Every finding on record at Wesley Manor

Based on interview, record review, and facility policy review, the facility failed to ensure resident council grievances were acted upon for two (Resident (R) 51 and R57) of six residents who attended resident council meetings. Additionally, six of six residents chosen by the facility to participate in a resident group interview did not know how to file a grievance or who the facility designated as the staff person responsible for assisting and responding to grievances that resulted from resident council meetings.The findings included: A facility policy titled, Grievance Process, revised 05/2021, revealed the Policy, stated it was, To ensure each resident can address dissatisfaction with policies, procedures, staff, and/or other residents and seek resolution without reprisal. Review of Resident Council Meeting minutes, dated 07/15/2025, revealed a resident had lost a pair of pajama pants and R51's family member reported the resident had missing socks. Review of a letter from the facility dated 07/21/2025, signed by the Director of Admissions and Social Services (DSS), indicated no grievances had been filed in the facility within the previous six months. During a resident council interview on 07/22/2025 at 9:31 AM, six of six residents who attended the meeting stated they did not know how to file a grievance and did not know the staff person who was responsible for responding to their grievances. In addition, two of six residents, R51 and R57, stated they had reported missing/lost clothing items to staff. R51 stated their family member had also reported that they were missing 10 pairs of socks. The residents revealed that no one followed up with them about the missing/lost items, and the items were not recovered. Review of R51's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/06/2025, revealed R51 had a Brief Interview Mental Status (BIMS) score of 14/15, indicating the resident was cognitively intact. R57 was also cognitively intact, based on a BIMS score of 15/15, as recorded on the annual MDS with an ARD of 06/23/2025. On 07/23/2025 at 10:06 AM, the DSS stated she was the Grievance Official for the facility. The DSS stated the Social Services Aide (SSA) attended resident council meetings and was to inform the DSS of any concerns or complaints. In addition, the Director of Activities sent the resident council meeting minutes to her for review. The DSS stated a grievance was a complaint, adding that the facility had not received many grievances. According to the DSS, depending on the complaint, it may rise to the level of a grievance. The DSS stated that a resident needed to specify that they wanted to file a grievance in order for a grievance to be filed. The DSS stated she had not received grievances for missing items and was not aware of recent resident council complaints of missing items. On 07/24/2025 at 5:11 PM, the Director of Nursing (DON) stated when a resident made a complaint that could not easily be resolved, a grievance form should be completed and an investigation into the complaint should be initiated. The DON stated that once the investigation was completed, the resolution should be documented on the grievance form, and the resident should be notified of the outcome. The DON stated the facility had not received a grievance in six months or more. On 07/24/2025 at 5:45 PM, the Administrator stated when a concern came from the resident council, he expected a staff member to notify social services, an investigation to begin, the resolution to be documented, and the resident be notified of the outcome. The Administrator also stated that residents should know who the grievance official was and how to file a grievance at the facility.

Based on observation, interview, record review, and facility policy review, the facility failed to follow physician's orders for one (Resident (R) 3) of 16 sampled residents. Staff failed to follow R3's physician's orders for both the treatment of a skin tear to the resident's right arm, as well as a surgical wound to the left heel.The findings included:Review of a facility policy titled, Skin Breakdown/Pressure Ulcer, revised 01/2025, revealed, 2. All interventions are reviewed with the resident's physician for approval. The policy revealed, 4. If breakdown has been identified: i. The Team Manager to obtain orders from the resident's physician and iv. The Team Manager will contact the resident's physician for the appropriate treatment and discuss additional intervention to promote wound healing and/or decrease the risk of further breakdown.1a. Review of the admission Record revealed the facility admitted R3 on 11/06/2024. According to the admission Record, the resident had a medical history that included diagnoses of dementia, disease of the skin and subcutaneous tissue, and type II diabetes mellitus with foot ulcer. Per a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/05/2025, R3 had a Brief Interview for Mental Status (BIMS) score of 10/15, which indicated the resident had moderate cognitive impairment.Review of R3's Care Plan, revealed it included a problem statement, revised 02/17/2025, that indicated the resident had potential for pressure ulcer development or skin breakdown. Per the care plan, the resident had fragile skin.Review of R3's Order Summary Report, dated 07/23/2025, included an order started on 06/26/2025, to cleanse a skin tear to the right antecubital (A/C) area (the area in front of the elbow) with normal saline, pat the area dry, apply bacitracin, and cover the area with a Tegaderm dressing (a thin, transparent, adhesive dressing). The order stated staff were required to check the area once daily for infection. The order also instructed staff to allow the dressing to fall off on its own, and that staff may replace the dressing as needed every day shift, until healed.During an observation on 07/21/2025 at 9:43 AM, R3 had scattered discoloration to the right upper extremity, and blood was observed on a dressing to the elbow area. Interview with R3 at this time revealed the areas were related to a bandage.During an interview on 07/23/2025 at 1:45 PM, Certified Nurse Assistant (CNA) 5 stated nurses had attempted multiple ways to remove a bandage to R3's right, upper extremity, causing the area to bleed.During an interview on 07/23/2025 at 2:00 PM, Registered Nurse (RN) 6 stated that on 07/09/2025, she attempted to remove R3's dressing; however, the bandage was tightly stuck to the skin, and she was unable to remove the dressing. She noted that staff attempted multiple ways to remove the bandage, including soaking the bandage with normal saline and baby soap. RN6 stated when the dressing was removed, the resident's arm began to bleed.During a follow-up interview on 07/24/2025 at 2:02 PM, RN6 reviewed R3's treatment orders and stated she had not seen the order for the dressing to be left on until it fell off, and she had been changing the dressing daily. RN6 stated that she had applied a dressing on 07/07/2025 during the day shift; however, when she returned to work on 07/09/2025, she noticed the dressing to the resident's antecubital area of the right upper extremity was now a bordered gauze type dressing (an absorbent gauze pad with an adhesive border, not the physician-ordered Tegaderm). RN6 stated that when she attempted to remove the dressing, it was very sticky and would not come off the arm. RN6 indicated she elicited RN7's assistance, who also attempted to remove the bandage without success. RN6 stated she then notified the charge nurse, RN8, who was able to remove the dressing. She stated that after the dressing was removed, the order was changed to a less adherent dressing.During an interview on 07/24/2025 at 8:24 PM, RN8 stated that, when she went to assist with the resident's wound care, she had no idea that the wrong dressing was on the site. RN8 stated she notified Nurse Practitioner (NP) 15, who was working in place of NP14, regarding the issue with R3's bandage. During an interview on 07/24/2025 at 7:48 PM, NP14 stated when she returned to work on 07/11/2025, she was notified that R3's dressing had to be soaked off. Further interview with NP14 revealed she expected staff to follow the provider's orders.During an interview on 07/24/2025 at 8:19 PM, the Director of Nursing (DON) stated she expected the staff to follow physician orders, ensure the correct dressing was in place, and notify the provider if an alternative bandage was needed.1b. R3's Care Plan also included a problem statement, revised 12/05/2024, that indicated the resident had skin impairment of the left heel related to a surgical wound. Interventions directed staff to follow facility protocols for treatment of injury (initiated 11/28/2024). R3's Order Summary Report, dated 07/23/2025, included an active order started on 07/02/2025, to cleanse the left heel with normal saline, pat the area dry, apply skin prep, cover the area with a foam dressing, and wrap with Kerlix.During an observation on 07/23/2025 at 5:22 PM, RN1 cleaned the wound to R3's left heel with saline soaked gauze, patted the wound dry with a gauze sponge, applied skin prep, then wrapped the left foot with a gauze wrap. RN1 was not observed to apply a foam dressing to the left heel as ordered, before wrapping the area with rolled gauze.During an interview on 07/23/2025 at 5:47 PM, RN1 confirmed she had excluded the foam dressing, which should have been applied during the resident's treatment.During an interview on 07/24/2025 at 5:30 PM, the DON indicated the nurses were trained to read the orders prior to administering a medication or treatment.During an interview on 07/24/2025 at 6:00 PM, the facility President stated he referred to the DON regarding expectations for wound care and following physician's orders.

Based on observation, interview, record review, and Centers for Disease Control and Prevention (CDC) information, the facility failed to ensure staff donned gloves when administering eye drops to one (R63) of six residents reviewed for medication administration. In addition, the facility failed to ensure staff performed hand hygiene as indicated during wound care for one (Resident (R) 3) of five residents reviewed for infection control.The findings included:1. Review of a CDC publication titled, Clinical Safety: Hand Hygiene for Healthcare Workers, dated 02/27/2024, revealed gloves should be worn, When needed for Standard Precautions (when you anticipate that you will come in contact with blood or other infectious materials, mucous membranes, non-intact skin, potentially contaminated skin, or contaminated equipment).Review of an admission Record revealed the facility admitted R63 to the facility on [DATE]. According to the admission Record, the resident had a medical history that included diagnoses of unspecified glaucoma and dry eye syndrome.Review of R63's July 2025, Medication Administration Record [MAR] revealed a transcription of an order for Refresh Liquigel Ophthalmic Gel 1 percent (%), with instructions to give one drop in both eyes four times a day for dry eyes.During an observation on 07/22/2025 at 11:45 AM, Certified Medication Aide (CMA) 4 administered the Refresh Liquigel, one drop to each eye (which is covered by a mucous membrane). CMA4 was not observed to don gloves prior to the administration of the eye drops. CMA4 utilized her left, ungloved hand to hold the resident's eye open and administered the eye drops with the right hand.During an interview on 07/22/2025 at 12:28 PM, CMA4 stated that she had been taught to wear gloves when administering eye drops but forgot because she was nervous during the observation.During an interview on 07/24/2025 at 5:30 PM, the Director of Nursing (DON) indicated CMA4 should have donned gloves before administering eye drops to R63.During an interview on 07/24/2025 at 6:00 PM, the facility President stated he referred to the DON for expectations regarding personal protective equipment (PPE) use.2. A CDC publication titled, Clinical Safety: Hand Hygiene for Healthcare Workers, dated 02/27/2024, revealed, Cleaning your hands reduces: - The potential spread of deadly germs to patients - The spread of germs, including those resistant to antibiotics. The publication revealed recommendations for hand hygiene included: Immediately before touching a patient. - Before performing an aseptic task such as placing an indwelling device or handling invasive medical devices. - Before moving from work on a soiled body site to a clean body site on the same patient. - After touching a patient or a patient's surrounding. - After contact with body fluids, or contaminated surfaces. - Immediately after glove removal. The publication revealed that healthcare facilities, Require healthcare personnel to perform hand hygiene based on CDC recommendations.Review of an admission Record revealed the facility admitted R3 on 11/06/2024. According to the admission Record, the resident had a medical history that included diagnoses of dementia, disorder of the skin and subcutaneous tissue, and type II diabetes mellitus with foot ulcer.Review of R3's Care Plan, included a problem statement revised 02/17/2025, that indicated the resident had the potential for pressure ulcer development or skin breakdown related to history of ulcers, immobility, and incontinence. Interventions initiated 07/02/2025 directed staff to provide enhanced barrier precautions (EBP - which includes the use of a gown and gloves when performing high-contact activities such as wound care.).Review of R3's Order Summary Report, dated 07/23/2025, included an active order started on 07/02/2025, to cleanse the left heel area with normal saline, pat the area dry, apply skin prep, cover with a foam dressing, and wrap with Kerlix.During an observation on 07/23/2025 at 5:22 PM, Registered Nurse (RN) 1 entered R3's room, performed hand hygiene with soap and water, and donned a pair of gloves and a gown. RN1 removed supplies from a treatment cart and placed them on a disposable drape on the resident's overbed table. RN1 then doffed her gloves and donned a clean pair before removing a sheet and a pillow from the resident's bed. RN1 removed her gloves, donned clean gloves, retrieved another disposable drape, and placed it under the resident's foot. The observation revealed RN1 then removed the soiled dressing, doffed her gloves, and donned a pair of clean gloves. RN1 cleaned R3's wound with saline soaked gauze, used gauze to pat the wound bed dry, applied skin prep, wrapped the foot with a gauze wrap and secured it with tape. RN1 was not observed to perform hand hygiene between glove changes.During an interview on 07/23/2025 at 5:47 PM, RN1 confirmed that, while performing wound care for R3, she did not perform hand hygiene between glove changes. RN1 stated she failed to perform hand hygiene (which can be accomplished through either washing of the hands or using alcohol-based hand rub (ABHR)) because she was allergic to the ABHR.

Based on observations, interviews, record reviews, review of facility policy, and prescriber information, the facility failed to ensure one resident (Resident (R) 2) of eight sampled residents were free from unnecessary medications. Specifically, R2 was administered multiple psychotropic medications with sedating effects and became lethargic. Additionally, R2 was prescribed Depakote (a psychotropic medication for seizures) and Geodon (an antipsychotic medication) without adequate indications for use. R2 developed involuntary movements of her lips and tongue (Tardive Dyskinesia) as an adverse side effect from administration of the antipsychotic medications. Findings include: Review of facility-provided policy titled PHYSICAN ORDERS dated July 2020 revealed . Complete the reason for the order section to include diagnosis to support medication use. Review of R2's Admission Record located in the resident's electronic medical record (EMR) under the Profile tab revealed R2 was admitted to the facility initially on 09/30/19 and readmitted on [DATE] with diagnoses which included dementia Alzheimer's (09/10/19) and psychotic disorder with delusions (06/01/21). Review of R2's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/30/22 located in the resident's EMR under the MDS tab revealed Brief Interview Mental Status (BIMS) score could not be completed, however, the facility assessed R2 moderately cognitively impaired. 1. Review of the manufacturer's prescribing information for Geodon, an antipsychotic medication, revealed Common side effects of GEODON include the following and should also be discussed with your doctor if they occur: Adults: Feeling unusually tired or sleepy and GEODON is not approved for the treatment of patients with dementia-related psychosis. Elderly patients with a diagnosis of psychosis related to dementia treated with antipsychotics are at an increased risk of death. Review of the manufacturer's prescribing information for Depakote sprinkles, an antiepileptic medication, revealed Most common adverse reactions (reported >5%) are . anorexia, . dizziness, . somnolence, . Due to a decrease in unbound clearance of valproate and possibly a greater sensitivity to somnolence in the elderly, the starting dose should be reduced in these patients. with regular monitoring for fluid and nutritional intake, dehydration, somnolence, and other adverse reactions. Dose reductions or discontinuation of valproate should be considered in patients with decreased food or fluid intake and in patients with excessive somnolence. Review of the manufacturer's prescribing information for Remeron (mirtazapine, an antidepressant) revealed adverse reactions included somnolence and to use with caution in elderly patients. Further review revealed, Sedating drugs, including REMERON/REMERONSolTab, may cause confusion and over-sedation in the elderly. Elderly patients may be at greater risk of developing hyponatremia. Caution is indicated when administering REMERON/REMERONSolTab to elderly patients . During an interview on 09/15/22 at 1:21 PM, R2's Family Member (F2) stated R2 was over sedated and on a medication for schizophrenia. F2 stated R2 did not have schizophrenia. F2 stated after months in the facility R2 went from up and active to needing to be in a wheelchair. F2 stated she was told R2 was in wheelchair because she was a risk to herself to prevent falls. F2 stated R2 was still capable of getting up and moving around so now they [the facility] said her behaviors changed so they changed her medication, they [the facility] said she was worse at night. F2 stated, we take her back [after appointments] and after that I noticed she [R2] was sleepy every time we visit. F2 stated R2 went to hospital from the facility on a Thursday and did not wake up until Sunday. F2 stated R2 was malnourished and high all the time. F2 reported the nurse said to me the discussion needed to be with psychologist and the nurse practitioner. Her behavior changed. I asked why they gave that much medication. What was her behavior? They said she was asking about my cousin. F2 stated when R2 awoke at the hospital the charge nurse asked me why she was so heavily sedated, and no one could tell me why. F2 stated R2 was taking Geodon [that] was the medication that was making her sleepy. Review of R2's Physicians Orders, located in the resident's EMR under the Orders tab for June 2022 revealed a. Geodon (Ziprasidone) capsule 20 MG [milligrams] Give 1 capsule by mouth two times a day for psychosis. with an order start date of 04/27/22. b. Depakote Sprinkles Capsule Delayed Release Sprinkle 125 MG . Give 1 capsule by mouth three times a day for poor impulse control order start date of 04/27/22 c. Mirtazapine Tablet 7.5 MG Give 1 tablet by mouth at bedtime for poor appetite with an order start date of 06/01/22. Review of R2's Medication Administration Record (MAR) for June 2022 revealed a. Geodon capsule 20 MG Give 1 capsule by mouth two times a day for psychosis was initialed with a check mark entered for 06/01/22-06/07/22 for morning (MRN) and bedtime (HS2), indicating administration. Geodon was not administered after 06/07/22. b. Mirtazapine Tablet 7.5 mg Give 1 tablet by mouth at bedtime for poor appetite with check mark and staff initials for 06/01/22-06/09/22 indicating administered. c. Depakote Sprinkles Capsule Delayed Release Sprinkle 125 MG . Give 1 capsule by mouth three times a day for poor impulse control had check with staff initials for all three times for 06/02/22-06/09/22, 06/01/22 twice a day (MRN and HS) and two times for the date of 06/10/22 (MRN and AFT). Review of R2's Progress Notes located in the resident's EMR under Notes tab revealed Date of Service: 06/07/22 . She was last seen on 06/01/22 and no medication changes were made at the time. This follow up was requested by staff. Reportedly she is 'not eating.' Overall declined in functioning. 'Sleeping all the time' No aggression or falls. PCP [primary care physician] started Remeron for appetite. Staff held all her medications this morning due to oversedation. Today, patient is found sitting in a broda chair in the common area with other residents, awake but lethargic and very confused, not answering any of my questions due to advanced dementia . Calm Poor eye contact Unfocused Very confused .Thin build Weakness . Alert Lethargic . I talked to direct care staff in length and collaborated with PCP/ Social services/DON [Director of Nursing] on plan of care. signed by Nurse Practitioner (NP). Review of R2's Physician's Order on resident's hard chart under Physician Orders tab revealed .dehydrated . send to hospital . Indication . lethargic . altered mental status. dated 06/10/22. Review of R2's NOTICE OF TRANSFER . on the inside cover of resident's hard chart revealed .Transfer . lethargic. dated 06/10/22. Review of R2's facility-provide document titled Discharge Summary revealed .present from the nursing home with decreased mentation lethargy and abnormal blood test showing hypernatremia and renal [kidney] failure . disoriented x 3/nonverbal patient/dry mucous membranes . She was started on D5W [Intravenous sugar solution to treat low blood sugar or water loss-dehydration] with encounter date of 06/10/22. During an interview on 09/16/22 at 12:42 PM, Licensed Practical Nurse (LPN) 1 confirmed antipsychotic medications could cause sleepiness and loss of appetite. LPN1 stated R2's family did not want her sedated. LPN1 stated R2 needed something (medication) to keep her seated instead of getting up from her chair and trying to walk. During an interview on 09/16/22 at 2:14 PM, Social Services Director (SSD) confirmed a chemical restraint was when a resident was overmedicated, and the medication was making resident lethargic. SSD confirmed R2 was awake and alert now. During an interview on 09/16/22 at 3:41 PM, Pharmacy Consultant (PC) confirmed sleepiness could be a side effect of Depakote and Geodon. PC confirmed R2 had a progress note on the resident's EMR that indicated she was over sedated on 06/07/22 written by the Nurse Practitioner (NP). PC confirmed she would recommend some of R2's medications to be discontinued or reduced due to her oversedation. During an interview on 09/16/22 at 5:00 PM, Medical Director stated the big issue with R2's medications was that she not only became less agitated but less responsive with the medication. Medial Director stated he expected the facility's nursing staff to follow physician's orders and question orders to advocate for a patient. 2. Review of Pfizer's manufacturer information titled GEODON revealed .WARNING: INCREASED MORTALITY IN ELDERLY PATEINTS WITH DEMENTIA-RELATED PSYCHOSIS. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at increased risk of death. GEODON is not approved treatment for patients with dementia-related psychosis .WARNINGS AND PRECAUTIONS . Tardive Dyskinesia: May develop acutely or chronically . A syndrome of potentially irreversible, involuntary, dyskinetic movement may develop in patients undergoing treatment with antipsychotic drugs . appears to be higher with elderly, especially elderly women . There is no know treatment established for tardive dyskinesia and the likelihood that it will become irreversible are believed to increase as the duration of the treatment and the total cumulative dose of antipsychotic treatment itself. Review of R2's physicians orders located in the resident's EMR under the Orders tab for June 2022 revealed .Geodon (Ziprasidone) capsule 20 MG Give 1 capsule by mouth two times a day for psychosis. with an order date of 04/27/22. Review of R2's MAR for June 2022 revealed .Geodon capsule 20 MG Give 1 capsule by mouth two times a day for psychosis. and initials with a check mark were entered for 06/01/22-06/07/22 for MRN and HS2 indicating administration. Review of R2's ABNORMAL INVOLUNTARY MOVEMENT SCALE (AIMS) located in resident's EMR under Assessment tab revealed on 12/01/19 R2's AIMS score was zero, indicating no involuntary movements. R2's AIMS score on 08/18/22 was nine and included moderate lip smacking and tongue movement. During an observation on 09/15/22 at 10:09, R2 was in the day area awake and alert. R2 was smacking her lips continuously and her tongue movement in and out of her mouth. During an observation on 09/15/22 at 2:54 PM, R2 was sitting on wheelchair in the day area with other residents. R2 was smacking her lips continuously and her tongue movement in and out of her mouth. During an observation on 09/16/22 at 10:02 AM, R2 was sitting on a therapeutic wheelchair in the day area on the unit. R2 was smacking her lips continuously and her tongue movement in and out of her mouth. During an interview on 09/15/22 at 2:02 PM, two of R2's Family Members (F2 and F3) confirmed R2 developed the symptoms of involuntary mouth movement in the last couple of months (lip smacking and tongue movement). During an interview on 09/15/22 at 3:07 PM, Certified Nursing Assistant (CNA) 2 confirmed R2 development the continuous mouth movement over the last couple of months. CNA2 stated R2 moved her mouth like that all the time, like she was eating something. During an interview on 09/16/22 at 9:10 AM, RN1 confirmed tardive dyskinesia was an adverse side effect of the administration of Depakote and/or other antipsychotic medications and displayed as lip smacking and or hand movements. During an interview on 9/16/22 at 12:42 PM, Licensed Practical Nurse (LPN) 1 confirmed R2 was not admitted to the facility with involuntary mouth movements. LPN1 confirmed antipsychotic medications and Depakote adverse side effects were tardive dyskinesia. LPN1 confirmed tardive dyskinesia was not reversible. During an interview on 09/16/22 at 3:41, PC confirmed tardive dyskinesia was irreversible adverse side effect of psychotropic medications. PC stated if a resident was showing symptoms of tardive dyskinesia, she would recommend the risk/benefit to the facility to re-evaluate resident's psychotropic medications and especially Geodon. PC confirmed she had not made any recommendations to the facility regarding R2's psychotropic medications. PC verified R2's AIMS score had elevated from March 2022 with a score of zero to a score of eight on June 2022 and indicated R2 was displaying involuntary movements. 3. Review of the prescribing information for Depakote Sprinkles under INDICATIONS AND USAGE revealed Depakote Sprinkle Capsules are an anti-epileptic drug indicated for: Monotherapy and adjunctive therapy of complex partial seizures and simple and complex absence seizures; adjunctive therapy in patients with multiple seizure types that include absence seizures. Review of R2's physician orders located in the resident's EMR under the Orders tab for June 2022 revealed the following: a. Depakote Sprinkles Capsule Delayed Release Sprinkle 125 MG [milligrams] . Give 1 capsule by mouth two times a day for poor impulse control [behavior not diagnosis] order date 06/15/22. b. Depakote Sprinkles Capsule Delayed Release Sprinkle 125 MG . Given 1 capsule by mouth two times a day for poor impulse control . order date 06/20/22 (duplicate order). Review of R2's Medication Administration Record (MAR) for June 2022 revealed the following: a.Depakote Sprinkles Capsule Delayed Release 125 MG Give 1 capsule by mouth three times a day for poor impulse control. and initials with a check mark indicating administration were entered for 06/01/22-06/13/22 for MRN [morning], 06/01/22, 06/03/22-06/13/22 for AFT [afternoon] and 06/01/22- 06/13/22 for HS2 [bedtime] b.Depakote Sprinkles Capsules Delayed Release 125 MG. by mouth two times a day for poor impulse control. and initials with a check mark were entered for 06/16/22-06/18/22 and 06/21/22 for MRN and 06/15/22-06/21/22 HS2. During an interview on 09/16/22 at 09:10 AM, Registered Nurse (RN) 1 stated impulse control meant the ability to stop yourself from doing something, terminal restlessness would be an example of loss of impulse control. During an interview on 09/16/22 at 3:41 PM, Pharmacy Consultant (PC) confirmed R2 had a physician's order for Depakote and no diagnosis included for the treatment and confirmed the indication on R2's physician's order was impulsivity. PC confirmed impulsivity was a symptom and not a diagnosis. During an interview on 09/16/22 at 2:14 PM, Social Services Director (SSD) confirmed R2 had a physician's order for Depakote twice a day for her behaviors. SSD confirmed R2 did not have a history of seizures. During an interview on 09/16/22 at 6:04 PM, Director of Nursing (DON) confirmed R2's physicians orders should include a diagnosis and indicated use for resident's behavior (poor impulse control). DON confirmed R2 had a physician order for Depakote for June 2022 for impulse control on her physician's order.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to maintain professional standards in two (2) of two (2) kitchens. Specifically, the facility failed to remove five (5) dented canned food items from one (1) of two (2) kitchens and failed to maintain accurate and complete refrigerator temperature logs in two (2) of two (2) kitchens. These failures had the potential to affect all residents of the facility who received food from the two kitchens. The findings include: Review of facility policy DRY STORAGE, revised 01/2019, revealed damaged dry goods containers were stored together in the main storeroom in a separate and distinct area away from the other food items. The area was labeled and the damaged food containers were returned to the vendor. The facility defined damaged containers as all dented cans/containers, all swollen containers, and all pull-top containers showing a fracture of the lid score line. Initial kitchen observation, on 02/22/2022 at 9:00 AM, revealed the facility had two (2) kitchens. Resident meals were prepared in the main kitchen, covered, and delivered to the satellite kitchen steam table for meal service. The satellite kitchen included a dry storage area for quick access, which contained snacks, beverage storage, and canned food storage. During observations of the dry storage area of the satellite kitchen, five (5) dented cans were found. Two (2) of the dented cans were still in the delivery box; the other three (3) were out on the shelf mixed in with intact canned foods. Continued observation revealed no designated area/shelf for staff to place dented cans to be returned to the supplier. Interview with Dietary Aid (DA) #1, on 02/22/2022 at 9:07 AM. She stated all the cans stayed on the shelf in the dry storage room. She stated she did not screen or unpack the cans and put them on the shelf. She did not know where the dented cans were supposed to be placed. Interview with DA #2, on 02/22/2022 at 9:10 AM, revealed there should be no dented canned goods in the storage area. She stated they should be separated and placed in an area designated for dented canned goods to be returned to the delivery company. She stated the dented can area was in the main kitchen. Initial observations of the main kitchen were conducted on 02/22/2022 at 9:15 AM and revealed a shelf dedicated to dented cans in the main dry goods storage area. Interview with the Registered Dietitian/Dietary Manager (RD/DM), on 02/22/2022 at 9:17 AM, revealed all dented cans were to be pulled aside and returned to the supplier for a credit. She stated there should be no dented cans on the shelf, and the dietary staff were to pull them out during sorting and storage. She stated if the cooks pulled a dented can from the shelf, it was not to be used, and the staff member should put the dented can on the designated shelf to be returned. She stated dented cans could introduce food-borne illness into the facility. Interview with the Director of Nursing (DON), on 02/24/2022 at 1:51 PM, revealed dented cans should be set aside and returned to the supplier to prevent the introduction of food-borne illness into the facility. Interview with Administrator, on 02/25/2022 at 11:40 AM, revealed dented cans should be removed and set aside to be sent back to the manufacturer. Interview with the Health Care Center Food Services Supervisor (HCCFSS), on 02/25/2022 at 2:18 PM, revealed DA #1 was employed at the facility for eight years and received training about removing dented cans from storage. She stated all dented cans should be pulled aside and brought to the main kitchen in the evening and that was the procedure of the satellite kitchen since her employment. She stated training was provided about the removal of dented cans upon hire and annually. 2. Review of facility policy RECORDING OF REFRIGERATOR AND FREEZER TEMPERATURES, revised 02/2022, reveled the Dietary Department checked and recorded refrigerator temperatures at the start and closing of the kitchen. This ensured both refrigerated and frozen food items were maintained at a temperature that prevented spoilage and growth of harmful microorganisms. Observation, on 02/22/2022 at 9:00 AM, revealed the facility had two (2) kitchens. The facility prepared resident meals in the main kitchen, covered the meals, and then sent the meals to the satellite kitchen steam table for meal service. The satellite kitchen had two (2) refrigerators, one (1) of which had a freezer. Continued observation revealed the white refrigerator/freezer temperature log was dated February 2022. No temperatures were logged for the month, which was 22 days. This refrigerator contained beverages and frozen snacks for residents. The thermometer inside the refrigerator read 35 degrees Fahrenheit (F). The thermometer inside the freezer read 0 degrees F. The reach in refrigerator temperature log was dated January 2022, and the temperature log was completed until 01/18/2022. Temperatures were not recorded for 12 days between 01/19/2022 and 01/31/2022. The recorded temperatures were within normal range. There was no February 2022 temperature log, therefore no temperatures were logged for 22 days. This refrigerator contained sandwiches, snacks, and dessert items for residents. The temperature inside the refrigerator read 40 F and was within normal range. Interview with Dietary Aid (DA) #1, on 02/22/2022 at 9:07 AM, revealed staff completed the temperature logs on the refrigerators twice daily; once in the morning and once at night. She stated she was not responsible for changing the temperature sheets. She stated she did not know why the logs were incomplete and not updated to February. Interview with DA #2, on 02/22/2022 at 9:10 AM, revealed staff updated the temperature logs monthly. She stated she did not know why the two refrigerator temperature logs in the satellite kitchen were not kept up to date or current. She stated the refrigerator temperature was checked twice a day and should be logged at that time. Observation of the main kitchen that served the campus, on 02/22/2022 at 9:15 AM, revealed the main kitchen had two (2) refrigerators and one (1) walk in freezer. The main refrigerator/freezer log was dated February 2022 and was complete until 02/10/2022. No temperatures were recorded for 12 days. The recorded temperatures between 02/01/2022 and 02/10/2022 were within normal range. This refrigerator and freezer were both walk in and were the main food storage for the facilities perishable and frozen goods. The thermometer in the walk-in main refrigerator read 30 F and the walk-in freezer's read -5 F. Temperatures were within normal range. Interview with the Registered Dietitian/Dietary Manager (RD/DM), on 02/22/2022 at 9:17 AM, revealed staff completed temperature logs for all the refrigerators and freezers twice daily and changed the form out monthly. She stated she did not know why the temperature logs were not switched out or updated in the satellite or main kitchens. Interview with the Director of Nursing (DON), on 02/24/2022 at 1:51 PM, revealed she expected the temperature logs in both kitchens to be recorded daily and kept up to date. Interview with the Administrator, on 02/25/2022 at 11:40 AM, revealed staff should complete the temperature logs per policy and completed daily. He stated there should be no missing temperatures. Interview with the Health Care Center Food Services Supervisor (HCCFSS), on 02/25/2022 at 2:18 PM, revealed staff switched out the log forms monthly and should be completed twice a day. She stated staff should complete the forms with no missing temperatures to ensure food safety. She stated she was not sure why so many temperature logs were incomplete in the kitchens. She stated temperature log training was covered upon hire and if found to be incomplete retraining occurred at that time. She stated she monitored the temperature logs weekly.

