 15 minute check sheets to confirm this. The Administrative team could not provide documentation that Resident #3 was on 15 minutes 1:1 supervision on 4/18/2014 or names of staff that were doing the checks. The Administrative team was shown another nurse note, dated the same day 4/18/2014 at 10:00 p.m., which revealed Resident #3 went to the bathroom window and lifted it, sounding the alarm. The Director of Nursing indicated that she did not know when Resident #3 was taken off supervision. She indicated that the only documented intervention related to Resident #3 lifting up the window was to educate him on not opening the window. The Director of Nursing and Administrator confirmed that this reflected two incidents of the resident manipulating the window, keeping in mind that Resident #3 exited the bathroom window while in room 19. The Administrative team could not demonstrate 1:1 supervision or 15 minute checks as per their "elopement risk" protocol. The Administrative team further could not provide names of any staff that may have been on 1:1 with Resident #3, on 4/18/2014 during the times from 7:50 p.m. through 10:00 p.m. At this time it was brought to the Administrative team's attention that the nurse note, dated 4/19/2014 4:45 p.m. The note indicated that Resident #3 was observed ambulating outside by the laundry room and carrying a shoulder bag with belongings. The Administrative team confirmed that Resident #3 actually turned off the alarm on his window and lifted the window up and climbed out the window and then out through the back area and through the wooden fence and then on the alley area. The Director of Nursing and Administrator both explained Resident #3 had a carton of milk, a bag full of clothes, a toothbrush and two or three grilled cheese sandwiches. The Administrative team indicated and after review of the nurse note dated 4/19/2014, Resident #3 was placed on 1:1 supervision with 15 minute check documentation and continued 24 hours a day for every day thereafter and continued to at least 4/23/2014. When asked, the Administrative team confirmed they did not have any documentation that Resident #3 was assessed for elopement risk at admission, as per their policy. The DON and ADON confirmed the first elopement risk assessment was done on 2/27/2014 (seven days after his admission). The Director of Nursing explained during this interview, on 4/21/2014 at approximately 1:00 p.m., they were working with the resident's wife and trying to find a better placement for Resident #3 as they believed at this time they cannot meet his needs. She further explained that Resident #3 would remain on 1:1 24 hour supervision. The Director of Nursing provided "8 hour shift frequent observation worksheet" 1:1 15 minute checks that were documented by the monitor assigned to Resident #3. It was documented that these sheets were completed for dates 4/20/2014 through 4/21/2014, 4/21/2014 through 4/22/2014, and 4/23/2014. The Administrative team was asked if they had completed any in-services/education related to elopement risks, exit seeking prevention on or after 3/5/2014 and on or after 4/19/2014. The Director of Nursing and Administrator indicated that they had conducted in-services but had no evidence of any sign in sheets or any other documentation with subject matter related to elopement and risks. Interviews on 4/21/2014 at approximately 7:00 a.m. and 3:30 p.m., 4/22/2014 and 4/23/2014 were with the following sampled staff members: Employee H, a Licensed Practical Nurse (LPN) that works the 11-7 shift was interviewed on 4/21/2014 at approximately 5:15 a.m. and revealed she was aware that Resident #3 had exited the facility a couple of times but was not sure as to when, but believed the last time was a couple of days ago. She indicated that he was now on 1:1 24 hour supervision. She indicated she believed she had not been in-serviced or trained with subject matter regarding elopement and risk within the past few months (to include 3/2014 and 4/2014). Employee O, a Certified Nursing Assistant (CNA) that works the 11-7 shift was interviewed on 4/21/2014 at approximately 5:20 a.m. and revealed she was aware of Resident #3's exit seeking behaviors, but had not had any in-services or training related to elopement or risks during or after the last two incidents or upon her orientation, which was approximately one month ago. Upon further interview, employee O was now aware of an "Elopement book" or book that shows what residents are on elopement risk. Employee F and J, both CNAs and work the 11-7 shift were interviewed at the same time on 4/21/2014 at approximately 5:25 a.m. Both employee F and J confirmed they were aware of Resident #3 and his exit seeking behaviors, but have not had any in-services or training since his last two exits (3/5/2014 and 4/19/2014). They further revealed they have been working at the facility for about one year and did not know of any book that indicated residents who are assessed as elopement risk. Both felt they could use more training in the area of elopements. Employee E, a CNA that works the 11-7 shift was interviewed on 4/21/2014 at 6:45 a.m. and indicated Resident #3 has had multiple attempts of eloping during this shift. She further indicated approximately one month ago the resident got out of his room and was found in the back alley that was not enclosed. She also indicated that he was noted to be still on the property to the best of her knowledge. She also indicated that she believed he had not eloped since and has been on 1:1 supervision. When asked, Employee E indicated she has not received any in-services or training related to elopement within the past few months (to include 3/2014 and 4/2014). She also was unaware of exactly where the elopement book was kept and that there should be one somewhere. Employee I, an LPN that works mainly 7-3 shift and had worked other shifts to include 3-11 was interviewed on 4/21/2014 at approximately 7:10 a.m. and indicated she was aware of Resident #3, who was an elopement risk and presented with exit seeking behaviors. She further indicated that over the weekend on 4/19/2014, he tried to elope and climbed out of his window and was found on the property alley at 4:05 p.m. She indicated that she was here during that shift and saw him in his room earlier at 3:30 p.m. seated in his wheelchair with his feet propped up on the bed and watching television. She explained that a little after 4:00 p.m. Resident #3 evidently went to his bathroom window and turned off the alarm and went out the window. She revealed that Resident #3 usually was seated in his wheelchair but can ambulate without assistance. Employee I indicated that Resident #3 was found at the end of the alley while still on the property and was found by a dietary worker. She added that Resident #3 was found with several grilled cheese sandwiches, a carton of milk, a bag filled with clothes and a toothbrush. The nurse stated that Resident #3 had exited the building prior to this date, while he was residing in another room (room 19). Employee I indicated that the building doors were locked at all times and Resident #3 had been on 1:1 supervision 24 hours a day since the last incident which occurred on 4/19/2014. She believed they were working on discharge planning with the wife of Resident #3. Employee I indicated she believed there had been an elopement drill and believed there had been in-services and training related to elopement but could not give specific or general times, when drills and in-services were conducted. Employee A, a CNA that works the 7-3 shift and had been employed eight years, was interviewed on 4/21/2014 at approximately 7:45 a.m. Employee A indicated she was aware of Resident #3 and his exit seeking behaviors and had been scheduled to monitor him for 1:1 supervision. She indicated she had heard of both instances when Resident #3 exited the building and knew they received training and in-services but could not remember the last time they had it. She was aware of the elopement book and where it was located. Employee A indicated that she knew that Resident #3 was moved from Room 19 to the current Room 7, and staff had placed an alarm on the window as an intervention. She further explained that Resident #3 found out how to turn off the alarm and turned it off and lifted the window up in the bathroom and exited into the alley. She did not know why he was not on 1:1 supervision at the time. Employee D, the lead CNA that works the 7-3 shift and had been employed approximately one year and a half, was interviewed on 4/21/2014 at approximately 9:50 a.m. Employee D explained that he was aware Resident #3 had exited the building twice and has been put on 1:1 24 hour supervision and had had a room change after the first incident on 3/5/2014. He indicated that he had not signed or attended any in-services or training related to elopement within the past two months to include (3/2014 and 4/2014). He further indicated he did not recall any elopement drills during his shift the past few months. Employee L, an LPN that works primarily 7-3 shift but had worked 3-11 shifts recently, was interviewed on 4/21/2014 at approximately 9:00 a.m. and revealed she knew of Resident #3 and his exit seeking behaviors and that he had exited his room twice. She indicated Resident #3 was placed on 1:1 supervision and moved to another room after the first incident (3/5/2014) and also an alarm was placed on the window. Employee L also indicated that Resident #3 was noted to have been lifted off 1:1 supervision the day or night before his last exit incident (4/19/2014). She also indicated he had been