Every finding on record at Willow Branch Health and Rehabilitation

Based on facility policy review, observations, and interviews, the facility failed to ensure the kitchen equipment and environment was maintained in a sanitary condition and failed to ensure a dietary aid wore a protective hair covering while working in the food preparation area which had the potential to affect 68 of 68 residents. The findings include: Review of the facility's policy titled, Equipment, dated 10/2019, revealed .center policy that all foodservice equipment is clean, sanitary .Dining Services Director ensures that all non-food contact equipment is clean . Review of the facility's policy titled, Staff Attire, dated 10/2019, revealed .the Dining Services Director insures [ensures] .all staff members .facial hair properly restrained . Review of the facility's policy titled, Equipment Cleaning Procedures, dated 7/2022, revealed .all dietary equipment and the environment are cleaned and sanitized in a manner that meets .federal regulations . all equipment should be cleaned as needed .Equipment that becomes soiled between scheduled cleanings must be properly cleaned and sanitized .walls, ceilings .must be free of chipped and/ or peeling paint and kept in good repair . During an observation on 4/28/2025 at 11:30 AM, with the Certified Dietary Manager (CDM), revealed the ice machine had a thick, crusty yellowish-brown substance to the top perimeter of the filter housing unit. Further observation revealed the ceiling above the ice machine was cracked in various areas with a large piece of ceiling hanging down. Continued observation revealed various patches of an unknown thick, black substance present to the missing ceiling area above the ice machine. During an observation on 4/28/2025 at 11:32 AM, revealed Dietary Aide (DA) A had facial hair and did not have on a facial hair covering while in the food preparation area. During an observation in the dish room on 4/28/2025 at 11:33 AM, with the CDM, revealed multiple areas of brown discoloration with chipped paint of various sizes present to the ceiling. During an observation on 4/28/2025 at 11:34 AM, with the CDM, revealed a thick, black dirt-like substance present to the baseboard perimeter and the floor beneath the 3-compartment sink. During an observation in the cooking area on 4/28/2025 at 11:35 AM, with the CDM, revealed a large area of missing paneling with moderate areas of an unknown thick, black substance present on the ceiling. During an interview on 4/28/2025 at 11:40 AM, the Maintenance Director (MD) confirmed the impairments to the kitchen and dish room ceiling areas was not sanitary from possible moisture damage and needed repairs. The MD confirmed the yellowish-brown substance present to the top of the ice machine was built-up mineral deposits from water condensation and needed to be cleaned. During an observation and interview on 4/28/2025 at 12:07 PM, with the CDM, revealed multiple areas of missing and chipped wall panels on the interior wall of the dry storage area. The CDM confirmed the impaired areas on the walls in the dry storage area had a previous water leak and needed repairs. During an observation on 4/28/2025 at 12:15 PM, revealed DA A did not have on a facial hair covering while in the cooking and food plating area. During an interview on 4/29/2025 at 10:12 AM, the CDM confirmed DA A did not wear a facial hair covering on 4/28/2025 during food preparation. The CDM stated all hair, including facial hair, should be covered while working in the kitchen. During an observation and interview on 4/29/2025 at 10:18 AM, with the CDM, revealed a thick, black dirt-like substance present to the perimeter of the baseboards and the floor underneath the 3-compartment sink. The CDM confirmed the area under the sink was not sanitary and needed to be cleaned.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to maintain a comfortable, well-kept, and homelike environment on 4 of 4 hallways for 4 residents (Resident #7, Resident #15, Resident #39 and Resident #271) of 68 residents reviewed for a homelike environment. The findings include: Review of the facility's policy titled, Safe and Homelike Environment, revised 2/2025, revealed .the facility will provide a safe, clean, comfortable and homelike environment .any environment in the facility that is frequented by residents .rooms, bathrooms, hallways, dining areas .determination of homelike should include the resident's opinion of the living environment .physical environment that is neat and well-kept .maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses including Chronic Kidney Disease, Hypertension, Chronic Obstructive Pulmonary Disease, and Rheumatoid Arthritis. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 scored a 6 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. During an interview on 4/28/2025 at 11:50 AM, Resident #7 stated the door to her bedroom was .very dirty . and also stated her doors at her home were clean and did not look like the door at the facility. During an observation on 4/28/2025 at 11:55 AM, Resident #7's door was not visibly soiled. Further observation of the door revealed several scuffs, scratches, chipped wooded, and multiple strips of transparent office tape was used to secure a vinyl kick plate (a replaceable thin sheet of plastic adhered to doors to prevent damage) to the door. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including Congestive Heart Failure, Diabetes, and Chronic Kidney Disease. Review of a quarterly MDS assessment dated [DATE], revealed Resident #15 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. During an interview on 4/28/2025 at 11:40 AM, Resident #15 stated the door to her room was .in bad shape . Resident #15 stated the door was broken and she did not use rubber bands or tape to repair broken or damaged items in her home. Resident #15 stated her room was not a homelike environment. During an observation on 4/28/2025 at 11:45 AM, revealed Resident #15's bedroom door handle was wrapped with a rubber band which was anchored to the resident's bathroom door handle holding the bedroom door open. The door also had several scuffs, scratches, chipped wood, and multiple strips of black colored tape used to secure a vinyl kick plate to the door. Further observation revealed the privacy curtain was not moveable, and the privacy curtain track was detached from the ceiling in 1 place. Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with diagnoses including Peripheral Vascular Disease, Chronic Obstructive Pulmonary Disease, and Morbid Obesity. Review of a quarterly MDS assessment dated [DATE], revealed Resident #39 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. During an observation 4/28/2025 at 9:00 AM, in Resident #39's room revealed broken sheetrock to the right of the central heat and air unit and the bottom trim baseboard peeling away from the wall. During an interview on 4/28/2025 at 3:00 PM, Resident #39 stated he was aware of broken sheet-rock and baseboard pulled from the wall. Resident #39 stated he was not sure why it had not been fixed but if he was at home he would have had it fixed already. Review of the medical record revealed Resident #271 was admitted to the facility on [DATE] with diagnoses including Epilepsy, Muscle Weakness, Dementia, and Mood Disturbance. Review of an admission MDS assessment dated [DATE], revealed Resident #271 scored a 3 on the BIMS assessment which indicated the resident had severe cognitive impairment. During an observation on 4/28/2025 at 11:30 AM, revealed Resident #271 was lying in bed. Further observation revealed the area behind Resident #271's entrance door revealed the baseboard was peeling off of the wall and paint was bubbled and peeling in various areas. Continued observation revealed in resident's bathroom revealed the paint was peeling and the baseboard was peeling away from the wall. Continued observation behind the resident's bed were deep gouges in wall and sheet rock was falling off. During a facility tour and interview on 4/30/2025 at 9:50 AM, with the Administrator and the Maintenance Director confirmed Resident #7, Resident #15, Resident #39 and Resident #271's rooms were not maintained in a homelike environment.

Based on facility policy review, observations, and interviews the facility failed to ensure the languages used by residents in the facility assessment was accurate to include sign language for 1 resident (Resident #12) of 17 residents reviewed. The findings include: Review of the facility's policy titled, Facility Assessment, dated 8/2024, revealed .a facility-wide assessment to determine what resources are necessary to care for our residents competently during both day-to-day operations .and emergencies .The facility assessment will at minimum address or include .the care required by the resident population .that consider the types of diseases, conditions .and other pertinent facts that are present within that population . Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Developmental Disorder of Speech and Language, Nonspeaking Deafness, and Weakness. Review of a 5-day admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #12 had absence of useful hearing and had severe cognitive impairment for daily decision making. Review of the Facility Assessment revised 3/2025, revealed the English was the language used by all residents in the facility. Further review of the Facility Assessment revealed sign language was not included in the Facility Assessment. During an observation on 4/28/2025 at 11:30 AM, revealed Resident #12 was laying in bed with her eyes closed. Further observation revealed a large sign on the wall of her room which included pictorial instructions on how to read and use sign language. During an interview on 4/29/2025 at 7:45 AM, Licensed Practical Nurse (LPN) B stated the staff used sign language to communicate with Resident #12. During further interview LPN B stated the resident used some sign language gestures created by herself for certain words, and also stated the resident was not able to use a dry erase board related to spelling and legibility difficulties. During an interview on 4/29/2025 at 2:30 PM, Certified Nursing Assistant (CNA) C stated Resident #12 could not use a dry erase board for communication related to writing difficulties. CNA C further stated the resident used sign language and other hand gestures to communicate with staff. During an observation on 4/30/2025 at 11:15 AM, revealed CNA C served Resident #12 a meal tray. During further observation Resident #12 performed hand gestures and sign languages to CNA C, and CNA C responded with hand gestures and sign language. During an interview on 4/30/2025 at 11:20 AM, the Director of Nursing (DON) stated Resident #12 used sign language to communicate with staff and also stated some staff members have started learning sign language to better communicate with Resident #12. During an interview on 4/30/2025 at 11:30 AM, the Administrator verified sign language was the primary method of communication for Resident #12. The Administrator stated the Facility Assessment was recently updated and confirmed the facility failed to include Sign Language in the Facility Assessment as a language used by the residents.

Based on facility policy review, observation, and interview the facility failed to store an insulin pen appropriately for 1 resident (Resident #3) of 3 residents reviewed for medications on 1 medication cart (200 hall medication cart) of 2 medication carts observed for medication storage. The findings include: Review of the facility's policy titled, Medication storage, revised 2/2025, revealed .all medications housed on our premises will be stored in accordance to the manufacturer's recommendations and ensure proper .temperature .all medications requiring refrigeration are stored in refrigerators . Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Dementia, Diabetes, and Obesity. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 scored an 11 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Review of a Physician's Order for Resident #3 dated 4/15/2025, revealed .Insulin Glargine administer 60 units .At Bedtime . During an observation on 4/29/2025 at 8:30 AM, revealed one unopened prefilled 3 milliliter Insulin Glargine syringe for Resident #3 was stored on the 200 hall medication cart. The prefilled insulin syringe was stored in a disposable plastic bag which read .REFRIGERATE . Further observation revealed the prefilled insulin syringe was delivered on 4/23/2025 (7 days) and had a sticker on the pen which read .REFRIGERATE UNTIL OPENED . During an interview on 4/29/2025 at 8:35 AM, Licensed Practical Nurse (LPN) B stated she did not know when the prefilled insulin syringe was removed from refrigeration and stated the pen was not opened and was not used. LPN B further stated the prefilled insulin syringe was available for resident use and confirmed the prefilled insulin syringe was not stored appropriately. During an interview on 4/30/2025 at 11:00 AM, the Director of Nursing (DON) confirmed the facility failed to appropriately store the prefilled insulin pen for Resident #3 in the 200 hall medication cart .

Based on facility policy review, medical record review, and interview, the facility failed to revise a comprehensive care plan to reflect the resident's current code status for 1 resident (Resident #46) of 20 residents reviewed for care planning. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated ,d+[DATE], revealed .The care planning process will include an assessment of the resident's strengths and needs and will incorporate the residents personal .preferences . Medical record review revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including Hip Fracture, Compression Fracture, and Diabetes. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #46 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of the comprehensive care plan for Resident #46 dated [DATE], revealed .Advanced Directives .Full Code .Resident advanced directives will be honored .CPR [cardiopulmonary resuscitation] will be performed when needed . Review of a Physician Orders for Scope of Treatment (POST) form for Resident #46 dated [DATE], revealed .Do not attempt resuscitation [DNR] .comfort measures only . was checked as the resident's preference for advanced directives. Review of a Physician's Order for Resident #46 dated [DATE], revealed .Code Status: DNR . During an interview on [DATE] at 11:05 AM, the Care Plan Coordinator confirmed Resident #46's care plan had not been revised to reflect the resident's advanced directive preference for a DNR code status.