Based on observation, interview, and facility policy review, it was determined the facility failed to maintain an infection control program to provide a safe and sanitary environment to prevent infections. Observations revealed Registered Nurse (RN) #1 wore an inappropriate face covering and popped pills into his bare hands before placing the medication in a medicine cup while administering medications. Additionally, observations revealed bio-hazard containers placed in improper locations to facilitate proper disposal of used personal protective equipment (PPE). The findings include: 1. Review of facility Standard Precautions Policy, revised 03/2020, revealed staff wore a mask and eye protection or a face shield to protect mucous membranes of the eyes, nose and mouth during procedures and resident-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions. Observation, on 02/23/2022 at 11:30 AM, revealed Registered Nurse (RN) #1 wore a cloth, [NAME]-type mask while obtaining a finger stick blood sugar and administering insulin to Resident #51. Interview with RN #1, on 02/23/2022 at 12:15 PM, RN #1 revealed he did not know if the cloth mask he wore was approved by the facility policy. RN #1 further stated the Director of Nursing (DON) had told him to change masks. Interview with the DON, on 02/23/2022 at 1:45 PM, revealed RN #1 was not wearing an approved mask and had not acted in accordance with the facility policies. Interview, on 02/25/2022 at 3:42 PM, with the Administrator, revealed staff should wear N95 or KN95 masks. 2. The facility did not provide a policy related to the use of bare hands while administering medications to residents. Observation and interview during medication administration, on 02/23/2022 at 12:35 PM, revealed Registered Nurse (RN) #1 punched out pills for one resident from the punch card into his ungloved/bare hand. The RN stated handling medications with a bare hand was not a proper/accepted standard practice for the administration of medications. Interview with the DON, on 02/23/2022 at 1:45 PM, revealed RN #1 should not have placed the pills into his bare hands, and he had not acted in accordance with the facility policies. Interview, on 02/25/2022 at 10:02 AM, with the Assistant Director of Nursing/Infection Prevention Coordinator revealed staff should pop pills out of the cards directly into the medicine cup; they should never be handled with a bare hand. Interview with the Administrator, on 02/25/2022 at 3:42 PM, revealed he did not think it was correct for staff to pop pills into their bare hands. 3. Review of the facility's Standard Precautions Policy, revised 03/2020, revealed staff removed gowns and performed hand hygiene before leaving a resident's room. Observation, on 02/23/2022 at 12:35 PM, revealed Registered Nurse (RN) #1 exited the room of a resident who in contact isolation. Continued observation revealed RN #1 removed his PPE, which consisted of a gown and gloves, while he was in the room. He carried the gown and gloves to a biohazard container which was located outside of the resident's room and down the hall about ten (10) feet from the resident's room. Interview with RN #1 immediately following the observation, revealed he did not know if the biohazard container should have been placed inside the resident's room. RN #1 stated he would have to check with someone in infection control. Interview, on 02/23/2022 at 1:45 PM, with the Director of Nursing (DON), revealed RN #1 did not follow approved infection control policies and the biohazard containers should have been placed inside the resident's room. Interview, on 02/25/2022 at 10:02 AM, with the Assistant Director of Nurses/Infection Prevention Coordinator revealed the biohazard containers for the disposal of PPE should be placed in the resident rooms. Interview with the Administrator, on 02/25/2022 at 3:42 PM, revealed RN #1's actions of disposing of PPE in the hallway was not in accordance to facility policy.

Based on observation, interview, record review, and facility policy review, the facility failed to assess one (1) of A total sample of twenty-three (23) residents, (Resident #18) for self-administration of medications. Observations and interview revealed staff left medications in Resident #18's room for him/her to self-administer. Record review revealed no documented assessments completed for Resident #18 to self-administer medications. The findings included: A review of the facility policy, SELF ADMINISTERING MEDICATIONS, revised 05/2016, revealed resident had the right to self-administer medications if the interdisciplinary team had determined it was appropriate and safe for the resident to do so. Additionally, as part of the overall evaluation, the staff and practitioner assessed each resident's mental and physical abilities to determine whether self-administering medications was clinically appropriate for the resident and performed a more specific skill assessment. Furthermore, the facility stored self-administered medications in a safe and secure place. The facility admitted Resident #18 on 01/19/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #18 with a Brief Interview for Mental Status (BIMS) score of fifteen (15), and determined the resident was cognitively intact. Continued review of the MDS revealed the resident independent with bed mobility and transfers, required supervision with eating, and required limited assistance with dressing, toilet use, and personal hygiene. A review of Resident #18's Comprehensive Care Plan, revised 12/22/2021, revealed no care plan to self-administer medications. The care plan further revealed Resident #18 at risk for behaviors due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician orders of Resident #18 for the month of February 2022 revealed no order to self-administer medications. Review of the facility assessments for Resident #18 no assessment to self-administer medications. Observation and interview, on 02/24/2022 at 9:17 AM, revealed Resident #18 sat in a recliner. A bedside table was within reach and contained a [MEDICATION(S)] Aerosol Inhaler 160 microgram (a medication for [CONDITION(S)]), a [MEDICATION(S)] Suspension Nasal Spray 50 microgram (a medication to treat nasal symptoms), and an Azelestine [MEDICATION(S)] Nasal Spray 137 microgram (a medication to treat nasal symptoms). Resident #18 revealed staff normally left the medications at the bedside for the resident to self-administer each morning. Resident #18 further revealed staff left the medications in the room all day and the resident normally took the medications back to the nurse later in the day, or sometimes the nurse would come back to get the medications later. Resident #18 stated a couple of different nurses left the medications at the bedside and a nurse provided the resident with education on the use of the medications, but he/she did not remember when staff provided the education. Observation and interview, on 02/24/2022 at 9:26 AM, revealed Licensed Practical Nurse (LPN) #1 exited another resident's room, room [ROOM NUMBER]. LPN #1 stated she left Resident #18's medications in his/her room so the resident could self-administer the medications; but then LPN #1 walked out of Resident #18's room to the computer to check off the medications. LPN #1 stated another resident needed something, so LPN #1 went into room [ROOM NUMBER]. LPN #1 stated she had just not gotten back to Resident #18's room to get the medications that were left. LPN #1 stated Resident #18 did not have an order or assessment to self-administer the medications but should have an order or assessment before self-administering the medications. Interview with the Assistant Director of Nursing and Infection Preventionist (ADON/IPC), on 02/25/2022 at 9:34 AM, revealed she was not aware Resident #18 was self-administering medications. She stated staff should have assessed Resident #18 prior to leaving medications for the resident to self-administer; and the resident did not have an order and was not assessed to self-administer medications. The ADON/IPC stated it was a collaborative effort with the Director of Nursing (DON), MDS Coordinator, and nurse managers to ensure the facility assessed residents before allowing them to self-administer medications. Interview with the MDS Coordinator, on 02/25/2022 at 9:46 AM, revealed the facility had not assessed Resident #18 to self-administer medications. The MDS Coordinator further stated the facility had not care planned Resident #18 to self-administer medications. Interview with the DON, on 02/25/2022 at 10:14 AM, revealed she was not aware Resident #18 self-administered medications. She stated Resident #18 did not have an order to self-administer medications and the facility had not assessed the resident to self-administer medication. The DON stated the facility should assess residents prior to them self-administering medications. The DON stated it was the interdisciplinary team's responsibility to ensure residents were appropriately assessed and deemed safe prior to self-administering medications. Interview with the Administrator, on 02/25/2022 at 11:24 AM, revealed Resident #18 did not have an order or assessment to self-administer medications. The Administrator indicated it was the responsibility of the nurses who passed the medications to ensure the facility assessed the residents before allowing self-administration of medications. The Administrator further stated the Director of Nursing (DON) was ultimately responsible for auditing medication practices to ensure residents were assessed before self-administration and ensure training was provided to all nursing staff.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents are free from abuse for one (1) of four (4) sampled residents (Resident #2). On 11/13/19 at approximately 3:00 PM, facility staff observed Resident #2's hand in Resident #1's pants. The staff person immediately intervened and separated the residents. Interview with the Director of Social Services, revealed Resident #1 was interviewed after the incident and admitted he/she did place Resident #2's hand in his/her pants, and would do it again if given the chance. The findings include: Review of the facility's Abuse Detection and Prevention Policy, revised April 2019, revealed each resident will be free from abuse. Per Policy, Abuse can include verbal, mental, sexual, physical abuse, corporal punishment, or involuntary seclusion. Review of the facility's Investigation, dated 11/13/19, and signed by the Director of Nursing (DON), revealed State Registered Nurse Aide (SRNA) #1 reported she witnessed Resident #2's hand in Resident #1's pants. The residents were immediately separated and Resident #1 was placed on one on one (1:1) staff supervision. On 11/13/19, Resident #1 and Resident #2's Physicians, and both of the residents' representatives were informed of the incident. The facility Administrator was notified of the incident on 11/13/19 at 3:20 PM. Additional notifications made by the facility on 11/13/19, included Hospice, Adult Protective Services, Crimes against Seniors, and the State Ombudsman. Continued review of the Investigation, revealed Resident #1 was interviewed by the Charge Nurse and the Director of Social Services, and during both interviews, the resident admitted he/she placed Resident #2's hand in his/her pants. On 11/13/19 at 7:00 PM, the facility transferred Resident #1 to an in-patient psychiatric unit at a local acute care hospital. Further review of the Investigation, revealed a head to toe skin assessment was completed for Resident #2 on 11/13/19 by a licensed nurse. The Social Services Director interviewed Resident #2, on 11/13/19, but the resident had no recollection of the incident. The Nurse Practitioner evaluated Resident #2 on 11/14/19; the Psychiatric Nurse Practitioner evaluated Resident #2 on 11/15 19; and the Clinical Psychotherapist evaluated Resident #2 on [DATE]. Continued review of the Investigation, revealed an emergency Quality Assurance (QA) meeting was held on 11/13/19 and facility staff reviewed Resident #1's and #2's care plans, reviewed the Abuse policy, and reviewed the staffing level at the time of the incident. Per the Investigation, on 11/14/19, staff members and all residents were interviewed. Resident interviews revealed there were no further concerns related to residents being touched inappropriately or harmed in any way. Staff education on abuse prevention was conducted on 11/14/19 and 11/15/19 and staff was required to complete a written quiz after the training. 1. Review of Resident #1's closed medical record revealed the facility admitted the resident on 06/19/19 with [DIAGNOSES REDACTED]. Review of Resident #1's Interdisciplinary Care Plan initiated 0[DATE], revealed a focus of redirecting and setting limits with the resident regarding his/her inappropriate sexual behavior (i.e., masturbating in public areas and showing genitals) Interventions included all staff to monitor and redirect the resident; staff to be kind, but firm when setting limits with the resident; explain to the resident that he/she had the right to masturbate, but in his/her room with the curtain pulled; and staff to monitor for events that might precipitate the behavior. Review of Resident #1's Behavior Note, dated 0[DATE] and time-stamped 16:17 (4:17 PM), revealed the resident was observed sitting in the common living area next to the water fountain with his/her genitals exposed. The Note further revealed the resident was rubbing self at the genital area. Per the Note, Licensed Practical Nurse (LPN) #1 explained to the resident that if he/she wanted to do that, the resident should do so in his/her room. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 09/04/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BI[CONDITION]) of a nine (9) out of fifteen (15) indicating moderate cognitive impairment. Review of the physician's orders [REDACTED]. Review of Resident #1's Progress/Communication Note dated 11/13/19 and time stamped 15:22 (3:22 PM), revealed the resident was noted at 3:00 PM by staff putting the resident from North 8-1's (Resident #2's) hand down inside his/her pants. Per the Note, when Resident #1 noticed the staff member was looking at him/her, the resident pulled Resident #2's hand out of his/her pants quickly. Further review of the Note, revealed the two (2) residents were separated by staff, and the facility staff notified Resident #1's Physician, Responsible Party, and the Director of Social Services, immediately. Additional review of the Note, revealed Resident #1 was questioned about the incident and stated, I did it, why not? The note was signed by Registered Nurse (RN#1). Review of the Notice of Transfer and Discharge issued to Resident #1's Guardian on 11/13/19, revealed the reason for the transfer/discharge was molested resident. Further review revealed the resident was transferred to a local hospital's in-patient psychiatric unit. 2. Review of Resident #2's clinical record revealed the facility admitted the resident on 04/29/19 with [DIAGNOSES REDACTED]. Review of Resident #2 Quarterly MDS Assessment, dated 10/28/19, revealed the facility assessed the resident as having a BI[CONDITION] of three (3) out of fifteen (15) indicating severe cognitive impairment. Review of Resident #2's Comprehensive Care Plan, initiated on 11/13/19, revealed the resident was at risk for signs and symptoms of trauma from molestation from a male resident. Further review of the care plan revealed the resident had a [DIAGNOSES REDACTED]. Interventions included administering medications as per the physician's orders [REDACTED]. Observation,of Resident #2 on 12/26/19 at 8:30 AM, revealed the resident was in bed, with his/her eyes open and was neatly dressed and groomed. The resident's bed was against the wall, in low position with a fall mat on the floor at the open side of the bed. The resident nodded when the Surveyor greeted the resident. Observation, on 12/26/19 at 10:00 AM, revealed Resident #2 was sitting in his/her wheelchair in the common area near the nurse's station, along with other residents. The resident was awake, but looked calm and in no apparent distress. Staff members were in the general area of the common living space. Review of Resident #2's Progress Note, dated 11/13/19 and time stamped 15:28 (3:28 PM), revealed staff noticed the resident from South 6-2 (Resident #1) putting Resident #2's hand down his/her pants. Staff immediately separated the residents, and a full body assessment was completed on Resident #2, with no injury noted. The Note further revealed the resident's Medical Doctor (MD), the family, and Director of Social Services were notified immediately. Review of Resident #2's Psychosocial Progress Note, dated 11/13/19 and time stamped 16:24 (4:24 PM), revealed the Director of Social Services interviewed Resident #2 after the incident occurred. Per the Note, Resident #2 did not demonstrate any remembrance of the incident, and the resident was not showing signs or symptoms of psychosocial harm or ill effect from the incident. The Social Worker's documentation further revealed a psychosocial referral would be made for the resident in order for the psych services provider to evaluate the resident's status. Review of Resident #2's Communication Progress Note, dated 11/13/19 at 19:05 (7:05 PM), revealed Resident #2's family was notified of the incident and the family member's response was documented as, That makes me feel better. Interview, on 12/26/19 at 11:51 AM and on [DATE] at 11:33 AM, with State Registered Nursing Assistant (SRNA) #1, revealed on 11/13/19 about 3:00 PM, she noticed Resident #2 was sitting in his/her wheelchair in the common area, and it looked like he/she was nodding off to sleep. SRNA #1 stated she approached Resident #2 because she thought the resident might need to be assisted to bed for a nap and as she got closer to Residents #1 and #2 who were sitting beside each other, she observed Resident #2's hand in Resident #1's pants. Per interview, Resident #1 removed Resident #2's hand from his/her (Resident #1's) pants when he/she saw her (SRNA #1). SRNA #1 stated when she separated the residents, Resident #1 did not say anything, but sat there for a few minutes. SRNA #1 further stated she immediately notified Registered Nurse (RN) #1. Per interview, RN #1 came to talk with Resident #1, and she (SRNA #1) took Resident #2 from the common living area and washed the resident's hands. SRNA #1 stated the incident was shocking because she had never seen Resident #1 do anything like that. Per interview, Resident #1 could be a little flirty with the staff, but she had never seen him/her even talk to residents of the opposite sex. Interview, on [DATE] at 9:00 AM with RN#1/Nurse Manager, revealed SRNA #1 reported on 01/13/19 she saw Resident #1 take Resident #2's hand and place it in his/her pants. Per interview, she instructed SRNA #1 to wash Resident #2 hands and she immediately took Resident #1 to his/her room. Per interview, she asked Resident #1 if he/she placed Resident #2's hand in his/her pants, and the resident responded affirmatively that he/she did place Resident #2's hand in his/her pants. Per interview, Resident #1 told her there was nothing wrong with doing that. RN#1 stated she contacted the Director of Social Services who came to Resident #1's room and took the resident to her office to interview him/her. RN #1 further stated she usually worked the day shift as the Charge Nurse, and she had not witnessed or heard that Resident #1 had inappropriately touched any other residents. Per interview, Resident #1 stayed in his/her room most of the time, and it was rare for him/her to be in the common living area of the facility. Interview, on 12/26/19 at 2:39 PM with Licensed Practical Nurse (LPN) #2, revealed she did not witness the incident on 11/13/19 between Resident #1 and Resident #2, but she was assigned to monitor Resident #1 with one on one (1:1) supervision after the incident. She stated the resident told her, I know I did something bad, but the resident did not tell her any details. LPN #2 said she had not previously observed Resident #1 display any inappropriate sexual behavior. Interview, on 12/26/19 at 3:10 PM, with LPN #1, revealed she routinely worked second shift/evening shift at the facility, and she performed the skin assessment on Resident #2 just after the incident on 11/13/19. LPN #1 stated she did not identify any new skin issues, and the resident did not look fearful or in any distress during the skin assessment. LPN #1 stated she had observed Resident #1 fondling self in the common living area on 0[DATE] and wrote the Behavior Note in Resident #1's clinical record on that date. LPN #1 stated she redirected the resident to his/her room on 0[DATE], and told the resident that would be a more appropriate location for privacy. Interview, on [DATE] at 8:30 AM with RN #2, revealed she had worked at the facility for three (3) years, and often worked on the South Hall. She confirmed that Resident #1 lived on the South Hall before his/her discharge on 11/13/19. She stated Resident #1 stayed in his/her room most of the time, but would attend an occasional planned activity if encouraged by staff. RN #1 further stated she had not witnessed Resident #1 display any inappropriate sexual behavior toward other residents. Per interview, on occasion the resident would be lying in bed with his/her genitalia exposed while eliminating his/her bladder. Further interview revealed she was aware of the incident on 11/13/19 between Residents #1 and #2. Per interview, she had observed Resident #2 since the day of the incident, and the resident had not shown any effects from the incident, and did not seem to be aware that it had happened. Interview, with the Director of Social Services, on 12/26/19 at 11:10 AM, revealed on 11/13/19 during the afternoon shift change at approximately 3:00 PM, SRNA #1 observed Resident #1 sitting by Resident #2 in the common living area near the nurses' station. She stated SRNA #1 reported that Resident #2's hand was inside Resident #1's pants, and Resident #1 had his/her hand around Resident #2's wrist holding Resident #2's hand in place as if to prevent Resident #2 from moving his/her hand out of Resident #1's pants. The Director of Social Services stated Resident #1 no longer lived at the facility because the facility transferred the resident to the local hospital's in-patient psychiatric unit on the evening of 11/13/19. She further stated the transfer and discharge was necessary because of Resident #1's display of inappropriate sexual behavior, and the resident's statement in an interview just after the incident that he/she would do it again if given the chance. Additional interview revealed Resident #1 was in end stage status for his/her diagnosed [MEDICAL CONDITION], and he/she received Hospice services during his/her stay at the facility. Interview, on [DATE] at 9:15 AM, with the Director of Nursing (DON), revealed Resident #1 stayed in his/her room most of the time, and on occasion, two (2) other male residents would go to Resident #1's room to visit him/her. She stated he/she would occasionally attend bingo activities. Per interview, LPN #1 notified her on 0[DATE] when Resident #1 was observed in the common living with his/her genitals exposed, and it was her understanding that LPN #1 counseled the resident to go to a private place to masturbate. Further interview with the DON, revealed on 11/13/19, when SRNA #1 observed the incident involving Residents #1 and #2, the residents were immediately separated from each other and Resident #1 was placed on one on one (1:1) supervision. She stated a licensed nurse conducted Resident #2's skin assessment and there were no identified irregularities. Per interview, the Director of Social Services interviewed Resident #1 after the incident and he/she admitted placing Resident #2's hand in his/her pants and stated he/she would do it again if given the chance. The DON stated at that point, it was determined that in order to keep all residents safe, Resident #1 could not stay in the facility. Per interview, Resident #1 was transferred to an in-patient psychiatric facility for evaluation. Further interview revealed it was her expectation residents were free from abuse. Interview, on [DATE] at 10:20 AM and on [DATE] at 11:55 AM, with the Administrator, revealed the DON and the Director of Social Services notified him of the incident related to Resident #1 and Resident #2 immediately. He stated the Director of Social Services suggested the resident be transferred to a psychiatric facility for evaluation, and he was in agreement. Per interview, the police department was notified of Resident #1's statement that he/she would inappropriately touch someone again if given the chance. The Administrator stated based on the actions and statement made by Resident #1, he did not think the resident was suited for the facility. The Administrator further stated he read the federal regulations related to transfer and discharge of residents to determine if immediate discharge was an appropriate action to take. Per interview, he called an emergency Quality Assurance (QA) meeting on 11/13/19, and the DON, the Director of Social Services, and the Chaplain, attended the meeting; and the Medical Director was informed of the situation. Per interview, during the QA meeting the attendees determined the facility had an acceptable reason for discharging Resident #1 from the facility. Further interview revealed through the facility Investigation, it was determined the incident did happen. Per interview, it was his expectation residents were free from abuse.