noted to have behaviors of playing with the alarm on the window and somehow turned the alarm off and went out the window again. She believed there had been in-services and training but did not know when. She indicated she could use more training when it comes to elopement and those who are at risk. Employee N, an LPN that works the 7-3 shift, was interviewed on 4/21/2014 at approximately 1:00 p.m. Employee N indicated she had been employed at the facility for almost one year and indicated she was here during the time when Resident #3 exited the building three days ago (Saturday 4/19/2014). She indicated she was on shift and remembered seeing Resident #3 at 3:30 p.m. and was noted by an aide (unknown) that Resident #3 was not in his room at 4:00 p.m. She explained she was told he was outside and immediately checked the monitor screens at the unit station that show the smoking area, and found he was not out there and at the same time, she was told he was not outside in the smoking are, but was outside on facility property in the back. She indicated he had been located already by other staff and that he was out in the alley drinking a carton of milk and had a bag of clothing with him. She indicated she immediately brought him back in and assessed him and he was without any injuries. Employee N indicated that a laundry aide had seen him out there but since he was dressed and had a bag. She did not think this was a resident. But when it was noted Resident #3 was out of his room, and the laundry worker (employee S) heard a resident was out of the building, she then ran to tell her (employee N) where that person was, and it was Resident #3. Employee was asked how she identified residents who were elopement risks. She explained that she already knew who was at risk. When asked about an elopement book with resident pictures, she was not aware of one. She also revealed she remembered there had been elopement training in the past, but not recently. Employee N also indicated that Resident #3 was taken off 1:1 supervision the day before he exited his room (4/19/2014) and had been noted to play with the alarm on the window prior to that. She also explained that she knew that Resident #3 knew how to turn the alarm off, as he had done it before. Employee G, a CNA that works 3-11 shift and 7-3 shift, was interviewed on 4/21/2014 at approximately 9:30 a.m. Employee G indicated that he has been employed at the facility about four months. He was aware Resident #3 is on 1:1 supervision and that he has exited the facility twice within the past month or so. He indicated he did not know where the elopement book was kept or any information as to who is considered an elopement risk was kept. He did not believe he had been in-serviced or trained the past two months to include (3/2014 and 4/2014) with regards to elopement or those who are at risk. He had not been part of an elopement drill and indicated he could use more training on the matter. Employee K, a CNA that works the 7-3 shift, was interviewed on 4/21/2014 at approximately 9:50 a.m. She indicated that she was aware of Resident #3's elopement behaviors and did not know of where information regarding who was elopement risk was kept. She was not aware of an "elopement book" with resident pictures. She further explained she believed she has had training on the matter, but does not know when. Employee Q, a Housekeeper that works different shifts, was interviewed on 4/23/2014 at 9:55 a.m. Employee Q indicated she did not know what residents are on elopement risk and would not know where the elopement book or book where resident information related to elopement risk was kept. Employee Q was aware that Resident (#3) was found outside the building and on the alleyway. Employee R, a kitchen aide/cook that works in the kitchen during the day and night shift, was interviewed on 4/23/2014 at approximately 10:00 a.m. He indicated that he was now aware of Resident #3 and his exit seeking behaviors. He did now know where information of who was an elopement risk was kept and did not know who was at risk. Employee R indicated that he was here at the facility on 4/19/2014 and he and employee U were outside the kitchen in the back. Employee R explained that employee U spotted a person who appeared to be a female down the alley near the road and was drinking milk. Employee R then looked and told employee U that that person was not a female and that it was Resident #3. Employee R indicated he told employee U to stand there and watch while he ran in to tell a nurse. Employee R indicated that by the time he reached the nurse station, the staff had just found out he was missing from the facility and he told them where Resident #3 was at. At this point, Employee R stated that Resident #3 was already found. He indicated it happened really fast. Employee R was also aware of resident #5 with exit seeking behaviors and saw her banging on windows and doors at times, trying to get out. He has not seen Resident #5 out of the building before but heard she had found a way out and came to the front door to be let back in. Employee R indicated he has not had any elopement training since he had been an employee here approximately three months and did not know how to identify a resident who was an elopement risk. He had not been part of an elopement drill

Based on review of the Administrator's job description, resident and staff interviews, clinical record reviews, and facility policies and procedures related to Abuse and Elopement, it was determined that the facility Administration failed to operationalize facility policies related to abuse for two of 20 sampled residents for abuse (#1 and #2), one (#1) of whom was a known sexual offender and two of 28 residents identified as an elopement risk (#3, #5). The Administrator failed to follow facility policy and procedures for abuse when admitting a sexual offender. The Administrator failed to assess Resident #1 and put a supervision and monitoring plan in place to ensure the protection of facility residents. The Administrator failed to provide protection per the abuse policy immediately following sexual abuse by providing emotional support and psychosocial services to Resident #2. In addition, the Administration failed to provide staff with the necessary information to protect Resident #2 from sexual approaches by Resident #1. The Administration failed to ensure that systems were in place to monitor and supervise Resident #1 and ensure the staff was trained to prevent a recurrence of sexual abuse by a known sexual offender. The Administration failed to manage in a manner that enabled it to use its resources effectively to maintain the highest practicable physical & psychosocial well-being for Residents #3 and #5, who were identified as needing closer supervision due to exit seeking and exit seeking behaviors. The administration did not ensure that the direct functions and operations of the facility were in accordance with current regulations governing long term care facilities policies for resident supervision and providing a safe environment, free of hazards. Review of both Resident #3 and #5's medical records, and observations determined that the facility failed to operationalize it's "Elopement, Leave of Absence" policy related to its procedures including that of 1) Elopement risk assessments for Residents # 3 and 5. The elopement risk assessment for Resident #3 was not completed for seven days following admission. The elopement risk assessment for Resident #5 was not completed for three months after admission; 2) Prevention. The facility did not ensure its environmental modification including contact alarm, placed on Resident #3's window, was effective, allowing the resident to exit the building from his bathroom window. The facility did not ensure staff interventions to include 15 minute checks and 1:1 supervision was put in place, as per their policy, after the 3/18/2014 attempt to exit the bathroom window. Resident #3 was not on any monitoring and exited the building on 4/19/2014 without staff ' s knowledge. Thirteen out of seventeen staff interviews (H, P, O, F, E, B, A, D,N, G, K, Q and R), determined that staff had not received any in-services/education related to elopement and elopement risks during the months of 3/2014 and 4/2014 up to 4/20/2014. Further, the staff indicated they were not sure of where an "elopement book" where resident pictures with elopement behaviors was located. 3) Physical Plant Safety. The facility did not take effective measures to ensure that, an area with maintenance equipment storage, to include areas at and below resident room windows, were free from "discarded and broken" equipment that included broken chairs, beds, air conditioner units, sharp edged metal equipment, tools, and other "discarded equipment." The facility did not ensure resident rooms were safe for residents with known exit seeking behaviors so as to eliminate or minimize the risk for elopement from that area. The facility did not monitor the safety of residents to include an area across from a back alley. This area had been observed with condemned and non-livable houses and was frequented by those who loitered. Administration demonstrated a lack of action and commitment to protect Resident #2, a mentally and intellectually disabled adult, from sexual abuse and demonstrated a lack of action and commitment to supervise Resident #3 and #5, who exhibited exit seeking behaviors. These system failures resulted in findings of Immediate Jeopardy which was removed on April 23, 2014 at 11:00 p.m. and the severity and scope was reduced to a D. Findings include: 1. On 4/22/2014 the Administrator provided the "Nursing Home Administrator" position description for review. The position description was signed and dated by the administrator on 7/3/2012 and revealed the following relevant information: Duties - I. Summary of Position: Responsible for the financial, administrative and personnel management of the facility. Maintains appropriate guidelines and regulations to assure the highest degree of attention and care is provided to residents at all times. Follows all company policies and procedures. A. Essential Functions 1. Supervisory Responsibilities (b.) Directs the work of employees (m.) Participates in training programs and assists in orientation of new staff. 