Based on review of a facility policy, review of facility incident reports, medical record review, and interviews, the Quality Assurance Performance Improvement committee failed to identify and correct deficiencies for facility failure of reporting and investigation of abuse and injuries of unknown origin for 5 residents (#6, #5, #10, #7, #13) of 12 residents reviewed. The facility's placed Residents #6, #7, #5, #10, and #13 in immediate jeopardy (IJ) (a situation in which a provider's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 6/2/2022 at 5:55 PM. The facility was cited Immediate Jeopardy for F-865 at a scope and severity of K The IJ was effective 4/3/2022 and was removed on 6/3/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 6/3/2022 and the corrective actions were verified onsite by the surveyor on 6/3/2022. The findings included: Review of a facility policy Quality Assurance & Performance Improvement (QAPI) Plan . not dated showed .We are committed to enhancing quality of life by nurturing individuals and independence .The purpose of QAPI .is to take a proactive approach to continually improve the way we care for and engage with our residents, caregivers, and other partners .to create an environment where people are loved, valued and at peace .Systematic Analysis and Systemic Action .use a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of change .determine whether and how identified problems may be caused or exacerbated by the way care and services are organized or delivered .comprehensively assesses all involved systems to prevent future events and promote sustained improvement . Review of an incident report for Resident #6 dated 4/12/2022 showed .resident was found to have scattered bruising on both arms bruising is from unknown source. Bruise left arm bruise right arm. No witnesses found . Medical record review of Resident #6's Nursing Progress Note dated 4/12/2022 showed .resident found to have scattered bruising on both arms from unknown source . Review of Resident #6's incident report dated 4/30/2022 showed .Bruise on LFA [left forearm] 6.4 cm [centimeters] X [by] 7 cm dark purple in color. Resident unable to give description . Medical record review of Resident #6's Nursing Progress Note dated 4/30/2022 showed .this nurse went to help pull resident up for breakfast and saw large purple bruise 6.4 [centimeters] X [by] 7 cm [centimeters] to LFA [left forearm], DON [Director of Nursing], ADON [Assistant Director of Nursing], MD [Medical Doctor], wife and wound nurse notified . During an interview with Registered Nurse (RN) #1 on 5/24/2022 at 8:05 AM, she stated .on 4/3/2022 I went into the resident's [#6] room at approximately 7:50 AM .the resident's hands were under the cover .I pulled down the sheet to see what was going on and his hands were inside his shirt sleeves and his shirt was tied in a hard knot. I yelled for the tech .We were not able to get the knot untied .We had to pull the shirt over his head. I took a picture of his hands and sent it to the DON and asked her if that was not abuse. She responded .the whole situation was under investigation . During an interview with the DON on 5/25/2022 at 5:30 PM, she stated she was made aware on 4/3/2022 the nurse found Resident #6's shirt with the sleeves tied. She stated .I said 'okay', I would investigate .Yes, in my professional opinion, I would see that as abuse .Either the next day or the next I did tell the Administrator what I was told and that I had spoken to [the alleged perpetrator of abuse] .There was no further investigation . During an interview with Certified Nursing Assistant [CNA] #4 on 6/1/2022 at 11:50 AM, she stated .I saw his [Resident #6] shirt sleeves tied with his hands inside. We tried to untie it, but the knot was too tight .No one ever asked me any questions about what we [RN #1 and CNA #4] found . Medical record review of Resident #5's Nursing Progress Note dated 4/20/2022 showed .Resident's daughter here asked if resident had fallen last night or today, resident has bruising noted on right bottom lip, left forearm, and bruising across the chest that is turning yellow and blue resident denies a fall. Daughter ask mother if it hurt resident stated it does not hurt . During an interview with RN #1 on 5/24/2022 at 8:05 AM she stated .On 4/20/2022, the resident's [#5] daughter asked if the resident [#5] had fallen last night or today. I was not aware of a fall. I went to the resident's room to assess her. She had bruising noted on right bottom lip, left forearm, and bruising across the chest that was turning yellow and blue. It was like a half circle .[Resident #5] denied having a fall. I asked the resident what happened, and she said 'a black guy pushed me' .So, I didn't [report the incident]. I did put what I found in a progress note, and I told the oncoming nurse . Continued interview confirmed the RN did not fill out an incident report related to the resident saying she was pushed. Medical record review of Resident #10's Nurses Progress Note dated 4/24/2022 showed .Resident c/o [complained of] back pain this AM and stayed in bed until this afternoon. When she tried to get up, she had a very difficult time and even walking. This nurse assessed her back and noted a purple bruise to her lower back measuring 7 cm X 5cm DON and MD [physician] made aware with new order Xray of lower back . During an interview with LPN #2 on 5/25/2022 at 9:45 AM, she stated .it was every time [CNA #1] would work, the next day we would find something on one of the residents; a bruise, a skin tear .I did an incident report on [Resident #10] .I reported the bruise to the DON and asked if I needed to chart anything about what the resident had said initially about [an unnamed alleged perpetrator] being rough with her the night before. She said no, they needed to investigate it first. I did not hear anything else .The female residents on the secure unit show signs of fear and anxiety when .[CNA #1] would come in for his shift. They try to walk away from him, yelling out. I have seen him interact with residents. He will take hold of their shoulders and guide them where he wants them to go, but I haven't witnessed him be aggressive with residents. No one on secure unit or the 500 hall, have had bruises or skin tears since he has been suspended [on 4/30/2022] . During an interview with CNA #7 on 5/26/2022 at 10:45 AM, she stated Resident #10 had reported to her that CNA #1 was rough with her the night before. CNA #7 stated she reported the allegation to LPN #3. CNA #7 also sated Resident #10 reported the same thing to LPN #2. During an interview with CNA #2 on 5/24/2022 at 10:40 AM, she stated she observed CNA #1 shove Resident #7 one evening when he was putting residents to bed.she [Resident #7] didn't want to go to bed. She tried to go around him [CNA #1] so he put his hands on her upper arms .and was guiding her forcibly down the hall to her room . CNA #2 stated she thought LPN #1 realized what was happening at the time when she alerted the LPN to what the CNA was doing .I thought he knew what happened .He said he would take care of it. I left that night at 10:00. I did not report it to anyone else. I thought [LPN #1] knew what was going on . During an interview with CNA #3 on 5/24/2022 at 1:15 PM, he stated he had observed CNA #1 shove Resident #7 and she about fell .I told [RN #1] the day nurse that he was physically pushing her .but every time they report it, nothing gets done. I told the ADON .I caught the ADON in the parking lot and asked her what was going on with the investigation .I told her then I specifically .seen him push .[Resident #7] and she had stumbled .She acted like she didn't know anything about it .This was after .[CNA #1] was suspended [on 4/30/2022] . During an interview with the ADON on 5/25/2022 at 5:48 PM, she stated she did not know until 5/24/2022, when this State Surveyor had asked about what had occurred. The ADON stated she had spoken to CNA #2 and had been told that CNA #1 had put his hands on Resident #7's outer shoulder area and guided her toward her room.I was told she did not lose her balance or stumble . She said .after .[CNA #1] had been suspended .[CNA #3] said he had thought .[CNA #1] was rough with the residents. He [CNA #3] basically gave the same account of the event as [CNA #2] did. He [CNA #3] did not tell me the resident [#7] had stumbled. I think he did use the word push .I told the DON about it when she got here. Basically, she asked me why it had not been reported before . During an interview with the DON on 5/26/2022 at 3:15 PM, she stated .I do not recall the ADON speaking to me about an allegation that [CNA #1] had pushed [Resident #7]. I did not do anything . During an interview with Licensed Practical Nurse [LPN #1] on 5/25/2022 at 7:40 AM, he stated .On May 18th we had a resident named [Resident #9] .we heard screaming coming from .[Resident #13's] room .we walked into the room and [Resident #9] has her [Resident #13] halfway off the bed with his hand pulling on her brief trying to get his hand down her brief. So, we separated them . LPN #1 stated she reported the incident to the ADON and DON. During an interview with CNA #6 on 5/25/2022 at 6:15 PM, she stated .it was the night of 5/18/2022 .We heard screaming and we ran into [Resident #13's] room. [Resident #9] had one hand inside of her brief and was trying to get the brief off. [LPN #1] told the DON and ADON and he said they said not to report it and basically pretend it didn't happen. I did not hear them say that, but I did witness what [Resident #9] did . During an interview with the Administrator on 6/2/2022 at 10:45 AM, he stated .I had no knowledge of the allegations of every time the CNA [#1] worked there were issues with resident injuries. If I had known about this, we might have been able to piece it together with the other ones .If the nurse reported concerns to the ADON and did not see an investigation or something being done, it should have been reported to me . During an interview with the Administrator on 6/2/2022 at 5:00 PM, he stated .the purpose of QAPI is basically to identify problems and improve performance. Then we do a PIP [performance improvement plan]. Then you monitor results month to month and adjust the process as needed. Based on the issues you have identified, I should have been notified of all allegations of abuse and injuries of unknown origin, even if the allegations could not have been substantiated. I see these employees' multiple times during the day, and the incidents were not reported to me. I am not sure why they didn't report it to me . The facility's corrective actions included: The DON assessed Resident #6 on 5/26/2022 and no adverse effects were identified to have occurred from his hands being tied. Residents #5, #7 and #10 were assessed by MDS/DON on 5/26/2022 and there was no evidence indicating any adverse effects from injuries of unknown origins or allegation of sexual abuse. Resident #13 discharged prior to 5/26/2022. CNA #1 was suspended on 4/30/2022 and terminated on 6/3/2022. The CNA did not work after 4/30/2022. Regional Director of Clinical Services (RDCS) interviewed the Nursing Home Administrator (NHA) and DON and determined that the root cause of not reporting and investigating these allegations and incidents were a result of not fully understanding the process of completing a thorough investigation and the regulation for reporting abuse and injuries of unknown origins. RDCS reviewed all incident reports for the last 30 days on 6/3/2022 to ensure that any injuries of unknown origin and allegations of abuse were reported and investigated fully. Four incidents were reviewed, and none were found to be affected by this practice. On 5/24/2022 the Administrator and DON were educated by the RDCS on investigating and reporting abuse, including injuries of unknown origin. This education was repeated 6/3/2022 by the RDCS. RDSC will audit all incident reports to ensure that all allegations of abuse and injuries of unknown origins are reported and investigated thoroughly starting 6/3/2022 and ongoing for 4 weeks, then will review 5 incident reports weekly for 4 weeks, then 3 weekly for 4 weeks and/or until substantial compliance is maintained. RDCS and NHA will interview five staff members weekly to determine if they have any knowledge of abuse starting 6/3/2022 and ongoing for 4 weeks, then 3 staff members weekly for 4 weeks, then 1 staff member weekly for four weeks and/or until substantial compliance is maintained. RDCS and/or the DON will review progress notes daily to identify any allegations of abuse and/or injuries of unknown injuries starting 6/3/2022 and ongoing for 12 weeks and/or until substantial compliance is maintained. QAPI meetings will occur weekly for four weeks to monitor progress and then monthly thereafter. Regional Director of Operations or Regional Director of Clinical will provide oversight of facility administration with a weekly 1:1 interaction reviewing the completed audits and QA (Quality Assurance) findings. The plan of correction will be reviewed weekly to ensure all the audits are completed and issues are identified for 4 weeks and/or until substantial compliance is achieved. Monthly QAPI meetings will be conducted and attended by Regional Director of Operations and Regional Director of Clinical for a period of three months to ensure compliance is sustained. AD HOC QAPI meeting was conducted 6/3/2022 to discuss the Immediate Jeopardy citations. Observation of Resident #5 on 6/3/2022 at 4:00 PM, in front of the nurses' station, showed the resident to be seated in a wheelchair, calm, well groomed, and no anxious or fearful behaviors were observed. Observation of Resident #7 on 6/3/2022 at 4:05 PM, in the secure unit dining room, showed the resident to be seated at a dining room table, calm, well groomed, and no anxious or fearful behaviors were observed. Observation of Resident #6 on 6/3/2022 at 4:25 AM, in the Serenity Room on the secure unit, showed the resident to be seated in a specialty wheelchair. He was calm, well groomed, and no anxious or fearful behaviors were observed. Resident #10 discharged from the facility on 10/26/2022. Medical record review of Resident #5 and #7 showed no new orders related to the allegations of abuse. Reviewed 4 incident reports occurring during the last 30 days with no concerns identified. Review of a facility in-service for abuse reporting and investigation dated 6/3/2022 was provided for the Administrator and DON. During an interview with the RDCS on 6/3/2022 at 4:45 PM, she confirmed she had reviewed all the facility incident reports for the last 30 days and had not identified any concerns related to abuse. Review of facility obtained interviews by the RDCS with 5 staff members dated 6/3/2022 showed staff were knowledgeable regarding resident abuse with no concerns identified. Review of a facility audit dated 6/3/2022 showed all documents and progress notes were reviewed with no indication of restraint use, injuries of unknown origin, or sexual abuse. During an interview with the RDSC on 6/3/2022 at 4:45 PM, she confirmed through her audits conducted on 6/3/2022 of incident reports and progress notes she had not identified any allegations of abuse. Review of a facility AD HOC meeting held on 6/3/2022 was confirmed. The facility's noncompliance continues at a scope and severity of E for monitoring of the effectiveness of the corrective actions. Refer to F-600, F-604, F-609, F-610