Based on interview, record review, and review of the facility's policy and resident handbook, it was determined the facility failed to invite one (1) of sixteen (16) sampled residents, Resident #43, to participate in his/her care plan conference. The findings include: Review of the facility's policy, Resident Care Plans, revised (MONTH) 2012, revealed the Director of Social Services would inform residents/families of scheduled care conference and encouraged them to attend. The resident and family members present would sign the care conference form at the end of the conference. Review of the facility's Resident Handbook, revised (MONTH) (YEAR), revealed the resident and responsible parties were invited to join the Director of Nursing and other staff in establishing goals of care for the resident. Review of the facility's, Your Rights as a Resident of a Long-Term Care Facility, dated (MONTH) (YEAR), revealed the resident had a right to participate in his or her assessment and care planning. Review of the clinical record revealed the facility admitted Resident #43 on 09/22/17, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status score of thirteen (13) out of fifteen (15) and determined the resident interviewable. Interview with Resident #43, on 04/30/18 at 2:40 PM, revealed the facility had not invited the resident to any care plan conferences. The resident stated the facility did not tell him/her anything regarding his/her care. The resident state he/she did not know anything because his/her daughter was controlling everything. The resident revealed the facility only talked to his/her daughter and not to him/her. Review of Resident #43's Care Plan Conference Summary Forms, dated 10/11/17, 01/03/18, 01/17/18, 03/07/18, and 04/04/18 revealed no signature of the resident or family member indicating they attended the conference. On 01/17/18 and 03/07/18, the facility checked a care plan conference was held with a family representative via telephone conference. The 04/04/18 Summary, stated the resident and family were invited, but did not attend. There was no resident signature to indicate the care plan was discussed with the resident. Review of Resident #43's Progress Notes, dated 09/22/17 to 04/04/18, revealed no documented evidence the resident was invited or attended the care plan conferences. Interview with the Resident Assessment Instrument (RAI) Coordinator, on 05/01/18 at 2:00 PM, revealed she attended the care plan meetings for each resident and stated all residents received a verbal invitation and the Social Services Director sent letters to family members. She stated Resident #43 was not invited to attend the care plan conferences because of his/her behaviors; however, she could not state what type of behaviors because the resident had not attended any care plan conferences. She stated the resident was upset with the daughter for placement in the facility and the facility conducted the care conference via telephone with the daughter. She revealed the resident was not informed of what was discussed at the care plan conference. The RAI Coordinator stated every resident should be invited to the care plan conference and if they could not attend in person, staff should go to their room and discuss their plan of care with them; however, that had not been done for Resident #43. She went on to state all parties present at the care plan conference were required to sign the form to show they participated in the care plan process. Interview with the Social Services Director (SSD), on 05/01/18 11:30 AM, revealed all residents were invited to the care plan conference verbally and she sent letters to the family members. She stated if the resident could not attend the care plan conference, the team would meet with the resident in their room. The SSD stated Resident #43 and his/her daughter did not get along because the resident was angry with the daughter for placement at the facility. She stated it was better to deal with the daughter instead of triggering behaviors in the resident. She stated she did not think Resident #43 had attended any care plan conferences. Interview with Certified Nursing Assistant (CNA) #1, on 05/02/18 at 10:25 AM, revealed she cared for Resident #43 many times, and had not witnessed any outburst or disruptive behaviors from the resident. CNA #1 stated she had not observed him/her get upset during family visits. She stated the resident had no behaviors that would prevent him from being informed about his/her care. Interview with Licensed Practical Nurse (LPN) #2, on 05/02/18 at 10:35 AM, revealed the only behaviors Resident 43 exhibited was to flirt with others. She stated she heard the resident on the resident's cell phone with his/her daughter and he/she was pleasant with no yelling noted. Interview with LPN #1, on 05/02/18 at 10:45 AM, revealed she cared for Resident #43 and was familiar his/her care needs. She stated when the resident was admitted ; he/she went through an adjustment period but had not exhibited any behaviors such as yelling at staff or others. Interview with the Director of Nursing, on 05/02/18 1:50 PM, revealed all residents were verbally invited to care plan conferences and should be included in their plan of care. She stated she was not aware Resident #43 had not attended any care plan conferences. She stated the resident should be included in the plan of care and she felt the facility had dropped the ball with this resident. Interview with the Administrator, on 05/02/18 at 3:48 PM, revealed Resident #43 was invited to care plan meetings but occasionally a conference call was conducted with Resident #43's daughter, who was his/her power of attorney. He stated he did not attend or plan the care plan meetings, but it was his understanding Resident #43 was always invited to care plan meetings with the exception of the conference calls that occurred only with Resident #43's daughter.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to develop a baseline care plan for one (1) of sixteen (16) sampled residents, Resident #310, for monitoring the effects of the resident's antipsychotic, opioid, and anticonvulsant medications. The findings include: Review of the facility's policy, Resident Care Plans, dated (MONTH) 2012, revealed upon admission, the facility would develop an initial care plan based on the resident's diagnosis, history, and current identified areas of concern. The care plan would include the date initiated, problem area, goals, interventions, department responsible for each intervention, and next goal review date. Review of Resident #310's clinical record revealed the facility admitted the resident on 04/26/18, with [DIAGNOSES REDACTED]. The facility had not conducted a Minimum Data Set (MDS) assessment because the resident had not been in the facility for the required fourteen (14) days. Review of Resident #310's Physician Orders, dated 04/01/18 to 04/30/18, revealed an order for [REDACTED]. Observation of Resident #310, on 04/30/18 at 2:00 PM, revealed the resident wandering about the secure unit. On 05/01/18 at 12:00 PM, the resident was observed in the secured unit's dining room, leaning to the right side, not eating, with his/her eyes closed. Staff had to prompt the resident several times to eat. Throughout the meal, Resident #310 chewed food with his/her eyes closed. Observation of Resident #310, on 05/02/18 at 12:00 PM, revealed the resident in the dining room not eating with eyes closed. At 1:45 PM, the resident was observed standing in the living room of the secure unit with eyes closed, mouth dropped open, and leaning forward. Observation at 2:30 PM, revealed the resident seated in the dining room during an activity with his/her eyes closed and leaning forward. Observation, on 05/02/18 at 3:05 PM, revealed the resident walking to the exit door and knocking on the glass, he/she would leave, and then immediately return to the door. The resident stood at the door waiting for someone to open the door. The resident's gait was very slow, his/her eyes closed at times, and the resident swayed back and forward. Observation revealed the resident moving his/her tongue around but was not thrusting out. The resident had no expression on his/her face and when called by name, the resident appeared to know his/her name, but was non-verbal. Review of Resident #310's Baseline Care Plan, dated 04/26/18, revealed staff was instructed to monitor for elopement attempts every shift. However, the care plan had no interventions to monitor for side effects of the antipsychotic medications. The care plan had an area labeled Medication/Treatment Orders with a box checked, see Medication Administration Record [REDACTED]. The care plan did not contain information related to monitoring side effects of the opioid, anticonvulsant, and antipsychotic medication. Review of Resident #310's MAR, for 04/24/18 to 04/30/18 and (MONTH) (YEAR), revealed no monitoring of the antipsychotic medications for side effects. Interview with Certified Nursing Assistant (CNA) #1, on 05/02/18 12:00 PM, revealed Resident #310 always slept during meals and would generally eat snacks later. Interview with Licensed Practical Nurse (LPN) #1, on 05/02/18 at 3:00 PM, revealed she assumed Resident #310 became tired from wandering throughout the night. She stated she could not recall whether the resident was assessed for sedation related to use of [MEDICATION NAME] and [MEDICATION NAME]. She stated the resident had always been like that, and if a resident appeared sedated, nurses would document in the nurses' notes. Interview with the Resident Assessment Instrument (RAI) Coordinator, on 05/02/18 at 10:05 AM, revealed the admitting nurse completed the baseline care plan; she developed the comprehensive care plan. She stated the baseline care plan should include the resident's behaviors and monitoring for side effects if the resident was taking an antipsychotic medication. The nurse who completed the baseline care plan was unavailable for interview. Interview with the Director of Nursing (DON), on 05/02/18 at 3:10 PM, revealed upon admission, all residents received a baseline care plan. She stated if a resident was on antipsychotics, opioids, or anticonvulsant medications, they should be listed on the baseline care plan. If any resident were on medications that required specific instructions for monitoring, it would be listed on MAR, in the nurses' notes, and on the baseline care plan so it could be transferred to the comprehensive care plan. The DON revealed all new admissions were reviewed the next day during the Clinical Care Meeting. Staff reviewed the 24-hour report, physician orders, and nurses' notes, and the baseline care plan would also be reviewed during the meeting. Interview with the Administrator, on 05/02/18 at 3:48 PM, revealed nurses were required to address signs and symptoms of sedation in a resident immediately, inform charge nurses, and follow the chain of command until the issue was resolved.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure residents were free from unnecessary medications for one (1) of sixteen (16) sampled residents, Resident #310. The resident received antipsychotic medications without adequate monitoring and appropriate [DIAGNOSES REDACTED]. The findings include: Review of the facility's policy, Antipsychotic Medication Use, dated (MONTH) (YEAR), revealed residents would only receive antipsychotic medications when necessary to treat specific conditions for which they were indicated and effective. Antipsychotic medications would not be used if the only symptoms were one or more of the following: Wandering, Poor Self-Care, Restlessness, Impaired Memory, Mild Anxiety, [MEDICAL CONDITION], Unsociability, Inattention, Indifference to Surroundings, Fidgeting, Nervousness, or Uncooperativeness. In addition, the policy stated nursing staff would monitor and report any of the following side effects to the attending physician: Sedation, Orthostatic [MEDICAL CONDITION], Lightheadedness, Dry Mouth, Blurred Vision, Constipation, [MEDICAL CONDITION], [MEDICATION NAME], Extrapyramidal effects, Akathisia, [DIAGNOSES REDACTED], Tremors, Rigidity, or Tardive Dyskinesia. Review of Resident #310's clinical record revealed the facility admitted the resident on 04/26/18, with [DIAGNOSES REDACTED]. The facility had not conducted a Minimum Data Set (MDS) assessment because the resident had not been in the facility for the required fourteen (14) days. Review of the Physician Orders, dated 04/01/18 to 04/30/18, revealed an order for [REDACTED]. Review of the Baseline Care Plan, dated 04/26/18, revealed staff was instructed to monitor for elopement attempts every shift; however, the care plan had no interventions to monitor for side effects of the antipsychotic medications. Review of Resident #310's Medication Administration Record [REDACTED]. Review of the Admission Progress Note, dated 04/26/18, revealed Resident #310 was admitted to a secure unit. The nurse documented the resident was alert to self, pleasant, but non-verbal. The nurse documented the resident attempted to leave with a family member and staff in the secure unit was instructed to monitor for the resident's exit seeking behaviors. At 4:06 PM, the nurse documented the resident frequently had to be redirected from the exit door of the unit. Continued review of the progress notes, dated 04/26/18 to 05/02/18, revealed the resident would pace within the secure unit and tap on the exit doors. Observation of Resident #310, on 04/30/18 at 2:00 PM, revealed the resident wandering about the secure unit. On 05/01/18 at 12:00 PM, the resident was in the secured unit's dining room, leaning to the right side, not eating, with his/her eyes closed. Staff prompted the resident several times to eat and throughout the meal, Resident #310 chewed food with his/her eyes closed. Observation of Resident #310, on 05/02/18 at 12:00 PM, revealed the resident in the dining room not eating with eyes closed. At 1:45 PM, the resident was standing in the living room of the secure unit with eyes closed, mouth dropped open, and leaning forward. Observation at 2:30 PM, revealed the resident seated in the dining room during an activity with his/her eyes closed and leaning forward. Observation, on 05/02/18 at 3:05 PM, revealed Resident #310 walking to the exit door and knocking on the glass. He/she would leave and then immediately return to the door. The resident stood at the door waiting for someone to open the door. The resident's gait was very slow, and his/her eyes closed at times and he/she swayed back and forward. Observation revealed the resident was moving his/her tongue around but was not thrusting out. The resident had no expression on his/her face and when called by name, the resident appeared to know his/her name, but was non-verbal. Interview with Certified Nursing Assistant (CNA) #1, on 05/02/18 12:00 PM, revealed Resident #310 always slept during meals and would generally eat snacks later. She stated the resident had two (2) doughnuts prior to lunch. Interview with Licensed Practical Nurse (LPN) #1, on 05/02/18 at 3:00 PM, revealed she assumed Resident #310 became tired from wandering throughout the night. She stated she could not recall whether the resident was assessed for sedation related to use of [MEDICATION NAME] and [MEDICATION NAME]. She stated the resident had always been like that, and if a resident appeared sedated, nurses would document in the nurses' notes. Interview with LPN #3, on 05/02/18 at 3:15 PM, revealed he worked the evening and night shift in the secure unit and was familiar with Resident #310's care. He stated the resident would wander about the unit and that was his/her only behavior to monitor. He revealed the resident was not combative toward staff or other residents and he/she slept most of the night and went to bed between 8:00 PM to 9:00 PM, and usually slept until 5:00 AM. He again stated the only behavior the resident exhibited was wandering. He stated the nurses charted by exception and any behaviors or side effects would be documented in the nurses' notes. The facility did not utilize Behavior Observation Protocol (BOP) sheets to monitor residents' behaviors. Interview with the Social Service Director, on 05/02/18 at 2:45 PM, revealed Resident #310 transferred to the secured unit of the Nursing Facility from a Personal Care Home (PCH) on 04/26/18, because of the resident's wandering and exit seeking behavior. She stated the Psychiatrist visited weekly and the resident was placed on the list to see the Psychiatrist regarding the use of [MEDICATION NAME] and the side effects. She stated the resident had early onset [MEDICAL CONDITION] and declined in the last two (2) months. She stated the resident had stopped walking for a while then improved but his/her wandering behaviors became worse. She stated the resident was exit seeking at the PCH prior to admission and that was the reason for the transfer to the locked secured unit of the Nursing Facility. She stated the resident was on the antipsychotic medications upon admission to control behaviors. She stated a Gradual Dose Reduction (GDR) had not been considered because the resident had only been at the Nursing Facility since 04/26/18, six (6) days. She stated she had not observed the resident for sedation and nurses would conduct an AIMS test for side effects. Interview with the Director of Nursing (DON), on 05/02/18 at 3:10 PM, revealed nurses were responsible for monitoring residents for signs and symptoms of sedation and document in the nurses' notes. The nurse would also put it on the 24-hour report sheet to inform the oncoming nurse to monitor for sedation. She further stated she had not conducted any audits to ensure nurses were monitoring and documenting behaviors and side effects. The DON revealed all new admissions were reviewed the next day during the Clinical Care Meeting, along with the 24-hour report, physician orders, and nurses' notes. At the meeting, the baseline care plan would also be reviewed. She stated she had not seen any reports of Resident #310 being sedated and staff was to observe for over sedation and tell her if a medication needed to be reduced or held. However, the facility did not use BOP sheets (behavior monitoring sheets). Interview with the Administrator, on 05/02/18 at 3:48 PM, revealed nurses were required to address signs and symptoms of sedation in a resident immediately. He stated nurses were required to inform charge nurses and to follow the chain of command until the issue was resolved. He revealed he did not know if staff notified Resident #310's physician regarding signs of sedation.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide a clean, comfortable, home like environment as evidence by seven (7) out of thirty-four (34) resident rooms had scraped and chipped doors, door casings, dresser drawers, molding, and walls. In addition, there were gouged and scraped areas in the main dining room. The findings include: Review of the facility's Preventative Maintenance Plan, not dated, revealed checks were done on the condition of the facility's floors, walls, ceiling, and maintenance logs on a daily basis. Observation of the West Hall, on 03/28/17 at 11:30 AM, revealed Room W3, bed 2, had a large gouge on the lower part of the wall near the head of the bed with plaster exposed and particles/debris on the floor; Room W8 had a cable plate hanging away from the wall and a gouged area on the wall near the head of the resident's bed; Room W9, bed 2, had a cable plate pulled away and hanging from the cable; and Room W10 had two (2) window blinds that hung down the right side of the blind unit, there were multiple slats broken at the bottom of the blinds. Observation of the Main Dining Room, on 03/28/17 at 3:15 PM, revealed the hallway outside the dining room had peeling wallpaper and gouged areas on the walls. The Dining Room entrance had black striped marks on both sides of the lower doorframe. Upon entering the Main Dining Room, the left wall had missing molding, chipped paint, and dried jagged glue residue. In addition, two (2) wood molding panels on the left interior wall had jagged edges at the bottom of the panel and at the chair rail trim. Observation of the North Hall, on 03/30/17 at 10:30 AM, revealed Room N1's walls, doors, and doorframes had scraped and chipped areas and black marks on the walls and doors. Observation of the South Hall, on 03/30/17 at 11:10 AM, revealed Room S1 had black scraped walls, doors, and dresser drawers. There was chipped paint on the walls, doors, doorframes, and dresser drawers. In addition, Room S3 had black marks on the door, doorframes, dressers, and walls. Interview with Certified Nursing Assistant (CNA) #1, on 03/30/17 at 10:04 AM, revealed staff reported any needed repairs to the Unit Manager (UM) and logged them in the Maintenance Log or Safety Log. She said the Maintenance Director checked the logs daily and completed the repairs. She also stated the logs were in the nurses' station and anyone could write a repair issue into the logs. Interview with Licensed Practical Nurse (LPN) #2, on 03/30/17 at 9:50 AM, revealed staff placed maintenance needs in one (1) of two (2) logs located in the nurses' station. She stated one (1) log was for regular maintenance and the other was for safety issues. She stated the Safety Log repairs needed to be completed as soon as possible. Interview with the UM, on 03/30/17 at 10:55 AM, revealed logs for maintenance repairs were attached to the wall at the nurses' station. She stated anyone could report issues and/or needs to her and she, or the reporting person, would write the issue in the log. She stated the Maintenance Director checked the logs daily. The UM stated the decor had been an issue and visiting families touring the facility for possible placement had remarked the environment looked junky. Interview with the Director of Nursing (DON), on 03/30/17 at 1:21 PM, revealed the facility did not perform routine rounding to observe for maintenance needs concerning repairs or needed improvements. She stated she had noticed the disrepair of the North, South, and West Halls, and the Dining Room, as well as the resident rooms. The DON stated she had added Room S8, on the South Hall, to the maintenance log for needed painting because she was in that room one day. The DON further stated families touring the building commented that the nursing units and hallways were not as pretty as the assisted living areas on the other side of the building. She stated she did not want the residents to feel uncomfortable in their rooms. Interview with the Maintenance Director, on 03/30/17 at 2:14 PM, revealed he checked the maintenance logs every morning. He stated he was available twenty-four (24) hours a day, seven (7) days a week, for emergent needs by phone or pager. He stated a contracted company recently painted all the rooms and repaired and painted the walls. He stated he tried to paint and repair rooms as time allowed. He stated he was unaware of the gouged wall in Room W3 on the West Hall. Review of the facility's Maintenance Log, revealed on 02/10/17 at 07:12 AM, staff made an entry on 03/23/17 at 12:15 PM, stating the family of the resident who resided on the North Hall, Room N1, bed 1, requested to have the room painted. Under the column, issues/items repaired, the Maintenance Director signed the repair was completed on 03/23/17 at 3:00 PM. There were no other entries related to surveyor observations. Interview with the Administrator, on 03/30/17 at 2:25 PM, revealed he was aware of the markings, damaged doorframes, chipped walls, dents, gouges, and painting needs in the facility. He stated the facility did not perform routine rounds of resident rooms and living areas to monitor for needed repairs. He stated the facility did not have current plans for painting or making improvements.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure the environment remained free of hazards for four (4) of seven (7) common areas. Observation revealed wooden handrails with rough, jagged surfaces and protruding screws. The findings include: Review of the facility's Preventive Maintenance Plan, not dated, revealed daily checks were done of the maintenance logs, floor, walls, and ceiling condition. Observation of the South Hall, on 03/28/17 at 10:12 AM, revealed a handrail located near Room S3 had a jagged joint on the left and gouged wood. A handrail located near Room S4 had a joint on the left side that was gouged at the screw insertion site. In addition, there was a handrail on the right side of Room S6 with a sharp edge underneath the rail and gouged wood at the joint. Observation of the North Hall, on 03/30/17 at 10:40 AM, revealed a handrail with jagged edges by the doorframe of Room N10. There was a handrail near the entrance of Physical Therapy with an exposed screw and sharp jagged edge. Observation of the East Hall, on 03/28/17 at 3:30 PM, revealed a handrail outside the double doors leading to the break room with jagged edges. The handrail at the end of the hall near the Main Dining Room entrance was jagged and gouged. The handrail across from the Beauty Shop was jagged and splintered. Observation of the West Hall, on 03/30/17 at 8:47 AM, revealed the handrail near Room W1 had a protruding screw with a sharp point. There was a protruded screw on the handrail near Room W3 that had a sharp surface. The handrail near Room W8 had an exposed screw with a sharp area on the underside of the rail. The sitting area between Rooms W3 and W5 had a missing handrail on the left wall along with dried wood type putty that was jagged on the handrail on the back wall; the wood type putty easily chipped and flaked off. Observation of the common area, on 3/30/17 at 10:00 AM, revealed a handrail to the left leading into the West Hall had jagged and gouged wood at the corner. The corner was near residents seated in wheelchairs. Observation of Resident #2, on 3/30/17 at 1:10 PM, revealed the resident on the East Hall in his/her wheelchair using the handrail with his/her left hand multiple times to self-propel down the hall. Observation of Resident #13, on 3/30/17 at 1:17 PM, revealed the resident in his/her wheelchair leaving the Dining Room by using the handrail to self-propel toward the South Hall to his/her room. Interview with Certified Nursing Assistant (CNA) #1, on 03/30/17 at 10:04 AM, revealed maintenance issues were reported to the direct supervisor and placed in one (1) of two (2) maintenance logs. The logs were located in the nurses' station and maintenance staff checked the logs daily. CNA #1 further stated she would have reported handrails with jagged edges to the supervisor. Interview with Licensed Practical Nurse (LPN) #2, on 03/30/17 at 9:50 AM, revealed there were two (2) logs at the nurses' station. She stated she notified the Unit Manager (UM) of any maintenance needs discovered. She also stated staff could contact the Maintenance Director by pager or phone for immediate repairs that posed a safety concern. LPN #2 stated she had not reported any issues regarding handrails with sharp or jagged edges. LPN #2 stated housekeeping wiped handrails down daily. Interview with LPN #3, on 03/30/17 at 10:17 AM, revealed two (2) maintenance logs were kept at the nurses' station. She stated one (1) log was for safety related issues and the other log was for regular maintenance. LPN #3 stated she considered loose and/or damaged handrails an immediate issue to address with maintenance. Interview with the UM, on 03/30/17 at 10:55 AM, revealed there were two (2) logs for maintenance. One (1) log was for safety related issues that required immediate action and the other log was for issues that repair could be delayed. She stated anything that would pose a direct safety risk for a resident would be listed in the safety log. She further stated she did not routinely check the handrails for safety. The UM stated it would benefit the resident's safety if staff checked the handrails on a routine basis. Review of the facility's Safety Equipment Repair Log, for December 2016, January 2017, February 2017, and March 2017, revealed no entries related to the observed handrails. Interview with the Housekeeping Supervisor, on 03/30/17 at 12:57 PM, revealed the housekeepers wiped handrails down daily to prevent the spread of infection. She stated she had not noticed changes to the handrails nor had staff notified her of issues concerning sharp, gouged, or jagged edged handrails. Interview with the Director of Nursing (DON), on 03/30/17 at 1:21 PM, revealed the facility kept two (2) maintenance logs for staff to report needed repairs. She stated loose handrails or handrails with jagged or gouged areas would be a safety issue. She stated many residents self-propelled from one area to another by using the handrails. The DON stated handrails with jagged edges or gouged wood could cause residents to get hurt. She stated a resident could obtain a skin tear that could be painful and could lead to an infection requiring hospitalization . She stated the facility did not routinely round to monitor needed repairs. Interview with the Maintenance Director, on 03/30/17 at 2:13 PM, revealed he checked the maintenance logs every morning when he started work. He stated he had been working on the handrails for over a year. He stated he was aware of the missing and jagged handrail on the West Hallway but no other issues concerning handrails. He stated he did not consider exposed screw heads as dangerous. The Maintenance Director stated he was responsible for all areas of the facility. He stated he made daily, weekly, and monthly rounds; however, he stated he did not routinely check handrails. He stated safety was his number one concern and staff was to report issues to him or write them in the maintenance logs. Interview with Administrator, on 03/30/17 at 2:25 PM, revealed safety of the residents was a major concern for the facility and gouged or sharp handrails were safety issues. The Administrator stated they could cause resident injury and require the resident needing first aid care. He stated an injury could lead to an infection and if serious, the injury might require emergency services.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure a bedside call light was operable for one (1) of sixteen (16) sampled residents, Resident #5. The findings include: Review of the facility's policy, Answering Call Lights, dated March 2017, revealed the facility was to ensure call lights were plugged in at all times and to report defective call lights to the nurse supervisor promptly. Observation during the initial environmental tour, on 03/28/17 at 10:31 AM, revealed Resident #5's call light was inoperable. When the resident pressed the red button, the lights on the wall and above the door remained off and the audible alarm did not sound. Further observation revealed the call light cord was coiled under his/her bedside table, unplugged from the wall. A second call light cord was plugged into the wall and the button for the second cord was coiled under the bedside table. Observation of Resident #5's room, on 03/28/17 at 10:44 AM, revealed Licensed Practical Nurse (LPN) #4 disconnected the second cord from the wall and plugged in Resident #5's primary call light cord. She had Resident #5 press the button and both lights and audible alarm operated. LPN #4 removed the second call light from the resident's room. Review of Resident #5's medical record revealed the facility admitted the resident on 02/14/17, with [DIAGNOSES REDACTED]. On 02/20/17, the facility completed an admission Minimum Data Set and assessed Resident #5 required two (2) staff persons for transfers and ambulation. Interview with Certified Nursing Assistant (CNA) #2, on 03/30/17 at 11:41 AM, revealed she did weekly rounds on her assigned residents on the South Hall, which included Resident #5. She tested call lights and made sure they were not tangled. She stated she was trained to round weekly and the training had been reinforced in staff meetings; however, she did not document the weekly rounds. She reported she had not encountered a second call light on any of her rounds. She further stated Resident #5 was at risk without his/her call light and could have fallen or choked. Interview with CNA #6, on 03/30/17 at 2:00 PM, revealed she cared for Resident #5 the evening of 03/27/17. She stated she did not check her residents' call lights routinely and was unaware of other CNAs rounding on call lights. She further stated staff would know if a call light was broken because the same residents used their call lights daily. She also stated Resident #5 called for help using the call light multiple times without difficulty on 03/27/17. She stated she had no knowledge of the second call light and felt it was abusive and lazy. She also stated there were replacement call lights in the nurses' station available to any staff and staff did not have to sign them out. Interview with the Unit Manager, on 03/30/17 at 3:10 PM, revealed she did not instruct the CNAs to check or monitor call lights. She was unsure when the lights were checked and by whom. She stated the CNAs sometimes got frustrated with Resident #5 as he/she did not try to do things for himself/herself but she could not imagine why staff would set up a second call light when state surveyors were in the building. She further explained Resident #5's call light could not have been out for very long as he/she used it often and staff would have noticed. She stated there were bad risks associated with a broken call light; it could have caused death. Interview with the Director of Nursing, on 03/30/17 at 3:30 PM, revealed she expected her nurses to ensure call lights were working properly. In addition, she rounded on all residents weekly and tested call light functionality. She had never encountered a second call light and was concerned that staff was unable to anticipate the care needs of Resident #5. She stated the second call light must have been plugged in on third (3rd) shift but had no idea who or why. Interview with the Director of Maintenance, on 03/30/17 at 3:10 PM, revealed the facility had no current audit system to monitor the functionality of call lights. He stated he was not in charge of rounding on call lights; nursing staff would call him with problems. Additionally, residents' safety could be affected if they did not get the care they needed because of a malfunctioning call light. Interview with the Administrator, on 03/30/17 at 3:20 PM, revealed if a resident's call light was unplugged, then the resident would not be able to get the help they may need. The Administrator stated the only issue the facility had identified with the call light system were, a few times, staff found call lights unplugged.