2. Plans, develops, organizes, implements, and directs the facility's programs and activities. Manages the overall day-to-day functions... 4. Ensures that each resident's right to fair and equitable treatment, self-determination, individuality, privacy, property, and civil rights, including the right to lodge a complaint, are strictly enforced. 5. Ensures that the most current resident care policies, personnel policies and other operational policies and procedures necessary to remain in compliance with required laws, regulations and guidelines are available and followed. 6. Evaluates and implements recommendations from the Residents Council, facility's consultants, task forces and regional personnel. 7. Ensures that an adequate number of personnel are employed to meet the needs of the residents and State Requirements ... 8. Coordinates Departments (b.) Discusses problems, management, and supervision of departments on a regular basis. 9. Ensures that the facility admits only those residents for whom it can provide the required care under its license. 11. Makes routine inspections of the facility to assure that established policies and procedures are being implemented and followed. 13. Creates and maintains an atmosphere of warmth, personal interest, and positive emphasis. 15. Ensures that all facility personnel, residents, visitors, etc. follow established safety regulations to include ... accident prevention ... 16. Monitors and ensures compliance with all state and federal regulations ... 18. Treats all residents, visitors, and staff with courtesy. 24. Safety - (a.) Knows and follows facility rules. (d.) Reports and documents any incidents or accidents of residents, staff or visitors. (e.) Reports all hazardous conditions/equipment to Maintenance 25. Resident Rights - (a.) Knows Resident Rights. Helps the residents exercise and/or protect their rights. (b.) Investigates resident complaints. III. Knowledge, Skills, and Abilities B. Understands the social psychological and recreational needs of the aged and other ill, disabled and emotionally upset people. 2. On 4/22/2014 the Administrator provided the Director of Nursing position description for review. This position description was signed and dated by the Director of Nursing on 1/20/2014. The policy revealed the following relevant information: Duties - I. Summary of position - Develops, organizes, evaluates and administers the patient care programs and services of the center, ensures the implementation of all clinical policies and procedures, and follows all company policies and procedures. II. Position responsibilities A. Essential Functions - - (1.) Supervisor Responsibilities (m) Participates in training programs and assists in orientation of new staff. - (2.) Leads, organizes, evaluates, and manages nursing and clinical personnel through sound management practices and delegation. - (3.) Makes daily patient rounds with the appropriate manager(s) to note resident/patient conditions and to ensure nursing personnel are performing their work assignments in accordance with acceptable nursing standards. - (5.) Attends regularly conducted staff meetings and participates regularly in continuing education in -service programs. - (8) Accountable for adherence by staff to policies, procedures and standards; delivery and proper documentation of patient care. - Provides for appropriate - (9) Provides for appropriate environment, equipment and supplies for the delivery of the prescribed patient care and creates an environment conducive to optimum staff development. - (22.) Safety (d) Reports all hazardous conditions/equipment to Supervisor. - (28.) Resident Rights (a.) Knows resident rights. Help the residents/patients exercise and /or protect their rights. 3. Review of the facility's "Abuse Manual" revised June 2012 revealed the following relevant information: Abuse Policy Policy Statement: The purpose of this policy is to ensure resident freedom from abuse, neglect, exploitation, and misappropriation of property (ANEM). The Administrator is responsible to assure the process. ANEM as defined below will not be tolerated in the facility. This includes residents, staff, agents of the facility, family members, legal guardians, friends, or interested parties. Policy Interpretation and Implementation: Definitions: 1. "Abuse" is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. 4. "Sexual abuse" is defined as, but is not limited to, sexual harassment, sexual coercion, or sexual abuse. 6. "Mental abuse" is defined as, but is not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. Procedure: 3. Prevention Issues a. Practice: The facility will provide proper support, education, and supervision designed to reduce the likelihood of abusive behaviors. 4. Identification: a. Practice: The facility will consider any event that is reported to any staff by patient/resident, family, or any other person involving any persons (e.g., resident to resident, employee/volunteer to resident, etc.) as possible abuse if it meets any of the following criteria: Any complaint of sexual harassment, coercion, or sexual abuse. 5. Protection: a. Practice: Patients/residents will be protected from harm during any investigation. b. Steps: Any individual found in danger of injury (physical or emotional) will be: 1. Removed from the source of the suspected abusive behavior. 2. Provided with medical and emotional support immediately following any individual suffering or suspected abuse. Abuse Investigations: Statement: All reports of resident abuse, neglect, exploitation, misappropriation of property and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Interpretation and Implementation: 2. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. 3. The individual conducting the investigation will, as a minimum: b. Review the resident's medical record to determine events leading up to the incident; j. Review all events leading up to the alleged incident. Preventing Resident Abuse Statement: Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse. Interpretation and implementation: Zero Tolerance of Abuse: 1. The facility's goal is to achieve and maintain an abuse-free environment. Contents of Abuse Prevention/Intervention Program: 2. Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: a. Training all staff and practitioners how to resolve conflicts appropriately; e. Involving the resident/family group council in developing, monitoring, and evaluating the facility's abuse prevention program; g. Training staff to understand and manage a resident's verbal or physical aggression; j. Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect; k. Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues; l. Conducting background investigations to avoid hiring persons or admitting new residents who have been found guilty (by a court of law) of abusing, neglecting or mistreating individuals or those who have had a finding of such action entered into the state nurse aide registry or state sex offender registry; m. Involving Attending Physicians and the Medical Director when findings of abuse have been determined. n. Involving qualified psychiatrists and other mental health professionals to help the staff manage difficult or aggressive residents; o. Identifying areas within the facility that may make abuse and/or neglect more likely to occur (e.g. secluded areas) and monitoring these areas regularly; p. Striving to maintain adequate staffing on all shifts to ensure that the needs of each resident are met; Reporting Abuse to Facility Management: Responsibility of Person(s) Observing Incidents of Abuse: 7. Staff members and persons affiliated with this facility shall not knowingly: Screen reports or withhold information to reporting agencies. Resident-to-Resident Altercations Interpretation and Implementation: Monitoring Residents for Aggressive/Inappropriate Behavior: 1. Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or to the staff. Occurrences of such incidents shall be promptly reported to the Nurse Supervisor, Director of Nursing (DON), and to the Administrator. 2. If two residents are involved in an altercation, staff will: c. Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation; e. Review the events with the Nursing Supervisor and DON including interventions to try to prevent additional incidents; f. Consult with the Attending Physician to identify treatable conditions such as acute [MEDICAL CONDITION] that may have caused or contributed to the problem; g. Make any necessary changes in the care plan approaches to any or all of the involved individuals; h. Document in the resident's clinical record all interventions and their effectiveness; i. Consult psychiatric services as needed for assistance in assessing the resident, identifying causes and developing a care plan for intervention and management as necessary or as may be recommended by the Attending Physician or Interdisciplinary Care Planning Team; j. Complete a Report of Incident/Accident form and document the incident, findings and any corrective measures taken in the resident's medical/clinical record; k. If, after carefully evaluation the situation, it is determined that care cannot be readily given within the facility, transfer the resident; Staff Responsible for Coordinating/Implementing Abuse Prevention Program Policies and Procedures Statement: The Administrator is responsible for the overall coordination and implementation of our facility's abuse prevention program policies and procedures. 