Based on review of a facility policy, medical record review, review of facility incident reports, interviews, and review of facility documentation, the facility failed to report to the State Survey Agency (SSA) an incident of abuse for 1 resident (#6), a cognitively impaired resident who was observed with his hands tied inside his shirt by his shirt sleeves; failed to report injuries of unknown origin for 3 residents (#6, #5, #10) when Resident #6 was observed with multiple bruises to the forearms, Resident #5 was found to have a bruise on the lip, left forearm, and across chest; and Resident #10 had a bruise to the back requiring an X-ray; and failed to report allegations of abuse for 4 residents (#6, #5, #7, #13) of 12 residents reviewed. The facility's failure to report abuse, injuries of unknown origin, and allegations of abuse to the SSA placed Residents #6, #5, #7, and #13, in Immediate Jeopardy (IJ) (a situation in which a provider's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 6/2/2022 at 5:55 PM. The facility was cited Immediate Jeopardy for F-609 at a scope and severity of K which constitutes Substandard Quality of Care. The IJ was effective 4/3/2022 and was removed on 6/3/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 6/3/2022 and the corrective actions were verified onsite by the surveyor on 6/3/2022. The findings included: Review of a facility policy Abuse, Neglect and Exploitation revised 3/22/2022 showed .It is the policy of this facility to provide protections for the health, welfare and rights of each resident .'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or anguish .it includes verbal abuse, sexual abuse, physical abuse, and mental abuse .IV. Identification of Abuse, Neglect and Exploitation .Possible indicators of abuse include, but are not limited to 1. Resident, staff, or family report of abuse. 2. Physical marks such as bruises or patterned appearances such as a handprint, belt, or ring mark on a resident's body. 3. Physical injury of a resident, of unknown source .6. Physical abuse of a resident observed .V. Investigation of alleged Abuse, Neglect and Exploitation .A. An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur .Reporting of all alleged violations to the Administrator, state agency, adult protective services .within specified timeframes: Immediately, but not later than 2 hours after the allegation is made . Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of Resident #6's comprehensive care plan dated 10/2/2020 showed Resident #6 was care planned for aggressive behaviors with activities of daily living (ADLs), rejection of care by staff, wandering and grabbing others, and sexually inappropriate behaviors with interventions in place. Medical record review of Resident #6's Incident Report dated 4/12/2022 showed .resident was found to have scattered bruising on both arms bruising is from unknown source. Bruise left arm bruise right arm. No witnesses found . Medical record review of Resident #6's Nursing Progress Note dated 4/12/2022 showed .resident found to have scattered bruising on both arms from unknown source . Medical record review of Resident #6's quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. The resident required extensive assistance of two or more staff with bed mobility and extensive assistance of one staff for locomotion, dressing and personal hygiene. Resident #6 was totally dependent on staff for transfers and toilet use and was independent with set-up help for eating. Review of Resident #6's incident report dated 4/30/2022 showed .Bruise on LFA [left forearm] 6.4 cm [centimeters] X 7 cm dark purple in color. Resident unable to give description . Medical record review of Resident #6's Nursing Progress Note dated 4/30/2022 showed .this nurse went to help pull resident up for breakfast and saw large purple bruise 6.4 [cm] X 7 cm to LFA, DON [Director of Nursing], ADON [Assistant Director of Nursing, MD [Medical Doctor], wife and wound nurse notified . During an interview with Registered Nurse (RN) #1 on 5/24/2022 at 8:05 AM, she stated .on 4/3/2022, I went into the resident's [#6] room at approximately 7:50 AM .the resident's hands were under the cover. His breakfast tray had been set up. I asked him why he wasn't eating. He said 'can't'. I pulled down the sheet to see what was going on and his hands were inside his shirt sleeves and his shirt was tied in a hard knot. I yelled for the tech [Certified Nurse Assistant (CNA) #4] to come to the room. We were not able to get the knot untied it was tied too hard. We had to pull the shirt over his head. I took a picture of his hands and sent it to the DON and ask her if that was not abuse. She responded with make sure he is in a hospital gown when you leave, and for me to know the whole situation was under investigation. She had to speak with the nurse .I asked her if I needed to send it to .[Administrator]. I did not get a response to that . During an interview with CNA #4 on 6/1/2022 at 11:50 AM, she stated .I went in to set up his [Resident #6's] breakfast. His hands were under the blanket which was normal. I raised his head and left the room. He is independent with eating after setup, in a couple of minutes .[RN #1] went in to give him medicine. She asked him why he wasn't eating, and she said he said 'can't'. She called me into the room. I came in his hands were out from the blanket. I saw his shirt sleeves tied with his hands inside. We tried to untie it, but the knot was too tight. I actually had to lower his bed so we could get his shirt off over his head .I don't know what happened or who did it. Breakfast comes pretty soon after I get here so it was early in my shift when .[RN #1] found it .[RN #1] told me she had notified someone, but I don't know who . During an interview with the DON on 5/25/2022 at 5:30 PM, she stated she was made aware on 4/3/2022 the nurse found Resident #6's shirt with the sleeves tied. She stated .I said 'okay' I would investigate .I spoke to [CNA #1] the next day .and he denied ever seeing or doing. Either the next day or the next I did tell the Administrator what I was told and that I had spoken to [CNA #1] .Yes in my professional opinion I would see that as abuse, and it was not .reported to the state. The bruise on 4/12 [2022] and 4/30 [2022] we determined as he was combative and swings his arms and hands when you are providing care and he could have hit it on the lift bar or the enabler bed rail, but no one had any knowledge of observing him hit anything to cause the bruises . Medical record review of Resident #6's Nursing Progress Note dated 5/27/2022 showed .ADON, DON, MDS, and DR [physician] .met to discuss incidents on 4/12 [2022], and 5/3 [2022] IDT [interdisciplinary team] determined cause of bruising in both incidents is that resident is resistive with care and combative with ADL's . This was the first documentation of an investigation for the causes of bruising and there was no documentation the injuries of unknown origin were reported to the SSA. During an interview with the Administrator on 6/2/2022 at 11:07 AM, he stated .I don't remember the DON reporting the incident of the resident's hands being tied .Obviously, the resident did not do it. You can't tie folks up. You can't tie their arms; this would have been classified as abuse and should have been .reported . Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of Resident #5's Nursing Progress Note dated 4/20/2022 showed .Resident's daughter here asked if resident had fallen last night or today, resident has bruising noted on right bottom lip, left forearm, and bruising across the chest that is turning yellow and blue resident denies a fall. Daughter ask mother if it hurt resident stated it does not hurt . Medical record review of Resident #5's quarterly MDS dated [DATE] showed a BIMS score of 8, indicating moderate cognitive impairment. Resident #5 required limited assistance of 1 staff for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene. Resident #5 required supervision of staff with walking and was frequently incontinent of bowel and bladder. During an interview with RN #1 on 5/24/2022 at 8:05 AM she stated .On 4/20/2022, the resident's [#5] daughter asked if the resident [#5] had fallen last night or today. I was not aware of a fall. I went to the resident's room to assess her. She had bruising noted on right bottom lip, left forearm, and bruising across the chest that was turning yellow and blue it was like a half circle. [Resident #5] denied having a fall. I asked the resident what happened, and she said, 'a black guy pushed me'. I just looked at her for a minute and she said 'well it wasn't you. You're not black or a male, and I'm not prejudice.' Her daughter looked at me and said 'no she isn't prejudice. We never have been' .The resident wasn't scared or upset. So, I didn't [report the injury]. I did put what I found in a progress note, and I told the oncoming nurse [LPN #1]. Her daughter asked her if it hurt. Resident [#5] stated it did not hurt .I did not fill out an incident report . During an interview with Resident #5 on 5/25/2022 at 8:35 AM, she stated she received good care. She stated .I reckon I will just set here for a while . When asked if anyone had ever mistreated her or hurt her, she smiled and stated .my brother when we were at home . During an interview with the ADON on 5/26/2022 at 5:30 PM, she stated .I was unaware of the incident until I saw the note in the 24-hour communications book stating that [Resident #5] had some bruising. I was off on 4/20/2022 and I didn't review the communication book. Honestly, I am not sure exactly when I reviewed the communications book, but that is when I saw the note. I asked the nurse that was working about it; if she could shed any light on what happened and went in and talked to the resident. The resident didn't know what happened . During the interview the ADON stated the incident was not reported to the State Survey Agency. During an interview with CNA #5 on 6/1/2022 at 11:30 AM, she stated .it was close to shift change when I saw the bruises. I asked the resident [#5] what happened, and she couldn't tell me anything. I reported to the nurse. I don't remember who the nurse was .I don't know if they already knew about the bruises or not when I reported it . During an interview with the Administrator on 6/2/2022 at 10:45 AM, he stated .I would have expected the staff member to report the allegation of abuse to me immediately, and I was not made aware of the allegation . The injury of unknown origin was not reported to the SSA. Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of Resident #10's admission MDS dated [DATE], showed a BIMS score of 6, indicating severe cognitive impairment. The resident required extensive assistance of one staff for bed mobility, dressing, and personal hygiene; limited assistance of one staff for transfer, walking, and toilet use; and supervision for locomotion and eating. Medical record review of Resident #10's Nurses Progress Note dated 4/24/2022 showed .Resident c/o [complaint of] back pain this AM and stayed in bed until this afternoon. When she tried to get up, she had a very difficult time and even walking. This nurse assessed her back and noted a purple bruise to her lower back measuring 7 cm [centimeters] X 5 cm DON and MD [physician] made aware with new order Xray of lower back . Medical record review of Resident #10's Radiology Report dated 4/24/2022 showed .There is anatomic alignment of the lumbar vertebrae. Lumbar vertebral bodies show [CONDITION(S)] osteophytic spurring. There is an osteoporotic compression involving the T-12 vertebra. The age of the compression is old or indeterminate . Review of Resident #10's Incident Report dated 4/24/2022 showed .resident complaining of lower back hurting. Upon assessment noted 7 cm X 5 cm purple bruise. Resident unable to give description . Review of a facility obtained interview from LPN #4/Wound Care Nurse, not dated, showed Resident #10 had a contracture of the left hip and knee and used a walker for ambulation.While performing wound care on the 400 hall and assisting with residents had observed on numerous occasions the way in which the resident sits. She did not ease herself into sitting position she collapses in chairs plops down and the residents [resident's] back hits the back of the chair . During an interview with Resident #10 on 5/25/2022 at 9:05 AM, she stated she received good care. I usually go to sleep and don't remember much about what happens .they are really busy, but they are pretty good to me . During the interview the resident was unable to recall having a bruise on her back or how she obtained the bruise. During an interview with LPN #2 on 5/25/2022 at 9:45 AM, she stated .I did an incident report on [Resident #10] on 4/24/2022. She was complaining of back pain when the CNA [CNA #7] went in to take her breakfast. She said 'that [alleged perpetrator] was in here last night and was rough with me'. She said he was rolling her around. Approximately an hour later she didn't want to set up to take her medicine because she said her back was hurting .About 11:00 AM I went in to give her medication and she did not want to set up to take medicine. She was complaining about her back again so I asked her if I could look at it. That was when she said the mattress was the reason her back was hurting. When I looked, she had a 7 cm X 5 cm purple bruise on her lower back. We did an X-ray, and it was negative for fractures. I reported the bruise to the DON and asked if I needed to chart anything about what the resident had said initially about [alleged perpetrator] being rough with her the night before. She said 'No' .I did not hear anything else . During an interview with the DON on 5/25/2022 at 5:37 PM, she stated .I was unaware of the incident on [Resident #10] until I saw the incident report. Must have been the next day when I saw the report .it was an allegation of abuse, and it was not reported to the state agency as an allegation of abuse . During an interview with CNA #7 on 5/26/2022 at 10:45 AM, she stated .I went into [Resident #10's] room to take her breakfast. She told me her back hurt. She said, 'I am glad you are here that [CNA #1] was here last night, and he was rough with me.' I went and told [LPN #3] what [Resident #10] had said to me and she went in to talk to [Resident #10]. I stayed in the room. She did tell [LPN #2] it was that [CNA #1]. Then she said her back hurt because of the mattress. Then she said it was because she had TB [[CONDITION(S)]] of the bone. I assume [LPN #2] called the DON or the ADON, but I don't know for sure. That was on a Saturday. I guess I should have reported it to the Administrator on Monday . During an interview with the Administrator on 6/2/2022 at 10:45 AM, he stated .I am unaware of this allegation. The resident alleged abuse with her statement. It should have been .reported immediately . Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of Resident #7's quarterly MDS dated [DATE] showed a BIMS score of 0, indicating severe cognitive impairment. Resident #7 required extensive assistance of 1 staff for bed mobility, transfer, dressing, and personal hygiene; limited assistance with walking in room and toilet use; and was independent with eating. During an interview with CNA #2 on 5/24/2022 at 10:40 AM, she stated .We have one resident [Resident #7] that wanders. She was in the hallway just walking around. He [CNA #1] said to her [Resident #7], 'You know what time it is?' and she said 'no'. She knew what he meant, and she [Resident #7] didn't want to go to bed. She tried to go around him [CNA #1], so he [CNA #1] put his hands on her [Resident #7] upper arms and said 'come on. You know what we have to do' and he had his arms and was guiding her forcibly down the hall to her room. [LPN #1] was in the room across from where [CNA #1] and I were, and I thought he [LPN #1] heard the resident. I just said [called LPN #1 by name] and he [LPN #1] said 'I got ya'. At that point I thought he knew what happened [between CNA #1 and Resident #7]. This was toward the end of March. He said he would take care of it. I left that night at 10:00. I did not report it to anyone else. I thought [LPN #1] knew what was going on. I wasn't back on his [LPN #1] hall anymore that night . During an interview with CNA #3 on 5/24/2022 at 1:15 PM, he stated he had observed CNA #1 shove Resident #7 .and she about fell . He [CNA #1] was trying to [NAME] them to bed. I told [RN #1] the day nurse that he was physically pushing her .[LPN #2] the other day nurse and .[LPN #1] the night shift nurse, but every time they report it nothing gets done .I told the ADON .I specifically .had seen him push .[Resident #7] and she had stumbled .She acted like she didn't know anything about it .This was after .[CNA #1] was suspended [4/30/2022] . During an interview with RN #1 on 5/26/2022 at 11:00 AM, she stated CNA #3 had reported to her that he saw CNA #1 push Resident #7, but he had not reported it to her until her next shift which was on 4/6/2022. RN #1 stated she did not report what CNA #3 told her to the DON. During an interview with LPN #2 on 5/25/2022 at 9:45 AM, she stated .I did work on 4/4/2022 day shift and I do not recall .[CNA #3] reporting that he had witnessed .[CNA #1] push .[Resident #7] on the night of 4/3/2022. During an interview with the ADON on 5/25/2022 at 5:48 PM, she stated she did not know until 5/24/2022, when this State Surveyor had asked about the allegation of Resident #7 being observed being pushed by CNA #1, what had occurred. After being made aware she then spoke to CNA #2 and had been told that CNA #1 had put his hands on Resident #7's outer shoulder area and guided her toward her room.I was told she did not lose her balance or stumble .I was on my way in the building it was after .[CNA #1] had been suspended .[CNA #3] .said he had thought .[CNA #1] was rough with the residents. He basically gave the same account of the event as .[CNA #2] did .I think he did use the word push .I told the DON about it when she got here. Basically, she asked me why it had not been reported before . During an interview with the DON on 5/26/2022 at 3:15 PM, she stated .I do not recall the ADON speaking to me about an allegation that .[CNA #1] had pushed .[Resident #7]. I did not do anything. I don't recall having a conversation about it with the ADON. Yesterday, 5/25/2022, was the first knowledge I had of the allegation . During an interview with LPN #1 on 6/1/2022 at 2:25 PM, he stated .I do not recall .[CNA #3] reporting to me that he witnessed .[CNA #1] push .[Resident #7] . During an interview with LPN #1 on 6/1/2022 at 5:00 PM he stated .I didn't realize what had happened. [CNA #2] did not report to me what she had seen at the time. Had I known what she was talking about, I would have contacted the DON . During an interview with the Administrator on 6/2/2022 at 11:15 AM, he stated .I was unaware of either allegation of .[Resident #7] being pushed by [CNA #1] or being handled roughly .both would have been allegations of abuse and should have been .immediately .reported to the state . Resident #13 was admitted to the facility on [DATE], readmitted on [DATE], and discharged on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of Resident #13's admission MDS dated [DATE] showed a BIMS score of 7, indicating severe cognitive impairment. The resident required extensive assistance of one-person physical assist with bed mobility, transfer, dressing toilet use and personal hygiene; limited assistance of one-person physical assistance with locomotion; and was independent with eating after setup. Medical record review of Resident #13's Nursing Progress Notes dated 5/17/2022 showed .Resident is noted with anxiety. She seems to have intermitted [intermittent] panic attacks to where she complains of SOB [shortness of breath], shakes and moans. Psych [psychiatric] NP [nurse practitioner] informed with N.O. [new order] Trazadone [antidepressant] 25 mg [milligrams] BID [twice a day] . Resident #9 was admitted to the facility on [DATE], discharged home on 5/6/2022, and readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of Resident #9's admission MDS dated [DATE] showed a BIMS score of 4, indicating severe cognitive impairment. Resident #9 exhibited physical behavioral symptoms directed toward others 1 to 3 days during the assessment period. The resident required extensive assistance of 1-person physical assist with bed mobility, transfer, locomotion, dressing, toilet use, and personal hygiene; limited assistance of 1-person physical assistance with walking; and was independent eating with setup help. Medical record review of Resident #9's comprehensive care plan dated 4/23/2022 showed the care plan was revised on 4/30/2022 and showed .is an elopement risk/wanderer r/t [related to] dementia .check placement and function of safety monitoring device every shift .distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book .Identify pattern of wandering: is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise .has the potential to be physically and verbally aggressive r/t dementia .administer medications as ordered .assess and anticipate resident's needs .provide physical and verbal cues to alleviate anxiety . During an interview with LPN #1 on 5/25/2022 at 7:40 AM, he stated .On May 18th, we had a resident named [Resident #9]. I was asked to let another employee outside of the side door. While [CNA #6] and I were walking back in, we heard screaming coming from [Resident #13's] room. She is discharged now. We walked into the room and [Resident #9] has her [Resident #13] half-way off the bed with his hand pulling on her brief trying to get his hand down her brief. So, we separated them. I had [CNA #6] to watch [Resident #9] while I reported it to the ADON and DON who were working that night. After I told them that, I was informed by the DON and the ADON not to put a note in the chart. If she said anything, we could just attribute it to her medications, and I was not comfortable with that. I made .sure he did not go in her room again, but I didn't know what to do after that . During an interview with the DON on 5/25/2022 at 5:35 PM, she stated .[LPN #1] came to us. We were both here and said [Resident #9] was in [Resident #13's] room and it looked like he was going to touch her brief. He reported he and the CNA had followed [Resident #9] into the room. To my knowledge he [Resident #9] never touched her. I can't say what he [Resident #9] was going to do. I told staff to monitor him [Resident #9] and nothing else was reported . During an interview with CNA #6 on 5/25/2022 at 6:15 PM, she stated .it was the night of 5/18/2022. I was the tech for 200 hall. The DON was on 300 and 100. ADON was on 400 and 500. I don't know what time it was, but I had been to my locker and was speaking to the nurse [LPN #1] on the 400 hall. We heard screaming and we ran into [Resident #13's] room. [Resident #9] had one hand inside of her brief and was trying to get the brief off. [LPN #1] told the DON and ADON and he said they said not to report it and basically pretend it didn't happen. I did not hear them say that, but I did witness what [Resident #9] did . During an interview with the ADON on 5/26/2022 at 7:40 AM, she stated .[LPN #1] reported that [Resident #9] entered the room. The resident [Resident #13] was hollering so they went in. I can't remember if he said he was reaching for or had a hold of her brief. The DON told him to monitor him. Nothing physical happened . During an interview with the Administrator on 6/2/2022 at 10:45 AM, he stated .an incident involving [Resident #9] and [Resident #13] was never reported to me . During the interview he confirmed this allegation of abuse was not reported to the SSA. The facility's corrective actions included: The DON assessed Resident #6 on 5/26/22 and identified no adverse effects that occurred from his hands being tied. Residents #5, #7 and #10 were assessed by MDS/DON on 5/26/2022 and identified no adverse effects from injuries of unknown origins or allegation of sexual abuse. Residents #11 and #13 discharged prior to 5/26/22 and were not assessed. CNA #1 was suspended on 4/30/2022 and terminated on 6/3/2022. The CNA did not work after 4/30/2022. RDCS (Regional Director of Clinical Services) and/or the NHA (Nursing Home Administrator) notified physician and responsible party of allegation of abuse for Resident #6 and of incidents of unknown origin for residents #5, #7 and #10 on 6/3/2022. With no new orders were received. All incident reports for the last 30 days were reviewed by RDCS and/or ADCS on 6/3/2022 and no other residents were found to be affected. All residents in the facility were interviewed or observed for signs of abuse according to their BIMS score on 5/26/2022. These interviews/observations indicated no signs of abuse. 5/24/2022 staff education on abuse including resident safety and reporting was initiated by RDCS and completed on 6/3/2022 for all staff except one staff member who was on maternity leave. The staff member will be in-serviced prior to being allowed to return to work. 5/24/2022 the Administrator was educated by the RDCS on reporting abuse. This education was repeated 6/2/2022 by the RDCS. RDCS will monitor documentation in the electronic system weekly for any noted use of restraints, injuries of unknown origins, or allegation of sexual abuse to ensure thorough investigations are completed and all allegations of abuse and incidents of unknown origin are reported starting on 6/3/2022 and ongoing for 12 weeks and/or until substantial compliance is maintained. RDCS and/or NHA will complete interviews with 5 staff weekly to ensure there are no allegations of abuse that are not documented in the EMR (electronic medical record) starting on 6/3/2022 and ongoing for 4 weeks, then 3 staff weekly for 4 weeks then 1 staff weekly for 4 weeks and/or until substantial compliance is maintained. Instances of non-compliance will be addressed with re-education by RDCS and disciplinary steps as applicable starting 6/3/2022. Observation of Resident #5 on 6/3/2022 at 4:00 PM, in front of the nurses' station, showed the resident to be seated in a wheelchair, calm, well groomed, and no anxious or fearful behaviors were observed. Observation of Resident #7 on 6/3/2022 at 4:05 PM, in the secure unit dining room, showed the resident to be seated at a dining room table, calm, well groomed, and no anxious or fearful behaviors were observed. Observation of Resident #6 on 6/3/2022 at 4:25 AM, in the Serenity Room on the secure unit, showed the resident to be seated in a specialty wheelchair, calm, well groomed, and no anxious or fearful behaviors were observed. Resident #10 discharged from the facility on 10/26/2022. Medical record review of Resident #5 and #7 showed no new orders related to the allegations of abuse. During an interview with the RDCS on 6/3/2022 at 4:45 PM, she confirmed she had reviewed all the facility incident reports for the last 30 days and had not identified any concerns related to abuse. Review of facility obtained resident interviews and facility obtained skin observations on 5/26/2022, in comparison with a facility roster, showed every resident had been reviewed, with no concerns identified. Review of staff education on abuse, resident safety, and reporting based on comparison of the facility staff roster and the in-service sign sheets, all staff except one staff member identified as being on maternity leave, had completed the education. During an interview with the RDSC on 6/3/2022 at 4:45 PM, she confirmed the staff member would not be allowed to return to work prior to receiving the education. Review of a facility audit dated 6/3/2022 showed all documents and progress notes were reviewed with no indication of restraint use, injuries of unknown origin, or sexual abuse. Review of facility obtained interviews by the RDCS with 5 staff members dated 6/3/2022 showed staff were knowledgeable of resident abuse with no concerns identified. Review of a facility in-service dated 6/2/2022 showed the Administrator and DON had received education on updated abuse investigation forms and process. During an interview with the RDSC on 6/3/2022 at 4:45 PM, she confirmed through her audits conducted on 6/3/2022 of incident reports and progress notes she had not identified any allegations of abuse. The facility's noncompliance continues at a scope and severity of E for monitoring of the effectiveness of the corrective actions.