Based on observation, interview, record review, and review of facility policies, it was determined the facility failed to maintain effective infection control practices for two (2) of seven (7) sampled residents, Resident #2 and #3. During wound care observations, the nurse did not perform hand hygiene, did not change potentially soiled gloves, and placed wound care supplies on potentially contaminated surfaces. The findings include: Review of the facility's policy, Handwashing/Hand Hygiene, dated 01/06/14, revealed staff was to perform hand hygiene before and after direct resident contact, before and after changing a dressing, after handling soiled or used dressings, after removing gloves, and after completion of duties. Review of the facility's policy, Skin Breakdown/Pressure Ulcer, dated August 2016, revealed staff should remove gloves after removing soiled bandages and wash their hands using soap and water. After handwashing, staff should open and prepare all supplies needed to complete the dressing change on a clean surface, and then don clean gloves in order to clean the wound bed. The policy further stated gloves should be removed after cleaning the wound bed and hands should be washed. Review of the facility's policy, Infection Control Guidelines for all Nursing Procedures, dated July 2013, revealed staff was to wash their hands with soap and water before and after direct contact with residents; after removing gloves; after contact with blood, body fluids, secretions, mucous membranes, or non-intact skin; or after handling items potentially contaminated with blood, body fluids, or secretions. Review of the clinical record for Resident #2, revealed the facility admitted the resident on 10/27/16, with [DIAGNOSES REDACTED]. Observation of Resident #2's wound care, on 03/09/17 at 10:30 AM, revealed Registered Nurse (RN) #1 did not wash her hands upon entering Resident #2's room and before donning gloves. RN #1 placed her supplies on the bedside table without first cleaning the table. RN #1 then removed her gloves, exited the resident's room without performing hand hygiene, and obtained tape from the treatment cart in the hallway. RN #1 re-entered the resident's room and donned gloves without performing hand hygiene. RN #1 assisted Resident #2 to turn in the bed, removed the soiled dressings from the resident's buttock, walked across the room to pick up a trashcan and brought it to Resident #2's bedside. Without changing gloves and performing hand hygiene after touching the trashcan, RN #1 cleaned the wound beds. RN #1 proceeded to apply padding to each wound bed and applied pads to cover the wounds, taped them in place, and then removed her gloves and exited the room without performing hand hygiene. RN #1 obtained more tape from the treatment cart, re-entered Resident #2's room, and entered the bathroom to collect new gloves. RN #1 did not perform hand hygiene prior to donning the gloves. After donning the gloves, RN #1 proceeded to apply additional tape to the dressing and applied cream to the resident's right and left buttock. RN #1 removed her gloves and adjusted the blankets on Resident #2's bed, then collected the used supplies from the bedside table and placed them in the trashcan. RN #1 collected the un-used supplies from the bedside table and carried them out to the treatment cart in the hallway, without performing hand hygiene prior to exiting the room. RN #1 then re-entered the resident room and entered the resident bathroom to wash her hands. Review of the clinical record for Resident #3, revealed the facility admitted the resident on 01/19/15, with [DIAGNOSES REDACTED]. Resident #3 had an unstagable pressure ulcer to his/her left heel. Observation of Resident #3's wound care, on 03/09/17 at 10:55 AM, revealed RN #1 gathered the wound care supplies from atop the treatment cart, including two (2) pair of disposable gloves, and entered Resident #3's room. She placed the wound care supplies, including the gloves, on Resident #3's bed, atop the bedspread. RN #1 picked up the trashcan bedside Resident #3's bed and placed it next to Resident #3's recliner, where he/she was seated and ready for the dressing change. RN #1 did not wash or sanitize her hands before donning the gloves she had earlier placed on Resident #3's bed. RN #1 used bandage scissors obtained from her uniform pocket to cut the gauze wrap from the resident's left heel. RN #1 then placed the bandage scissors on the resident's bed with the other supplies. Without changing her gloves, RN #1 examined the heel ulcer by touching the exposed heel ulcer. RN #1 removed her gloves and without washing or sanitizing her hands, donned the other pair of gloves. RN #1 cleansed the wound and patted the wound dry. RN #1 continued with the wound treatment by opening and using packaged [MEDICATION NAME] swabs she obtained from atop the resident's bedspread. RN #1 then opened a pad and placed it over the cleansed heel wound and wrapped the heel with gauze. RN #1 removed her gloves and obtained a roll of tape from her pocket, dropped the roll of tape on the floor, picked it up and proceeded to secure the gauze with the tape. RN #1 applied Resident #3's non-skid sock and protective boot. RN #1 picked up her bandage scissors from Resident #3's bed, and without cleaning the scissors; she placed them back in her uniform pocket. She tied up the bag of soiled dressings and left Resident #3's room with the bag. RN #1 did not wash or sanitize her hands before leaving Resident #3's room, and walked the bag to the soiled utility room. She entered a code on the door's keypad using her fingers, before she was able to enter the room. RN #1 deposited the bag in a can in the soiled utility room and washed her hands at the sink in the soiled utility room. Interview with RN #1, on 03/09/17 at 2:55 PM, revealed staff should perform handwashing before and after any treatments, and change gloves when soiled or encounter anything soiled. RN #1 stated she did not recall performing hand hygiene upon entering the resident rooms, prior to donning gloves to begin treatment of [REDACTED]. RN #1 further she stated she did not change her gloves or perform hand hygiene after removing the soiled dressings or after touching the trashcans. RN #1 stated failure to perform hand hygiene, prior to and during wound care, could lead to an infection in the wound. RN #1 also stated failure to wash hands prior to exiting the room could lead to the spread of infection to other residents. She stated the residents in the facility were vulnerable to infections. Continued interview with RN #1 at 2:55 PM, revealed she placed the supplies for Resident #3's wound care on the resident's bed, on his/her bedspread. She stated she did not create a clean field, but the dressing change was not a sterile procedure. RN #1 stated she typically cleaned her bandage scissors with hand sanitizer or soap and water after using them for wound care. She further stated she should not have placed the scissors on the resident's bed, as they could have become contaminated since she did not place them on a clean field. RN #1 stated she should have washed her hands before leaving the resident's room with the tied bag of soiled dressings. Interview with the Director of Nursing (DON), on 03/09/17 at 3:45 PM, revealed staff should perform hand washing prior to entering a resident room or providing care. The DON stated when performing wound care, hand hygiene should be performed prior to donning gloves and removing the dressing. She further stated staff should remove gloves after removing the soiled dressing, perform hand hygiene, and don new gloves prior to continuing with wound care. The DON further stated failure to wash hands prior to entering a resident room and providing care could lead to the spread of infection to that resident. She also stated staff exiting resident rooms without washing their hands could lead to the spread of infection to other residents. The DON stated she and one (1) other nurse observed infection control practices while rounding the facility, and the results were documented and discussed in the Quality Assurance (QA) meetings. Interview with the Administrator, on 03/09/17 at 5:00 PM, revealed the DON or Staff Development person rounded to ensure staff performed hand hygiene and glove changes. He further stated the DON or Staff Development Nurse would discuss any need for additional training or in-services during the QA meeting.

Based on observation, interview, and review of the Material Safety Data Sheet (MSDS), it was determined the facility failed to ensure one (1) of one (1) soiled utility room between the North and South Units was locked from 01/26/16, 01/27/16 and 01/28/16. Staff left one (1) fifty (50) pound box of laundry detergent open, and sitting on the floor, and three (3) red biohazard containers were in the soiled utility room that contained full sharps containers and had the potential to effect fourteen (14) of forty-four (44) residents living on the North and South Nursing Units. One (1) resident was independently ambulatory; ten (10) residents self-propelled in wheelchairs; and, three (3) residents were independently ambulatory with a walker. The findings include: The facility did not provide a policy on hazardous chemical or hazardous waste storage. Review of the MSDS for 1/4 Cup Laundry Detergent, revealed it contained three (3) hazardous ingredients including: Sodium Carbonate, Sodium Metasilicate, and Sodium Tripolyphosphate. Further review of the MSDS, revealed 1/4 Cup Laundry Detergent could cause problems including: serious eye damage, including pain redness and watering; skin irritation, including delayed pain, drying and redness; irritation or burns to the mouth, throat, or stomach if ingested; and irritation or burns to the nose, throat and respiratory system if inhaled. In addition, the MSDS revealed 1/4 Cup Laundry Detergent should be stored in a tightly closed container and locked up. Observation of the soiled utility room, on 01/26/16 at 11:18 AM, revealed the door was ajar and unlocked. Above the door handle was a key pad. Inside of the soiled utility room sitting on the floor in front of a washing machine was an open fifty (50) pound box of 1/4 Cup Laundry Detergent. In addition, there were three (3) large red biohazard containers that contained sharps containers with used syringes and needles. Observation of the soiled utility room with the Staff Development Coordinator, on 01/26/16 at 12:36 PM, revealed the soiled utility room door was ajar and unlocked. Further observation of the soiled utility room, revealed an open fifty (50) pound box of 1/4 Cup Laundry Detergent sitting on the floor and three (3) large biohazard containers in the room. The Staff Development Coordinator stated the door should have been locked because the room contained hazardous material which could be harmful to the residents. In addition, the Staff Development Coordinator stated she had never seen a resident enter the soiled utility room. Observation, on 01/26/16 at 3:15 PM, revealed the soiled utility door remained ajar and unlocked. Inside of the soiled utility room remained the open fifty (50) pound box of 1/4 Cup Laundry Detergent sitting on the floor, and the three (3) red biohazard containers with full sharps containers. Observation, on 01/27/16 at 7:46 AM, revealed Certified Nursing Assistant (CNA) #4 exited the soiled utility room and left the door ajar and unlocked. The soiled utility room continued to have an open fifty (50) pound box of 1/4 Cup Laundry Detergent sitting on the floor, and three (3) large biohazard containers with sharps containers. Observation during the environmental tour with the Maintenance Director and Administrator, on 01/28/16 at 1:45 PM, revealed the soiled utility door remained ajar and unlocked. Inside the soiled utility room, revealed two (2) large biohazard waste containers remained. Interview with the Housekeeping Supervisor, on 01/26/16 at 2:40 PM, revealed all staff had been given the code to access the soiled utility room. The soiled utility room was used to store housekeeping supplies, dirty linens, and trash. In addition, there was a washing machine for staff to use for heavily soiled linens. The Housekeeping Supervisor stated the soiled utility door was to remain closed and locked at all times, and chemicals should be kept off the floor and she was unaware the soiled utility door was unlocked and stated this was a resident safety concern. Upon inspection of the soiled utility door, by the Housekeeping Supervisor revealed the door would not fully close or lock unless you pulled the handle closed as you exited the room. Interview with Housekeeper #1, on 01/27/16 at 7:37 AM, revealed the soiled utility room was to be kept closed and locked. In addition, Housekeeper #1, revealed chemicals and waste could be harmful to residents and should be inaccessible to residents. Housekeeper #1 stated she had never seen the soiled utility door unlocked nor had she seen a resident enter the soiled utility room. Interview with CNA #4, on 01/27/16 at 7:50 AM, revealed when she exited the soiled utility room she did not realize the door was ajar. The soiled utility door would not fully close unless she pulled the door handle closed as she exited. However, CNA #4 stated she did not report the issue with the door to maintenance or write it on the Maintenance Log kept at the nurses' station. CNA #4 stated the soiled utility door should be kept locked because laundry detergent was kept in the room, and a resident could ingest it and get sick. Interview with Registered Nurse (RN) #1, at 8:46 AM on 01/27/16, revealed the soiled utility room should be locked at all times because it contained biohazard waste, and laundry detergent which could be potentially harmful to residents. RN #1 stated she had never noticed the door unlocked, nor had staff reported to her that the soiled utility door was not closing properly until CNA #4 brought it to her attention. RN #1 stated she called the Maintenance Director to repair the door and checked the door to ensure it was closed and locked. Interview with the Assistant Director of Nursing (ADON), on 01/28/16 at 9:56 AM, revealed she did not do environmental rounds in the facility, and had never seen the soiled utility room unlocked. In addition, the ADON stated biohazard waste and chemicals should be stored away from residents in a secured, locked area. In addition, the ADON stated all staff should have taken more cautious measures to ensure the soiled utility room was locked and secured upon exiting the room. Interview with the Director of Nursing (DON), on 01/28/16 at 10:17 AM, revealed chemicals and biohazard waste should be kept in secure locations, and inaccessible to residents. The DON stated the facility should have ensured the soiled utility room was kept locked at all times. In addition, the DON revealed all staff had been trained to write down maintenance concerns on the Maintenance log kept at the nurses' station, or to call the Maintenance Director directly for emergencies. The DON stated the facility did not maintain a hazard free environment. Interview with the Maintenance Director during the environmental tour, on 01/28/16 at 1:35 PM, revealed he checked the function of the doors throughout the building on a monthly basis. He was not aware of any issue with the soiled utility room door until 01/28/16 and he determined the door was not closing quickly enough or with enough force to engage the lock. The Maintenance Director stated he adjusted the door closure on 01/28/16. However, stated it still needed adjustment as it was observed ajar during the environmental tour by himself and the Administrator. The Maintenance Director stated he relied on facility staff to alert him of environmental issues by writing it down on the Maintenance Log kept at the nurses' station. Interview with the Administrator during the environmental tour, at 1:45 PM on 01/28/15, revealed the soiled utility room door should be closed and locked at all times. Biohazard waste stored in the room could be harmful to residents. In addition, the Administrator stated he had not observed the soiled utility door open before, nor had he observed a resident attempt to enter the soiled utility room.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to develop a care plan sufficient to meet the needs of one (1) of fifteen (15) sampled residents (Resident #4). Although the facility developed a care plan for the care of an indwelling catheter, they failed to address how the staff was to prevent infections during that care. The facility care planned Resident #4 to have routine indwelling catheter care and the staff failed to provide the care utilizing proper technique. The findings include: Review of the facility's policy regarding Resident Care Plans, revised March 2015, revealed the policy was to ensure all residents had an initial needs care plan upon admission and their care plan was reviewed and updated promptly for care changes. In addition, the policy stated interventions that required nursing staff to carry out would be placed on the Certified Nursing Assistant (CNA) assignment sheet. Observation of Certified Nursing Assistant (CNA) #3, on 01/27/16 at 3:56 PM, revealed she performed perineal and catheter care for Resident #4 in the bathroom while the resident stood in front of the toilet. The CNA's technique did not follow standards of practice or prevention of infection. CNA #3 performed hand hygiene, put on gloves, then removed Resident #4's catheter bag from the privacy bag and hung it on the underside of the wheelchair, allowing the bottom of the catheter bag to lay on the floor throughout perineal and catheter care. Resident #4 stated ouch several times as CNA #3 was wiping the labia from front to back. The catheter tubing was not anchored to the resident's leg, and was pulled taut. CNA #3 then used a clean wash cloth to cleanse approximately four (4) inches of the catheter toward the resident's perineal area. Interview with CNA #3, at 4:10 PM on 01/27/16, revealed she followed her CNA assignment sheet to learn the care needs of the residents she was caring for. CNA #3 stated catheter care was not listed on the CNA assignment sheet for Resident #4; however, she completed catheter care once per shift. In addition, she documented resident care on the Nursing Care Flow Sheet and Event Charting form; however, there was no spot to document catheter care. Review of Resident #4's Foley Catheter care plan, dated 03/26/15, revealed the goal was the resident would be clean and dry on a daily basis and have no significant side effect of his/her catheter. The interventions directed the staff to check/change the catheter per physician orders; provide routine indwelling catheter care and inform the charge nurse of significant findings; monitor output every shift; check/change per CNA sheet for bowel movement and potential leaking; monitor skin with each incontinent episode and with bathing two times per week; provide pads/briefs and assistance with them per CNA sheet; notify the charge nurse of any negative changes in skin condition; medications per physician orders; treatments per physician orders; monitor for signs and symptoms of urinary tract infection [MEDICAL CONDITION] such as fever, foul smelling urine, dark urine, sediment or mucus in urine and notify the charge nurse; and, irrigate the indwelling catheter per physician orders. Review of Resident #4's Hospice Care Interdisciplinary Team (IDT) Report, dated 01/14/16, revealed a problem was [MEDICAL CONDITION]. The goal was to attain the desired level of symptom control. Interventions directed staff to keep the indwelling catheter in place and monitor for signs and symptoms of infection or other complications, and determine the presence of pain and/or bladder spasms. Review of the Certified Nursing Assistant (CNA) Assignment Sheet, revealed Resident #4 wore briefs, had an indwelling catheter, and staff should empty and record the catheter output every shift. In addition, staff was to check Resident #4 every two (2) hours, toilet per resident request, and change his/her brief as needed. The CNA assignment sheet did not indicate where, when or how to perform catheter care and did not specify steps to be taken to prevent possible contamination and infection as stated in the policy. Review of Resident #4's Nursing Care Flow Sheet and Event Charting, dated January 2016, revealed there was no documentation of indwelling catheter or perineal care completion as directed per facility policy. Interview with the Minimum Data Set (MDS) Coordinator, on 01/28/16 at 8:40 AM, revealed the purpose of the care plan was to ensure the best possible care for the residents. In addition, a resident care plan should be specific enough to guide the care. Ensuring a catheter bag was off the floor, anchoring indwelling catheter tubing, and cleansing catheters away from Resident #4 are all common knowledge interventions that all staff should know and therefore did not need to be included on Resident #4's catheter care plan or on the CNA Assignment Sheets. Further interview, revealed the MDS Coordinator did not think catheter care needed to be documented in the clinical record. Interview with the Staff Development Coordinator, on 01/27/16 at 9:00 AM, revealed Resident #4's care plan was not implemented correctly regarding indwelling catheter care. In addition, the catheter care plan was not specific enough to guide care, as routine catheter care was not specified in the Perineal care policy. In addition, the Staff Development Coordinator reviewed the Nursing Care Flow Sheet and Event Charting and stated CNA's had not documented perineal or catheter care as directed to per facility policy. Interview with the Assistant Director of Nursing (ADON), on 01/27/16 at 9:20 AM, revealed Resident #4's care plan was not correctly implemented as staff had not documented indwelling catheter care in the clinical record, as directed per facility policy. Resident #4's indwelling catheter care plan was not specific enough to guide care, as it did not specify the frequency catheter care should be provided, and did not include interventions specific to pain management and infection prevention. Interview with the Director of Nursing (DON), at 10:27 AM on 01/28/16, revealed care plans are a guide to direct care staff and based upon resident needs assessments. After reviewing Resident #4's indwelling catheter care plan the DON stated it was not specific enough to guide care as the intervention of routine catheter care was vague and ambiguous. In addition, the CNA Assignment Sheet for Resident #4 should have included the intervention of catheter care, so CNA's know to complete it. The DON stated staff must properly implement care plans for them to be effective. In addition, the DON stated it was facility policy to document the completion of perineal and catheter care.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure indwelling catheter care was provided using proper techniques to prevent the possible contamination of the catheter and possible infection for one (1) of sixteen (16) sampled residents, (Resident #4). Certified Nursing Assistant (CNA) #3 failed to use proper technique during catheter care for Resident #4 by cleaning the tubing towards the meatus. The findings include: Review of the facility's policy regarding Perineal Care (which included indwelling catheter care), revised 01/06/14, revealed during indwelling catheter care staff were to hold the catheter near the meatus, clean the catheter from the meatus down the catheter about four (4) inches; clean downward away from the meatus, with one stroke; repeat as needed with a clean area of the washcloth for each stroke, and dry the area. Do not tug or pull on the catheter, and secure the catheter. Review of Resident #4's clinical record revealed the facility admitted the resident on 03/18/15 with [DIAGNOSES REDACTED]. The facility admitted Resident #4 with an indwelling catheter. Review of the Cumulative Infection Sheets, revealed Resident #4 had two (2) UTIs in the past four (4) months, with onset dates of 10/02/15 and 12/29/15. Review of Resident #4's Culture and Sensitivity (C&S) results, reported 10/01/15 revealed the resident was positive for [DIAGNOSES REDACTED] Pneumoniae and [MEDICATION NAME] Faecalis of the urine. Review of the C&S results, reported 12/31/15 revealed Resident #4 was positive for [DIAGNOSES REDACTED] Pneumoniae, Pseudomonas Aeruginosa, and [MEDICATION NAME] Faecalis of the urine. Review of the physician orders, dated 10/01/15, revealed Resident #4 was started on Bactrim Single Strength twice a day for seven (7) days and on 10/02/15, revealed Resident #4 was started on [MEDICATION NAME] 250 milligrams (mg) every six (6) hours for seven (7) days. Physician orders [REDACTED].#4 was started on Keflex 250mg four (4) times a day for seven (7) days. On 01/03/16 a new physician order [REDACTED].#4 on [MEDICATION NAME] 500mg two (2) times per day for seven (7) days. Observation of perineal and catheter care, at 3:56 PM on 01/27/16, revealed CNA #3 assisted Resident #4 to the restroom via wheelchair. CNA #3 instructed Resident #4 to stand in front of the toilet. CNA #3 performed hand hygiene, put on gloves, then removed Resident #4's catheter bag from the privacy bag and hung it on the underside of the wheelchair, allowing the bottom of the catheter bag to lay on the floor throughout perineal and catheter care. Further observation, revealed Resident #4 stated ouch several times as CNA #3 was wiping the labia from front to back. The catheter tubing was not anchored to the Resident #4's leg, and was pulled taut. CNA #3 then used a clean wash cloth to cleanse approximately four (4) inches of the catheter tubing toward Resident #4's perineal area. Interview with CNA #3, at 4:10 PM on 01/27/16, revealed she received training approximately one month ago on proper pericare and catheter care. CNA #3 stated, she did not realize the catheter bag was lying on the floor, and stated this could lead to infection as there are germs on the floor. In addition, she stated Resident #4 should have had a leg strap on so the catheter would not pull and possibly cause pain for the resident. CNA #3, stated she did not realize she cleaned the catheter toward the resident and said she was trained to clean the catheter away from the resident, as it was important to prevent infections. Interview with the Minimum Data Set (MDS) Coordinator, on 01/28/16 at 8:40 AM, revealed ensuring a catheter bag was off the floor, anchoring indwelling catheter tubing, and cleansing catheters away from Resident #4 are all common knowledge interventions that all staff should know and lack of catheter care or improper catheter care could lead to infections. Interview with the Staff Development Coordinator, on 01/27/16 at 9:00 AM, revealed a catheter bag on the floor, unsecured catheter tubing, and wiping a catheter toward a resident were improper technique which could contribute to infections. Interview with the Assistant Director of Nursing (ADON), on 01/27/16 at 9:20 AM, revealed staff did not demonstrate proper catheter care technique. The ADON stated staff should have kept Resident #4's catheter bag off the floor and wiped the catheter tubing away from the resident. Interview with the Director of Nursing (DON), at 10:27 AM on 01/28/16, revealed proper catheter care included keeping a catheter bag off the floor, anchoring catheters to the resident to prevent tugging, and cleansing catheter tubing away from the resident.