4. On 4/21/14 at 12:30 p.m. an interview was conducted with Employee "N", a licensed practical nurse (LPN), who has worked at the facility since July of 2013 with a full time assignment normally on Station One for the 3:00 p.m. - 11:00 p.m. shift. Employee "N" stated she was familiar with Resident #1 and described Resident #1 as friendly and nice. She stated he would self-propel in his wheelchair throughout the building talking to everyone. She stated Resident #1 was known to have a little bit of an aggression issue and could be mean at times, over react, and escalate. Resident #1 was not on her assignment, but she had worked with him in the past and stated she did his admission so she knew a little bit more about him. Employee "N" stated she did not see anything upon admission that said Resident #1 was a sexual offender, but she was told this by an unknown employee a few days after his admission. Employee "N" stated she witnessed Resident #1 a few times in the hall with one of his hands on Resident #23's legs. She would ask him what he was doing and he would just say he was trying to move her. Employee "N" would tell him it's inappropriate to touch other residents and to please move along. She would tell him if he needs help moving someone to call the staff and we would move the resident for him. Employee "N" stated she would report these incidents to the nurse assigned to Resident #1 but was unsure what was done with this information. In addition to her observing Resident #1's hand on the legs of Resident #23, Employee "N" reported that about a month or two ago Resident #20 reported to her that Resident #1 had promised Resident #2 a cigarette if she would lift up her shirt. Resident #20 reported that Resident #2 had lifted her shirt and Resident #1 had touched her. Employee "N" stated that Resident #20 could not speak but she wrote this to her on a piece of paper. In response to this allegation, Employee "N" stated she immediately headed outside to the smoking area where the alleged incident was said to have occurred. As Employee "N" headed to this area, Resident #2 was already observed back inside the facility. Employee "N" stated she reported this to the Director of Nursing (DON) and in turn, the Administrator had viewed the surveillance tapes for the outside area. Employee "N" did not know if anything was found on the tapes and she thought an incident report had been completed but was unsure. Continued interview with Employee "N" revealed she had a recent incident on 04/06/2014 involving Resident #1 and Resident #2. In this instance, Employee "N" stated she was sitting at her nurses' station when she overheard Resident #2, a female resident, saying "Stop, don't touch me, leave me alone." Employee "N" said Resident #2 was not usually that vocal so she went to see what was going on. When she entered the area, she saw that Resident #1's back was to her. She walked up to see what he was doing, and she witnessed Resident #1's arm under the dressing gown of Resident #2 about "mid forearm deep." Employee "N" went in front of Resident #2 and said "What are you doing? Leave that woman alone." Resident #1 told her he was just trying to move Resident #2. Employee "N" stated she immediately moved Resident #2 away from Resident #1 and reported this to the LPN, Employee "T" assigned to both Resident #1 and Resident #2. Employee "N" and "T" then placed Resident #1 on 1:1 supervision and the DON was called. Employee "N" spoke to the DON who told her to call the abuse hotline and the police which she did. The report was accepted by the hotline and the police came out later that night to see Resident #1. When the police arrived, Resident #1 was in bed with staff outside of his door as the resident was unable to get out of bed on his own. The police spoke to Resident #1 and took a statement from Employee "N." The police said they would be working with the State to investigate this further and they wanted to know if Resident #2's guardian wanted to press charges. Employee "N" thinks that the family of Resident #2 did want to press charges; however, she thought there was some questions about Resident #2's mental status and was unsure if they were able to press charges. Employee "N" stated "Unfortunately, we are not a big staff on 3:00 p.m. - 11:00 p.m. so it is hard to keep track of everyone. We try to continuously monitor the outside but it was late and the aides were busy putting residents to bed." Both Resident #1 and Resident #2 are all over the facility and there were no special parameters for monitoring Resident #1. However, he was placed on 1:1 after the incident and by the time she returned to work the following Wednesday, he had been discharged . Employee "N" stated she was also familiar with Resident #2 and described her as fun with a very hyper personality. She stated she loved cigarettes, soda, and Doritos. Resident #2 was not on her regular assignment but she knew the resident because she self-propelled throughout the building in her wheelchair (w/c) and she talked a lot. 5. An interview with Employee "T" revealed he was an LPN, had worked at the facility for about four and a half months and currently worked on the 3:00 p.m. - 11:00 p.m. He stated he was familiar with Resident #2 as he took care of her. He described Resident #2 as confused, uses a w/c but can also walk but not steady. He stated staff constantly redirect her and tell her to sit back in the chair. Occasionally, Resident #2 gets agitated because she always wants a soda or Doritos. She is compliant with medications and is not combative, but can be disruptive at times. Employee "T" stated he was also familiar with Resident #1. He described Resident #1 as compliant with medications, self-propelling in his w/c and sometimes needing to be re-directed. Employee "T" stated he had never witnessed Resident #1 touching other residents or staff inappropriately, but he was told about an incident by Employee "N." When Employee "T" was asked by the surveyor if he knew that Resident #1 was a sexual offender he stated "No, I was not aware of this. Is that true? I was not aware of that. Nobody told me that." Employee "T" stated Resident #1 was supervised "just like any other resident." Employee T stated he did rounds every one to two hours on his residents and the aides do the same. There was no special monitoring for Resident #1 prior to the incident on 4/6/2014, but after that he immediately checked Resident #2 to see if she had any issues and spoke with her. She said something but Employee "T" could not understand what she said. Resident #2 had no physical markings and she seemed her usual self. He also checked Resident #1 with Employee "N." Employee "T" stated "I was not happy with him. I said ... what did you do?" Resident #1 said he did nothing; he was just touching her w/c. Resident #1 denied it. Resident #1 had no physical injuries. Employee "T" stated he called Resident #2's sister and reported the incident to her. He stated the sister said she was going to press charges. Employee "T" stated the police came in that night and spoke to Resident #1 and immediately following the incident he was placed on 1:1 supervision. Follow up interview with Employee "T" on 4/22/2014 at 3:24 p.m. revealed that he called the psychiatric nurse on either 4/6/2014 or 4/7/2014 to see Resident #1; however, he did not call or get any orders for psychological or psychiatric services for Resident #2. 6. Review of the Florida Department of Law Enforcement website (<http://offender.fdle.state.fl.us/>) on 4/21/2014 revealed Resident #1 was listed as a known sexual offender with an adjudication of guilty/convicted on 4/5/1991 of Lewd, Lascivious Act on a Child Under 16 (F.S. 800.04), gender unknown. The resident's address listed on the website was that of this nursing facility. 