Based on review of a facility policy, medical record review, review of facility incident reports, interview, and review of facility documentation, the facility failed to investigate allegations of physical abuse for 2 residents (#6 and #7) when Resident #6 was observed with his hands tied inside his shirt by his shirt sleeves and Resident #7 was observed being pushed by CNA #1; failed to investigate injuries of unknown origin for 3 residents (#6, #5, #10) when Resident #6 was found with bruising to his arms, Resident #5 was found with a bruise on the lip, left forearm, and across the chest, and Resident #10 had a bruise to the back requiring an X-ray; and failed to investigate an allegation of sexual abuse for 1 resident (#13) of 12 residents reviewed. The facility's failure to investigate allegations of abuse and injuries of unknown origin placed Residents #6, #7, #5, #10, and #13 in Immediate Jeopardy (IJ) (a situation in which a provider's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 6/2/2022 at 5:55 PM. The facility was cited Immediate Jeopardy for F-610 at a scope and severity of J which constitutes Substandard Quality of Care. The IJ was effective 4/3/2022 and was removed on 6/3/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 6/3/2022 and the corrective actions were verified onsite by the surveyor on 6/3/2022. The findings included: Review of a facility policy Abuse, Neglect and Exploitation revised 3/22/2022 showed .It is the policy of this facility to provide protections for the health, welfare and rights of each resident .Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or anguish .it includes verbal abuse, sexual abuse, physical abuse, and mental abuse .IV. Identification of Abuse, Neglect and Exploitation .Possible indicators of abuse include, but are not limited to 1. Resident, staff, or family report of abuse. 2. Physical marks such as bruises or patterned appearances such as a handprint, belt, or ring mark on a resident's body. 3. Physical injury of a resident, of unknown source .6. Physical abuse of a resident observed .V. Investigation of alleged Abuse, Neglect and Exploitation .V. Investigation Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur . Resident #6 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of Resident #6's comprehensive care plan dated 10/2/2020 and revised on 10/14/2020 showed .may exhibit aggressive behavior with ADL's [activities of daily living] as well as abusive language . Review of Resident #6's Incident Report dated 4/12/2022 showed .resident was found to have scattered bruising on both arms bruising is from unknown source. Bruise left arm bruise right arm. No witnesses found . Medical record review of Resident #6's Nursing Progress Note dated 4/12/2022 showed .resident found to have scattered bruising on both arms from unknown source . Medical record review of Resident #6's quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 0, indicating the resident was severely cognitively impaired. The resident required extensive assistance of two or more-person physical assist for bed mobility; extensive assistance of one-person physical assist for locomotion, dressing and personal hygiene; was totally dependent with the assist of one to two persons for transfer and toilet use; and was independent eating with set up help. Review of Resident #6's incident report dated 4/30/2022 showed .Bruise on LFA [left forearm] 6.4 cm [centimeters] X [by] 7 cm dark purple in color. Resident unable to give description . During an interview with Registered Nurse (RN) #1 on 5/24/2022 at 8:05 AM, she stated .on 4/3/2022 I went into the resident's [Resident #6] room at approximately 7:50 AM .the resident's hands were under the cover. His breakfast tray had been set up .I pulled down the sheet to see what was going on and his hands were inside his shirt sleeves and his shirt was tied in a hard knot. I yelled for the tech [Certified Nursing Assistant (CNA) #4] to come to the room. We were not able to get the knot untied. It was tied too hard. We had to pull the shirt over his head. I took a picture of his hands and sent it to the DON and asked her if that was not abuse. She responded with make sure he is in a hospital gown when you leave, and for me to know the whole situation was under investigation. She had to speak with the nurse .I asked her if I needed to send it to .[Administrator]. I did not get a response to that . During an interview CNA #1 (caregiver on the night shift when incident occurred) on 5/24/2022 at 10:00 AM, he stated Resident #6 was not combative so he would have no reason to tie his hands and stated, I've never tied a resident's hands in a shirt, and I have not had any reports of anyone else doing that . During an interview with the Director of Nursing (DON) on 5/25/2022 at 5:30 PM she stated she was made aware on 4/3/2022 the nurse found Resident #6's shirt with the sleeves tied. The DON stated .I said, 'okay', I would investigate and to make sure he was in a hospital gown before they left. I spoke to [CNA #1] the next day. I asked if he had ever seen any resident's shirt sleeves tied or had ever tied anyone's shirt sleeves together and he denied ever seeing or doing. Either the next day or the next, I did tell the Administrator what I was told and that I had spoken to [CNA #1]. There was no further investigation .Yes in my professional opinion I would see that as abuse, and it was not investigated . The DON stated the bruises on 4/12/2022 and 4/30/2022 were determined to be a result of Resident #6 being combative and swinging his arms and hands when the staff was providing care. He could have hit it on the lift bar or the enabler bed rail, but no one had any knowledge of observing him hit anything to cause the bruises, and there was no official investigation. Review of Resident #6's Nursing Progress Note dated 5/27/2022 showed .ADON [Assistant Director of Nursing], DON, MDS, and DR [doctor] .met to discuss incidents on 4/12 [2022], and 5/3 [2022] IDT [interdisciplinary team] determined cause of bruising in both incidents is that resident is resistive with care and combative with ADL's . The Nursing Progress Note on 5/27/2022 was the first documentation of an IDT review or investigation of bruises Resident #6 sustained. During an interview with CNA #4 on 6/1/2022 at 11:50 AM, she confirmed she was called to Resident #6's room and saw the resident tied in his shirt sleeves.I saw his shirt sleeves tied with his hands inside. We tried to untie it, but the knot was too tight. I actually had to lower his bed so we could get his shirt off over his head . During an interview with the Administrator on 6/2/2022 at 11:07 AM, he stated .I don't remember the DON reporting the incident of the resident's hands being tied. We should have investigated it further .The bruises [that occurred on 4/12/2022 and 4/30/2022] should have been investigated further .and they were not . Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of Resident #7's comprehensive care plan dated 9/16/2020 and revised on 10/14/20 showed .She can become verbally aggressive toward staff and resistant to care .Do not argue with resident .Talk to resident in calm manner when resisting care . The care plan was revised on 10/15/2020 and showed .Has exhibited behaviors of yelling and screaming with threatening behaviors during care .Ask her why she is yelling, do not argue with her address her concerns .Refer to psych services as needed .Has exhibited behaviors of rejecting care .When resident is approaching exit door often redirect her into activity room or serenity room .When resisting care stop, calmly talk with resident to help resident understand what you are here to help her with . The care plan was revised on 10/19/2020 and showed .Has exhibited behaviors of rejecting care from staff and will block her door so that staff cannot enter at times .Allow .[Resident #7] to make decisions regarding care such as picking out clothing, preference on bathing schedule . Medical record review of Resident #7's quarterly MDS dated [DATE] showed a BIMS score of 0, indicating severe cognitive impairment. Resident #7 required extensive assistance of 1 staff for bed mobility, transfer, dressing, and personal hygiene. Review of Resident #7's Nursing Progress Notes dated 4/1/2022 - 5/2/2022 showed no documentation of any allegations of abuse. During an interview with CNA #2 on 5/24/2022 at 10:40 AM, she stated .We have one resident [Resident #7] that wanders. She was in the hallway just walking around. He [CNA #1] said to her [Resident #7] 'you know what time it is?' and she said 'no'. She [Resident #7] knew what he [CNA #1] meant, and she didn't want to go to bed. She [Resident #7] tried to go around him [CNA #1], so he put his hands on her upper arms and said 'come on. You know what we have to do,' and he had his arms and was guiding her forcibly down the hall to her room. [LPN #1] was in the room across from where [CNA #1] and I were, and I thought he [LPN #1] heard the resident .I just said [called LPN #1 by name] and he said, 'I got ya'. At that point, I thought he knew what happened [between CNA #1 and Resident #7]. This was toward the end of March. He said he would take care of it. I left that night at 10:00. I did not report it to anyone else. I thought [LPN #1] knew what was going on . CNA #2 reported she thought LPN #1 heard her when she alerted LPN #1 of what was happening and that she was reporting the allegation of abuse to LPN #1. During an interview with CNA #3 on 5/24/2022 at 1:15 PM, he stated he had observed CNA #1 shove Resident #7 .and she about fell .He [CNA #1] was trying to [NAME] them to bed. I told [RN #1] the day nurse that he was physically pushing her. [LPN #2] the other day nurse and .[LPN #1] the night shift nurse .I told the ADON . During an interview with LPN #2 on 5/25/2022 at 9:45 AM, she stated she had worked on 4/4/2022 day shift and did not recall CNA #3 reporting that he had witnessed CNA #1 push Resident #7 on the night of 4/3/2022. During an interview with Resident #7 on 5/25/2022 at 12:45 PM, she was pleasant, but unable to appropriately answer questions related to allegations of abuse, or someone mistreating her, pushing her, or making her do anything she did not want to do. During an interview with the ADON on 5/25/2022 at 5:48 PM, she stated she did not know about any allegations until 5/24/2022, when this State Surveyor had asked about the allegation Resident #7 was observed being pushed by CNA #1. After being made aware, she then spoke to CNA #2 and had been told that CNA #1 had put his hands on Resident #7's outer shoulder area and guided her toward her room.I was told she did not lose her balance or stumble . She said she spoke to CNA #2 in the parking lot after CNA #1 had been suspended on 4/30/2022. CNA #2 said he had thought CNA #1 was rough with the residents. CNA #2 basically gave the same account of the event as CNA #3 did. He [CNA #2] did not tell me the resident had stumbled .I think he [CNA #2] did use the word push, but I didn't ask him to demonstrate what he had seen. I told the DON about it when she got here. Basically, she asked me why it had not been reported before . During an interview with RN #1 on 5/26/2022 at 11:00 AM she stated .he [CNA #3] did report it to me that he saw [CNA #1] push [Resident #7], but my next shift was on 4/6 [2022] . During an interview with the DON on 5/26/2022 at 3:15 PM, she stated .I do not recall the ADON speaking to me about an allegation that [CNA #1] had pushed .[Resident #7]. I did not do anything. I don't recall having a conversation about it with the ADON. Yesterday [5/25/2022] was the first knowledge I had of the allegation. I did not do an investigation. When the witness saw the resident being pushed, they should have immediately intervened, and after the resident was safe, have reported to the nurse. The nurse should have removed the accused CNA, then the nurse should have called the Administrator, myself, or the ADON so an investigation could have been started .that did not occur . During an interview with the Administrator on 6/2/2022 at 11:15 AM, he stated .I was unaware of either allegation of [Resident #7] being pushed by [CNA #1] or being handled roughly. Both would have been allegation of abuse and should have been reported and immediately investigated . Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of Resident #5's Nursing Progress Note dated 4/20/2022 showed .Resident's daughter here asked if resident had fallen last night or today, resident has bruising noted on right bottom lip, left forearm, and bruising across the chest that is turning yellow and blue resident denies a fall. Daughter ask mother if it hurt resident stated it does not hurt . Medical record review of Resident #5's quarterly MDS dated [DATE] showed a BIMS score of 8, indicating moderate cognitive impairment. The resident required limited assistance of 1 staff for bed mobility, transfer, locomotion on and off the unit, dressing, toilet use and personal hygiene, and supervision with walking. During an interview with RN #1 on 5/24/2022 at 8:05 AM she stated .On 4/20/2022, the resident's [Resident #5] daughter asked if the resident [Resident #5] had fallen last night or today. I was not aware of a fall. I went to the resident's room to assess her. She had bruising noted on right bottom lip, left forearm, and bruising across the chest that was turning yellow and blue. It was like a half circle. [Resident #5] denied having a fall. I asked the resident what happened, and she said a black guy pushed her .Her daughter said 'I don't know if I would believe her or not' . I did put what I found in a progress note, and I told the oncoming nurse [Licensed Practical Nurse (LPN) #1]. Her daughter asked her if it hurt. Resident stated it did not hurt .I did not fill out an incident report . During an interview with Resident #5 on 5/25/2022 at 8:35 AM, she stated she received good care. When asked if anyone had ever mistreated her or hurt her, she smiled and stated .my brother when we were at home . During an interview with the ADON on 5/26/2022 at 5:30 PM, she stated .I was unaware of the incident until I saw the note in the 24-hour communications book stating that [Resident #5] had some bruising .I am not sure exactly when I reviewed the communications book, but that is when I saw the note. I asked the nurse that was working about it, if she could shed any light on what happened, and went in and talked to the resident. The resident didn't know what happened . During the interview she stated an incident report should have been completed and the incident was not investigated as an injury of unknown origin. During an interview with CNA #5 on 6/1/2022 at 11:30 AM, she stated .it was close to shift change when I saw the bruises [on Resident #5]. I asked the resident what happened, and she couldn't tell me anything. I reported to the nurse. I don't remember who the nurse was .I don't know if they already knew about the bruises or not when I reported it . During the interview, CNA #5 stated RN #1 was off and so RN #1 would not have been the nurse she reported the bruising to. During an interview with the Administrator on 6/2/2022 at 10:45 AM, he stated this incident of bruising for Resident #5 was not investigated as an injury of unknown origin. Resident #10 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of Resident #10's admission MDS dated [DATE] showed a BIMS score of 6, indicating severe cognitive impairment. The resident required extensive assistance of one staff for bed mobility, dressing and personal hygiene; limited assistance of one for transfer, walking, and toilet use; and supervision for locomotion and eating. Medical record review of Resident #10's Nurses Progress Note 4/24/2022 showed .Resident c/o [complaint of] back pain this AM and stayed in bed until this afternoon. When she tried to get up, she had a very difficult time and even walking. This nurse assessed her back and noted a purple bruise to her lower back measuring 7 cm X 5 cm DON and MD [medical doctor] made aware with new order Xray of lower back . Medical record review of Resident #10's Radiology Report dated 4/24/2022 showed .There is anatomic alignment of the lumbar vertebrae. Lumbar vertebral bodies show [CONDITION(S)] osteophytic spurring. There is an osteoporotic compression involving the T-12 vertebra. The age of the compression is old or indeterminate . Review of Resident #10's Incident Report dated 4/24/2022 showed .resident complaining of lower back hurting. Upon assessment noted 7 cm X 5 cm purple bruise. Resident unable to give description . Review of a facility obtained interview from LPN #4/Wound Care Nurse, not dated, showed Resident #10 had a contracture of the left hip and knee, and used a walker for ambulation. While performing wound care on the 400 hall and assisting with residents had observed on numerous occasions the way in which the resident sits. She did not ease herself into sitting position she collapses in chairs plops down and the residents [resident's] back hits the back of the chair . During an interview with Resident #10 on 5/25/2022 at 9:05 AM, she stated she received good care. I usually go to sleep and don't remember much about what happens .they are really busy, but they are pretty good to me . During the interview, the resident was unable to recall having a bruise on her back or how she obtained the bruise. During an interview with LPN #2 on 5/25/2022 at 9:45 AM, she stated .it was every time [CNA #1] would work. The next day we would find something on one of the residents, a bruise, a skin tear .I did an incident report on [Resident #10] on 4/24/2022. She was complaining of back pain when the CNA [CNA #7] went in to take her breakfast she said 'that [expletive] was in here last night and was rough with me.' She said he was rolling her around. Approximately an hour later she didn't want to set up to take her medicine because she said her back was hurting .About 11:00 AM, I went in to give her medication and she did not want to set up to take medicine. She was complaining about her back again, so I asked her if I could look at it. That was when she said the mattress was the reason her back was hurting. When I looked, she had a 7 cm X 5 cm purple bruise on her lower back. We did an X-ray, and it was negative for fractures. I reported the bruise to the DON and asked if I needed to chart anything about what the resident had said initially about that [expletive] being rough with her the night before. She said 'No' they needed to investigate it first. I did not hear anything else. The female residents on the secure unit show signs of fear and anxiety when [CNA #1] would come in for his shift. They try to walk away from him, yelling out. I have seen him interact with residents. He will take hold of their shoulders and guide them where he wants them to go, but I haven't witnessed him be aggressive with residents. No one on secure unit or the 500 hall have had bruises or skin tears since he has been suspended . During an interview with the DON on 5/25/2022 at 5:37 PM, she stated .I was unaware of the incident on [Resident #10] until I saw the incident report. Must have been the next day when I saw the report. We did interviews and they showed she often sat down on a chair arm, so we determined it was self-inflicted by her dropping herself down. It was investigated on 4/25/2022. I do not have a formal written investigation . Interview confirmed there was no documentation of an investigation of the bruising. During an interview with CNA #7 on 5/26/2022 at 10:45 AM, she stated . I went into [Resident #10's] room, to take her breakfast. She told me her back hurt. She said, 'I am glad you are here. That [expletive] was here last night, and he was rough with me.' I went and told [LPN #3] what [Resident #10] had said to me and she went in to talk to [Resident #10] .she [Resident #10] did tell [LPN #2] it was that [expletive]. Then she said her back hurt because of the mattress. Then she said it was because she had TB [[CONDITION(S)]] of the bone. I assume [LPN #2] called the DON or the ADON, but I don't know for sure. No one came in an interviewed me or anything. No one asked me about what the resident told me . Medical record review of Resident #10's Nursing Progress Note dated 5/27/2022 showed .ADON, DON, MDS, RDCS [Regional Director Clinical Services] and Dr [doctor - Medical Director] met to discuss incidents on 4/24/2022. IDT [interdisciplinary team] determined cause of bruising of the incident is that resident sits down forcefully due to stiffness in leg from polio as a child. She often sits down hard on the arm of chairs as well . The Nursing Progress Notes was the first documented of an IDT review or investigation of the Resident #10's bruising and allegation of abuse. During an interview with the Administrator on 6/2/2022 at 10:45 AM, he stated .I am unaware of this allegation. The resident alleged abuse with her statement. It should have been investigated .immediately . Resident #13 was admitted to the facility on [DATE], readmitted on [DATE], and discharged on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of Resident #13's admission MDS dated [DATE] showed a BIMS score of 7, indicating severe cognitive impairment. Resident #13 required extensive assistance of one-person physical assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene; limited assistance of one-person physical assistance with locomotion; and was independent with eating after setup help. Medical record review of Resident #13's Nursing Progress Notes dated 5/17/2022 showed .Resident is noted with anxiety. She seems to have intermitted [intermittent] panic attacks to where she complains of SOB [shortness of breath], shakes and moans. Psych NP [Nurse Practitioner] informed with N.O. [new order] Trazadone [antidepressant] 25 mg [milligrams] BID [twice a day] . Resident #9 was admitted to the facility on [DATE], discharged home on 5/6/2022, and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of Resident #9's comprehensive care plan dated 4/23/2022 and revised on 4/30/2022 showed .is an elopement risk/wanderer r/t [related to] dementia .distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book .has the potential to be physically and verbally aggressive r/t dementia .administer medications as ordered .assess and anticipate resident's needs .provide physical and verbal cues to alleviate anxiety . Medical record review of Resident #9's admission MDS dated [DATE] showed a BIMS score of 4, indicating severe cognitive impairment. Physical behavioral symptoms directed toward others was observed 1 to 3 days during the assessment period. The resident required extensive assistance of 1-person physical assistance with bed mobility, transfer, locomotion, dressing, toilet use, and personal hygiene; limited assistance of 1-person physical assistance with walking; and was independent eating with setup help. During an interview with LPN #1 on 5/25/2022 at 7:40 AM, he stated .On May 18th we had a resident named [Resident #9]. While .[CNA #6] and I were walking back in, we heard screaming coming from .[Resident #13's] room .we walked into the room and .[Resident #9] has her [Resident #13] half-way off the bed with his hand pulling on her brief, trying to get his hand down her brief. So, we separated them. I had [CNA #6] to watch [Resident #9] while I reported it to the ADON and DON who were working that night. After I told them that, I was informed by the DON and the ADON not to put a note in the chart. If she said anything, we could just attribute it to her medications, and I was not comfortable with that. I made .sure he did not go in her room again, but I didn't know what to do after that . During an interview with the DON on 5/25/2022 at 5:35 PM, she stated .the nurse came to us, and we were both here and said [nurse said Resident #9] was in [Resident #13's] room and it looked like he was going to touch her brief. He reported he and the CNA had followed [Resident #9] into the room. To my knowledge he never touched her. I can't say what he was going to do. I told staff to monitor him and nothing else was reported . During an interview with CNA #6 on 5/25/2022 at 6:15 PM, she stated .it was the night of 5/18/2022. I was the tech for 200 hall. The DON was on 300 and 100. ADON was on 400 and 500. I don't know what time it was, but I had been to my locker and was speaking to the nurse [LPN #1] on the 400 hall. We heard screaming and we ran into [Resident #13's] room. [Resident #9] had one hand inside of her brief and was trying to get the brief off. [LPN #1] told the DON and ADON and he said they said not to report it and basically pretend it didn't happen. I did not hear them say that, but I did witness what [Resident #9] did . During an interview with the ADON on 5/26/2022 at 7:40 AM, she stated .[LPN #1] reported that [Resident #9] entered the room. The resident [Resident #13] was hollering so they went in .The DON told him to monitor him. Nothing physical happened . During an interview with the Administrator on 6/2/2022 at 10:45 AM, he stated .an incident involving .[Resident #9] and .[Resident #13] was never reported to me .this should have been investigated further. It is a he said she said as to what was reported to the DON and ADON. It would have been good to have a clarification .this was not investigated as an allegation of abuse . The facility's corrective actions included: The DON assessed Resident #6 on 5/26/2022 and identified no adverse effects had occurred from his hands being tied. Residents #5, #7 and #10 were assessed by MDS/DON on 5/26/2022 and identified no adverse effects from injuries of unknown origins or allegation of sexual abuse. Resident #13 discharged prior to 5/26/2022 and was not assessed. CNA #1 was suspended on 4/30/2022 and terminated on 6/3/2022. The CNA did not work after 4/30/2022. On 6/3/2022, the Regional Director of Clinical Services (RDCS) completed Incident investigations/abuse allegations for residents #6, #5, #7 and #10. All residents with a BIMS of 8 or greater were interviewed by clinical team on 5/26/2022 to determine if there were any unresolved allegations of abuse. Residents with a BIMS below 8 were assessed by clinical team on 5/26/2022 to determine if there were any injuries of unknown origin and no other residents were found to be affected. Both the Administrator and DON and were educated by the Regional Director of Clinical Services (RDCS) on reporting abuse on 5/24/2022. On 5/25/2022, the DON and the Administrator were educated on investigating resident injuries. This education was repeated 6/3/2022 by the RDCS. The RDCS will monitor documentation in the electronic system weekly starting 6/3/2022 for any noted use of restraints, injuries of unknown origins, or allegation of sexual abuse. This monitoring will continue for 4 weeks. RDCS and/or the Nursing Home Administrator (NHA) will interview 5 staff weekly to determine if they have any knowledge of abuse or injuries of unknown origin starting 6/3/2022 and continuing for 4 weeks, then 2 staff weekly for four weeks, then 1 staff weekly for four weeks and/or until substantial compliance is maintained. RDCS and/or DON will review all incidents to ensure a thorough investigation is completed to determine root cause of injury and that all allegations of abuse and injuries of unknown origin are reported, beginning 6/3/2022 for a period of 4 weeks, then will review 5 incidents weekly for four weeks, then 3 incidents weekly for four weeks and/or until substantial compliance is maintained. RDCS and/or ADCS (Area Director of Clinical Services) will educate NHA and DON on updated process for tracking incident investigations on 6/3/2022. Any incidents of non-compliance will be addressed with re-education and the disciplinary process as applicable beginning 6/3/2022. Resident #10 discharged from the facility on 10/26/2022. Observation of Resident #6 on 6/3/2022 at 4:25 AM, in the Serenity Room on the secure unit, showed the resident to be seated in a specialty wheelchair. He was calm, well groomed, and no anxious or fearful behaviors were observed. Observation of Resident #5 on 6/3/2022 at 4:00 PM, in front of the nurses' station, showed the resident to be seated in a wheelchair calm, well groomed, and no anxious or fearful behaviors were observed. Observation of Resident #7 on 6/3/2022 at 4:05 PM, in the secure unit dining room, showed the resident to be seated at a dining room table, calm, well groomed, and no anxious or fearful behaviors were observed. Medical record review of Resident #5 and #7 showed no new orders related to the allegations of abuse. Review of facility obtained resident interviews and facility obtained skin observations on 5/26/2022, in comparison with a facility roster, showed every resident had been reviewed, with no concerns identified. Review of a facility in-service dated 6/2/2022 showed the Administrator and DON had received education on updated abuse investigation forms and process. During an interview with the RDSC on 6/3/2022 at 4:45 PM, she confirmed through her audits conducted on 6/3/2022 of incident reports and progress notes, she had not identified any allegations of abuse. Review of facility obtained interviews by the RDCS with 5 staff members dated 6/3/2022 showed staff were knowledgeable regarding resident abuse with no concerns identified. Review of a facility in-service dated 6/3/2022 showed the Administrator and DON were educated on investigation and reporting of allegations of abuse. Confirmed by Administrator signature and DON's verbal consent for signature. The facility's noncompliance continues at a scope and severity of E for monitoring of the effectiveness of the corrective actions.