Based on observation, interview, record review, and review of the facility's policy and Mosby's textbook, it was determined the facility failed to ensure Certified Nursing Assistants (CNA) utilized proper technique during indwelling catheter care for one (1) of sixteen (16) sampled residents, (Resident #4). CNA #3 failed to utilize proper technique while performing catheter care for Resident #4 when the catheter tubing was cleaned towards the meatus. The findings include: Review of the facility's policy regarding Perineal Care (which included indwelling catheter care), revised 01/06/14, revealed during indwelling catheter care staff were to hold the catheter near the meatus, clean the catheter from the meatus down the catheter about four (4) inches. Clean downward away from the meatus, with one stroke. Repeat as needed with a clean area of the washcloth for each stroke, and dry the area. Do not tug or pull on the catheter, and secure the catheter. In addition, the policy directed staff to document in the resident's medical record the date and time perineal care was given, and the name and title of the individual who provided perineal care. Review of the Mosby's textbook for Long-Term Care Assistants, Fourth Edition, revealed step 7 raise the bed for body mechanics; step 8 lower the side rail near the CNA; step 10 cover the person with a bath blanket; step 12 fold back the blanket to expose the genital area; step 17 hold the catheter near the meatus; step 18 clean the catheter from the meatus down the catheter about 4 inches. Clean downward, away from the meatus with one stroke. Repeat as needed with a clean area of the washcloth. Use a clean washcloth if needed; step 19 rinse the catheter. Rinse from the meatus down the catheter about 4 inches. Rinse downward, away from the meatus with one stroke. Repeat as needed with a clean area of the washcloth. Review of Resident #4's clinical record revealed the facility admitted the resident on 03/18/15 with [DIAGNOSES REDACTED]. The facility admitted Resident #4 with an indwelling catheter. Observation of perineal and catheter care, at 3:56 PM on 01/27/16, revealed CNA #3 assisted Resident #4 to the restroom via wheelchair. CNA #3 instructed Resident #4 to stand in front of the toilet. CNA #3 performed hand hygiene, put on gloves, then removed Resident #4's catheter bag from the privacy bag and hung it on the underside of the wheelchair, allowing the bottom of the catheter bag to lay on the floor throughout perineal and catheter care. Further observation, revealed Resident #4 stated ouch several times as CNA #3 was wiping the labia from front to back. The catheter tubing was not anchored to the resident's leg, and was pulled taut. CNA #3 then used a clean wash cloth to cleanse approximately four (4) inches of the catheter toward Resident #4's perineal area. Interview with CNA #3, at 4:10 PM on 01/27/16, revealed she received training approximately one month ago on proper pericare and catheter care. CNA #3 stated, she did not realize the catheter bag was lying on the floor, and stated this could lead to infection as germs are on the floor. In addition, she stated Resident #4 should have had a leg strap on so the catheter would not pull and possibly cause pain for the resident. CNA #3, stated she did not realize she cleaned the catheter toward the resident and said she was trained to clean the catheter away from the resident, as it was important to prevent infections. Interview with the Minimum Data Set (MDS) Coordinator, on 01/28/16 at 8:40 AM, revealed ensuring a catheter bag was off the floor, anchoring indwelling catheter tubing, and cleansing catheters away from Resident #4 are all common knowledge interventions that all staff should know. Further interview, revealed the MDS Coordinator did not think catheter care needed to be documented in the clinical record. The MDS Coordinator stated that lack of catheter care or improper catheter care could lead to infections. Interview with the Staff Development Coordinator, on 01/27/16 at 9:00 AM, revealed a catheter bag on the floor, unsecured catheter tubing, and wiping a catheter toward a resident were improper technique which could contribute to infections. In addition, the Staff Development Coordinator reviewed the Nursing Care Flow Sheet and Event Charting and stated CNA's had not documented perineal or catheter care as directed to per facility policy. Interview with the Assistant Director of Nursing (ADON), on 01/27/16 at 9:20 AM, revealed staff had not documented indwelling catheter care in the clinical record, as directed per facility policy, nor did staff demonstrate proper catheter care technique. The ADON stated staff should have kept Resident #4's catheter bag off the floor and wiped the catheter tubing away from the resident. Interview with the Director of Nursing (DON), at 10:27 AM on 01/28/16, revealed proper catheter care included keeping a catheter bag off the floor, anchoring catheters to the resident to prevent tugging, and cleansing catheter tubing away from the resident. In addition, the DON stated it was facility policy to document the completion of perineal and catheter care.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure a Comprehensive Care Plan was revised related to the use of a hard cervical collar for one (1) of sixteen (16) sampled residents, (Resident #6). Resident #6 returned from the hospital with a hard cervical collar on 01/31/15; however, the facility did not revise the resident's care plan to include proper use and monitoring of the device to prevent wounds. On 02/18/15, the facility identified Resident #6 had developed two (2) wounds on the back of the head as a result of the cervical collar rubbing. (Refer to F314 and F498) The findings include: Review of the facility's policy regarding Resident Care Plan, revised February 2013, revealed the Health Care Center (HCC) Team Manager or Nurse Team leader would update the care plan promptly as changes occurred. Review of Resident #6's clinical record revealed the facility admitted the resident on 09/25/13 with [DIAGNOSES REDACTED]. Review of Resident #6's Quarterly Minimum Data Set (MDS) assessment, completed on 12/04/14, revealed the facility assessed the resident as rarely/never understood with short term and long term memory problems. The facility assessed the residents bed mobility as extensive assistance and total dependence for transfers, dressing and personal hygiene. The facility assessed the resident at risk for pressure ulcers with no current or history of pressure ulcers. Review of the Comprehensive Care Plan for Resident #6 revealed the facility developed a care plan on 09/12/14 for risk of skin breakdown related to the resident sitting quite a bit, with a goal to prevent skin breakdown through the next quarter. Interventions included: pressure reduction mattress; treatments per Physician orders; incontinent care; space boots in bed; and, monitor skin with incontinent care and bathing and report any changes to the nurse. Review of the hospital records for Resident #6, dated 01/31/15, revealed the resident returned to the facility after a fall with an injury with orders to wear a hard cervical collar at all times until seen for follow-up by the Physician. Continued review of the Comprehensive Care Plan for Resident #6 revealed the care plan had not been revised for the resident to indicate the use of the hard cervical collar or to direct staff on the assessment and care of the skin under the collar. Continued review of physician orders [REDACTED]. An order was written on 02/12/15 to assess the skin under the collar every shift. The orders were placed on the Medication Administration Record [REDACTED]. Observation, on 02/17/15 at 5:00 PM, of Resident #6 revealed the resident was laying on the bed. The resident had a cervical collar on, but it was up on the face and did not appear to be in the proper position. Observation, on 02/18/15 at 7:42 AM, of Resident #6 revealed the resident was in bed, with the cervical collar on, but was positioned up on the face. Interview with Certified Nursing Assistant (CNA) #2, on 02/20/15 at 12:05 PM, revealed the CNAs received report from the nurses and if they had questions about the resident's care they could ask the nurse. The CNA stated she was familiar with the care needs of the resident; however, received no training on the collar and it was not on the CNA care plan. Interview with Licensed Practical Nurse (LPN) #2, on 02/19/15 at 2:15 PM, revealed she was not responsible to revise care plans. She stated the charge nurse or desk nurse updated the comprehensive care plan and Certified Nursing Assistant (CNA) care plans when physician orders [REDACTED]. Interview with LPN #6, on 02/19/15 at 2:35 PM, revealed she was the second shift Supervisor. She stated when a physician order [REDACTED]. She stated when Resident #6 returned from the hospital with a hard cervical collar, the care plan should have been revised to ensure the residents needs were identified and care needs were met. She stated the Resident Assessment Coordinator was responsible to follow up to ensure the orders received had been placed on the care plan. Interview with Registered Nurse (RN) #3, on 02/20/15 at 11:15 AM revealed she was the day shift Unit Manager. She stated the person who takes the orders off was responsible to update the comprehensive care plan and CNA care plan. She stated when Resident #6 returned from the hospital with the hard cervical collar, it should have been placed on the care plan. She stated the care plan coordinated the care of the resident so the resident could receive the best possible care. Interview with LPN #3, on 02/20/15 at 11:48 AM, revealed she never updated the care plan because the charge nurse and Resident Assessment Coordinator were responsible for updating the care plan. Interview with RN #2, on 02/20/15 at 10:40 AM, revealed she was the Resident Assessment Coordinator. She stated the process for care plan development or revision occurred when the nurses received a new order. They had the opportunity to develop or revise the care plan. She then followed-up on the physician order [REDACTED]. She stated she was aware of the fall with Resident #6 because she had seen everything on the twenty-four hour report when the resident returned from the hospital. She stated she had not added anything to the care plan, because in multiple places on the care plan, it stated treatment per physician order [REDACTED]. Per interview, she didn't think she needed to repeat what was on the medication record and treatment record for Resident #6. She stated she believed the care plan was sufficient to meet the needs of Resident #6. She did not think specific interventions needed to be added to the care plan to ensure appropriate care was provided related to the use of the collar.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the Comprehensive Care Plan was consistently followed to prevent accidents for one (1) of sixteen (16) sampled residents, (Resident #6). The facility assessed Resident #6 to require the use of a postural vest to maintain posture while sitting in a wheelchair. A physician's orders [REDACTED]. The falls care plan was revised on 09/26/14 to include the physician order [REDACTED]. However, on 01/30/15, CNA #2 failed to apply the postural vest on Resident #6 while up in the wheelchair and left the resident unattended in the resident's room. The resident fell from the wheelchair and sustained a concussion, a contusion to the face, and laceration to the forehead requiring a hospital transfer and sutures. (Refer to F323 and F498) The findings include: Review of the facility's policy regarding Resident Care Plans, revised April 2013, revealed Care Plans would include the date initiated; problem area; goals; interventions; the department responsible for each intervention; and, the goal review date. Changes to the care plan may occur due to changes in the resident's behavior; a new onset of falls; an addition of a new medication; and, a new onset of skin changes. Review of the facility's policy regarding CNA Assignment sheets/Resident Plan of Care, revised January 2014, revealed each CNA would be provided a CNA assignment sheet/Plan of Care that followed the resident's comprehensive care plan, and directed the CNA on the care to provide based on physician orders [REDACTED]. Review of Resident #6's clinical record revealed the facility admitted the resident on 09/25/13 with [DIAGNOSES REDACTED]. Review of Resident #6's Quarterly Minimum Data Set (MDS) assessment, completed on 12/04/14, revealed the facility assessed the resident as rarely/never understood with short term and long term memory problems. The facility assessed the resident's bed mobility as extensive assistance and total dependence for transfers, dressing and personal hygiene. Review of the Comprehensive Care Plan for Resident #6, revealed the facility developed a care plan on 09/12/14 for risk of falls related to progression of Alzheimer's and Dementia, with a goal to be free from preventable falls while remaining restraint free, in order to decrease the risk of injury from falls, through the next quarter. Interventions included to assist with balance during care giving; toilet and transfer per the CNA sheet; therapy to screen quarterly; monitor for unsafe behavior; clip alarm at all times; bed sensor pad in bed and in wheelchair; and, bed wedges when in bed. On 09/26/14 the falls care plan was revised with a new intervention for a postural vest on the resident when up in the wheelchair. Review of the incident investigation, dated 01/30/15 at 7:45 PM, revealed CNA #2 reported she had put a gown on Resident #6 for bed, placed the tab alarm back on the resident, then left the room to get the mechanical lift. When she came back, less than a minute later, the resident was laying on the floor, on the left side, in a pool of blood, with the tab alarm sounding. The resident was sent to the hospital for an evaluation. Continued review of the incident investigation, dated 01/30/15, revealed the Director of Nursing (DON) interviewed CNA #2 on 01/31/15 regarding the fall. The CNA stated she had not put the postural vest on the resident when she left the room to get the lift because the order for the vest said for the resident to have it on when out of bed, but it did not say the resident couldn't be without it at any time, when out of bed. She didn't feel like she needed to put the postural vest on the resident just to go down the hallway to get the lift. Review of the hospital transfer records, dated 01/30/15- 01/31/15, revealed Resident #6 sustained a concussion, scalp laceration, and contusion to the face, from a fall at the nursing home. Discharge instructions included use of a hard cervical collar. Interview with CNA #2, on 02/19/15 at 1:15 PM, revealed she had worked with Resident #6 and was familiar with the resident's care needs. She stated she got her information about resident care needs from the CNA care plan and reports from the previous shift. She stated Resident #6 had a tab alarm, sensor pad when in bed and wheelchair, and a postural vest when up in the wheelchair. She stated she did not know the resident was a falls risk prior to the fall on 01/30/15 and was not aware of any previous falls. She stated she believed the postural vest was used when Resident #6 was up in the wheelchair for posture and not to prevent falls. She stated she had never left the resident unattended, without the postural vest in place while up in the wheelchair, prior to this incident. Review of the CNA care plan for Resident #6, not dated, and used by staff prior to the fall on 01/30/15, under the section mobility devices, positioning and safety, the interventions included a postural vest when up in the wheelchair; a clip alarm at all times; a sensor pad to the wheelchair; and a bed sensor. Interview with Licensed Practical Nurse (LPN) #6, on 02/19/15 at 2:35 PM, revealed she was the second shift Supervisor and her responsibility was to oversee floor staff to ensure they were providing appropriate care for the residents. She stated the CNAs received a daily care plan that included the care needs of the residents and any new orders were given to staff in daily report. She ensured residents were getting proper care by observing the residents, and looking at the CNA books to ensure they documented care provided. She stated Resident #6 should not have been left without the postural vest in place as it was ordered for safety. She stated the order was on the comprehensive care plan and the CNA care plan; however, CNA #2 failed to follow the care plan as required. Interview with LPN #2, on 02/19/15 at 2:15 PM, revealed she had provided care for Resident #6 on a regular basis and was familiar with the resident's care needs. She stated she received report every morning and generally gave report to CNAs daily on what was going on with the residents on the unit. She ensured the CNAs were providing the proper care by supervising them, and going behind them. She looked at the residents everyday to make sure they were clean and had everything they needed. She stated the resident used the postural vest for safety because he/she would slump over. She stated she believed CNA #2 knew the resident required the postural vest for safety; however, made a mistake by failing to follow the care plan. Interview with Registered Nurse (RN) #3, on 2/20/15 at 11:15 AM, revealed she was the charge nurse on day shift. Her responsibility was to help the nurses as needed, answer questions staff may have, and ensure residents received care as ordered. She stated Resident #6 had the intervention to wear the postural vest when up in the wheelchair that was on the comprehensive care plan and the CNA care plan. She stated if a staff member was assigned to a resident and there was something they were not familiar with, they were told to ask questions. She stated CNA #2 was probably in a hurry and wasn't thinking about the safety of the resident when she failed to apply the postural vest for Resident #6. Interview with the DON, on 02/20/15 at 2:52 PM, revealed the care plan stated for the resident to wear the postural vest when up in the wheelchair and the resident was up in the chair when he/she fell . She acknowledged the CNA failed to follow the care plan by not applying the postural vest on the resident when the resident was up in the chair.

Based on observation, interview, record review, and review of the facility's policy it was determined the facility failed to ensure residents admitted without pressure sores did not develop pressure sores, for one (1) of sixteen (16) sampled residents (Resident #6). The hospital returned Resident #6 on 01/31/15 with a hard cervical collar in place with orders for a hard cervical collar to be worn at all times. The facility failed to assess and monitor the skin under the collar appropriately, failed to train staff on the assessment of the skin under the collar, use of the collar, and proper application of the collar, and failed to develop a Comprehensive Care Plan for use of the hard cervical collar, resulting in the resident developing two (2) wounds on the back of the residents head. (Refer to F280 and F498) The findings include: Review of the facility's policy regarding skin breakdown/pressure ulcer, revised October 2014, revealed an avoidable pressure ulcer was the development of a pressure ulcer in which the facility failed to do one or more of the following: evaluate the residents clinical condition and pressure ulcer risk factors; define and implement interventions that were consistent with resident needs, goals, and standards of practice; monitoring and evaluating the interventions; and, revision of approaches as appropriate. Friction was defined as a mechanical force exerted on skin that was dragged across any surface. The policy did not include any information on assessment and prevention regarding residents with splints or devices that may cause pressure. Review of Resident #6's clinical record revealed the facility admitted the resident on 09/25/13 with [DIAGNOSES REDACTED]. Review of Resident #6's Quarterly Minimum Data Set (MDS) assessment, completed on 12/04/14, revealed the facility assessed the resident as rarely/never understood with short term and long term memory problems. The facility assessed the residents bed mobility as extensive assistance and total dependence for transfers, dressing and personal hygiene. The facility assessed the resident at risk for pressure ulcers with no current or history of pressure ulcers. Review of the Comprehensive Care Plan for Resident #6 revealed the facility developed a care plan on 09/12/14 for risk for skin breakdown related to the resident sits quite a bit, with a goal to prevent skin breakdown through the next quarter. Interventions included: pressure reduction mattress; treatments per Physician orders; incontinent care; space boots in bed; and, monitor skin with incontinent care and bathing and report any changes to the nurse. Review of the hospital records for Resident #6, dated 01/31/15, revealed the resident returned to the facility after a fall with an injury with orders to wear a hard cervical collar at all times until seen for follow-up by the Physician. Continued review of the Comprehensive Care Plan for Resident #6 revealed the care plan was not revised to indicate the use of the hard cervical collar for the resident. Continued review of physician orders [REDACTED]. An order was written on 02/12/15 to assess the skin under the collar every shift. Review of the Medication Administration Record [REDACTED]. Observation of Resident #6, on 02/17/15 at 5:00 PM, revealed the resident laying on the bed. The resident had a cervical collar on, but it was positioned up on the face and did not appear to be in the proper position. Observation, on 02/18/15 at 7:42 AM, revealed the resident was in bed with the cervical collar on and was position up on the face as the previous day. Interview with LPN #2, on 02/19/15 at 10:45 AM, revealed staff had identified two (2) spots on the back of the residents head on 02/18/15. Review of the incident report for Resident #6, dated 02/18/15 at 11:15 AM, revealed two (2) area's were identified on the back of the residents head. The first area was a circular scabbed area that measured 2.5 centimeters by 1 centimeter. The second area just below the first area was a circular scabbed area that measured 1.25 centimeters by 0.75 centimeters. In the description, the Assistant Director of Nursing documented, she instructed the charge nurse to call the Physician regarding the cervical collar due to the collar rubbing the resident's head. Continued interview with LPN #2, on 02/19/15 at 2:15 PM, revealed Resident #6 returned from the hospital with the cervical neck collar. The resident was required to wear it at all times. She stated it was on the MAR indicated [REDACTED]. LPN #2 stated when residents come back from the hospital with splints and devices, therapy usually trained staff on the proper use; however, they had not trained staff on the use of the hard cervical collar when Resident #6 came back from the hospital. She stated they received orders for Resident #6, on 02/18/15, to pad the back of the cervical collar. Observation, on 02/19/15 at 12:45 PM, of the skin assessment completed by LPN #2 for Resident #6, revealed two (2) scabbed areas on the back of the resident's head. One area was smaller and just below the larger area. Observation of the removed cervical neck collar for Resident #6, due to meal time, revealed dried serosanguinous substance on the inner back side of the collar over two (2) flat white buttons that attached the Velcro piece to the collar. Interview with LPN #6, on 02/19/15 at 2:35 PM, revealed she was the second shift Supervisor. She stated Resident #6 was readmitted to the facility on [DATE] with orders for a hard cervical collar not a soft collar. She stated she had not been trained on the hard cervical neck collar when the resident returned; however, staff should have because it was a different collar and staff needed to know where the pressure points were for that collar and this resident. She stated the cervical collar should have been put on the resident's Comprehensive Care Plan because it identified the problem and ensured care needs were met. Interview with LPN #3, on 02/20/15 at 11:48 AM, revealed when Resident #6 returned from the hospital on [DATE] with the hard cervical collar, she had questioned it because the collar was not on the resident in the correct position. She stated she had talked with the Nurse Practitioner, but the Physician did not want to make a change until the resident was seen during follow-up. She stated no one at the facility instructed staff on the use of the collar or where to assess the skin when the resident returned from the hospital. Interview with the DON, on 02/20/15 at 2:52 PM, revealed staff should have been trained on assistive devices used in the facility. She stated obviously, there was a system problem related to training of staff on assistive devices used in the facility. She stated it was a risk to the residents if the staff were not trained because the care needs may not be met.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents for one (1) of sixteen (16) sampled residents, (Resident #6). The facility assessed Resident #6 to require the use of a postural vest to maintain posture during sitting in a wheelchair. On 01/30/15, Certified Nursing Assistant (CNA) #2 failed to apply the postural vest on Resident #6 while up in the wheelchair and left the resident unattended in the resident's room. The resident fell from the wheelchair and sustained a concussion, a contusion to the face, and laceration to the forehead requiring a hospital transfer and sutures. (Refer to F282 and F498) The findings include: Review of the facility's policy regarding Falls and Fall Risk Management, revised 05/16/13, revealed the purpose of assessing falls and their causes was to provide guidelines for assessing a resident after a fall and to assist in identifying the cause of a fall. The staff would evaluate functional and psychological factors that may increase the risk of falls including: ambulation; mobility; gait; balance; excessive motor activity; Activities of Daily Living capabilities; activity tolerance; continence; and, cognition. Under the section Continuing Successful Interventions, it stated if interventions had been successful in preventing falls, staff would continue the interventions. Review of the incident investigation, dated 01/30/15 at 7:45 PM, revealed CNA #2 reported she had put a gown on Resident #6 for bed, placed the tab alarm back on the resident, then left the room to get the mechanical lift. When she came back, less than a minute later, the resident was laying on the floor, on the left side, in a pool of blood, with the tab alarm sounding. The resident was sent to the hospital for an evaluation. Continued review of the incident investigation, dated 01/30/15, revealed the Director of Nursing (DON) interviewed CNA #2 on 01/31/15 regarding the fall. The CNA stated she had not put the postural vest on the resident when she left the room to get the lift because the order for the vest said for the resident to have it on when out of bed, but it did not say the resident couldn't be without it at any time, when out of bed. She didn't feel like she needed to put the postural vest on the resident just to go down the hallway to get the lift. Review of the hospital transfer records, dated 01/30/15- 01/31/15, revealed Resident #6 sustained a concussion, scalp laceration, and contusion to the face, from a fall at the nursing home. Discharge instructions included use of a hard cervical collar. Interview with CNA #2, on 02/19/15 at 1:15 PM, revealed she had worked with Resident #6 and was familiar with the resident's care needs. She stated she got her information about resident care needs from the CNA care plan and reports from the previous shift. She stated Resident #6 had a tab alarm, sensor pad when in bed and wheelchair, and a postural vest when up in the wheelchair. She stated she did not know the resident was a falls risk prior to the fall on 01/30/15 and was not aware of any previous falls. She stated she believed the postural vest was used when Resident #6 was up in the wheelchair for posture and not to prevent falls. She stated she had never left the resident unattended, without the postural vest when up in the wheelchair, prior to this incident. She stated she had not been trained on the use of the postural vest for this resident or for any other resident. Interview with Licensed Practical Nurse (LPN) #6, on 02/19/15 at 2:35 PM, revealed she was working on the evening when Resident #6 sustained the fall and CNA #2 called her to the room and she found the resident on the floor, turned to the left side, with blood pooled on the floor. She stated CNA #2 told her she had turned to get the lift and the resident fell . The CNA did not tell her she had left the room to get the lift. She stated the DON did not interview her after the incident. LPN #6 stated Resident #6 should not have been left without the postural vest in place as it was ordered for safety. She stated she was very comfortable that CNA #2 was aware the resident required the postural vest on at all times when up in the wheelchair and, it was on the CNA care plan. She stated Resident #6 was weak, and had no control of his/her trunk at all and if you sat the resident up, the resident would fall forward, backward or sideways. Review of the CNA care plan in place prior to the 01/30/15 fall revealed under the section mobility devices, positioning and safety, the interventions included: postural vest when up in the wheelchair; a clip alarm at all times; a sensor pad to wheelchair; and a bed sensor. Observation, on 02/17/15 at 5:00 PM, of Resident #6 revealed the resident laying on the bed. Bed bolsters were in place to the side of the bed and a tab alarm was on the shirt by the left shoulder. The resident had on a cervical collar but it was up on the face and did not appear to be in the proper position. A scab was noted on the residents forehead and the left eye had a light purple area over the eye lid. The resident was vocalizing with no apparent intent. Review of Resident #6's clinical record revealed the facility admitted the resident on 09/25/13 with [DIAGNOSES REDACTED]. Review of the Occupational Therapy (OT) notes for Resident #6, revealed Therapist #2 completed an initial evaluation on 08/15/14 for poor positioning and hyperextension of the neck, with functional goals for caregiver/nursing staff to ensure resident was positioned in a high back wheelchair to increase postural alignment and to increase safety. On 08/18/14, Therapist #1 documented the resident did not require a lap buddy any more. On 08/19/14 she documented, observation of the resident in the wheelchair, with the head and neck flexed forward and sleeping. The resident required readjustment at the hips to increase postural alignment. On 08/29/14 she documented, observation of the resident at breakfast with the resident's trunk leaning forward. On 09/03/14, 09/05/14, and 09/09/14 Therapist #1 documented the resident was exhibiting neck extension. Review of the Comprehensive Care Plan for Resident #6, revealed the facility developed a care plan on 09/12/14 for risk of falls related to progression of Alzheimer's and Dementia, with a goal to be free from preventable falls while remaining restraint free, in order to decrease the risk of injury from falls, through the next quarter. Interventions included assist with balance during care giving; toilet and transfer per the CNA sheet; therapy to screen quarterly; monitor for unsafe behavior; clip alarm at all times; bed sensor pad in bed and in wheelchair; and, bed wedges when in bed. Further review of the OT notes for Resident #6 revealed on 09/16/14 Therapist #1 documented the resident continued with neck extension and changed posture very frequently. On 09/18/14 she documented due to leaning forward from the pillow, she would plan to place a postural vest on the resident to increase the residents alignment and stability. Review of physician orders [REDACTED]. Continued review of the resident's care plan revealed on 09/26/14 the care plan was revised with a new intervention for postural vest on resident when up in the wheelchair. Further review of the OT notes for Resident #6 revealed, on 09/30/14, Therapist #2 documented the resident remained leaning forward and was very rigid when repositioned. Review of the Falls Risk Assessment, dated 12/02/14, revealed the facility assessed Resident #6 on 12/02/14 as a high falls risk with a score of 55.0 on the Morse fall scale. A score over 45 indicated a high risk. The facility indicated on the mental status assessment the resident had previous falls, was non-ambulatory, had impaired gait, and forgot limits. Review of the Restraint Screening for Resident #6, dated 12/02/14, revealed LPN #2 documented the resident had a safety vest as a restraint for safety, but did not complete the the last two (2) questions: did it limit the residents mobility, and was the resident able to remove the device. The form was then signed off by LPN #1 as the designated signature. Interview with LPN #2, on 02/20/15 at 12:05 PM, revealed she had completed the restraint assessment for Resident #6 on 12/02/14, but did not know why she did not answer all of the questions. She stated she called it a safety vest because it was for safety due to the resident leaning forward. She stated Registered Nurse (RN) #2, the Resident Assessment Coordinator, had left restraint assessments for staff to complete during the resident's Minimum Data Set Assessment period. She went on to say she was not sure if she had been trained on how to complete the restraint assessment. She stated an accurate assessment was important to ensure the change in a condition was reported. Interview with RN #2, the Resident Assessment Coordinator, on 02/20/15 at 10:40 AM, revealed nurses were assigned to complete restraint assessments for residents on admission, quarterly, and with any change in condition. The form was then returned to her department where she was usually the person who signed off as completed. She stated the restraint screening completed for Resident #6 on 12/02/14 was inaccurate because they called it a safety vest and not a postural vest and all the questions were not answered. She stated if the assessment was not completed or accurate, proper care could not be ensured. She went on to say, she was in the process of completing a Significant Change Assessment and it would be coded as a restraint since the resident had a fall. Interview with RN #3, on 02/20/15 at 11:15 AM, revealed RN #2, who was the Resident Assessment Coordinator, was responsible to oversee restraint assessments. RN #3 gave restraint assessments to nurses to complete as needed. She stated she was not trained on completing the restraint assessment, but if it was not completed it would not be an accurate assessment and could result in the residents not receiving the best care possible. Review of Resident #6's Quarterly Minimum Data Set (MDS) assessment, completed on 12/04/14, revealed the facility assessed the resident as rarely/never understood with short term and long term memory problems. The facility assessed the resident's bed mobility as extensive assistance and total dependence for transfers, dressing and personal hygiene. Under the section Restraints, the facility assessed the resident as having no restraint. Interview with RN #2, the Resident Assessment Coordinator, on 02/20/15 at 9:28 AM, revealed when she completed the Quarterly Assessment for Resident #6 in December 2014, she had assessed the postural vest as a positioning devise and not a restraint because the resident was not trying to get up. Interview with LPN #2, on 02/19/15 at 2:15 PM, revealed she had provided care for Resident #6 on a regular basis and was familiar with the resident's care needs. She stated the postural vest was implemented for Resident #6 because the resident was leaning forward and it was intended for positioning and to prevent the resident from falling out of the chair. LPN #2 stated it was not safe for the resident to be up in the wheelchair without the postural vest, but she could see where it might be misleading to the CNA by it being called a postural vest. Interview with CNA #4, on 02/19/15 at 2:00 PM, revealed she had provided care for Resident #6 and was familiar with the resident's needs. She stated at the beginning of the shift she retrieved her CNA care plans for residents she was assigned. She then received report from the nurse before the shift and if anything had changed on her assigned residents. She was only familiar with one (1) fall with Resident #6 that occurred most recently. She stated Resident #6 used the postural vest to keep the resident sitting up straight because the resident leaned forward and moved around frequently and was at risk for falls. She stated the postural vest was required when Resident #6 was up at any time because the resident was not safe without it. Interview with RN #3, on 2/20/15 at 11:15 AM, revealed she was the charge nurse on day shift. Her responsibility was to help the nurses as needed, answer questions staff may have, and ensure residents received care as ordered. She stated Resident #6 was referred to therapy because the resident was leaning forward. Therapy had worked with the resident and recommended the postural vest for safety and positioning. After therapy had initiated an assistive device, they usually trained all the staff on the proper use of the device. She stated if a staff member was assigned to a resident and there was something they were not familiar with they were told to ask questions. She stated the CNAs may not have been properly trained on the use of the postural vest if the training was not facility wide because some staff could have been missed. Interview with OT #1, on 02/19/15 at 1:45 PM, and on 02/20/15 at 8:20 AM, revealed she was the Therapy Department Director for the facility. She stated she had treated Resident #6. She stated the resident did have a lap buddy restraint previously due to falls. She stated the lap buddy was discontinued because the resident stopped trying to get up and was observed more leaning forward and side to side. She stated the resident was very difficult to work with because his/her posture changed so frequently. She stated they had tried multiple other things like pillows, and rolled blankets to improve the resident's posture, but the resident's tone changed so much they implemented the postural vest for postural stability. She stated poor posture could lead to falls and it would be in the resident's best interest if the postural vest was on at all times while up in the wheelchair. She stated the physician's orders [REDACTED]. She stated it was up to nursing to assess the postural vest as a restraint. She stated when new devices were implemented for residents they trained the staff on duty that day on the use of the device and then those staff would pass it along to everyone else. Per the her OT note, dated 10/06/14, staff was educated on positioning and tightening of the postural vest for proper use. However, she did not have any evidence of who was trained on the use of the postural vest. She stated it was not her practice to keep documentation of staff trained on assistive devices from her department. Interview with RN #1, the Staff Development Coordinator, on 02/20/15 at 12:23 PM, revealed CNAs were trained to use their CNA sheet as a guide to provide care for the residents. If they had any questions they were to ask a nurse. She stated the last training on falls was 10/15/14 for the nurses and clips alarm training for CNAs. She stated if a resident had an incident, the DON or Nurse Manager would let her know if more education was needed; however, there was no additional training after Resident #6 had a fall. She stated all staff should be trained on equipment used in the facility and believed the therapy department was doing all the training on therapy equipment. She stated she had not completed any staff training on the use of the postural vest but it was probably needed. She stated RN #2, the Resident Assessment Coordinator, was responsible to oversee restraint assessments and she had not completed any staff training on restraint assessments or use. Interview with the DON, on 02/20/15 at 2:52 PM, revealed she, the Assistant Director of Nursing, the Resident Assessment Coordinator, and Staff Development met every morning regarding falls in the facility; however, the Therapy Director did not attend. She stated when a resident had a fall, they determined what new interventions needed to be added. When Resident #6 had the fall she did the investigation and determined the intervention on the CNA care plan for the postural vest said, on when up in the chair, and not at all times. She stated the care plan stated for the resident to wear when up in the wheelchair and the resident was up in the chair when he/she fell , but she could see where there was room for interpretation as CNA #2 stated. The DON stated staff should have been trained on assistive devices used in the facility and did not know they were not trained on the use of the postural vest or that there was no documentation from the therapy department on who was trained on devices. Their system for restraint assessments needed work and obviously their training on restraints, assessments and devices had a problem. She stated the risk for the residents were their care needs may not be met.