7. Review of the clinical record for Resident #1 revealed this [AGE] year old male resident was admitted [DATE] and discharged to the hospital on [DATE]; readmitted on [DATE] and discharged on [DATE] with return not anticipated. Review of the face sheet revealed this resident was his own responsible party and had relevant [DIAGNOSES REDACTED]. Review of the Florida Pre-Admission Screening and Resident Review (PASRR) Mental Illness Level II Determination Summary Report dated 9/2/2011 revealed the following relevant information: ...The patient was residing in another nursing home owned by the same corporation. The patient was released from prison on 6/1/2007 and was convicted of Lewd and Lascivious indecent abuse on a child under 16 on 5/21/1990 ...According to public record, this patient has a history of Lewd, Lascivious Child U/16; F.S. 800.04 (Principal) and is a registered sexual offender. Due to these circumstances, special consideration should be given with regards to local ordinances, placement in a facility that does not accept minor patients (under the age of 18), or a facility in which he will not be in close proximity to visiting children. It should be noted that residents in nursing care facilities are typically vulnerable to the actions of others and should there be a significant change in his mental status or orientation, it is recommended that an additional resident review be conducted ... Review of the most recent MDS dated [DATE] revealed Resident #1 had a BIMS of 13 out of a possible 15. The resident had trouble with sleep nearly every day according to his mood interview. He was independent with locomotion on and off the unit with setup help only. He required extensive assistance/one person physical assistance with bed mobility, transfers, dressing, toileting and bathing. Review of nurses' notes for the duration of the resident's stay from 10/18/2013 - 4/7/2014 revealed the following relevant entries: 4/6/2014 8:20 p.m. Resident was watched (by nurses' station one) stroking another female resident's thigh while that female resident was saying to him: Stop it! Stop it! Immediately residents were separated and spoke to him about the issue. He stated he was trying to move her chair. We told him that when another resident needs help he has to call us, not touch female residents. And also he admitted in front of the nurse that he was warned at 3:00 p.m. by me and female resident that he was stroking now to avoid her and not ever to talk to her. Director of Nursing (DON), Assistant Director of Nursing (ADON) informed. DON asked to call the police also. The police came to gather information about the issue. Signed by Employee "T." 4/7/2014 Resident in bed resting post incident no signs and symptoms of distress. Will continue to monitor. 4/7/2014 2:00 p.m. Resident remains 1:1 with staff member. Will continue to monitor. 4/7/2014 8:38 p.m. Transported via Sheriff's office to hospital under a Baker Act 52 per psychiatric Advanced Registered Nurse Practitioner (ARNP). Doctor and ARNP notified. Review of the Certificate of Professional Initiating involuntary Examination at 7:20 p.m. on 4/7/2014 completed by the psychiatric ARNP revealed a [DIAGNOSES REDACTED]. This document noted the Resident was unable to determine for himself whether examination was necessary AND There was substantial likelihood that without care or treatment the person will cause serious bodily harm to others in the near future as evidenced by recent behaviors. Supporting evidence: Patient found with his hand up a female patients gown between knee and peri-area yesterday eve. This was discovered when nurse went to find out why a female patient yelled "help ...stop it ... let go of me." Patient denies behavior and is currently on 1:1. Review of the entire clinical record to include physician progress notes [REDACTED]. This resident's criminal history/sexual offense was not addressed anywhere in the clinical record and no care plan was developed to address the resident's behavior problems or potential to abuse others. 8. Review of the clinical record for Resident #2 revealed a face sheet indicating this female resident was [AGE] years old, and was admitted to the facility on [DATE]. The resident had a level one Pre-Admission Screen and Record Review (PASRR) dated 2/18/10. Review of this screening revealed the resident had a primary [DIAGNOSES REDACTED]. The resident had a determination of incapacity signed by a physician on 10/29/2009 which documented that this resident lacked the capacity to give informed consent to make medical decisions and did not have reasonable medical probability of recovering mental and physical capacity to directly exercise her rights. Review of Resident #2's most recent minimum data set assessment ((MDS) dated [DATE] revealed a score of 9 out of 15 on the brief interview for mental status (BIMS). The resident displayed the following signs of [MEDICAL CONDITION]: Inattention (behavior present fluctuates; comes and goes; changes in severity) Disorganized thinking (behavior continuously present, does not fluctuate) The resident's mood interview revealed she felt down, depressed, and was having trouble sleeping (2-6 days; several days). The resident required limited assistance/one person physical assistance with transfers and dressing, extensive assistance/one person physical assistance with personal hygiene, bathing, and toilet use, and was independent with no physical help needed for locomotion on and off the unit. Review of nurses' notes revealed the following relevant entries: 4/6/2014 8:20 p.m. A male resident was found by 3-11 nurse (station 1) stroking resident's thigh. And also the resident was saying to him: Stop it! Stop it! Immediately, the staff separated both residents, re-direct and spoke firmly with the male resident on the issue. (The male resident was warned by me, the nurse at 3:00 p.m. to avoid female resident. (He admitted ). Resident was checked thoroughly. Apparently has no injuries at all. Resident is intellectually disabled. DON, ADON were called. DON instructed to call the police. Resident's proxy was called (sister was informed, Medical Doctor (MD) was called). Message left. Male resident is on 1:1 out of bed. Being checked every 15 minutes. This note was signed by LPN, Employee "T." 4/8/2014 ....easily distracted. Does not recall incident of 4/6/14 and no apparent injury. Sister proxy aware of situation. Social services (SS) will contact sister today who request exploring relocating resident to be closer to sister. No additional nurses' notes or social service notes addressing Resident #2's physical and emotional well-being post incident were found. In addition, review of all nurse's notes and social service notes from November 2013 to April 22, 2014 revealed no information related to the allegation made by Resident #20 in which Resident #2 was said to have lifted her shirt and been touched by Resident #1. Continued review of the record revealed Resident #2 was seen by the psychiatric Advanced Registered Nurse Practitioner (ARNP) on 4/15/2014. This assessment noted the resident to have [DIAGNOSES REDACTED]. The resident was noted to be agitated, verbal, hi-pitched, mood "good" she says. Frequently asking for items and interrupting nurse all shift. Plan: add [MEDICATION NAME] 50 mg twice a day for agitation and increase [MEDICATION NAME] to 6 caps 125 mg 9:00 a.m. and 9:00 p.m. This assessment made no mention of the sexual abuse which had occurred on 4/6/2014. Observation of Resident #2 revealed the following information: 4/21/2014 at 6:00 a.m.: Resident #2 was a well-nourished female resident observed sitting upright on the side of the bed in a four bed ward. The resident was clean, well groomed and did not appear to be in any distress. 4/21/2014 at 12:20 p.m.: Resident #2 was seated in the main dining room with three tablemates. Resident was observed to socialize with her tablemates but was difficult to understand. An interview was conducted with Resident #2 on 4/21/2014 at 1:13 p.m. She revealed that she did not think anybody in the facility had ever touched her inappropriately or sexually. She did not recall knowing Resident #1. She did not recall anyone ever putting their hand on her leg and stated she did not think this had occurred. She stated she felt safe in the facility and liked living there. A telephone interview was attempted with Resident #2's sister on 4/21/14 at 11:31 and 4/22/2014 at 8:31 a.m. but she was not available to talk and stated she would call this surveyor back. As of 4/

Based on resident record review, policy and procedure review, and staff and resident interviews, it was determined that the facility's Quality Assessment and Assurance Committee failed to identify errors and omissions in Administration's implementation of facility policies for abuse. The facility failed to follow their own policy when they admitted a sexual offender into the facility, Resident #1. The facility Administrator failed to inform the Quality Assurance Committee that a known sexual offender was admitted and was residing in the facility thus resulting in no action plan being developed to address this resident's criminal history and provide protection to elderly and vulnerable adults. The facility's failure to identify a known sexual offender and put a plan in place to supervise this resident and afford protection to all facility residents resulted in a sexual abuse on one of 20 sampled residents for abuse, Resident #2 an intellectually disabled and vulnerable adult. The facility's Administration failed to implement policies and procedures related to quality assurance, prevention, identification, protection, investigation and resident to resident altercations despite multiple staff members having knowledge of or witnessed Resident #1 touching females. These failures resulted in findings of immediate jeopardy which was removed on April 23, 2014 at 11:00 p.m. and the severity and scope was reduced to a D. Findings include: 1. Review of the facility's Abuse Manual Revised June 2012 revealed the following relevant information: Analyzing Occurrences of Abuse, Neglect, Mistreatment and Theft/Misappropriation of Resident Property Statement: All occurrences of abuse, neglect, mistreatment, injuries of unknown source and theft or misappropriation of resident property will be analyzed by the Quality Assessment and Assurance Committee to determine if system changes need to be made. Interpretation and Implementation: 1. The Quality Assessment and Assurance Committee will review all reports of abuse, neglect, mistreatment, injuries of unknown source and theft of misappropriation of resident property during their regularly scheduled meetings. 2. Reviews of each occurrence will be made to determine if policies, procedures or facility systems need to be modified to prevent further incidents of abuse or theft. 