Based on review of a facility policy, medical record review, interviews, and observation of photographs, the facility failed to ensure 1 resident (#6) of 12 residents reviewed was free from physical restraints used for staff convenience when the resident was observed on 4/3/2022 by 2 staff members with his shirt sleeves tied together with his hands inside. The facility's failure to ensure a resident was free from restraints used for staff convenience placed Resident #6 in Immediate Jeopardy (IJ) (a situation in which a provider's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 6/8/2022 at 10:00 AM. The facility was cited Immediate Jeopardy for F-604 at a scope and severity of J which constitutes Substandard Quality of Care. The IJ was effective 4/3/2022 and was removed on 6/3/2022. An acceptable removal plan, which removed the immediacy of the jeopardy, was received on 6/3/2022 at 2:30 PM, and the corrective actions were verified onsite by the surveyor on 6/3/2022. The findings included: Resident #6 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a facility policy Restraint Free Environment dated 1/2/2020 and revised on 3/23/2022 showed .Each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints .Physical restraints may include, but are not limited to .c. fastening fabric or clothing so that a resident's freedom of movement is restricted . Medical record review of Resident #6's comprehensive care plan dated 10/2/2020 showed the care plan was revised on 10/14/2020 and stated, .may exhibit aggressive behavior with ADL's [activities of daily living] as well as abusive language .change [MEDICATION(S)] [medication to treat anxiety] to 0.5 mg [milligrams] AM and 1 mg po [by mouth] PM and add [MEDICATION(S)] 0.5 mg po day PRN [as needed] for anxiety X [times] 14 days .at times of increased anxiety .[Resident #6] in a calm and unhurried manner .increased scheduled [MEDICATION(S)] [medication to treat anxiety] to 1 mg BID [twice daily] .provide diversional activities .at times of increased anxiety . The care plan was revised on 10/19/2020 and showed the resident had exhibited behaviors of rejecting care by staff members, wandering, grabbing others on the unit, and sexually inappropriate behaviors . Medical record review of Resident #6's quarterly Minimum Data Set (MDS) dated [DATE] showed a BIMS score of 0, indicating severe cognitive impairment. The resident required extensive physical assistance of two or more persons with bed mobility; extensive physical assistance of one person for locomotion, dressing and personal hygiene; was totally dependent on one to two persons for transfers and toilet use; and was independent eating with setup help. Medical record review of a nurse note dated 5/3/2022 showed .resident is very resistive to care and combative during all ADL's. He often grabs everything and swings arms around during care . During an interview with Registered Nurse (RN) #1 on 5/24/2022 at 8:05 AM, she stated .on 4/3/2022, I went into the resident's [Resident #6's] room at approximately 7:50 AM. The resident's hands were under the cover. His breakfast tray had been set up. I asked him why he wasn't eating. He said 'can't'. I pulled down the sheet to see what was going on and his hands were inside his shirt sleeves and his shirt was tied in a hard knot. I yelled for the tech [Certified Nursing Assistant (CNA) #4] to come to the room. We were not able to get the knot untied. It was tied too hard. We had to pull the shirt over his head. I took a picture of his hands and sent it to the DON .She responded with make sure he is in a hospital gown when you leave and for me to know the whole situation was under investigation .He [Resident #6] can be combative and resist care .he will grab things and swing his arms . During an interview with CNA #1 (caregiver on the night shift when incident occurred) on 5/24/2022 at 10:00 AM, he stated Resident #6 was not combative so he would have no reason to tie his hands and stated .I've never tied a resident's hands in a shirt, and I have not had any reports of anyone else doing that . During an interview with CNA #3 on 5/24/2022 at 1:15 PM, he stated .[Resident #6] can be combative with care. He will grab you or anything else in his reach . Observation on 5/25/2022 of a picture taken of Resident #6 on 4/3/2022, showed Resident #6 lying in bed, visible from the chin to the waist. Resident #6 was wearing a burgundy cotton long sleeve t-shirt. The shirt, at the top, was pulled all the way up to the top of the resident's neck, underneath his chin. The sleeves were pulled down so that there was an excess of material lengthened beyond the hands at least a foot and forced the resident's arms to be bent at the elbows, with the extra length of both sleeves beyond the hands tied together in a very tightly bound knot, with the hands bound over his abdomen. The knot appeared to have been tied more than once, in a double or triple knot. The knot was fashioned so that the hands were completely encased in the shirt and the resident would have been unable to utilize his hands for any movement, and unable to free himself from the knotted sleeves or from his shirt. The resident would have been unable to use or do anything with his arms or hands. During an interview with the DON on 5/25/2022 at 5:30 PM, she stated she was made aware on 4/3/2022 the nurse found Resident #6's shirt with the sleeves tied. She stated .I said 'okay', I would investigate and to make sure he was in a hospital gown before they left. I spoke to .[CNA #1] the next day. I asked if he had ever seen any resident's shirt sleeves tied or had ever tied anyone's shirt sleeves together, and he denied ever seeing or doing . During an interview with CNA #4 on 6/1/2022 at 11:50 AM, she stated .I went in to set up his breakfast. His hands were under the blanket which was normal. I raised his head and left the room. He is independent with eating after setup. In a couple of minutes, [RN #1] went in to give him medicine. She asked him why he wasn't eating, and she said he said 'can't'. She called me into the room. I came in. His hands were out from the blanket. I saw his shirt sleeves tied with his hands inside. We tried to untie it, but the knot was too tight. I actually had to lower his bed so we could get his shirt off over his head. Ever since then, I always put him in a hospital gown before I leave to make sure that can't happen again. He didn't say anything when we got the shirt off. He just started eating. He didn't really shown no emotion .I don't know what happened or who did it. Breakfast comes pretty soon after I get here, so it was early in my shift when [RN #1] found it .He does get combative at times. He will swing his arms. You have to tell him what you are doing . During an interview with the Administrator on 6/2/2022 at 11:07 AM, he stated .Obviously the resident did not do it. You can't tie folks up. You can't tie their arms . The facility's corrective actions included: 5/26/2022 Resident #6 was assessed and was found to have no adverse effects from sleeves being tied together. 5/26/2022 All residents were interviewed or observed for signs of abuse according to their BIMS score. These interviews/observations indicated no signs of abuse. 5/24/2022 staff education on abuse, resident safety, and reporting was initiated by RDCS (Regional Director of Clinical Services) and completed on 6/3/2022 for all staff except for one staff member who is on maternity leave. This staff member will be in-serviced prior to being allowed to return to work. RDCS and/or DON/ADON (Assistant Director of Nursing) will audit progress notes daily for indications of abuse beginning 6/2/2022. DON/ADON will interview 5 staff weekly regarding knowledge of resident abuse and will immediately follow the abuse investigation process for every allegation of abuse beginning 6/3/2022. RDCS/ADCS (Area Director of Clinical Services) will in-service DON and NHA (Nursing Home Administrator) on 6/3/2022 regarding updated abuse investigation forms and process. RDCS/ADCS will review all allegations of abuse to ensure appropriate reporting to SSA (State Survey Agency) has been conducted. All staff education was started by RDCS 6/2/2022 on abuse related to restraint education and was completed by 6/3/2022 except for five employees (3 full-time Licensed Practical Nurses and 2 PRN CNAs ) who will be educated prior to being allowed to return to work. Observation of Resident #6 on 6/3/2022 at 4:25 AM, in the Serenity Room on the secure unit, showed the resident to be seated in a specialty wheelchair. He was calm, well groomed, dressed appropriately for the inside temperature, no odors or signs of incontinence were observed, and no anxious or fearful behaviors were observed. Review of facility obtained resident interviews and facility obtained skin observations on 5/26/2022, in comparison with a facility roster, showed every resident had been reviewed, with no concerns identified. Staff education on abuse, resident safety, and reporting was reviewed based on comparison of the facility staff roster and the in-service sign sheets, only one staff member identified as being on maternity leave had not completed the education. During an interview with the RDSC on 6/3/2022 at 4:45 PM, she confirmed the staff member would not be allowed to return to work prior to receiving the education. Review of a facility audit dated 6/2/2022 showed all documents and progress notes were reviewed with no indication of restraint use, injuries of unknown origin or sexual abuse. Review of a facility audit dated 6/3/2022 showed all documents and progress notes were reviewed with no indication of restraint use, injuries of unknown origin or sexual abuse. Reviewed facility obtained interviews by the ADON with 5 staff members dated 6/3/2022 regarding knowledge of resident abuse with no concerns identified. Review of a facility in-service dated 6/2/2022 showed the Administrator and DON had received education on updated abuse investigation forms and process. During an interview with the RDSC on 6/3/2022 at 4:45 PM, she confirmed through her audits conducted on 6/2/2022 and 6/3/2022 of incident reports and progress notes, she had not identified any other allegations of abuse. Review of staff education on abuse related to restraints based on comparison of the facility staff roster and the in-service sign sheets, 5 employees were identified to have not completed the education. During an interview with the RDSC on 6/3/2022 at 4:45 PM, she confirmed all staff members will be required to receive the in-service on abuse related to restraints prior to their next shift. The facility's noncompliance continues at a scope and severity of D for monitoring of the effectiveness of corrective actions.