Based on interview, record review, and review of staff training and education, it was determined the facility failed to ensure nurse aides were trained on the use of assistive devices to prevent accidents for one (1) of sixteen (16) sampled residents, (Resident #6). Interview and record review revealed nursing assistants had not been trained on the use a postural vest for Resident #6. Certified Nursing Assistant (CNA) #2 failed to apply the device to Resident #6 on 01/30/15, resulting in a fall from the wheelchair that caused a concussion, contusion to the face, and laceration to the forehead requiring a hospital transfer and sutures. In addition, nursing assistants had not been trained on the proper use of a cervical collar for Resident #6 when the resident returned from the hospital on [DATE]. The facility failed to train staff on the assessment of the skin under the collar, use of the collar, and proper application of the collar resulting in the resident developing two (2) wounds on the back of the residents head. (Refer to F314 and F323) The findings include: The facility did not provide a policy regarding staff training and education. Review of the incident investigation, dated 01/30/15 at 7:45 PM, revealed CNA #2 reported she put a gown on Resident #6 for bed, placed the tab alarm back on the resident, then left the room to get the mechanical lift. When she came back, less than a minute later, the resident was laying on the floor, on the left side, in a pool of blood, with the tab alarm sounding. The resident was sent to the hospital for an evaluation. Continued review of the incident investigation, dated 01/30/15, revealed the Director of Nursing (DON) interviewed CNA #2 on 01/31/15 regarding the fall. The CNA stated she had not put the postural vest on the resident when she left the room to get the lift because the order for the vest said for the resident to have it on when out of bed, but it did not say the resident couldn't be without it at any time, when out of bed. She didn't feel like she needed to put the postural vest on the resident just to go down the hallway to get the lift. Review of the hospital discharge instruction for Resident #6, revealed on 01/31/15, the resident was transferred back to the facility with an order for [REDACTED]. Interview with CNA #2, on 02/19/15 at 1:15 PM, revealed she had not been trained on the use of the postural vest for this resident and thought it was used for posture, but not to prevent falls. CNA #2 stated the resident came back from the hospital with the collar; however, she had not been educated on the reason for its use or proper positioning of the collar for the resident. Interview with CNA #4, on 02/19/15 at 2:00 PM, revealed she could not remember if she had been trained on the postural vest used for Resident #6, but it was common sense. In regards to the hard cervical collar on Resident #6, she stated she had been trained previously on the neck collars; however, not for Resident #6. She was unsure who did the training previously on the use of neck collars. Interview with Registered Nurse (RN) #3, on 02/20/15 at 11:15 AM, revealed she was the Unit Manager for the Health Care Unit. She stated she thought the Therapy Department conducted the training on assistive devices implemented by the Therapy Department. She stated Resident #6 was evaluated and treated by the Therapy Department because the resident was leaning forward and at risk for falls. She stated if training was not facility wide someone might not receive the training; therefore, the CNAs were probably not adequately trained on the use of the postural vest. In regards to the hard cervical collar, she was not aware of any training completed when Resident #6 returned from the hospital with the cervical collar by the Therapy Department or Staff Development. Interview with Licensed Practical Nurse (LPN) #2, on 02/19/15 at 2:15 PM, revealed she had been trained on the use of the postural vest for Resident #6 by the Therapy Department, but was unaware of who trained the other staff on it's use. She believed therapy did the training since they recommended the assistive device. LPN #2 stated when residents come back from the hospital with splints and devices, therapy usually trained staff on the proper use. However, they had not trained staff on the use of the hard cervical collar when Resident #6 came back from the hospital. Interview with Occupational Therapist #1, on 02/19/15 at 1:45 PM, and on 02/20/15 at 8:20 AM, revealed when new assistive devices were implemented for residents they trained the staff on duty that day on the use of the device and then those staff would pass it along to everyone else. She stated she did not have any evidence of who was trained on the use of the postural vest. She stated it was not her practice to keep documentation of staff trained on assistive devices from her department. In regards to the hard cervical collar for Resident #6, she stated therapy had not picked up the resident when he/she returned from the hospital because they were unsure of the Physician follow-up; therefore, she did not train the staff on the use of the cervical collar. Interview with RN #1, the Staff Development Coordinator, on 02/20/15 at 12:23 PM, revealed the most recent staff training was falls on 10/15/14 for the nurses and clip alarm training for CNAs. She stated if a resident had an incident, the DON or Nurse Manager would let her know if more education was needed; however, there was no additional training after Resident #6 had the fall on 01/30/15. She stated all staff should be trained on equipment used in the facility and believed the Therapy Department was doing all the training on therapy equipment. She stated she had not completed any staff training on the use of the postural vest but it was probably needed. She stated in regards to the hard cervical collar, Resident #6 was readmitted with on 01/31/15, and staff had not brought it to her attention that training was needed. However, she acknowledged she had seen the resident wearing the cervical collar. Interview with the DON, on 02/20/15 at 2:52 PM, revealed staff should have been trained on assistive devices used in the facility and was unaware all staff was not trained on the use of the postural vest or that there was no documentation from the Therapy Department on who was trained on devices. She stated obviously there was a system problem related to training of staff on assistive devices used in the facility. She stated it was a risk to the residents if staff was not trained because the resident care needs may not be met.

Based on observation, interview, record review, and review of the facility's policy regarding "Abuse Detection and Prevention", it was determined the facility failed to complete a thorough investigation regarding allegations of sexual abuse for one (1) of six (6) sampled resident (#2). The facility failed to follow their Abuse Detection and Prevention Policy related to conducting a thorough investigation, protecting residents from further abuse, and reporting the allegation to the State Survey Agency. On 09/05/11, facility staff observed Resident #2 kissing Resident #6 and taking his/her hand and placing it in his/her unzipped pants. On 09/26/11, facility staff observed Resident #2 with his/her hands under Resident #1's blanket in the living room, with his/her hand moving up and down around the resident's genital area. The facility failed to complete a thorough investigation of both incidents, by failing to interview the alleged perpetrator (Resident #2), as well as the other residents on the unit. The facility's failure to provide supervision placed residents at risk for serious injury, harm, impairment or death. Immediate Jeopardy was identified on 09/29/11, was determined to exist on 09/05/11 and is ongoing. Substandard Quality of Care (SQC) was identified in the areas of 42 CFR 483.13 Resident Behavior and Facility Practices F225, F226, and 42 CFR 483.25 Quality of Care F323. The findings include: Review of the facility policy "Abuse Detection and Prevention", revised January 2010, regarding...3. Prevention.... j. Resident behaviors which might lead to injury of others will be assessed and addressed through the interdisciplinary team process. Appropriate instruction will be communicated to nurse aides through the assignment sheets so as to prevent resident-to-resident abuse ... 5. Investigation...d. Investigation will include an interview of the alleged victim, alleged perpetrator and all potential witnesses to the allegation...e. Interviews will be conducted by the Vice President of Nursing or her designee with one additional staff person with exceptions authorized by the Vice President of Nursing &Client Services. Document content of interviews....f. Statements may be requested from any and all individuals interviewed....g. The resident's medical record will be reviewed for information applicable to the abuse allegation...h. Information from all sources will be compiled and included in Abuse investigation Reports... i. Upon receiving reports of physical or sexual abuse, the nurse in charge shall be assigned to immediately examine the resident. Findings of the examination must be recorded in the nurse's notes of the resident's medical record and on an Incident/Abuse form. (Note: If sexual abuse is suspected or alleged. DO NOT bathe the resident or wash the resident's clothing or linen. (Call the police immediately.) Interview with the Social Services Director, on 09/28/11 at 2:30 PM, revealed she was responsible for investigating any allegations of abuse, and reporting these to the required state agencies. The Social Services Director revealed she was primarily responsible for investigations of suspected abuse. A review of the facility's investigation, dated 09/05/11, revealed an incident had occurred between Resident #6 and Resident #2 in the living room of the facility. The facility investigation stated that CNA #6 (who was currently sitting with Resident #6 and an employee of the facility), reported to the 7-3 RN Charge Nurse that Resident #2 had put his/her hand on Resident #6's shoulder, then leaned over and kissed his/her. CNA #6 reportedly tried to separate the two resident's; however, Resident #6 refused to leave the area. At that time both resident's continued watching TV, and approximately 15 minutes later, Resident #2 grabbed Resident #6's hand and put his/her hand down his/her pants. The two were immediately separated and CNA #6 informed 7-3 RN Charge Nurse and the Director of Nursing. Continued review of the investigation revealed Resident #6 had primary [DIAGNOSES REDACTED]. The only statement obtained in the investigation was the witness (CNA #6) who reported the incident. Interview with the CNA #6, on 09/29/11 at 4:30 PM, revealed Resident #6 and Resident #2 had been sitting together every day, and Resident #6 considered Resident #2 a boyfriend. The CNA stated she did not think of this as a problem with abuse. There was no documented evidence of an entry into the medical record that the incident had occurred. Also, there was no evidence the facility conducted an examination or assessment per the facility policy. In addition, there was no evidence the required 5 day follow up investigation, which determines the outcome of the investigation, was not reported to the state agency. Interview with the RN Supervisor on the North Hall, on 09/29/11 at 5:30PM, revealed after the 09/05/11 altercation with Resident #2 and resident #6, the Director of Nursing was notified; however, nothing else was done at that time because Resident #6 had previously been provided a sitter during the day. There was no evidence the victim had been examined after the incident. Continued interview with the Social Services Director, on 09/28/11 at 2:30 PM, revealed there was no specific action taken after the first incident involving Resident #2. The Social Services Director also stated the facility determined this was an isolated incident and did not warrant further action, because everyone felt the two residents were friends. Interview with the Director of Nursing, on 09/28/11 at 6:45 PM, revealed she did not look at the initial incident as a problem with Resident #2 but as a staff issue. The DON stated that since Resident #6 already had scheduled sitters, she felt Resident #6 was protected; however, she did not think about the other residents in the facility, or view this as a new behavior for Resident #2. She stated the resident should have been assessed initially, and care planned for behaviors, although the resident had not exhibited those behaviors before the 09/05/11 incident. Therefore, the facility could provide no evidence of interventions put in place to prevent further recurrence of potential sexual abuse as the facility did not restrict Resident #2's access to the other residents nor did they increase supervision of Resident #2. Review of a second investigation involving Resident #2, dated 09/26/11, revealed an incident had occurred between Resident #2 and Resident #6 in the patio room of the facility at approximately 11:00 AM. CNA #2 reported to CNA #1 she had observed Resident #2 with his/her hand under a blanket that was covering Resident #1. Resident #1 was sleeping at that time. The report revealed that Resident #2 had his/her hand in the lower region of Resident #1's body, and it appeared the resident was touching his/her genital area. Resident #2 was removed from the area and sitters were arranged to sit with Resident #2 during his/her waking hours. The physician was notified, and a medication was ordered to decrease the resident's sexual desire and control these impulses. Resident #1 was listed on the report as having primary [DIAGNOSES REDACTED]. While, the facility provided Resident #2 with a sitter from 6:30AM-10:30PM, they were unable to show how the facility supervised the resident from 10:30PM-6:30AM. In addition, the facility did not have evidence that they assessed the resident through the interdisciplinary process by developing a behavior care plan for the resident. Review of Resident #2's clinical record, on 09/28/11, revealed no documentation the incident had occurred on 09/26/11. However, review of the nurses notes, on 09/29/11, revealed a late entry nurses note, dated 09/12/11, which stated "resident was sitting in common area on couch with N12-2 (Resident #1), his pants were unzipped with his penis exposed under a pillow. This nurse asked him/her to please put it back in his pants". There was no indication the facility had assessed Resident #2 for the new behaviors. Interview with the RN Supervisor on the North Hall, on 09/29/11 at 5:30PM, revealed when the 09/26/11 incident regarding Resident #2 and Resident #1 was reported to her, she immediately notified the Director of Nursing. There was no evidence the victim had been examined after incident. Further interview with the Social Services Director related to the second incident, on 09/26/11, revealed after the incident, she did not interview the alleged perpetrator, because she did not think he/she would remember. She also stated she did not interview any other residents during the investigation, since sitters were placed with Resident #2 after this incident. Further interview with the DON, on 09/28/11, revealed that appropriate interventions were put into place after the second incident with Resident #2, on 09/26/11. She stated appropriate agencies were notified, family and physician, as well as providing sitters from 6:30 AM-10:30 PM. The DON stated the resident did not usually get up at night and slept through the night. Monitoring of the resident was put into place. However, Resident #2 should have been assessed and care planned for behaviors after the incident, and a more thorough investigation completed. Observation of Resident #2, on 09/28/11 at 7:15 PM, revealed the resident ambulating about in the hallway independently, with a sitter following behind the resident. An attempt to interview Resident #2 regarding the 09/05/11 incident revealed he/she did not remember the incident. Multiple observations of Resident #2, on 09/28/11 at 2:00 PM, 3:30 PM, 5:20 PM, and 7:15 PM revealed the resident was out of his/her room, ambulating independently in the hallway, or sitting in the patio, or living room. Interview with CNA #1, on 09/29/11 at 2:50 PM, revealed she had not witnessed Resident #2 going into other resident's rooms; however, interview with CNA #2, on 09/28/11 at 5:30 PM, revealed Resident #2 had been observed getting up at night and ambulating to the living room to sit. Therefore, Resident #2 continued to have access to the other residents related to the hours without restriction or supervision by facility staff. Review of the investigation revealed that lack of conducting a thorough investigation and implementing protection of other residents by the facility left the potential for other residents to be sexually assaulted by Resident #2. Interview with the Director of Nursing and Administrator, on 09/29/11 at 1:10PM, revealed the Social Services Director was responsible for conducting the investigation; however, they were responsible for ensuring the investigations were done. Interview with the Social Services Director, on 09/28/11 at 2:30PM, revealed she was primarily responsible for investigations of abuse and sometimes and Director of Nursing would assist; however, the Social Services Director stated mainly she completed them.

Based on interview and record review, it was determined that Immediate Jeopardy identified during the abbreviated survey 09/29/11 had been removed as evidenced by the facility's institution of an effective system to conduct thorough investigations, protect residents from further abuse and report the allegation to the state agency; however, non-compliance continued to exist at a S/S of a "D" as the facility had not completed the Quality Assessment and Assurance (QAA) initiative related to the new revised policy and system for conducting investigations, analysis of monitoring results of audits, and the development and implementation of the Plan of Correction (POC). The findings include: Review of the acceptable Allegation of Compliance (AOC), received on 10/13/11, revealed: 1. On 09/29/11, the facility alleged the immediate jeopardy was removed due to personal sitters being assigned to Resident #2 beginning on 09/26/11, and alleged non-compliance until training could be provided by 10/01/11. 2. The facility alleged the Medical Director, who was also Resident #2's physician, was contacted immediately after the incident, and was notified immediately of the OIG investigation, on 09/29/11. The Medical Director was involved in modifying Resident #2's plan of care, and aware of the ongoing monitoring and interventions. Review of the QA minutes and interview with the Director of Nursing, on 10/13/11, revealed the Medical Director had been directly involved with the investigation and implementation of the new changes. 3. The facility alleged the current "Abuse Detection and Prevention" policy was modified on the way investigations were conducted. A check list was developed to ensure that all aspects of the policy were being followed after each incident of suspected abuse. An audit was developed to ensure the policy was followed. Interview with facility staff, on 10/13/11, on the North Unit with RN #1 at 4:50 PM , CNA #1 at 5:00 PM, CNA #2 at 5:05 PM, and CNA #4 at 2:10 PM; on South Unit with LPN #1 at 4:55 PM; CNA #3 at 5:10 PM, and LPN #2 at 2:15 PM, revealed they had been in-serviced on the new Abuse Detection and Protection Policy, and were knowledgeable of what steps to take with new behaviors and procedures to follow. Validation of the training was reviewed on 10/13/11, and determined that all care-giving staff had been trained on the revised policy with a plan in place to inservice any PRN (as needed) staff prior to being placed on the schedule to work. Interview with the Director of Nursing, on 10/13/11 at 2:30 PM, revealed while the facility had implemented several corrective measures to remove the immediate jeopardy, the following areas had not been completed: Social Services would be responsible for completing the check list when conducting investigations and would review all investigations with the Director of Nursing (DON), the DON would audit all social service work relating to investigations, a subcommittee quality assurance meeting would be conducted after all incidents, and staff education would be provided to review the policy or procedure. She further revealed new monitoring tools, education of all care-giving staff, and care planning of all residents should prevent this situation from happening again. While the facility has had two QA subcommittee meetings, the meetings were held to discuss issues related to the immediate jeopardy; however, not the correction of the deficient practice. In addition record review revealed, the facility had not responded with an acceptable Plan of Correction as of 10/13/11 in order to allege a date of compliance to correct deficiencies.

Based on observation, interview, record review, and review of the facility's policy regarding "Abuse Detection and Prevention", it was determined the facility failed to implement their facility policy and procedure related to two allegations of suspected abuse. The facility failed to follow their Abuse, Prevention and Detection Policy by not ensuring all staff was trained on abuse and prevention procedures and failed to ensure the procedure was followed after an allegation was made. The facility failed to identify an allegation as abuse, conduct a thorough investigation and report and protect the residents. The facility was knowledgeable of two incidents of sexual abuse occurring on 09/05/11 and 09/26/11 by a resident perpetrator. The facility staff observed Resident #2, kissing Resident #6 and took his/her hand and placed it in his/her unzipped pants and rubbing Resident #1's genital area. The facility continued to allow Resident #2, the perpetrator, to have access to the other residents after both incidents of sexual abuse. Resident #2, while cognitively impaired, is independent with ambulation. The facility's failure to follow facility policy placed residents at risk for serious injury, harm, impairment or death. Immediate Jeopardy was identified on 09/29/11, was determined to exist on 09/05/11 and is ongoing. Substandard Quality of Care (SQC) was identified in the areas of 42 CFR 483.13 Resident Behavior and Facility Practices F225, F226, and 42 CFR 483.25 Quality of Care F323. The findings include: Review of the facility policy regarding "Abuse Detection and Prevention," revised January 2010, under 3. Prevention.... j. Resident behaviors which might lead to injury of others will be assessed and addressed through the interdisciplinary team process. Appropriate instruction will be communicated to nurse aides through the assignment sheets so as to prevent resident-to-resident abuse 5. Investigation: a. investigations of abuse, neglect or misappropriation of resident property shall begin immediately after discovery...d. investigation will include an interview of the alleged victim, alleged perpetrator and all potential witnesses to the allegation... f. Statements will be requested from any and all individuals interviewed; g. the resident's medical record will be reviewed for information applicable to the abuse investigation...h. information from all sources will be compiled and included in Abuse Investigation Reports....i. Findings of the examination must be recorded in the nurse's notes of the resident's medical record...and...6. Protection c. In cases of resident-to-resident abuse, where one resident is at risk for injuring others due to their behavior and their behavior is not readily managed or extinguished, one to one supervision will be provided until a permanent plan to protect all residents has been implemented .... Interview with the Administrator, on 09/29/11 at 2:00 PM, revealed the Social Services Director was responsible for conducting investigations regarding suspected abuse. Record review for Resident #2 revealed the facility admitted the resident on 09/02/10, with [DIAGNOSES REDACTED]. Review of the admission history and physical, dated 10/06/10, revealed the resident had no behaviors prior to admission. Review of the resident's comprehensive significant change, dated 06/09/11 revealed no behaviors had been exhibited, with a Brief Interview for Mental Status (BIMS) score of 4, which determined severe cognitive impairment. 1. Review of the facility's investigation, dated 09/05/11, revealed at approximately 2:00 PM, an inappropriate incident occurred between Resident #6 and Resident #2 in the living room of the facility. The facility investigation stated that CNA #6 (who was currently sitting with Resident #6), reported to the 7-3 RN Charge Nurse that Resident #2 had put his/her hand on Resident #6's shoulder; the resident then leaned over and kissed his/her. CNA #6 reportedly tried to separate the two resident's; however, Resident #6 refused to leave the area. At that time both resident's continued watching TV, and approximately 15 minutes later, Resident #2 grabbed Resident #6's hand and put his/her hand down his/her pants. The two were immediately separated and CNA #6 informed the 7-3 RN Charge Nurse and the Director of Nursing. Resident #6 had a primary [DIAGNOSES REDACTED]. However, there was no evidence the facility followed their policy relating to Prevention by not thoroughly investigating the cause of the incident, or documentation of the incident in the resident's medical record. Findings revealed there was no evidence of a 5 day follow up investigation reported the the State Agency after the initial incident on 09/05/11. Also, there was no evidence that documentation of the findings of the examination of the victim (Resident #6) was in the medical record. In addition, related to the Protection aspect of the policy, there was no evidence the facility protected all residents in the facility by assessing Resident #2 for behaviors after the incident or provided one to one supervision (sitter) for the resident per facility policy. In addition, there were no interventions put into place to prevent reccurrence of the incident with Resident #2. Interview with the Social Services Director, on 09/2811 at 2:30 PM, revealed the facility felt the two residents were friends and therefore, determined this was an isolated incident, which did not warrant further action. The Social Services Director stated she is responsible for conducting the suspected abuse incidents, as well as reporting. She stated she had failed to complete a follow up investigation (5 day requirement) or send to the state agency. Interview also revealed she was responsible for documenting incidents in the clinical record and should have documented in the nurses notes, or social services notes. Interview with the Director of Nursing (DON), on 09/28/11 at 6:45 PM, revealed CNA #6 should have intervened when the Resident #2 first kissed Resident #6. The DON revealed initially she did not look at the situation as a behavior problem with Resident #2, but as a staff issue. The DON stated that since Resident #6 already had scheduled sitters, she felt the resident was protected. The DON also stated this was a new behavior for Resident #2, and should have been assessed and care planned at that time. The DON revealed that the facility policy required residents with one to one altercations to be assessed for behaviors, placed with supervised sitters, examined, care planned, and monitored. However, the DON stated she was looking at the incident from an entirely different perspective. Interview with the Administrator, on 09/29/11 at 2:00 PM, revealed he thought the policy had been followed regarding the 09/05/11 incident since Resident #6 already had a sitter. However, the Administrator stated he viewed this as an isolated incident, since the behavior had not been observed prior to this incident. The Administrator revealed the policy had not been followed. 2. A second investigation involving Resident #2, dated 09/26/11, revealed an incident had occurred between Resident #2 and Resident #1 in the patio room of the facility at approximately 11:00 AM. CNA #2 reported to CNA #1 that she had observed Resident #2 with his/her hand under a blanket that was covering Resident #1. The report revealed that Resident #2 had his/her hand in the lower region of Resident #1's body and appeared the resident was touching his/her genital area, while the resident was sleeping. While the facility implemented the following interventions. 1) The facility removed Resident #2 from the area, and sitters were arranged to sit with Resident #2 during his/her waking hours from 6:30 AM-10:30 PM. 2) The physician was notified, and a medication was ordered to decrease the resident's sexual desire and control these impulses. There was no evidence the facility provided 1:1 supervision from 10:30 PM until 6:30 AM during the night hours, despite the resident's independence with ambulation. Additionally, interview with CNA #2 revealed that Resident #2 did have a history of getting up at night and ambulating independently to the living room; thus, allowing the resident to have unsupervised access to other residents for 8 hours of the night. Resident #1 was listed on the report as having primary [DIAGNOSES REDACTED]. Review of the clinical record on 09/28/11 revealed no documentation the incident had occurred. Review also revealed a thorough investigation had not been completed. On 09/28/11 at 2:30 PM, the Social Services Director revealed that she had not conducted a thorough investigation. She stated she had not interviewed the alleged perpetrator (Resident #2) or conducted interviews with the other resident's on the wing, because she did not think they would remember. Continued interview with the DON revealed, after the 09/26/11 incident, the resident was placed on 1:1 supervision on days and evenings; however, the resident would not require a sitter on the night shift because the resident slept all night. However, interview with CNA #2, on 09/28/11 at 5:30 PM, revealed Resident #2 had been observed getting up at night and ambulating independently to the living room to sit. Observation of Resident #2, on 09/28/11 at 7:15 PM, revealed the resident ambulating about in the hallway independently. An attempt to interview Resident #2, regarding the 09/05/11 incident, revealed he/she did not remember the incident. Multiple observations, on 09/28/11 at 2:00 PM, 3:30 PM, 5:20 PM, and 7:15 PM, revealed the resident was out of his/her room, ambulating in the hallway, or sitting in the patio or living room. Interview with Resident #2, on 09/28/11 at 5:15 PM, revealed the resident was unable to recall any events or details of the incident on 09/05/11. Continued interview with the Administrator also revealed the policy had been revised on January 2010, and contained information on procedures for resident to resident altercations. The Administrator revealed he did not see this as an issue.

Based on interview and record review, it was determined that Immediate Jeopardy identified during the abbreviated survey 09/29/11 had been removed as evidenced by the facility's institution of an effective system to conduct thorough investigations, protect residents from further abuse and report the allegation to the state agency; however, non-compliance continued to exist at a S/S of a "D" as the facility had not completed the Quality Assessment and Assurance (QAA) initiative related to the new revised policy and system for conducting investigations, analysis of monitoring results of audits, and the development and implementation of the Plan of Correction (POC). The findings include: Review of the acceptable Allegation of Compliance (AOC), received on 10/13/11, revealed: 1. On 09/29/11, the facility alleged the immediate jeopardy was removed due to personal sitters being assigned to Resident #2 beginning on 09/26/11, and alleged non-compliance until training could be provided by 10/01/11. 2. The facility alleged the Medical Director, who was also Resident #2's physician, was contacted immediately after the incident, and was notified immediately of the OIG investigation, on 09/29/11. The Medical Director was involved in modifying Resident #2's plan of care, and aware of the ongoing monitoring and interventions. Review of the QA minutes and interview with the Director of Nursing, on 10/13/11, revealed the Medical Director had been directly involved with the investigation and implementation of the new changes. 3. The facility alleged the current "Abuse Detection and Prevention" policy was modified on the way investigations were conducted. A check list was developed to ensure that all aspects of the policy were being followed after each incident of suspected abuse. An audit was developed to ensure the policy was followed. Interview with facility staff, on 10/13/11, on the North Unit with RN #1 at 4:50 PM , CNA #1 at 5:00 PM, CNA #2 at 5:05 PM, and CNA #4 at 2:10 PM; on South Unit with LPN #1 at 4:55 PM; CNA #3 at 5:10 PM, and LPN #2 at 2:15 PM, revealed they had been in-serviced on the new Abuse Detection and Protection Policy, and were knowledgeable of what steps to take with new behaviors and procedures to follow. Validation of the training was reviewed on 10/13/11, and determined that all care-giving staff had been trained on the revised policy with a plan in place to inservice any PRN (as needed) staff prior to being placed on the schedule to work. Interview with the Director of Nursing, on 10/13/11 at 2:30 PM, revealed while the facility had implemented several corrective measures to remove the immediate jeopardy, the following areas had not been completed: Social Services would be responsible for completing the check list when conducting investigations and would review all investigations with the Director of Nursing (DON), the DON would audit all social service work relating to investigations, a subcommittee quality assurance meeting would be conducted after al incidents, and staff education would be provided to review the policy and procedure. She further revealed new monitoring tools, education of all care-giving staff, and care planning of al residents should prevent this situation from happening again. While the facility has had two QAA subcommittee meetings, the meetings were held to discuss issues related to the immediate jeopardy; however, not the correction of the deficient practice. In addition, record reveiw revealed, the facility had not responded with an accdeptable Plan of Correction as of 10/13/11 in order to allege a date of compliance to correct deficiencies.