3. The Quality Assessment and Assurance Committee will provide the Administrator with a written report of its findings and recommendations. The Administrator will review such recommendations and act accordingly. 4. Notification of any changes to our abuse prevention program policies and procedures will be provided to residents and facility staff as established by facility policy and training programs. Abuse Policy Policy Statement: The purpose of this policy is to ensure resident freedom from abuse, neglect, exploitation, and misappropriation of property (ANEM). The Administrator is responsible to assure the process. ANEM as defined below will not be tolerated in the facility. This includes residents, staff, agents of the facility, family members, legal guardians, friends, or interested parties. Policy Interpretation and Implementation: Definitions: 1. "Abuse" is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. 4. "Sexual abuse" is defined as, but is not limited to, sexual harassment, sexual coercion, or sexual abuse. 6. "Mental abuse" is defined as, but is not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. Procedure: 3. Prevention Issues a. Practice: The facility will provide proper support, education, and supervision designed to reduce the likelihood of abusive behaviors. 4. Identification: a. Practice: The facility will consider any event that is reported to any staff by patient/resident, family, or any other person involving any persons (e.g., resident to resident, employee/volunteer to resident, etc.) as possible abuse if it meets any of the following criteria: Any complaint of sexual harassment, coercion, or sexual abuse. 5. Protection: a. Practice: Patients/residents will be protected from harm during any investigation. b. Steps: Any individual found in danger of injury (physical or emotional) will be: 1. Removed from the source of the suspected abusive behavior. 2. Provided with medical and emotional support immediately following any individual suffering or suspected abuse. 7. Quality Assurance Committee a. Practice: The Quality Assurance Committee will analyze, investigate, and track all allegations of the above and assure the facility policies, procedures, and practices are maintained. b. Steps: 1. The Quality Assessment and Quality Improvement (QA/QI) Committee will maintain an accurate summary of investigation. 2. The QA/QI Committee will track, trend, and analyze all occurrences in a concurrent fashion for the purpose of proactive response. 3. The Administrator is responsible to assure that the entire process is in place and that all employees are educated no later than upon new hire orientation and again annually. 4. The above is in addition to the monthly Risk Management/QA/QI Committee meeting as required by Florida Statute for Florida facilities. Abuse Investigations: Statement: All reports of resident abuse, neglect, exploitation, misappropriation of property and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Interpretation and Implementation: 2. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. 3. The individual conducting the investigation will, as a minimum: b. Review the resident's medical record to determine events leading up to the incident; j. Review all events leading up to the alleged incident. Preventing Resident Abuse Statement: Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse. Interpretation and implementation: Zero Tolerance of Abuse: 1. The facility's goal is to achieve and maintain an abuse-free environment. Contents of Abuse Prevention/Intervention Program: 2. Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: a. Training all staff and practitioners how to resolve conflicts appropriately; e. Involving the resident/family group council in developing, monitoring, and evaluating the facility's abuse prevention program; g. Training staff to understand and manage a resident's verbal or physical aggression; j. Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect; k. Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues; l. Conducting background investigations to avoid hiring persons or admitting new residents who have been found guilty (by a court of law) of abusing, neglecting or mistreating individuals or those who have had a finding of such action entered into the state nurse aide registry or state sex offender registry; m. Involving Attending Physicians and the Medical Director when findings of abuse have been determined. n. Involving qualified psychiatrists and other mental health professionals to help the staff manage difficult or aggressive residents; o. Identifying areas within the facility that may make abuse and/or neglect more likely to occur (e.g. secluded areas) and monitoring these areas regularly; p. Striving to maintain adequate staffing on all shifts to ensure that the needs of each resident are met; Reporting Abuse to Facility Management: Responsibility of Person(s) Observing Incidents of Abuse: 7. Staff members and persons affiliated with this facility shall not knowingly: Screen reports or withhold information to reporting agencies. Resident-to-Resident Altercations Interpretation and Implementation: Monitoring Residents for Aggressive/Inappropriate Behavior: 1. Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or to the staff. Occurrences of such incidents shall be promptly reported to the Nurse Supervisor, Director of Nursing (DON), and to the Administrator. 2. If two residents are involved in an altercation, staff will: c. Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation; e. Review the events with the Nursing Supervisor and DON including interventions to try to prevent additional incidents; f. Consult with the Attending Physician to identify treatable conditions such as acute [MEDICAL CONDITION] that may have caused or contributed to the problem; g. Make any necessary changes in the care plan approaches to any or all of the involved individuals; h. Document in the resident's clinical record all interventions and their effectiveness; i. Consult psychiatric services as needed for assistance in assessing the resident, identifying causes and developing a care plan for intervention and management as necessary or as may be recommended by the Attending Physician or Interdisciplinary Care Planning Team; j. Complete a Report of Incident/Accident form and document the incident, findings and any corrective measures taken in the resident's medical/clinical record; k. If, after carefully evaluation the situation, it is determined that care cannot be readily given within the facility, transfer the resident; Staff Responsible for Coordinating/Implementing Abuse Prevention Program Policies and Procedures Statement: The Administrator is responsible for the overall coordination and implementation of our facility's abuse prevention program policies and procedures. 2. An interview was conducted with the Administrator and Director of Nursing (DON) on 4/21/2014 at 10:56 p.m. The Administrator revealed the facility has an outside marketing person who typically visits with a potential resident prior to admission and gathers all applicable information. After that, a nurse to nurse report is done, and then the admissions coordinator will run financials and a background check to see if the resident is on the Florida sexual offender website. The Administrator stated "typically" if a resident is on that website we don't "typically" accept them. We knew Resident #1 was on there, but he had an issue which was not sexually related at a sister facility, and he needed placement. We were concerned that he was on the sexual offender listing, but from the reports we got from his previous facility he had not shown any inappropriate sexual behavior and at the first sign of it here we removed him from this facility. The Administrator stated he had been with the company for 6 years and stated he knew the former council had put in to place as a pseudo policy and procedure to not accept sexual offenders for the last 3 years. He stated the policy is "typically" we do not accept them. We look at the people individually and on a case by case basis, but "typically" we do not accept sexual offenders. The Administrator stated that the facility had no sexual offenders residing in the facility at this time and that he was aware that Resident #1 was a sexual offender from the time he was originally admitted in October of 2013. The Administrator stated Resident #1 was treated as any other resident was. The facility did not provide any special one on one or "anything like that." Resident #1 was monitored through observation to ensure nothing was happening. The Administrator said "this was the first instance that we heard of it and we took what action we thought was appropriate." The Administrator stated this first instance involved Employee "N" hearing a commotion in the dining room. Employee "N" saw Resident #1 with his hand up Resident #2 ' s skirt. The Administrator stated the staff was "somewhat aware" that Resident #1 was a sexual offender. He stated some of the nurses were aware but the Administrator did not have a sit down with his staff to inform them that Resident #1 was a registered sexual offender. The Administrator stated "any time a resident has an issue [MEDICAL CONDITION] something we don't want to infringe on the resident's dignity. We don't want them to be treated any different than anyone else as far as ADL care. Typically, we don't accept sexual offenders so it is not an issue." The Administrator stated residents and family members were not notified that a registered sexual offender was residing in the facility. "We didn't send out a notice about it. I am not aware of having a policy and