Based on review of a facility policy, medical record review, review of facility incident reports, interview, and observation of photographs, the facility failed to prevent abuse for 2 residents (#6, #13) of 12 residents reviewed. Resident #6 was a cognitively impaired resident who was found with his hands tied in his shirt sleeves. Resident #13 was the victim of sexual abuse perpetrated by Resident #9. The facility's failure to prevent abuse of Resident #6 placed Resident #6 in Immediate Jeopardy (IJ) (a situation in which a provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 6/2/2022 at 5:55 PM. The facility was cited Immediate Jeopardy for F-600 at a scope and severity of J which constitutes Substandard Quality of Care. The IJ was effective 4/3/2022 and was removed on 6/3/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 6/3/2022 and the corrective actions were verified onsite by the surveyor on 6/3/2022. The findings included: Review of a facility policy Abuse, Neglect and Exploitation revised 3/22/2022 showed .It is the policy of this facility to provide protections for the health, welfare and rights of each resident .'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or anguish .it includes verbal abuse, sexual abuse, physical abuse, and mental abuse . Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of Resident #6's comprehensive care plan dated 10/2/2020 and revised 10/14/2020 showed .may exhibit aggressive behavior with ADL's [activities of daily living] as well as abusive language .change [MEDICATION(S)] [medication used to treat anxiety] to 0.5 mg [milligrams] AM and 1 mg po [by mouth] PM and add [MEDICATION(S)] 0.5 mg po day PRN [as needed] for anxiety X [times] 14 days .at times of increased anxiety talk to .[Resident #6] in a calm and unhurried manner .increased scheduled [MEDICATION(S)] [medication used to treat anxiety] to 1 mg BID [twice daily] .provide diversional activities .at times of increased anxiety . The care plan was revised on 10/19/2020 and showed Resident #6 had exhibited behaviors of rejecting care by staff members, wandering, grabbing others on unit, and sexually inappropriate behaviors. Medical record review of Resident #6's quarterly Minimum Data Set (MDS) dated [DATE] showed a BIMS score of 0, indicating severe cognitive impairment. The resident required extensive physical assistance of two or more persons with bed mobility; extensive physical assistance of one person for locomotion, dressing and personal hygiene; was totally dependent on one to two persons for transfers and toilet use; and was independent eating with setup help. Medical record review of Resident #6's Nursing Progress Note dated 5/3/2022 that showed .resident is very resistive to care and combative during ADL's [activities of daily living]. He often grabs everything and swings arms around during care . During an interview with Registered Nurse (RN) #1 on 5/24/2022 at 8:05 AM, she stated .on 4/3/2022, I went into the resident's [Resident #6's] room at approximately 7:50 AM. The resident's hands were under the cover. His breakfast tray had been set up. I asked him why he wasn't eating. He said 'can't'. I pulled down the sheet to see what was going on and his hands were inside his shirt sleeves and his shirt was tied in a hard knot. I yelled for the tech [Certified Nursing Assistant (CNA) #4] to come to the room. We were not able to get the knot untied. It was tied too hard. We had to pull the shirt over his head. I took a picture of his hands and sent it to the DON and asked her if that was not abuse. She responded with make sure he is in a hospital gown when you leave .She had to speak with the nurse .I asked her if I needed to send it to .[Administrator]. I did not get a response to that .He [Resident #6] can be combative and resist care .he will grab things and swing his arms . During an interview with CNA #1 (caregiver on the night shift when incident occurred) on 5/24/2022 at 10:00 AM, he stated Resident #6 was not combative so he would have no reason to tie his hands and stated .I've never tied a resident's hands in a shirt, and I have not had any reports of anyone else doing that . During an interview with CNA #3 on 5/24/2022 at 1:15 PM, he stated Resident #6 could be combative during ADL care .he will grab you or anything else in his reach . Observation on 5/25/2022 of a picture taken of Resident #6 on 4/3/2022, showed Resident #6 lying in bed, visible from the chin to the waist. Resident #6 was wearing a burgundy cotton long sleeve t-shirt. The shirt, at the top, was pulled all the way up to the top of the resident's neck, underneath his chin. The sleeves were pulled down so that there was an excess of material lengthened beyond the hands at least a foot and forced the resident's arms to be bent at the elbows, with the extra length of both sleeves beyond the hands tied together in a very tightly bound knot, with the hands bound over his abdomen. The knot appeared to have been tied more than once, in a double or triple knot. The knot was fashioned so that the hands were completely encased in the shirt and the resident would have been unable to utilize his hands for any movement, and unable to free himself from the knotted sleeves or from his shirt. The resident would have been unable to use or do anything with his arms or hands. During an interview with the DON on 5/25/2022 at 5:30 PM, she stated she was made aware on 4/3/2022 the nurse found Resident #6's shirt with the sleeves tied. The DON stated .I said 'okay', I would investigate and to make sure he was in a hospital gown before they left. I spoke to [CNA #1] the next day. I asked if he had ever seen any resident's shirt sleeves tied or had ever tied anyone's shirt sleeves together, and he denied ever seeing or doing .Yes in my professional opinion I would see that as abuse .The bruise on 4/12 and 4/30 we determined as he was combative and swings his arms and hands when you are providing care and he could have hit it on the lift bar or the enabler bed rail. But no one had any knowledge of observing him hit anything to cause the bruises . Medical record review of Resident #6's Nursing Progress Note dated 5/27/2022 showed .resident is resistive with care and combative with ADL's . During an interview with CNA #4 on 6/1/2022 at 11:50 AM, she stated .I went in to set up his breakfast. His hands were under the blanket which was normal. I raised his head and left the room. He is independent with eating after setup. In a couple of minutes, [RN #1] went in to give him medicine. She asked him why he wasn't eating, and she said he said 'can't'. She called me into the room. I came in. His hands were out from the blanket. I saw his shirt sleeves tied with his hands inside. We tried to untie it, but the knot was too tight. I actually had to lower his bed so we could get his shirt off over his head. Ever since then, I always put him in a hospital gown before I leave to make sure that can't happen again. He didn't say anything when we got the shirt off. He just started eating. He didn't really show no emotion .I don't know what happened or who did it. Breakfast comes pretty soon after I get here, so it was early in my shift when [RN #1] found it .He does get combative at times. He will swing his arms. You have to tell him what you are doing . During an interview with the Administrator on 6/2/2022 at 11:07 AM, he stated .I don't remember the DON reporting the incident of the resident's hands being tied .Obviously, the resident did not do it. You can't tie folks up. You can't tie their arms. This would have been classified as abuse . Resident #13 was admitted to the facility on [DATE], readmitted on [DATE], and discharged on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of Resident #13's admission MDS dated [DATE] showed a BIMS score of 7, indicating severe cognitive impairment. The resident required extensive physical assistance of one person with bed mobility, transfer, dressing toilet use, and personal hygiene; limited physical assistance of one person with locomotion; and was independent for eating with setup help. Medical record review of Resident #13's Nursing Progress Notes dated 5/17/2022 showed .Resident is noted with anxiety. She seems to have intermitted [intermittent] panic attacks to where she complains of SOB [shortness of breath], shakes and moans. Psych [psychiatric] NP [nurse practitioner] informed with N.O. [new order] Trazadone [antidepressant] 25 mg BID . Resident #9 was admitted to the facility on [DATE], discharged home on 5/6/2022, and readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of Resident #9's admission MDS dated [DATE] showed a BIMS score of 4, indicating severe cognitive impairment. Resident #9 exhibited physical behavioral symptoms directed toward others 1 to 3 days during the assessment period. The resident required extensive physical assistance of 1 person with bed mobility, transfer, locomotion, dressing, toilet use, and personal hygiene; limited physical assistance of 1 person with walking; and was independent for eating with setup help. Medical record review of Resident #9's comprehensive care plan dated 4/23/2022 and revised on 4/30/2022, showed .is an elopement risk/wanderer r/t [related to] dementia .check placement and function of safety monitoring device every shift .distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book .Identify pattern of wandering: is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise .has the potential to be physically and verbally aggressive r/t dementia .administer medications as ordered .assess and anticipate resident's needs .provide physical and verbal cues to alleviate anxiety . During an interview with LPN #1 on 5/25/2022 at 7:40 AM, he stated .On May 18th we had a resident named [Resident #9]. I was asked to let another employee outside of the side door. While [CNA #6] and I were walking back in, we heard screaming coming from [Resident #13's] room. She is discharged now. We walked into the room and [Resident #9] has her [Resident #13] half-way off the bed with his hand pulling on her brief trying to get his hand down her brief. So, we separated them. I had [CNA #6] to watch [Resident #9] while I reported it to the ADON and DON who were working that night .I made .sure he [Resident #9] did not go in her [Resident #13] room again. But I didn't know what to do after that . During an interview with the DON on 5/25/2022 at 5:35 PM, she stated .[LPN #1] came to us .and said [Resident #9] was in [Resident #13's] room and it looked like he was going to touch her brief. He reported he and the CNA had followed [Resident #9] into the room. To my knowledge he never touched her. I can't say what he was going to do. I told staff to monitor him and nothing else was reported . During an interview with CNA #6 on 5/25/2022 at 6:15 PM, she stated .it was the night of 5/18/2022. I was the tech for 200 hall. The DON was on 300 and 100. ADON was on 400 and 500. I don't know what time it was, but I had been to my locker and was speaking to the nurse [LPN #1] on the 400 hall. We heard screaming and we ran into [Resident #13's] room. [Resident #9] had one hand inside of her brief and was trying to get the brief off .I did witness what [Resident #9] did . During an interview with the ADON on 5/26/2022 at 7:40 AM, she stated .[LPN #1] reported that [Resident #9] entered the room. The resident [Resident #13] was hollering so they went in. I can't remember if he said he was reaching for or had a hold of her brief. The DON told him [LPN #1] to monitor him [Resident #9]. Nothing physical happened . During an interview with the Administrator on 6/2/2022 at 10:45 AM, he stated .an incident involving [Resident #9] and [Resident #13] was never reported to me .It is a he said she said as to what was reported to the DON and ADON. It would have been good to have a clarification . The facility's corrective actions included: 5/26/2022 Resident #6 was assessed and was found to have no adverse effects from sleeves being tied together. Resident #13 discharged prior to 5/26/2022 and was not assessed. 5/26/2022 All residents were interviewed or observed for signs of abuse according to their BIMS score. These interviews/observations indicated no signs of abuse. 5/24/2022 staff education on abuse, resident safety, and reporting was initiated by RDCS (Regional Director of Clinical Services) and completed on 6/3/2022 for all staff except for one staff member who is on maternity leave. This staff member will be in-serviced prior to being allowed to return to work. RDCS and/or DON/ADON (Assistant Director of Nursing) will audit progress notes daily for indications of abuse beginning 6/2/2022. DON/ADON will interview 5 staff weekly regarding knowledge of resident abuse and will immediately follow the abuse investigation process for every allegation of abuse beginning 6/3/2022. RDCS/ADCS (Area Director of Clinical Services) will in-service DON and NHA (Nursing Home Administrator) on 6/3/2022 regarding updated abuse investigation forms and process. RDCS/ADCS will review all allegations of abuse to ensure appropriate reporting to SSA (State Survey Agency) has been conducted. All staff education was started by RDCS 6/2/2022 on abuse related to restraint education and was completed by 6/3/2022 except for five employees (3 full-time Licensed Practical Nurses and 2 PRN CNAs ) who will be educated prior to being allowed to return to work. Observation of Resident #6 on 6/3/2022 at 4:25 AM, in the Serenity Room on the secure unit, showed the resident to be seated in a specialty wheelchair. He was calm, well groomed, dressed appropriately for the inside temperature, no odors or signs of incontinence were observed, and no anxious or fearful behaviors were observed. Review of facility obtained resident interviews and facility obtained skin observations on 5/26/2022, in comparison with a facility roster, showed every resident had been reviewed, with no concerns identified. Staff education on abuse, resident safety, and reporting was reviewed based on comparison of the facility staff roster and the in-service sign sheets, only one staff member identified as being on maternity leave had not completed the education. During an interview with the RDSC on 6/3/2022 at 4:45 PM, she confirmed the staff member would not be allowed to return to work prior to receiving the education. Review of a facility audit dated 6/2/2022 showed all documents and progress notes were reviewed with no indication of restraint use, injuries of unknown origin or sexual abuse. Review of a facility audit dated 6/3/2022 showed all documents and progress notes were reviewed with no indication of restraint use, injuries of unknown origin or sexual abuse. Reviewed facility obtained interviews by the ADON with 5 staff members dated 6/3/2022 regarding knowledge of resident abuse with no concerns identified. Review of a facility in-service dated 6/2/2022 showed the Administrator and DON had received education on updated abuse investigation forms and process. During an interview with the RDSC on 6/3/2022 at 4:45 PM, she confirmed through her audits conducted on 6/2/2022 and 6/3/2022 of incident reports and progress notes, she had not identified any other allegations of abuse. Review of staff education on abuse related to restraints based on comparison of the facility staff roster and the in-service sign sheets, 5 employees were identified to have not completed the education. During an interview with the RDSC on 6/3/2022 at 4:45 PM, she confirmed all staff members will be required to receive the in-service on abuse related to restraints prior to their next shift. The facility's noncompliance continues at a scope and severity of D for monitoring of the effectiveness of corrective actions.