Based on observation, interview, record review, and review of the facility's policy regarding "Abuse Detection and Prevention", it was determined the facility failed to develop a plan of care for supervision of behaviors for one (1) of six (6) sampled residents (Resident #2). Resident #2, was observed, on 09/05/11, to kiss Resident #6 and to take his/her hand and place it in his/her unzipped pants, with no facility intervention. On 09/26/11, Resident #2 was again observed with his/her hands under Resident #1's blanket in the living room, with his/her hand moving up and down around the resident's genital area. The facility failed to assess and develop a plan of care to address Resident #2's sexual behaviors. This failure placed residents at risk for serious injury, harm impairment or death. Immediate Jeopardy was identified on 09/29/11, was determined to exist on 09/05/11 and is ongoing. The findings include: Review of the facility policy regarding "Abuse Detection and Prevention," revised January 2010, under 3. Prevention.... j. Resident behaviors which might lead to injury of others will be assessed and addressed through the interdisciplinary team process. Appropriate instruction will be communicated to nurse aides through the assignment sheets so as to prevent resident-to-resident abuse ... The facility admitted Resident #2 on 09/02/10 with [DIAGNOSES REDACTED]. Review of the comprehensive annual assessment on 06/09/11 under the CAA (Care Assessment Area) revealed the facility assessed the resident as having had a cognitive decline and severely impaired cognition and was not considered interviewable. In addition, review of the MDS (Minimum Data Set) Behavior Section E revealed the facility assessed the resident as having no behaviors. Review of the plan of care, dated 02/28/11, revealed no evidence the resident had been assessed or a care plan developed for behaviors. However, a care plan was presented on the evening of 09/28/11 after surveyor intervention. Review of the facility investigation, dated 09/05/11, revealed at approximately 2:00 PM an inappropriate incident occurred between Resident #6 and Resident #2 in the living room of the facility. CNA #6 reported to the 7-3 RN Charge Nurse that Resident #2 had put his/her hand on Resident #6's shoulder and leaned over and kissed his/her. CNA #6 reportedly tried to separate the two resident's, however Resident #6 refused to leave the area. At that time both resident's continued watching TV, and approximately 15 minutes later, Resident #2 grabbed Resident #6's hand and put his/her hand down his/her pants. The two were immediately separated and CNA #6 informed the 7-3 RN Charge Nurse and the Director of Nursing. Review of the facility's investigation revealed no evidence the facility had evaluated the cause of the incident or implemented interventions to address Resident #2's new behavior. Interview with Social Services revealed the IDT was responsible for careplanning the resident's behaviors; however, the team did not follow up on this as they should have. Review of Resident #2's care plan at the time of the initial incident on 09/05/11 revealed..2. Cognitive loss as evidenced by impairment in short term memory related to [DIAGNOSES REDACTED]. Furthermore, review of the careplan after the incident revealed there was no documented evidence the facility had developed a care plan for the resident's new behavior or addressed supervision needs to protect other residents. Interview with CNA #6, on 09/29/11 at 4:30 PM, revealed there was no information on the assignment sheet to direct staff in the management of Resident #2's behaviors or the incidents that had taken place. Interview with the Director of Nursing (DON), on 09/28/11 at 6:45 PM, revealed Resident #2 should have been assessed at that time and care planned for behaviors as this was a new behavior for Resident #2. 2. Review of a second incident regarding Resident #2, dated 09/26/11, revealed CNA #2 reported to CNA #1 that she had observed Resident #2 with his/her hand under a blanket that was covering Resident #1, who was sleeping at the time. The report revealed that Resident #2 had his/her hand in the lower region of Resident #1's body and appeared the resident was touching his/her genital area. While the report also revealed the facility removed Resident #2 from the area, arranged sitters to sit with Resident #2 during his/her waking hours, notified the physician, and medication was ordered to decrease the resident's sexual desire and control these impulses; there was no documented evidence that the facility developed a care plan to address the resident's behaviors and need for 1:1 supervision per their policy, until 09/28/11 after surveyor intervention. Observation of Resident #2, on 09/28/11 at 7:15 PM, revealed the resident was ambulating about in the hallway independently. An attempt to interview Resident #2, regarding the 09/05/11 incident, revealed he/she did not remember the incident. Multiple observations, on 09/28/11 at 2:00 PM, 3:30 PM, 5:20 PM, and 7:15 PM, revealed the resident to be out of his room, ambulating in the hallway, or sitting in the patio or living room. Interview with the Director of Nursing, on 09/28/11 at 6:45PM revealed the Interdisciplinary Team (IDT) is responsible for initiating the plan of care, nursing, social services or activities. Interview with the Administrator, on 09/29/11 at 2:00 PM, revealed the care plan should have been developed after the onset of the new behaviors. Refer to F323. S/S " J "

Based on interview and record review, it was determined that Immediate Jeopardy identified during the abbreviated survey (09/29/11) had been removed as evidenced by the facility's institution of an effective system to develop plans of care for supervision of resident behaviors; however, non-compliance continued to exist at a S/S of a "D" as the facility had not completed the Quality Assessment and Assurance (QAA) initiative related to monitoring care plans, analysis of monitoring results of audits, and the development and implementation of the Plan of Correction (POC) as related to care plans. The findings include: Review of the acceptable Allegation of Compliance (AOC), received on 10/13/11, revealed: On 09/29/11, the facility alleged the immediate jeopardy was removed due to personal sitters being assigned to Resident #2 beginning, on 09/26/11, and alleged non-compliance until training could be provided by 10/01/11. The facility alleged the Medical Director, who was also Resident #2's physician, was contacted immediately regarding the incident, and was notified immediately of the OIG investigation, on 09/29/11. The Medical Director was involved in modifying Resident #2's plan of care, and aware of the ongoing monitoring and interventions. Review of the QA minutes and interview with the Director of Nursing, on 10/13/11 at 2:30 PM, revealed the Medical Director had been directly involved with the investigation and implementation of the new changes. Interview with facility staff, on 10/13/11, on the North Unit with RN #1 at 4:50 PM, CNA #1 at 5:00 PM, CNA #2 at 5:05 PM, and CNA #4 at 2:10 PM; on South Unit with LPN #1 at 4:55 PM; CNA #3 at 5:10 PM, and LPN #2 at 2:15 PM revealed they had been in-serviced and were knowledgeable of what steps to take with new behaviors and procedures to follow. Validation of the training was reviewed on 10/13/11 and determined that all care-giving staff had been trained on the revised policy and a plan to inservice any PRN (as needed) staff prior to being placed on the schedule to work, was in place. Interview with the Director of Nursing, on 10/13/11 at 2:30 PM, revealed while the facility had implemented several corrective measures to remove the immediate jeopardy, the following had not been completed: 1. The staff would inform the team manager of any behavior/issues; 2. The team managers would take appropriate steps to ensure safety of the residents involved; 3. The team manager would then begin the assessment process and would contact the on-call management staff for direction and/or recommendations; 4. Current staff would then be informed of the situation by the team manager and what interventions would be initiated; 5. Resident Care assignment sheets would be updated by the team manager to reflect the new interventions. This information would also be reflected on the resident's plan of care. The care plan would be updated within 24 hours from the decision on new interventions; 6. The team manager would then inform on-coming staff of the interventions at change of shift. This would be done at each subsequent change of shift by each team manager; 7. The vice president of nursing and client services would be responsible for ensuring that the process was followed correctly. Interview with the Director of Nursing on 10/13/11 at 2:30 PM, and interview with facility staff, on 10/13/11 on the North Unit with RN #1 at 4:50 PM, on South Unit with LPN #1 at 4:55 PM; and LPN #2 at 2:15 PM, revealed they had been in-serviced regarding the care planning process including: implementation of the new monitoring tools; education of all care-giving staff; and care planning of all residents; and it should prevent this situation from happening again. The Administrator was out of town on the day of the revisit, and was unavailable for interview. While the facility has had two QAA subcommittee meetings the meetings were held to discuss issues related to the immediate jeopardy; however, not the correction of the deficient practice. In addition record review revealed, the facility had not responded with an acceptable Plan of Correction as of 10/13/11 in order to allege a date of compliance to correct deficiencies.

Based on observation, interview, record review, and review of the facility's policy regarding "Abuse Detection and Prevention", it was determined the facility failed to provide adequate supervision for one (1) of six (6) sampled residents (Resident #2). The facility failed to follow their Abuse Policy and Procedure related to protection in cases of resident to resident abuse. On 09/05/11 facility staff reported an allegation of sexual abuse related to Resident #2 kissing and placing Resident #6's hand in his/her unzipped pants. The facility failed to initiate 1:1 supervision of Resident #2 to protect other residents from potential abuse. On 09/26/11, facility staff reported a second allegation of sexual abuse related to Resident #2 touching and rubbing Resident #1's genital area. While the facility initiated 1:1 supervision of Resident #2 from 6:30 AM to 10:30 PM, the facility failed to provide supervision for Resident #2 from 10:30 PM to 6:30 AM. The facility's failure to provide supervision placed residents at risk for serious injury, harm, impairment or death. Immediate Jeopardy was identified on 09/29/11, was determined to exist on 09/05/11 and is ongoing. Substandard Quality of Care (SQC) was identified in the areas of 42 CFR 483.13 Resident Behavior and Facility Practices F225, F226, and 42 CFR 483.25 Quality of Care F323. The findings include: Review of the facility policy regarding "Abuse Detection and Prevention", revised January 2010, under... 6. Protection .... c. In cases of resident-to-resident abuse, where one resident is at risk for injuring others due to their behavior and their behavior is not readily managed or extinguished, 1:1 supervision will be provided until a permanent plan to protect all residents has been implemented .... Review of Resident #2's clinical record revealed the facility admitted the resident on 09/02/10, with [DIAGNOSES REDACTED]. Review of the previous admission history and physical, dated 10/06/10, revealed the resident had no behaviors prior to admission. Review of the resident's comprehensive significant change, dated 06/09/11, revealed the facility assessed Resident #2 as having no behaviors exhibited, with a Brief Interview for Mental Status (BIMS) which determined Resident #2 had severe cognitive impairment. Review of Resident #2's care plan (updated on 06/22/11) revealed: 2. Cognitive loss as evidenced by impairment in short term memory related to [DIAGNOSES REDACTED]. There was no evidence a care plan had been developed for resident behavior. Review of the facility investigation dated, 09/05/11, revealed at approximately 2:00 PM, an inappropriate incident occurred between Resident #6 and Resident #2 in the living room of the facility. The facility investigation stated that CNA #6 (who was currently sitting with Resident #6), reported to the 7-3 RN Charge Nurse that Resident #2 had put his/her hand on Resident #6's shoulder and leaned over and kissed him/her. CNA #6 reportedly tried to separate the two resident's; however, Resident #6 refused to leave the area. At that time both resident's continued watching TV, and approximately 15 minutes later, Resident #2 grabbed Resident #6's hand and put his/her hand down his/her pants. The two were immediately separated and CNA #6 informed 7-3 RN Charge Nurse and the Director of Nursing. Details of the incident were confirmed by the CNA. Interview with the 7-3 RN Charge Nurse, on 09/29/11 at 5:30 PM, revealed CNA #6 reported the incident to her immediately, which was then reported to the Director of Nursing. Continued review of the incident revealed no documented evidence the facility initiated any supervision of Resident #2 to protect residents. Furthermore, there was no documented evidence the facility assessed and evaluated Resident #2 related to the new onset of sexual behaviors. Review of the clinical record and careplan after the incident revealed no new interventions were implemented to address staff supervision of Resident #2 or the sexual behaviors. There was no evidence a care plan had been developed for the resident's new behaviors. Interview with CNA #6, on 09/29/11 at 4:30 PM, revealed Resident #2 had never exhibited this type of behavior before the 09/05/11 incident. Interview with the Social Services Director, on 09/28/11 at 2:30 PM, revealed there was no specific actions taken after the incident. The Social Services Director also stated the facility determined this was an isolated incident and did not warrant further action, because everyone felt the two residents were friends. Interview with the Director of Nursing (DON), on 09/28/11 at 6:45 PM, revealed CNA #6 should have intervened when the Resident #2 first kissed Resident #6. The DON revealed she did not look at the situation as a problem with Resident #2, but as a staff issue. The DON stated that since Resident #6 already had scheduled sitters, she felt Resident #6 was protected. The DON also stated this was a new behavior for Resident #2, and should have been assessed at that time and care planned for behaviors. In addition, further review of the nurses notes revealed a late entry nurses note, dated 09/12/11 at 3:20 PM, which revealed: "Resident was sitting in common area on couch with N12-2, (Resident #1), his/her pants were unzipped with his penis exposed under a pillow". There was no evidence the facility assessed Resident #2 for any new behaviors. Review of a second investigative report, dated 09/26/11, revealed an incident had occurred between Resident #2 and Resident #1 in the patio room of the facility at approximately 11:00 AM. CNA #2 reported to CNA #1 that she had observed Resident #2 with his/her hand under a blanket that was covering Resident #1, who was sleeping at the time. The report detailed that Resident #2 had his/her hand in the lower region of Resident #1's body and it appeared the resident was touching his/her genital area. The report also revealed the facility removed Resident #2 from the area, and established 1:1 supervision form 6:30 AM to 10:30 PM. The facility notified the physician and received an order for [REDACTED]. The clinical record, on 09/28/11, revealed no documentation the incident had occurred. Interview with CNA #2, on 09/28/11 at 5:30 PM, confirmed the information in the investigative report. Interview with CNA #1, on 09/28/11 at 2:50 PM, revealed she was coming from the West Hall, and observed Resident #2 sitting next to Resident #1 with his/her hand under Resident #1's blanket, and appeared to have an up and down motion, using his/her hand. Interview also revealed the residents were separated, and immediately reported to the Director of Nursing, at which time Resident #2 was assigned sitters from 6:30 AM-10:30 PM, during waking hours. CNA #1 stated she had not witnessed the resident going into other resident's rooms since the first incident on 09/05/11; however, interview with CNA #2 revealed Resident #2 had been observed getting up at night and going to the living room to sit. Interview with Social Services Director, on 09/28/11 at 2:30 PM, revealed the facility did not develop a care plan for behaviors after the incident. Interview with the Director of Nursing on 09/28/11 at 6:45PM revealed Resident #2 had never exhibited these behaviors before; however, stated that after the first incident, the resident should have been assessed and care planned for behaviors. The DON stated that according to their facility policy, the resident should have been supervised after the sexual encounter with Resident's #6. Observation of Resident #2, on 09/28/11 at 7:15 PM, revealed the resident was ambulating about in the hallway independently. An attempt to interview Resident #2 regarding the 09/05/11 incident revealed he/she did not remember the incident. Multiple observations, on 09/28/11 at 2:00 PM, 3:30 PM, 5:20 PM, and 7:15 PM revealed the resident was out of his/her room, ambulating in the hallway, or sitting in the patio, or living room. Interview with the Director of Nursing, on 09/28/11 at 6:45 PM, revealed after the incident, the physician and responsible parties were notified, and the resident was placed on 1:1 sitter supervision. The DON also stated the physician ordered medication to decrease sexual impulses, and a psychological consult was ordered. Interview with the Administrator, on 09/29/11 at 2:00 PM, revealed he thought the incidents were addressed by providing the residents with sitters, and felt this incident was isolated since the behavior had not been observed prior to the initial incident. The Administrator also revealed that he reviews investigations at times with the Director of Nursing and Social Services Director; however, he did not review the 09/05/11 incident and discussed the 09/26/11 incident in the morning meeting. The second incident was identified as an abuse allegation; however, he did not ensure the abuse policy was followed by investigating, protecting, reporting, and educating the staff. While the Administrator felt providing sitters for the resident addressed the incident the facility did not ensure the perpetrator, Resident #2, was supervised 1:1 by facility staff 24 hours a day since 09/05/11 and had not developed a permanent plan as specified per their policy. This failure prevented the facility from protecting it's residents from further abuse.

Based on interview and record review, it was determined that Immediate Jeopardy identified during the abbreviated survey 09/29/11 had been removed as evidenced by the facility's institution of an effective system to identify resident behaviors and provide supervision; however, non-compliance continued to exist at a S/S of a "D" as the facility had not completed the Quality Assessment and Assurance (QAA) initiative related to the new revised policies and systems for identifying, reporting and supervising behaviors, analysis of monitoring results of audits, and the development and implementation of the Plan of Correction (POC). The findings include: Review of the acceptable Allegation of Compliance (AOC), received on 10/13/11, revealed: 1. On 09/29/11, the facility alleged the immediate jeopardy was removed due to personal sitters being assigned to Resident #2 beginning, on 09/26/11, and alleged non-compliance until training could be provided by 10/01/11. 2. The facility alleged the Medical Director, who was also Resident #2's physician, was contacted immediately after the incident and notified immediately of the OIG investigation, on 09/29/11. The Medical Director was involved in modifying Resident #2's plan of care, and aware of the ongoing monitoring and interventions. Review of the QA minutes and interview with the Director of Nursing, on 10/13/11 at 2:30 PM, revealed the Medical Director had been directly involved with the investigation and implementation of the new changes. Interview with facility staff, on 10/13/11, on the North Unit with RN #1 at 4:50 PM , CNA #1 at 5:00 PM, CNA #2 at 5:05 PM, and CNA #4 at 2:10 PM; on South Unit with LPN #1 at 4:55 PM; CNA #3 at 5:10 PM, and LPN #2 at 2:15 PM revealed they had been in-serviced and were knowledgeable of what steps to take with new behaviors and what procedures to follow. On 10/13/11, validation of the training was reviewed and it was determined that all care-giving staff had been trained on the revised policy and a plan was in place to inservice any PRN (as needed) staff prior to being placed on the schedule to work. Interview with the Director of Nursing, on 10/13/11 at 2:30 PM, revealed although the facility had implemented several corrective measures to remove the immediate jeopardy, the following areas had not been completed: 1. The staff were to inform the team manager of the resident's behavior/issue; 2. The team managers were to take appropriate steps to ensure the safety of the residents involved; 3. The team manager then would begin the assessment process and contacts the on-call management staff for any directions; 4. The on duty staff would then be informed of the situation by the team manager and what interventions would be taken; 5. Resident Care assignment sheets would be updated with the new interventions by the team manager. This information would be reflected on the resident's plan of care. The care plan would be updated within 24 hours with the new interventions; 6. The team manager would inform on-coming staff of the interventions at change of shift. This would be done at each subsequent change of shift by each team manager; 7. The vice president of nursing and client services, will be responsible for ensuring the new process was followed correctly. Continued interview with the Director of Nursing, on 10/13/11 at 2:30 PM, and interview with facility staff on 10/13/11 on the North Unit with RN #1 at 4:50 PM, on South Unit with LPN #1 at 4:55 PM; and LPN #2 at 2:15 PM, revealed they had been in-serviced regarding the implementation of the new monitoring tools, education of all care-giving staff, and it should prevent this situation from happening again. The Administrator was unavailable for interview as he was out of town on the day of the revisit. While the facility has had two QAA subcommittee meetings the meetings were held to discuss issues related to the immediate jeopardy; however, not the correction of the deficient practice. In addition record review revealed, the facility had not responded with an acceptable Plan of Correction as of 10/13/11 in order to allege a date of compliance to correct deficiencies.

Based on observation, interview, and record review, it was determined the facility's administration failed to administer effectively to ensure adequate supervision and protection of all residents residing in the facility. In addition, the administration failed to ensure thorough investigations were completed according to the facility policies and procedures for resident to resident altercations. The facility also failed to provide training to staff after two incidents of suspected abuse. This affected one (1) of six (6) sampled residents (Resident #2). On 09/05/11, facility staff observed Resident #2 kissing Resident #6 and took his/her hand and placed it in his/her unzipped pants. On 09/26/11, the facility staff again observed Resident #2 with his/her hands under Resident #1's blanket in the living room, with his/her hand moving up and down around the resident's genital area. The facility's failure to administer effectively and efficiently to provide supervision placed residents at risk for serious injury, harm impairment or death. Immediate Jeopardy was identified on 09/29/11, was determined to exist on 09/05/11 and is ongoing. The findings include: Review of two facility investigations, dated 09/05/11 and 09/26/11, revealed sexual altercations had occurred regarding Resident #2; however, the facility did not to address the first incident or implement interventions regarding Resident #2's behaviors or assess and care plan the resident for behaviors. In addition, the facility did not to supervise Resident #2 allowing access to other residents. (Refer to F279 "J", F323 "J") Further review of the facility investigation revealed there was no evidence the facility had completed a thorough investigation by evaluating the cause of the incident, nor assessing and putting interventions into place to prevent reoccurrence of the incident. Interview with the Social Services Director, on 09/28/11 at 2:30PM revealed the IDT (Interdisciplinary Team) was responsible for careplanning the resident's behaviors; however, the team did not follow up on this as they should have. (Refer to F225 "J", F225 "J") Interview with the Social Services Director, on 09/28/11 at 2:30 PM, revealed she was responsible for conducting the investigation and reporting the alleged abuse She was responsible for reporting to the State agencies; however, she revealed there were no interviews with residents involved nor was it reported to the state agencies. In addition, the investigation did not include interviews with other residents in the facility. Observation of Resident #2, on 09/28/11 at 7:15 PM, revealed the resident ambulating independently about in the hallway. Multiple observations, on 09/28/11 at 2:00 PM, 3:30 PM, 5:20 PM, and 7:15 PM revealed the resident out of his/her room, independently ambulating in the hallway, or sitting in the patio or living room with a sitter at his/her side. Interview with the Staff Development Coordinator (SDC), on 09/29/11 at 4:30PM, revealed she was responsible for the training in the facility. The SDC revealed Abuse in-services are completed annually and upon hire. She also stated the last facility wide Abuse in-service was in March 2010 and was not scheduled again until November 2011. Interview with the Assistant Director of Nursing, on 09/28/11 at 7:00PM, revealed there was no formal or documented training involved with staff since the incident. The ADON stated the facility had not completed training because Resident #2 now had a sitter from 6:30AM-10:30PM, and did not feel necessary. Interview with the Director of Nursing, on 09/28/11 at 6:45 PM, revealed she did not look at the initial incident as a problem with Resident #2, but as a staff issue. The DON also stated this was a new behavior for the resident, and should have been assessed and care planned at that time for behaviors. Interview with the Administrator, on 09/29/11 at 2:00 PM, revealed he thought the incidents were addressed by providing the resident's with sitters. The Administrator stated he felt the first incident was isolated since the behavior had not been observed prior to the initial incident. The Administrator stated the Staff Development Coordinator had been hired a few months ago; however, there had been no training for staff since the two incidents. The Administrator stated he was not routinely involved in the facility's investigations. Although he reviewed investigations at times with the Director of Nursing and Social Services Director, he had not reviewed these incidents. Thus, there was no evidence the facility Administration took action and oversight to ensure Policy and Procedure protection of residents from abuse. (Refer to F520 "J")

Based on interview and record review, it was determined that Immediate Jeopardy identified during the abbreviated survey 09/29/11 had been removed as evidenced by the facility's institution of an effective system to administer effectively to ensure adequate supervision and protection of all residents residing in the facility, conduct thorough investigations according to the facility policies and procedures for resident to resident altercations, careplanning resident behaviors and provide training to staff; however, non-compliance continued to exist at a S/S of a "D" as the facility had not completed the Quality Assessment and Assurance (QAA) initiative related to the newly revised policies and systems for supervision of residents, careplanning, conducting thorough investigations, training of staff, analysis of monitoring results of audits, and the development and implementation of the Plan of Correction (POC). The findings include: Review of the acceptable Allegation of Compliance (AOC), received on 10/13/11, revealed: 1. On 09/29/11, the facility alleged the immediate jeopardy was removed due to personal sitters being assigned to Resident #2 beginning, on 09/26/11, and alleged non-compliance until training could be provided by 10/01/11. 2. The facility alleged the Medical Director, who was also Resident #2's physician, was contacted immediately after the incident, and the OIG investigation, on 09/29/11. The Medical Director was involved in modifying Resident #2's plan of care, and was aware of the ongoing monitoring and interventions. Review of the QA minutes and interview with the Director of Nursing, on 10/13/11 at 2:30 PM, revealed the Medical Director had been directly involved with the investigation and implementation of the new changes. 3. The current Abuse Detection and Prevention policy was modified on the way investigations were conducted. A check list was developed to ensure that all aspects of the policy were being followed after each incident of suspected abuse and an audit was developed to ensure the policy was followed. Interview with facility staff, on 10/13/11, on the North Unit with RN #1 at 4:50 PM , CNA #1 at 5:00 PM, CNA #2 at 5:05 PM, and CNA #4 at 2:10 PM; on South Unit with LPN #1 at 4:55 PM; CNA #3 at 5:10 PM, and LPN #2 at 2:15 PM revealed they had been in-serviced on the new Abuse Detection and Protection Policy, and were knowledgeable of what steps to take with new behaviors and what procedures to follow. Validation of the training was reviewed on 10/13/11 and it was determined that all care-giving staff had been trained on the revised policy and a plan was in place to inservice any PRN (as needed) staff prior to being placed on the schedule to work. Interview with the Director of Nursing, on 10/13/11 at 2:30 PM, revealed while the facility had implemented corrective measures to remove the immediate jeopardy, the following areas had not been completed: 1. The staff would inform the team manager of the behavior/issue when it occured; 2. The team managers would then take appropriate steps to ensure the safety of the resident(s) involved; 3. The team manager on duty would then begin the assessment process and contact the on-call management staff for any direction and/or recommendations; 4. Current staff would then be informed of the situation by the team manager and what interventions would be initiated; 5. The Resident Care assignment sheets would be updated by the team manager to reflect the new interventions and presented to the nursing staff. This information would also be reflected on the resident's plan of care. The care plan would be updated within 24 hours with the new interventions; 6. The team manager would inform on-coming staff of the interventions at change of shift during report. This would be done at each subsequent change of shift by each team manager; 7. The vice president of nursing and client services, will be responsible for ensuring that the process was followed correctly. In addition, Social Services would be responsible for completing the check list when conducting investigations. The Director of Nursing (DON), would review all investigations and would audit all social service work relating to investigations. Furthermore, a subcommittee quality assurance meeting would be conducted after all incidents, and staff education would be provided to review the policy and procedure. She further revealed new monitoring tools, education of all care-giving staff, and care planning of all residents should prevent this situation from happening again. While the facility has had two QA subcommittee meetings, the meetings were held to discuss issues related to the immediate jeopardy; however, not the correction of the deficient practice. In addition, record review revealed, the facility had not responded with an acceptable Plan of Correction as of 10/13/11 in order to allege a date of compliance to correct deficiencies.