procedure that says I need to send out a public notice to residents and family members informing them of this." The Administrator did verify that the abuse hotline, the police, and the State Survey and Certification agency had been notified using the federal immediate/5 day report of the alleged incident on 4/6/2014. The Administrator confirmed that the federal reports did not make any mention that Resident #1 was a registered sexual offender. The Administrator had no explanation for why this information was missing from the Federal Report. The Administrator stated Resident #1 had a challenge at one of our sister facilities, and we were trying to help them out of that situation and again "we don't typically accept these residents." The DON stated she had spoken to a couple of staff members about Resident #1 being a sexual offender after the resident's sister came to visit after a recent hospitalization for aggressive behavior. According to the DON, the resident's sister told staff that he was a sexual predator, but he wasn't on the list because he had been grandfathered in. The DON said the staff was not concerned about it, and it was more a topic for the rumor mill. Subsequent interview with the DON on 4/22/14 at 10:17 a.m. revealed she wanted to let it be known that she was not aware that Resident #1 was a sexual offender during his stay at the facility. The DON stated she started working at the facility in January of 2014 and the first time she found out about this was when another State agency came in and showed her the Sexual Offender flyer on their computer. This was after Resident #1 had been discharged from the facility on 4/7/2014. The nurses had reported to her in the past that he would stroke the hand of female residents and give the female residents attention. The staff would divert him. The DON was not overly concerned about this behavior because she did not know he was a sexual offender. Her awareness was more heightened to watch him around female residents based on the nurses' reports, but she had no reason with the knowledge she had at the time to believe the behavior would escalate. The DON stated had she known, she would have been more aggressive in monitoring, more aggressive in trying to find alternative placement, and she would have made the staff aware so they could monitor him. Further investigation and interview with the administrator, DON, and ADON on 4/22/2014 at 12:15 p.m. revealed the last QA meeting was held 3/26/2014. Incidents were discussed and actions were put in place to prevent similar occurrences. Resident #1's sexual offender status was not discussed in the last QA meeting. The next QA meeting was scheduled for 4/23/2014 and items on the agenda for discussion would be infection control, elopement, weights, falls, orders (signed not signed), residents discharged from facility with reasons, and Baker Acts. An action plan would be developed based on the meeting. Each department provides input and education as to how things could have been done better/differently and if the interventions were effective or not. We use the PDSA model (Plan-Do-Study-Act) and incorporate the QAPI (Quality Assurance and Performance Improvement) process. Resident #1's incident will be discussed at the next meeting on 4/23/2014. We also have weekly risk and daily meetings where Resident #1's sexual offender status has been discussed since the event on 4/6/2014. We attack it right then and put new plans in effect. The weekly risk meetings go deeper related to education and policy. The policy and procedure indicates we cannot have a sexual offender in the building at all, and we do not have any currently. Continued investigation and interview with the DON on 4/22/14 at 6:25 p.m. revealed she recalled being told about an allegation made by Resident #20 related to Resident #2 lifting her shirt and Resident #1 touching her. The DON verified that Employee "N" had reported this to her in March 2014 before daylight savings time, and she thinks it occurred on a Sunday evening. The DON stated I believe that the staff said it was still light out, but it was after dinner and before smoke break at 7:00 p.m. As a result of the allegation, the DON stated she and the Administrator reviewed the surveillance tapes of the outside smoking area extensively for several hours before the time of the allegation through several hours after that. The DON stated we never did see that happen but we did see that a couple of days earlier Resident #2 had lifted her shirt and Resident #1 motioned her away with his hand and shook his head no. There was no audio on the tape so the exact exchange was unknown but the body language was a no. The DON stated the interdisciplinary team met about this and came up with an approach to ensure Resident #2 wore a tight fitting undergarment or a bra as she did not have anything on underneath her shirt at the time of the event. The DON stated the activities director went out and purchased a bra or bras as a result of this. Review of Resident #2's record by the DON revealed no documentation could be found related to the resident's behavior of lifting her shirt in a public area and no care plan was located in her clinical record which had an approach related to the wearing of undergarments. The Administrator joined this interview at 6:40 p.m. on 4/22/2014 and stated there was nothing substantiated in this allegation made by Resident #20 indicating that Resident #2 had lifted her shift and Resident #1 had touched her. He stated Resident #2 has a behavior of lifting her shirt and that she has done this to him in the past, yet the behavior was not directed at any particular person. The Administrator said the event was reported as having had occurred in the memory garden (smoking area). "We viewed the tapes and there was no event." The Administrator stated that based on the tapes, we did not report the allegation as we looked at all of our data and nothing showed us abuse had occurred. The Administrator stated no occurrence/incident report was done for this and no documentation of the investigation was maintained. Occurrence reports and abuse reports are discussed during the monthly Quality Assurance (QA) meetings. We discuss where incidents occur, what the dynamic was, what the time of day was, and the physical environment. The incidents are tracked and trended and a root cause analysis is completed to reduce further occurrences. Abuse reports are handled in the same manner. Telephone interview with the Administrator on 4/23/2014 at 1:42 p.m. revealed they do not normally go over new admissions during the QA meetings unless something was to come up. The Administrator could not recall anything about admissions being discussed during the October or November 2013 QA meeting (Resident #1 was a registered sexual offender admitted [DATE]). Review of the QA/Risk Management information provided by the facility for meetings held on 10/30/2013 and 11/27/2013 revealed no information to indicate the topic of an admission of a sexual offender, supervision, or abuse had been discussed. 3. An interview with the Medical Director on 4/23/2014 at 11:10 a.m. revealed he has been the Medical Director at the facility for about 6 - 7 months, and he was never informed that a sexual offender was residing in the facility until 4/7/2014, the day that Resident #1 was baker acted. The Medical Director stated this nursing home was not the right setting for a sexual offender. Review of the QA/Risk Management sign-in sheets for 10/30/2013 and 11/27/2013 revealed this Medical Director was present during both of these meetings. Review of the QA information provided by the facility about the topics of discussion during these two QA meetings revealed no information related to the admission of a sexual offender on 10/18/2013. 4. Review of the Florida Department of Law Enforcement website (<http://offender.fdle.state.fl.us/>) on 4/21/2014 revealed Resident #1 was listed as a known sexual offender with an adjudication of guilty/convicted on 4/5/1991 of Lewd, Lascivious Act on a Child Under 16 (F.S. 800.04), gender unknown. The resident ' s address listed on the website was that of this nursing facility. 5. On 4/21/14 at 12:30 p.m. an interview was conducted with Employee "N", a licensed practical nurse (LPN), who has worked at the facility since July of 2013 with a full time assignment normally on Station One for the 3:00 p.m. - 11:00 p.m. shift. Employee "N" stated she was familiar with Resident #1 and described Resident #1 as friendly and nice. She stated he would self-propel in his wheelchair throughout the building talking to everyone. She stated Resident #1 was known to have a little bit of an aggression issue and could be mean at times, over react, and escalate. Resident #1 was not on her assignment, but she had worked with him in the past and stated she did his admission so she knew a little bit more about him. Employee "N" stated she did not see anything upon admission that said Resident #1 was a sexual offender, but she was told this by an unknown employee a few days after his admission. Employee "N" stated she witnessed Resident #1 a few times in the hall with one of his hands on Resident #23's legs. She would ask him what he was doing and he would just say he was trying to move her. Employee "N" would tell him it's inappropriate to touch other residents and to please move along. She would tell him if he needs help moving someone to call the staff and we would move the resident for him. Employee "N" stated she would report these incidents to the nurse assigned to Resident #1 but was unsure what was done with this information. In