Based of review of a facility document PBJ (Payroll Based Journal) Nurse Staffing Summary dated 4/1/2022-6/2/2022 and interview, the facility failed to provide the required minimum 8 hours of Registered Nurse (RN) Coverage on 3 of 63 days. The findings include: Review of the facility's Payroll Based Journal dated 4/1/2022 - 6/2/2022 showed the facility failed to provide the required minimum 8 hours daily of RN coverage. On 4/10/2022, 6.73 hours of RN coverage was provided. On 4/24/2022, 6.68 hours of RN coverage was provided. O on 5/8/2022, 6.43 hours of RN coverage was provided. During an interview with the Area District of Clinical Services on 6/3/2022 at 3:30 PM, she acknowledged the facility failed to provide the required minimum daily of 8 hours RN coverage on 3 of the last 63 days.

Based on facility policy reviews, observations, and interviews, the facility failed to ensure infection control practices were followed for 3 of 8 rooms observed for transmission-based precautions and the facility staff failed to perform hand hygiene during meal tray delivery observations for 2 of 5 hallways observed for dining. The findings include: Review of the isolation signage, undated, posted on the quarantine resident rooms showed, .For all staff Contact Precautions in addition to Standard Precautions Before entering room .Perform hand hygiene .Put on gown or apron .Put on gloves . Review of the facility's policy titled, .Infection Prevention and Control Program ., dated 9/2/2020, showed .Standard Precautions .Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures . Review of the facility's policy titled, .Hand Hygiene ., dated 3/24/2021, showed .All staff will perform proper hand hygiene procedures to prevent the spread of infection .Between resident contacts After handling contaminated objects .during resident care . During an observation on 3/21/2022 at 11:55 AM showed an isolation room, signage on the door stated .Contact Precautions .Before entering room .Put on gown .Put on gloves . Hanging on the door directly below the isolation sign was a blue fabric storage container with pockets containing Personal Protective Equipment (PPE) supplies. Continued observation revealed the Speech Therapist (ST) did not donn PPE, entered the room and interacted with the resident. Further observation showed the ST exited the isolation room. The ST's face mask was positioned under her nose. During an interview on 3/21/2022 at 11:59 AM, the ST confirmed she had not donned the gown and gloves prior to entering the isolation room. During an observation on 3/21/2022 at 12:05 PM showed an isolation room, signage on the door stated .Contact Precautions .Before entering room .Put on gown .Put on gloves . Hanging on the door directly below the isolation sign was a blue fabric storage container with pockets containing PPE supplies. CNA #4 entered a resident's room during dining observations without gown or gloves. During an interview on 3/21/2022 at 12:08 PM, LPN #2 confirmed anyone entering an isolation room should donn appropriate PPE (gown and gloves). During an interview on 3/21/2022 at 12:10 PM, CNA #4 confirmed the resident was on Transmission Based Precaution (TBP). CNA #4 stated, .I usually do [wear PPE] and should put on gown and gloves . Further interview showed CNA #4 failed to donn PPE before she entered the isolation room. During an interview with the Director of Nurses (DON) on 3/22/2022 at 8:15 AM, the DON confirmed the ST had not followed the infection control practices when she entered the isolation room. During an observation on 3/22/2022 at 2:27 PM showed an isolation room, the signage on the door stated .Contact Precautions .Before entering room .Put on gown .Put on gloves . Hanging on the door directly below the isolation sign, was a blue fabric storage container with pockets containing PPE supplies. The Social Worker (SW) was observed without a gown or gloves sitting in a chair in a resident's room. During an observation and interview on 3/22/2022 at 2:35 PM, the DON confirmed the social worker had not donned PPE while entering an isolation room. The SW confirmed she did not have gown or gloves on in an isolation room. During an observation on 3/21/2022 at 12:01 PM, CNA #2 removed a meal tray off the meal cart and carried the tray into a room. CNA #2 touched the bed controls to raise the head of bed, and touched the over bed table, opened the lid off the meal, touched the lids of the drinks, and opened the silverware. Further observation showed CNA #2 exited the room without performing hand hygiene. Continued observation showed CNA #2 proceeded to the meal cart, picked up the meal tray, and entered a room. CNA #2 set the meal tray on a bed side table. CNA #2 and CNA #3 assisted the resident up in the bed. Both CNA's applied gloves prior to assisting the resident up in the bed. CNA #2 removed gloves, applied a clean pair of gloves without performing hand hygiene, and proceeded to wash the resident's face. CNA #2 washed the residents face prior to performing hand hygiene. During an observation on 3/21/2022 at 12:08 PM, LPN #3 removed a resident's tray from the meal tray cart, walked into the room, placed the tray on the bedside table, resident refused the tray, and LPN #3 exited the room with the tray. LPN #3 placed the tray in the clean meal tray cart. Continued observation showed no hand hygiene was performed. Further observation showed LPN #3 bent over, pulled up her pants, walked around the cart, and removed another meal tray. LPN#3 entered the room, placed the tray on the bedside table, lifted the lid from the meal tray, proceeded to set meal tray up, and exited the room without performing hand hygiene. During an interview on 3/21/2022 at 12:35 PM, CNA #2 confirmed that she did not perform hand hygiene between passing trays. She stated she touched the overbed tables and bed controls in both rooms; she also assisted with patient care. During an interview on 3/22/2022 at 8:20 AM, the DON stated she expected staff to sanitize hands between patients.