Based on observation, interview, record review, and review of the facility plan of correction for immediate Jeopardies identified on 10/20/10 and 12/21/10 in the area of F323 (Supervision), it was determined the facility failed to maintain an effective quality assurance program (QA) to identify quality concerns. Review of the 10/20/10 plan of correction, it was determined the facility failed to ensure that staff were trained on the appropriate use of assistive devices, per manufacturer's recommendations, to prevent accidents. The facility's failure to ensure adequate training of their staff resulted in an avoidable accident for Resident #1. On 10/07/10, staff transported Resident #1 using a Rollator walker, when the Rollator walker flipped over causing the resident to sustain a head injury. Resident #1 required hospitalization with [DIAGNOSES REDACTED]. The facility's failure to ensure staff were appropriately trained regarding the safe use of assistive devices placed residents at risk for serious injury, harm, impairment or death. Review of the plan of correction for the 12/21/10 determined the facility failed to provide quality care, treatment, and supervision of residents identified by the facility as at risk for elopement. The facility failed to ensure policies and procedures were developed which detailed staff responsibilities, and failed to ensure staff was trained related to the policies and procedures. The facility failed to ensure alarms were functioning properly and audible to alert staff when the emergency exit door was opened at the end of the corridor/tunnel. On 12/12/10, Resident #4 and Resident #5 who the facility identified as at risk for elopement exited the locked unit and the facility without staff knowledge or supervision. Resident #4 and Resident #5 were found standing outside the facility. Immediate Jeopardy was found to exist on 12/17/10 and the facility was notified of Immediate Jeopardy and Substandard Quality of Care on 12/17/10. The facility failed to investigate and develop plans of action in response to identified problems. Members of the QA committee were aware their system to identify allegations of suspected abuse had failed. However, all aspects of the facility's system to recognize new behavior for residents were not investigated, thus preventing the facility from implementing the needed plans of action to correct the deficient area. This failure affected all residents of the facility relative to the system for ensuring that residents are assessed, supervised, and a plan of care developed after resident to resident altercations. In addition, the facility did not perform a quality assessment and investigation relative to the two separate incidents of resident to resident altercations, on 09/05/11 and 09/26/11. The facility also failed to provide re-training after the two incidents of suspected sexual abuse were reported. Additionally, the facility failed to maintain compliance related to supervision to prevent accidents after having two previous Immediate Jeopardy citations since 10/2010. The failure of the facility to conduct thorough quality assessments ensuring adequate supervision and protection of all residents were received placed the residents in Immediate Jeopardy. The Immediate Jeopardy was identified on 09/29/11 and determined to exist on 09/05/11 and is ongoing in the areas of: (483.13 F225 "J"; 483.13 F226 "J"; 483.20 F279 " J"; 483.25 F323 "J"; 483.75 F490 "J"; and 483.75 F520 "J". Substandard Quality of Care (SQC) was determined to exist in the areas of 483.13 Resident Behavior and Facility Practices (F225 "J") 483.13 Resident Behavior and Facility Practices (F226 "J") and 483.25 Quality of Care (F323 "J"). The facility will also be cited under Quality Assurance for previous non-compliance, based on previous Immediate Jeopardy identified in areas of 483.25 F323 S/S "K", 483.75 F490 S/S "K" on 12/14/10, and 483.25 F323 S/S "J" identified on 10/20/10. The findings include: Review of the 12/20/10 statement of deficiencies revealed Immediate Jeopardy was identified in F323. Review of the facility's plan of correction revealed the facility's Administrator would participate in policy and procedure revision and attend regularly scheduled meetings of the Quality Assurance Committee. Interviews and record review revealed Resident #2 did not receive an assessment for behaviors after two incidents of suspected sexual abuse occurred, on 09/05/11 and 09/26/11. (Refer to F323). Interview with the Administrator, on 09/29/11 at 1:20 PM, revealed the last Quality Assurance Meeting (QA) had been held, on 07/21/11, with the Medical Director in attendance. The Administrator revealed no behaviors had been discussed this year in their Quality Assurance meeting, nor had the Abuse Policy been discussed. The Administrator stated the QA meeting was held monthly with facility staff, then, a more formal QA meeting is held quarterly, at which time the Medical Director attends. In addition, interview with multiple members of the QA committee, on 09/29/11, with the Administrator and Director of Nursing at 3:45 PM, Assistant Director of Nursing at 3:00 PM, Staff Development Coordinator at 4:30 PM, and the Medical Director (was called at 5:30 PM-did not return call), revealed the facility had not taken steps to investigate the system of how residents were assessed and supervised after incidents of suspected abuse. Neither the Administrator or DON had identified, until surveyor intervention, that Resident #2's behaviors had not been assessed and care planned, and the incidents had not been thoroughly investigated. (refer to F323) Members of the QA committee, including the Administrator and DON, were unaware until surveyor intervention, that Resident #2 had not been assessed for the new behavior, or did not realize the facility policy was not followed regarding "Abuse Detection and Prevention". Interview with the Administrator, on 09/29/11 at 2:00 PM, revealed he thought the incidents with Resident #2 had been addressed by providing sitters, and felt this incident was isolated since the behavior had not been observed prior to the initial incident. The Administrator also revealed he reviews investigations at times with the Director of Nursing and Social Services Director; however, interview revealed that both the Administrator and Director of Nursing were not aware the investigations were incomplete, the behaviors had not been assessed and care planned and protection of residents during the investigation had not been implemented through 1:1 supervision per the policy. Furthermore, the facility was unable to provide evidence that their QA program had identified quality concerns related to supervision to prevent accidents and had reviewed their systems to ensure continued compliance after repeated Immediate Jeopardy citations related to supervision in 2010.

Based on interview and record review, it was determined that Immediate Jeopardy identified during the abbreviated survey 09/29/11 had been removed as evidenced by the facility's institution of an effective system to maintain an effective Quality Assessment and Assurance program (QAA) to identify quality concerns; however, non-compliance continued to exist at a S/S of a "D" as the facility had not completed the Quality Assessment and Assurance (QAA) initiative related to the newly revised policies and systems for conducting investigations, training staff, careplanning resident behaviors, and supervision of residents. The findings include: Review of the acceptable Allegation of Compliance (AOC), received on 10/13/11, revealed: 1. On 09/29/11, the facility alleged the immediate jeopardy was removed due to personal sitters being assigned to Resident #2 beginning on 09/26/11, and alleged non-compliance until training could be provided by 10/01/11. 2. The Medical Director, who was also Resident #2's physician, was contacted immediately after the incident, and was notified immediately of the OIG investigation, on 09/29/11. The medical director was involved in modifying Resident #2's plan of care, and aware of the ongoing monitoring and interventions. Review of the QA minutes and interview with the Director of Nursing, on 10/13/11 at 2:30 PM, revealed the Medical Director had been directly involved with the investigation and implementation of the new changes. 3. The current Abuse Detection and Prevention policy was modified on the way investigations were conducted. A check list was developed to ensure that all aspects of the policy were being followed after each incident of suspected abuse. An audit was developed to ensure the policy was followed. Interview with the Director of Nursing, on 10/13/11 at 2:30 PM, revealed while the facility had implemented several corrective measures to remove the immediate jeopardy, the following areas had not been completed: Social Services would be responsible for completing the check list when conducting investigations and would review all investigations with the Director of Nursing (DON), the DON would then audit all social service work relating to investigations. Additionally, a subcommittee quality assurance meeting, which would be conducted after all incidents and staff education would be provided to review the revised policy or procedure. She further revealed education of all care-giving staff, new monitoring tools and care planning of the residents should prevent this situation from happening again. While the facility has had two QA subcommittee meetings, the meetings were held to discuss issues related to the immediate jeopardy; however, not the correction of the deficient practice. In addition, record review revealed, the facility had not responded with an acceptable Plan of Correction as of 10/13/11 in order to allege a date of compliance to correct deficiencies.

Based on record review, observation, and interview, it was determined the facility failed to provide quality care, treatment, and supervision of residents identified by the facility as at risk for elopement for two (2) of thirteen (13) sampled residents. The facility failed to ensure policies and procedures were developed which detailed staff responsibilities, and failed to ensure staff was trained to the policies and procedures. The facility failed to ensure alarms were functioning properly and audible to alert staff when the emergency exit door was opened at the end of the corridor/tunnel. On 12/12/10, Resident #4 and Resident #5 who the facility identified as at risk for elopement exited the locked unit and the facility without staff knowledge or supervision. Resident #4 and Resident #5 were found standing outside the facility with minimum temperature of 22 (twenty-two) degrees Farenheit in the Louisville area as reported by the National Weather Service on 12/12/10. Immediate Jeopardy was found to exist on 12/17/10 and the facility was notified of Immediate Jeopardy and Substandard Quality of Care on 12/17/10. The findings include: Record review of the Policy and Procedure for Elopement of Residents with revision date of 01/10, revealed the policy was intended to ensure the safety of residents who were at risk for elopement, including procedures for identification of residents at risk for elopement, maintenance of the locked unit, and notification procedures during actual elopement event. The policy stated that the resident care plan and nurse aide assignment sheets would address the elopement risk. Interview with the Vice President of Nursing (VPN) on 12/17/10 at 1:35pm revealed that all residents on the West Hall locked unit were at risk for elopement since all residents had some cognitive impairment. The VPN stated that the residents who exhibited exit-seeking behaviors were identified as elopement risks on the Nursing Assistant Assignment Sheets. 1. Record review revealed the facility admitted Resident #4 on 09/10/10 with a [DIAGNOSES REDACTED].#4 as having severely impaired cognitive skills with memory problems. Record review of Nursing Assistant Assignment Sheets for 12/11/10, revealed the facility identified Resident #4 as an elopement risk. Record review of Nurse's Notes, on 12/12/10 at 5:00pm documented by LPN #1 revealed the Hall Nurse identified Resident #4 could not be found on the unit and a search was conducted. The resident was found outside the facility near the emergency door. LPN #1 documented in the Nurse's Notes on 12/12/10 at 5:30pm that Resident #4 was assessed after the elopement and determined there was no injury to Resident #4. Interview with CNA #5, on 12/17/10 at 3:05pm, revealed they were told Resident #4 left the unit with another resident on 12/12/10 during the time they were monitoring residents in the common area of the West Hall. CNA #5 did not observe Resident #4 leave the unit. Interview with LPN #1, on 12/17/10 at 3:55pm, revealed that during medication pass on 12/12/10 at 5:00pm, a family member stated they were unable to locate Resident #5. LPN #1 remembered seeing Resident #4 and Resident #5 near the door as an Assisted Living Resident left the unit on a scooter, and wondered if the two residents may have followed the Assisted Living Resident off of the unit. LPN #1 stated Resident #4 was missing during a busy time on the West Hall as CNA #5 was monitoring residents in the common area where chair alarms were sounding from residents who needed assistance to stand. LPN #1 stated CNA #3 was off the unit when Resident #4 was missing. Resident #4 was found holding hands with Resident #5 outside the exit door. LPN #1 stated she did not consider Resident #4 to be an elopement risk because Resident #4 was a follower as Resident #4 was often seen holding hands while walking with other residents. LPN #1 did not know how long Resident #4 was locked outside but did not think it could have been longer than thirty (30) minutes. Interview with LPN #2, on 12/17/10 at 4:20pm, revealed he was in charge during the time Resident #4 was reported missing. LPN #2 was called to the West Hall and was advised Resident #4 was missing from the unit. LPN #2 reported seeing Resident #4 with Resident #5, five (5) minutes before both residents were reported missing. LPN #2 led the search for the residents, and stated Resident #4 was found with Resident #5 outside the facility near the emergency exit door. LPN #2 did not think the residents were outside longer than five (5) minutes. 2. Record review revealed the facility admitted Resident #5 on 05/20/10 with medical [DIAGNOSES REDACTED]. Review of a Discharge Summary from a local psychiatric facility, dated 05/20/10, revealed Resident #5 was admitted due to paranoid behavior, had attempted to leave the home, and the family could not safely manage the resident at home. The Minimum Data Set assessment dated [DATE] revealed the facility assessed Resident #5 as having moderately impaired cognitive skills, required supervision with memory problems, and detailed no wandering behaviors. Record of Nursing Assistant Assignment Sheet dated 12/11/10, revealed the facility identified Resident #5 as an elopement risk. Record review of Nurse's Notes dated 12/12/10 at 5:00pm revealed Resident #5 could not be found on the West Hall and a search was conducted. Resident #5 was found standing outside the facility by the emergency exit door. Nurse's notes dated 12/12/10 at 5:30pm revealed Resident #5 was assessed after the elopement with no signs of physical injury documented. Interview with CNA #5, on 12/17/10 at 3:05pm, revealed she was told Resident #5 left the West Hall while she was monitoring residents with chair alarms in the common area on 12/12/10. CNA #5 said she assisted in the search for Resident #5 who was found outside the facility near the emergency exit door. Interview with LPN #1 on 12/17/10 at 3:55pm, revealed she was notified Resident #5 was not on the West Hall unit by the resident's husband during the medication pass on 12/12/10 at 5:00pm. LPN #1 reported seeing Resident #5 with Resident #4 at the locked door as an Assisted Living Resident on a scooter went through the door and wondered if the residents may have followed the Assisted Living Resident off of the West Hall. LPN #1 said the elopement occurred during a busy time on the unit because CNA #5 was watching residents in the common area where chair alarms sounded, and CNA #3 was off the unit on a break. After conducting a search, LPN #1 said Resident #5 was found standing outside of the facility near the emergency exit door with Resident #4, and did not know how long the residents were outside but did not think it was longer than thirty (30) minutes. Interview with CNA #3, on 12/17/10 at 4:15pm, revealed he was off the unit from 4:30pm until 5:00pm on dinner break. When CNA #3 returned to the unit, they were told Resident #5 could not be found on the unit. CNA #3 assisted in the search and said Resident #5 was found outside the facility with Resident #4. Interview with LPN #2, on 12/17/10 at 4:20pm, revealed he was the charge nurse on 12/12/10 when the elopement of Resident #5 was reported. LPN #2 saw Resident #5 with Resident #4 near the locked door of the West Hall before being told both residents were missing. LPN#2 began the search on the West Hall and said Resident #5 was found with Resident #4 outside the facility near the emergency exit door, and stated both residents were outside no longer than five (5) minutes. Record review of the facility investigation regarding the elopement of Resident #4 and Resident #5 revealed that all staff working on the West Hall were interviewed, but no written documentation was completed of the investigation. Interview with LPN #1 on 12/17/10 at 3:55pm revealed she could not recall hearing the emergency exit door alarm on the West Hall that during the elopement of Resident #4 and Resident #5. Interview with CNA #3 on 12/17/10 at 4:15pm revealed he could not recall hearing an audible alarm at the time of the elopement of Resident #4 and Resident #5. Interview with LPN #2 on 12/17/10 at 4:20pm revealed he did not recall hearing an audible alarm at the time of the elopements and said, "Sometimes the alarm is low and can be hard to hear." Interview with the VPN, on 12/17/10 at 5:35pm, revealed the alarm failed to alert staff to the elopement of Resident #4 and Resident #5 and that a service call was performed on 12/13/10 to ensure the alarm was functioning properly. Telephone interview with the Director of Maintenance, on 12/17/10 at 6:15pm, revealed that he was aware of the service repair work completed on 12/13/10 and stated he did not test the alarm system or visualize a demonstration of the alarm system after the repair. The Director of Maintenance stated he didn't see any reason to check the alarm because, "I took their word for it." Observation on 12/17/10 at 12:45pm with the Administrator and Vice President of Nursing revealed the exit door at the end of the tunnel/corridor which led outside was equipped with an alarm system. However, when the Administrator opened the exit door, no audible alarm sounded in the tunnel. The Administrator explained the alarm did not sound in the tunnel; the alarm sounded near the nursing station to alert staff on the unit that the exit door had been opened. The Administrator explained the annunciator box was located in a common area across from the nursing station and sounded when the tunnel/corridor exit door was opened. Further observation, on 12/17/10 at 4:45pm, revealed the alarm was not audible on the West Hall Unit or the nursing station. Further observation revealed CNA #6, LPNA #1, LPN #3, LPN #2, and the VPN stated the alarm was not audible on the West Hall locked unit, halfway down the West Hall, at the Nurse's Station, halfway down the South Hall, or in the resident rooms. The VPN stated, the alarm was not tested after the repair because it was assumed the work on the alarm had been completed. The VPN stated, "I was surprised when I heard it. It is not fixed, it doesn't make enough sound to alert anyone (of the exit door opening)." The Administrator stated, "I would agree that we need a louder alarm." Observation with the Administrator on 12/17/10 at 4:45pm during a test of the alarm on the emergency exit door revealed staff members had difficulty hearing the alarm on the West Hall. CNA #6, with three (3) years of service at the facility, said the VPN told her the alarm meant a resident had left the West Hall, and was not sure what to do to locate the resident and did not know what the alarm meant. While the facility had identified both Residents #4 and #5 as at risk for elopement and noted this on the Nurse Aide Care Plan, there was no evidence that the facility ensured the security of the locked unit after the occurrence of the two elopements on 12/12/10. Interviews with staff revealed the facility was aware that the door alarms did not sound at the time of the elopement; however on 12/17/10, the facility's door alarm system continued to fail as the alarms were not audible throughout the facility despite having contractors attempt to repair the door alarms on 12/13/10. Furthermore, the facility did not ensure all staff was knowledgeable regarding the alarms as evidenced by CNA #3 being unaware of what the alarms meant and what to do. The facility provided an acceptable credible Allegation of Compliance (AOC) on 12/21/10. The facility AOC detailed the facility implemented a plan to provide around the clock observation of the West Hall doors by positioning a CNA not involved in resident care to monitor the West Hall doors. The CNA would continue to monitor the doors until a new entry/lock system was installed to be accessed by key only. The alarm would be upgraded to an audible level to alert staff on the West Hall and adjoining units that the emergency exit door had been opened. On the spot inservices were planned to educate staff of the risk of elopement and promote stategies to prevent elopement on the West Hall. The Elopement Policy and Procedure would be updated to include staff responsibilities in the event of an elopement, and in-services and elopement drills were implemented. A monthy audit of the facility's alarm system was implemented. The Vice President of Nursing provided the Assisted Living Residents with a letter outlining preventive actions to avoid elopement, and held a meeting to discuss the risk of elopement on the West Hall. Record review of Elopement Inservices provided by the VPN revealed one-hundred (100%) compliance and completed attendance sheets of staff in attendance. The VPN also provided an updated Elopement Policy and Procedure which detailed staff responsibilities during an elopement with attendance sheets, and documentation of an Elopement Drill conducted on 12/20/10. Record review revealed the facility's alarm system audit was completed 12/20/10. Verified the completion of the meeting with the Assisted Living Residents regarding the notice given to ensure elopement prevention. On 12/20/10 and 12/21/10, observation revealed a CNA was stationed continuously monitoring the West Hall door to prevent elopement. Interview with the CNA confirmed that her job duty was strictly to monitor the door and was not to be used for direct care. Further observation on 12/20/10 revealed a service contractor at the facility installing/upgrading an alarm on the emergency exit door. Immediately Jeopardy was verified to be removed prior to exit on 12/21/10; however, non compliance continues at 42 CFR 483.25, F323, at a scope and severity of "E" based on the facility's need to evaluate the effectiveness of the interventions implemented related to supervision to prevent elopement and continued monitoring of the facility's elopement prevention systems.

Based on record review, observation, and interview the facility failed to provide administrative support and management which demonstrated effective use of resources to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Substandard Quality of Care and Immediate Jeopardy were identified to exist in CFR 483.25 (F323, and F490). The facility failed to ensure adequate supervision to prevent accidents for two (2) residents out of a sample of thirteen (13), Resident #4 and Resident #5 who the facility identified as elopement risks. The facility Administration failed to implement effective interventions to prevent the recurrence of the elopement. The facility failed to ensure staff was knowledgeable and trained to the elopement procedures and door alarms. The facility failed to ensure the door alarms were audible throughout the facility. On 12/12/10, Residents #4 and #5 exited the facility, without staff knowledge and supervision. Both residents were found locked outside of the facility for an undetermined period of time. The National Weather Service detailed as the minimum temperature in the Louisville, Kentucky area on 12/12/10 was twenty-two (22) degrees Fahrenheit. The facility identified ten (10) of sixty-seven (67) residents as being at risk for elopement or wandering. Immediate Jeopardy was found to exist on 12/17/10 when the facility failed to ensure adequate supervision for residents #4 and #5 to prevent elopement which was likely to cause serious injury, harm, impairment or death to a resident. The facility was notified of Immediate Jeopardy and Substandard Quality of Care on 12/17/10. The findings include: Review of the facility's "Elopement of Residents" policy and procedure, revised 01/10, revealed the facility was to ensure the safety of residents who are at risk for elopement. The procedures included: staff would consider any resident who attempted to leave the facility or who had a known history of exit seeking at risk for elopement; the care plan and nurse aide assignment sheet will address the elopement risk; staff observing resident(s) attempts to leave shall intervene, using distraction, redirection or other means to prevent the resident from leaving; hall nurse shall document any attempts of resident elopement in the nurses notes; staff will supervise residents who insist on leaving the facility by taking them outside and staff will obtain a walkie-talkie in the event of an emergency; all doors are code or key locked to prevent elopement without staff knowledge; if a resident at risk for elopement learns the code to the door locks, maintenance staff will be notified immediately and the codes on all the doors will be changed; in the event of an elopement the Shift Supervisor will call 911 and report the incident, assign staff to specific areas on the property to begin the search and will notify the family, Physician, Administrator, Vice President of Nursing (VPN), and Client Services immediately; staff will conduct a physical exam of the resident, complete an incident report, document in the medical record and turn dial to green to indicate follow-up charting is required; and the Nurse Program Manager/ADON or VPN will discuss with the physician and family the behavior that was noted at the time of the elopement, causal factors, and interventions to be put into place to eliminate the risk, having the new interventions added to the nurse aide assignment sheets and care plans. Interview with the Vice President of Nursing (VPN), on 12/17/10 at 1:35pm, revealed all residents on the West Hall locked unit were considered to be at risk for elopement since all residents had some cognitive impairment. The VPN stated that the residents who were identified as elopement risks on the Nursing Assistant Assignment Sheets demonstrated exit-seeking behaviors on the unit. Record review of the nurse's notes for both resident #5 and #4 revealed on 12/12/10 both residents were found outside the locked unit and outside the facility at approximately 5:00 pm. Review of the medical records for both residents #5 and #4 revealed the facility had identified them as at risk for elopement and the nurse aide assignment sheets detailed this risk dated 12/11/10. Interview with LPN #1, on 12/17/10 at 3:55pm, and review of Resident #5's medical record revealed the facility had not identified either resident missing until Resident #5's spouse reported being unable to find Resident #5. The facility initiated a search and found Resident #5 and #4 standing outside an exit door of the facility. Interviews with LPN #1, CNA #5 (on 12/17/10 at 3:05pm), CNA #3 (on 12/17/10 at 4:15pm) and LPN #2 (on 12/17/10 at 4:20pm) revealed none of these staff was knowledgeable of either resident leaving the facility nor had they heard an audible door alarm that would signify a resident had exited the building. Continued interview with LPN #1 revealed she remembered seeing resident #4 and #5 near the door as an Assisted Living resident exited the unit on a scooter. Interview with the VPN on 12/17/10 at 5:35pm revealed that the alarm failed to alert staff to the elopement of Resident #4 and Resident #5 and that a service call was performed on 12/13/10 to ensure the alarm was functioning properly. While the facility identified the door alarms weren't functioning properly and had a contractor work on the doors on 12/13/10, observation on 12/17/10 at 12:45pm with the Administrator and Vice President of Nursing found the exit door at the end of the tunnel/corridor which led outside was equipped with an alarm system. When the Administrator opened the exit door, no audible alarm sounded in the tunnel. The Administrator explained the alarm did not sound in the tunnel; the alarm sounded near the nursing station to alert staff on the unit that the exit door was opened. The Administrator explained the annunciator box was located in a common area across from the nursing station and sounded when the tunnel/corridor exit door was opened. The alarm was not audible at the nursing station, or behind closed and locked doors of the West Hall Locked Unit. Further observation, on 12/17/10 at 4:45pm with the Administrator and Vice President of Nursing, CNA #6, LPNA #1, LPN #2 revealed during a demonstration of the door alarms, the alarm was not audible on the West Hall Locked Unit, the South Hall, the nursing station, or in the residents' rooms. The VPN stated the alarm was not tested after the repair was completed because it was assumed the work on the alarm had been completed. The VPN stated, "I was surprised when I heard it. It is not fixed; it doesn't make enough sound to alert anyone (of the exit door opening)." Interview by telephone with the Director of Maintenance on 12/17/10 at 6:15pm revealed that he was aware of the service repair work completed on 12/13/10 and stated that he did not test the alarm system or visualize a demonstration of the alarm system after the repair. The Director of Maintenance stated he didn't see any reason to check the alarm because, "I took their word for it." Continued interview with the Administrator revealed that the alarm needed to be louder. Furthermore, there was no evidence that the administration increased supervision of the ten residents identified as elopement risk to prevent elopement recurrence while being aware of the door alarm failure. During the demonstration of the alarm with the Administrator, on 12/17/10 at 4:45pm, CNA #6, with three (3) years of service at the facility, was observed asking the Administrator what she should do to locate the resident and that she didn't know what the alarm meant. Review of the Elopement Policy and Procedure revealed there was no documented procedure detailing the use of the alarms or what staff was to do in the event of the alarm. The policy and procedure also did not detail any information about the maintenance of the door alarm system used to identify if a resident had left the unit or the facility. Therefore, the administration did not ensure the Elopement policy and procedure included the use of the door alarms and their maintenance. The administration did not ensure all staff was knowledgeable to the elopement prevention systems the facility had implemented as evidenced by CNA #6's lack of knowledge to what actions should be taken or what the alarms meant. The facility provided an acceptable credible Allegation of Compliance (AOC) on 12/21/10. The facility AOC detailed the facility implemented a plan to provide around the clock observation of the West Hall doors by positioning a CNA not involved in resident care to monitor the West Hall doors. The CNA would continue to monitor the doors until a new entry/lock system was installed to be accessed by key only. The alarm would be upgraded to an audible level to alert staff on the West Hall and adjoining units that the emergency exit door had been opened. On the spot in-services were planned to educate staff of the risk of elopement and promote strategies to prevent elopement on the West Hall. The Elopement Policy and Procedure would be updated to include staff responsibilities in the event of an elopement, and in-services and elopement drills were implemented. A monthly audit of the facility's alarm system was implemented. The Vice President of Nursing provided the Assisted Living Residents with a letter outlining preventive actions to avoid elopement, and held a meeting to discuss the risk of elopement on the West Hall. Record review of Elopement In-services provided by the VPN revealed one-hundred (100%) compliance and completed attendance sheets of staff in attendance. The VPN also provided an updated Elopement Policy and Procedure which detailed staff responsibilities during an elopement with attendance sheets, and documentation of an Elopement Drill conducted on 12/20/10. Record review revealed the facility's alarm system audit was completed 12/20/10. The completion of the meeting with the Assisted Living Residents regarding the notice given to ensure elopement prevention was verified. On 12/20/10 and 12/21/10, observation revealed a CNA was stationed continuously monitoring the West Hall door to prevent elopement. Interview with the CNA confirmed that her job duty was strictly to monitor the door and was not to be used for direct care. Further observation on 12/20/10 revealed a service contractor at the facility installing/upgrading an alarm on the emergency exit door. Interview with the VPN on 12/17/10 at 5:35pm regarding administrative efforts to remove Immediate Jeopardy related to potential elopements revealed a Quality Assurance meeting was scheduled for 12/21/10 to discuss elopement issues. The VPN also stated the Elopement Policy was determined to be inadequate because the policy did not include actions to be taken in case of actual elopement. The VPN reported that the Administrative group met on 12/20/10 to discuss options to further secure the West Hall. The VPN did not know if the Medical Director had been advised of the Immediate Jeopardy which resulted from the elopement of Resident #4 and Resident #5. Interview with the Administrator on 12/20/10 at 3:30pm revealed that the Administrative Group met on 12/20/10 to discuss the Immediate Jeopardy and options to secure the West Hall. The Administrator stated that the Medical Director was not in attendance and did not know if the Medical Director was aware of the Immediate Jeopardy which resulted from the elopement of Resident #4 and Resident #5. The facility provided an acceptable credible Allegation of Compliance (AOC) on 12/21/10. Immediately Jeopardy was verified to be removed prior to exit on 12/21/10; however, non compliance continues at 42 CFR 483.75 Administration, F490, at a scope and severity of "E."