addition to her observing Resident #1's hand on the legs of Resident #23, Employee "N" reported that about a month or two ago Resident #20 reported to her that Resident #1 had promised Resident #2 a cigarette if she would lift up her shirt. Resident #20 reported that Resident #2 had lifted her shirt and Resident #1 had touched her. Employee "N" stated that Resident #20 could not speak but she wrote this to her on a piece of paper. In response to this allegation, Employee "N" stated she immediately headed outside to the smoking area where the alleged incident was said to have occurred. As Employee "N" headed to this area, Resident #2 was already observed back inside the facility. Employee "N" stated she reported this to the Director of Nursing (DON) and in turn, the Administrator had viewed the surveillance tapes for the outside area. Employee "N" did not know if anything was found on the tapes and she thought an incident report had been completed but was unsure. Continued interview with Employee "N" revealed she had a recent incident on 04/06/2014 involving Resident #1 and Resident #2. In this instance, Employee "N" stated she was sitting at her nurses' station when she overheard Resident #2, a female resident, saying "Stop, don't touch me, leave me alone." Employee "N" said Resident #2 was not usually that vocal so she went to see what was going on. When she entered the area, she saw that Resident #1's back was to her. She walked up to see what he was doing, and she witnessed Resident #1's arm under the dressing gown of Resident #2 about "mid forearm deep." Employee "N" went in front of Resident #2 and said "What are you doing? Leave that woman alone." Resident #1 told her he was just trying to move Resident #2. Employee "N" stated she immediately moved Resident #2 away from Resident #1 and reported this to the LPN, Employee "T" assigned to both Resident #1 and Resident #2. Employee "N" and "T" then placed Resident #1 on 1:1 supervision and the DON was called. Employee "N" spoke to the DON who told her to call the abuse hotline and the police which she did. The report was accepted by the hotline and the police came out later that night to see Resident #1. When the police arrived, Resident #1 was in bed with staff outside of his door as the resident was unable to get out of bed on his own. The police spoke to Resident #1 and took a statement from Employee "N." The police said they would be working with the State to investigate this further and they wanted to know if Resident #2 ' s guardian wanted to press charges. Employee "N" thinks that the family of Resident #2 did want to press charges; however, she thought there was some questions about Resident #2's mental status and was unsure if they were able to press charges. Employee "N" stated "Unfortunately, we are not a big staff on 3:00 p.m. - 11:00 p.m. so it is hard to keep track of everyone. We try to continuously monitor the outside but it was late and the aides were busy putting residents to bed." Both Resident #1 and Resident #2 are all over the facility and there were no special parameters for monitoring Resident #1. However, he was placed on 1:1 after the incident and by the time she returned to work the following Wednesday, he had been discharged . Employee "N" stated she was also familiar with Resident #2 and described her as fun with a very hyper personality. She stated she loved cigarettes, soda, and Doritos. Resident #2 was not on her regular assignment but she knew the resident because she self-propelled throughout the building in her wheelchair (w/c) and she talked a lot. 6. An interview with Employee "T" revealed he was an LPN, had worked at the facility for about four and a half months and currently worked on the 3:00 p.m. - 11:00 p.m. He stated he was familiar with Resident #2 as he took care of her. He described Resident #2 as confused, uses a w/c but can also walk but not steady. He stated staff constantly redirect her and tell her to sit back in the chair. Occasionally, Resident #2 gets agitated because she always wants a soda or Doritos. She is compliant with medications and is not combative, but can be disruptive at times. Employee "T" stated he was also familiar with Resident #1. He described Resident #1 as compliant with medications, self-propelling in his w/c and sometimes needing to be re-directed. Employee "T" stated he had never witnessed Resident #1 touching other residents or staff inappropriately, but he was told about an incident by Employee "N." When Employee "T" was asked by the surveyor if he knew that Resident #1 was a sexual offender he stated "No, I was not aware of this. Is that true? I was not aware of that. Nobody told me that." Employee "T" stated Resident #1 was supervised "just like any other resident." Employee T stated he did rounds every one to two hours on his residents and the aides do the same. There was no special monitoring for Resident #1 prior to the incident on 4/6/2014, but after that he immediately checked Resident #2 to see if she had any issues and spoke with her. She said something but Employee "T" could not understand what she said. Resident #2 had no physical markings and she seemed her usual self. He also checked Resident #1 with Employee "N." Employee "T" stated "I was not happy with him. I said ... what did you do?" Resident #1 said he did nothing; he was just touching her w/c. Resident #1 denied it. Resident #1 had no physical injuries. Employee "T" stated he called Resident #2's sister and reported the incident to her. He stated the sister said she was going to press charges. Employee "T" stated the police came in that night and spoke to Resident #1 and immediately following the incident he was placed on 1:1 supervision. Follow up interview with Employee "T" on 4/22/2014 at 3:24 p.m. revealed that he called the psychiatric nurse on either 4/6/2014 or 4/7/2014 to see Resident #1; however, he did not call or get any orders for psychological or psychiatric services for Resident #2. 7. Review of the clinical record for Resident #1 revealed this [AGE] year old male resident was admitted [DATE] discharged to the hospital on [DATE]; readmitted on [DATE] and discharged on [DATE] with return not anticipated. Review of the face sheet revealed this resident was his own responsible party and had relevant [DIAGNOSES REDACTED]. Review of the Florida Pre-Admission Screening and Resident Review (PASRR) Mental Illness Level II Determination Summary Report dated 9/2/2011 revealed the following relevant information: ...The patient was residing in another nursing home owned by the same corporation. The patient was released from prison on 6/1/2007 and was convicted of Lewd and Lascivious indecent abuse on a child under 16 on 5/21/1990 ...According to public record, this patient has a history of Lewd, Lascivious Child U/16; F.S. 800.04 (Principal) and is a registered sexual offender. Due to these circumstances, special consideration should be given with regards to local ordinances, placement in a facility that does not accept minor patients (under the age of 18), or a facility in which he will not be in close proximity to visiting children. It should be noted that residents in nursing care facilities are typically vulnerable to the actions of others and should there be a significant change in his mental status or orientation, it is recommended that an additional resident review be conducted ... Review of the most recent Minimum Data Set assessment ((MDS) dated [DATE] revealed Resident #1 had a score of 13 out of a possible 15 on the brief interview for mental status (BIMS). The resident had trouble with sleep nearly every day according to his mood interview. He was independent with locomotion on and off the unit with setup help only. He required extensive assistance/one person physical assistance with bed mobility, transfers, dressing, toileting and bathing. Review of nurses' notes for the duration of the resident's stay from 10/18/2013 - 4/7/2014 revealed the following relevant entries: 4/6/2014 8:20 p.m. Resident was watched (by nurses' station one) stroking another female resident's thigh while that female resident was saying to him: Stop it! Stop it! Immediately residents were separated and spoke to him about the issue. He stated he was trying to move her chair. We told him that when another resident needs help he has to call us, not touch female residents. And also he admitted in front of the nurse that he was warned at 3:00 p.m. by me and female resident that he was stroking now to avoid her and not ever to talk to her. Director of Nursing (DON), Assistant Director of Nursing (ADON) informed. DON asked to call the police also. The police came to gather information about the issue. Signed by Employee "T". 4/7/2014 Resident in bed resting post incident no signs and symptoms of distress. Will continue to monitor. 4/7/2014 2:00 p.m. Resident remains 1:1 with staff member. Will continue to monitor. 4/7/2014 8:38 p.m. Transported via Sheriff 's office to hospital under a Baker Act 52 per psychiatric Advanced Registered Nurse Practitioner (ARNP). Doctor and ARNP notified. Review of the Certificate of Professional Initiating involuntary Examination at 7:20 p.m. on 4/7/2014 completed by the psychiatric ARNP revealed a [DIAGNOSES REDACTED]. This document noted the Resident was unable to determine for himself whether examination was necessary AND There was substantial likelihood that without care or treatment the person will cause serious bodily harm to others in the near future as evidenced by recent behaviors. Supporting evidence: Patient found with his hand up a female patients gown between knee and peri-area yest