Based on record review and interview, the facility failed to implement a care plan with an appropriate interventions after a fall for 2 residents (#29, #251) of 14 residents reviewed for falls. The finding included: Resident #29 was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)], Major Depressive Disorder, and Anxiety. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #29 scored an 8 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident required limited assistance of 1 staff member for bed mobility and transfer. Review of the facility Post Fall Review dated 1/18/2022 revealed Resident #29 had a fall without injury on 1/18/2022. Continued review showed the intervention implemented after the fall to prevent future falls was to instruct the resident to push the call bell for assistance. Review of the Care Plan updated 1/18/2022 revealed Resident #29 was at risk for falls related to [CONDITION(S)] Medication, and Impaired Balance. Continued review showed Resident #29 had a fall without injury on 1/18/2022. Further review revealed the resident's new intervention was updated to reflect the instruction of use of a call bell. During an interview on 3/23/2022 at 2:43 PM, the Director of Nursing (DON) confirmed instructing Resident #29 to push the call bell after a fall on 1/18/2022 was an inappropriate intervention for a cognitively impaired resident. Resident #251 was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)] Disease, Coronary Artery Disease, Dementia, and Depression. Review of the facility Post Fall Review dated 3/14/2022 showed Resident # 251 was instructed to use the call light for assistance with ambulation. Review of the Care Plan updated 3/14/2022 revealed Resident #251 was at risk for falls related to Dementia, [CONDITION(S)] Medication, and Impaired Balance. Resident #251 had a fall without injury on 3/14/2022. Further review revealed the resident's new intervention was updated to reflect the instruction of use of a call bell. Review of a 5-day admission MDS dated [DATE] revealed the resident scored a 7 on the BIMS indicating the resident was severely impaired. The resident required limited assistance of 1 staff member for bed mobility, transfer, dressing, and toileting. The resident used a walker for ambulation. During an interview with the DON on 3/22/2022 at 1:33 PM, revealed the resident was instructed to use the call light after a fall. The DON confirmed that the resident was cognitively impaired and instructing the residents to use the call light would not be an appropriate intervention. The DON stated .we need to do .BIMS education with the staff .I don't think they fully understand what .[BIMS] means .

Based on medical record review, facility documentation review, and interview the facility failed to have adequate staffing to ensure supervision for residents with wandering behaviors of 1 (Resident #2) of 5 residents reviewed. The facility's failure to provide adequate staffing to ensure supervision for Resident #2 resulted in physical harm for Resident #1 when Resident #2 abused Resident #1 resulting in multiple bruises and swelling, and a laceration to left upper lip which required 4 sutures. . The findings include: Resident #1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of Resident #1's quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating the resident was cognitively impaired, required physical assist of 1 for all activities of daily living (ADLs). Medical record review of Resident #1's care plan revised 7/5/2021, revealed the resident had impaired cognitive function/dementia or impaired thought process related to dementia. Resident #2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of Resident #2's care plan dated 8/6/2021, revealed the resident required assistance with ADLs, was an elopement risk/wanderer with interventions documented to distract the resident from wandering. Continued review revealed Resident #2 had the potential to be physically aggressive related to dementia. Medical record review of Resident #2's admission MDS dated [DATE] revealed a BIMS score of 5, indicating the resident was severely cognitively impaired, with no behaviors noted, required 1-person physical assist with dressing, eating, and toilet use. Continued review revealed the resident used a walker for assistance with ambulation. Review of an incident report dated 8/27/2021 and timed 1:45 AM revealed an allegation of a resident-to-resident altercation which involved Resident #1 and Resident #2. Resident #1 sustained multiple bruises on the face and was bleeding when Resident #2 entered Resident #1's room and was found leaving Resident #1's room with blood on her hands and on a bag of candy. Police were notified and 911 was called. Resident #1 was sent to the hospital for evaluation and treatment. Resident #2 was monitored 1:1 until sent to hospital for her aggressive behavior. Review of facility documentation dated 9/13/2021 revealed the facility census of residents on 9/13/2021 through 9/14/2021 was 58. Interview with the Administrator on 9/13/2021, at 12:35 PM, revealed he received a phone call on 8/27/2021 at approximately 2:00 AM, from the Director of Nursing (DON) who stated there had been a resident-to-resident altercation between Resident #1 and Resident #2. A Certified Nursing Assistant (CNA) #4 reported Resident #2 had been seen coming out of Resident #1's room on night of 8/27/2021 after the incident. The Administrator stated a CNA had answered a call light for Resident #1 and observed Resident #1 had facial bleeding, bruising, and swelling. The Administrator stated Resident #1 was sent to the hospital, received sutures in her lip and returned to the facility on [DATE] at approximately 6:00 AM. Interview with Licensed Practical Nurse (LPN) #2 on 9/13/2021 at 6:15 PM, revealed was assigned to work nightshift at the facility. LPN #2 stated most nights there are 2 nurses and 2 CNAs working for the entire building. LPN #2 confirmed staff were to always be in the memory care (secure unit) to provide care and supervision to the residents. Interview with CNA #2 on 9/13/2021, at 6:30 PM, stated was assigned to work nightshift at the facility. CNA #2 stated most nights the facility has 2 nurses and 2 CNAs. Interview with CNA #3 on 9/13/2021, at 6:45 PM, stated was assigned to work nightshift at the facility. CNA#3 stated the facility has 2 nurses and some nights 2-3 CNAs in the facility. CNA #3 stated 1 CNA must share the memory hall (secure) unit and the 500 hallways. Interview with LPN #1 on 9/14/2021, via telephone at 8:50 AM, stated she worked on the night of the incident on 8/27/2021 in the memory care unit. LPN#1 stated on the night of 8/27/2021, there were 2 nurses and 2 CNAs. LPN #1 stated the incident happened on the memory care unit. LPN #1 stated the nurse and CNA assigned to the memory unit were also assigned to work another hallway as well as the memory unit. LPN #1 confirmed at the time of the incident no staff member was present on the memory hall unit when the abuse occurred. Interview with CNA #1 on 9/14/2021, at 9:20 AM, via telephone, stated she had worked the night of the incident on 8/27/2021.The CNA stated there were 2 nurses and 2 CNAs on duty in the faclity the night of of the incident on the memory care unit. CNA #1 stated heard another CNA (CNA#4) call for assistance when the incident happened. CNA#1 stated when Resident #1 was injured from Resident #2 no staff member was present in the memory unit. Interview with the DON on 9/14/2021 at 11:00 AM, stated the memory care hallway (secure unit) was supposed to always have a staff member present. The DON confirmed a staff member should always be in the memory care unit to provide resident care. The DON confirmed it was reported to her no staff member was present when the abuse incident happened on 8/27/2021 between Resident #1 and Resident #2.

Based on facility policy review, medical record review, facility incident report, police report, and interview, the facility failed to prevent abuse for 1 resident (Resident #1) of 5 residents reviewed for abuse. The facility's failure to prevent abuse for Resident #1 resulted in physical harm, with multiple bruises and swelling to face, and a laceration to left upper lip which required 4 sutures. The findings include: Review of the facility policy Compliance with Reporting allegations of Abuse/Neglect/Exploitation undated revealed . Abuse .The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish . Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment . Resident #1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of Resident #1's care plan dated 7/5/2021 revealed the resident required assistance with ADLs (activities of daily living) related to cerebral infarction, systolic heart failure and [CONDITION(S)]. Continued review revealed Resident #1 required mechanical lift for total assistance with 2 staff members, had impaired cognitive function/dementia or impaired thought process related to Dementia. Medical record review of Resident #1's quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating the resident was severly cognitively impaired. The resident required 2 staff physical assist for bed mobility, required 1 staff physical assist for dressing, eating, toilet use and was non-ambulatory. Resident #2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of Resident #2's progress note dated 8/11/2021 revealed .was transferred here from [another facility name] where she previously resided with a longstanding history of underlying dementia with behaviors . Medical record review of Resident #2's admission MDS dated [DATE], revealed a BIMS score of 5, indicating the resident was severely cognitively impaired, with no behaviors noted, required 1-person physical assist with dressing, eating, toilet use, and personal hygiene. Continued review revealed the resident used a walker for assistance with ambulation. Medical record review of Resident #2's care plan dated 8/6/2021, revealed the resident required assistance with ADLs, was an elopement risk/wanderer, and had the potential to be physically aggressive related to Dementia. Review of an incident report dated 8/27/2021, at 1:45 AM, revealed an allegation of a resident-to-resident altercation which involved 2 residents (Resident #1 and Resident #2). Resident #1 sustained multiple bruises on the face and was bleeding. Resident #2 was found to have blood on her hands and blood on a bag of candy. Police were notified and 911 was called. Resident #2 was monitored 1:1 until sent to hospital for evaluation of aggressive behavior toward Resident #1. Medical record review of the hospital ED (emergency department) records for Resident #1 dated 8/27/2021, revealed .History of present illness: The patient presents with facial injury. The onset was just prior to arrival. Patient is an [AGE] year-old female with past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient is a resident at [name of facility] and was reportedly assaulted. She was found with facial trauma and report that a female wearing a pink shirt came into her room and struck her in the face. She has facial swelling and a lip laceration. She is anticoagulated on [MEDICATION(S)]. She specifically denies any headache, neck pain or stiffness, chest pain, shortness of breath, abdominal pain, nausea, throat swelling or difficulty breathing .no acute facial fractures seen . Review of the police report dated 8/27/2021 revealed, .Initial Report, Narrative Officer: [officer's name] On Friday August 27, 2021 I Ofc. [Officer name] along with Ofc. [Officer's name] and Lt. [Lieutenant] [name] responded to [address of the facility] room [Resident #1's room number] regarding an assault. On arrival [Resident #1] was on her bed with a busted swollen bloody lip, and signs of being struck multiple times in the forehead, and cheek area. I spoke with [Resident #1's name] who stated that she didn't get a good look at who assaulted her .While speaking with staff they stated that [Certified Nursing Assistant (CNA) # 4's name] was the first person to notice and told them about it. They also stated she was working that hall at the time of the incident. She stated that all resident in the hall were acting up today, while walking down the hall she noticed [Resident #2] standing outside of the door of [Resident #1's name] room with a bag of candy oranges in her hand, so she walked her back to her own room. She [CNA #4] said she then went into [Resident #1 name] room and noticed the injuries on her person before running to the nurses for help .I noticed there was blood in the palm of [Resident #2's name] hands but not very much and no signs on her knuckles .I was advised that they check on them [residents] every 2 hours .She [Resident #1] was transported by EMS to the hospital for her injuries. Interview with the Administrator on 9/13/2021, at 12:45 PM, revealed the facility believed Resident #2 wanted Resident #1's candy. Administrator stated the bag of candy had blood on the bag. Administrator stated the only blood Resident #2 had on her was on shirt and hands. Administrator stated an assessment was completed on Resident #2 and she had no injuries noted. Continued interview with the Administrator on 9/13/2021, revealed he received a phone call on 8/27/2021 at approximately 2:00 AM, from the Director of Nursing (DON). She reported a resident-to-resident altercation on 8/27/2021 between Resident #1 and Resident #2. CNA #4 reported Resident #2 had been seen coming out of Resident #1's room on night of 8/27/2021. The Administrator stated CNA #4 had went to answer a call light for Resident #1 on the night of 8/27/2021 after the incident. CNA #4 reported she had observed Resident #1, with facial bleeding, bruising, and swelling. CNA #4 called Licensed Practical Nurse (LPN) #1 for assistance. CNA #4 reported Resident #1 stated a gray headed woman with a pink shirt had hit her. The Administrator stated CNA #4 had seen Resident #2 with a bag of candy and helped Resident #2 back to her room. LPN #1 assessed Resident #1 and made phone calls. The police arrived before Emergency Medical Service. The Administrator stated the police investigated due to the facial bleeding, swelling, and bruising. The Administrator stated Resident #1 was sent to the hospital. The Administrator stated Resident #1 stated it was a woman with a pink shirt on which had hit her. The Administrator stated the police and staff observed Resident #2 had on a pink shirt. Resident #2 had blood on her hand and on a sleeve of her shirt. The Administrator stated Resident #1 was sent to local hospital, received sutures in her lip and was returned to the facility later in the morning on 8/27/2021. Administrator stated Resident #2 was placed on 1:1 supervision and was sent to the hospital for psychiatric evaluation. Observation of Resident #1 on 9/13/2021 at 1:30 PM and 6:30 PM revealed the resident had multiple facial bruises and bruising around both eyes and on both checks. Observation of Resident #1 on 9/14/2021 at 9:15 AM revealed multiple facial bruises and bruising around both eyes and on both checks. Interview with LPN #1 on 9/14/2021, via telephone at 8:50 AM, stated .was on duty the night of 8/27/2021, a CNA [CNA #4] called for help in the memory unit [secure unit] .ran to help the CNA observed [Resident #1] had blood on face, appeared was coming out of her mouth . LPN #1 stated Resident #1's face was swollen and bruised. Continued interview with LPN #1 revealed Resident #2 would wander up and down hallway and sometimes in other residents' rooms. LPN #1 stated no staff member was present on the memory care unit (secure unit) when the abuse happened on 8/27/2021. Interview with CNA #1 on 9/14/2021, at 9:20 AM, via telephone, stated she had worked the night of the incident on 8/27/2021. The incident occurred on the memory care unit. CNA #1 stated heard another CNA (CNA#4) call for assistance when the incident happened. CNA#1 stated when Resident #1 was injured from Resident #2 no staff member was present in the memory unit. CNA#1 stated Resident #2 was seen by CNA #4 leaving Resident #1's room on 8/27/2021. CNA #1 stated on the night of 8/27/2021, 2 nurses and 2 CNAs were scheduled to work in the facility, but no staff member was present in the memory [secure] unit when the abuse occurred. CNA #1 stated had not observed Resident #2 with aggressive behavior prior to this incident. Interview with the Administrator and Director of Nursing (DON) on 9/14/2021, at 11:00 AM, stated Resident #2 had no aggressive behaviors prior to the incident with Resident #1. The DON confirmed Resident #1 had sustained lip laceration which required 4 sutures. Continued interview with the Administrator and DON confirmed Resident #2 was responsible for Resident #1's injuries.

Based on review of facility policy, observation, and interview, the facility failed to ensure staff adhered to established infection prevention and control policies related to appropriate use of Personal Protective Equipment (PPE) for 2 staff members observed wearing cloth face masks on 1 of 5 observation days, potentially affecting 60 residents in the facility. The findings include: Review of the facility's policy, Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures revised on 5/20/2020, showed .While in the building personnel are required to adhere to established infection prevention and control policies including .Appropriate use of PPE .Cloth face coverings for source control ARE NOT considered PPE. Staff should wear a facemask at all times when in the facility . During observation and interview on 11/5/2020 at 4:15 PM, Housekeeper #1 was observed on the 500 hallway wearing a cloth face mask. Housekeeper #1 stated she had been instructed to wear a facemask at all times while in the facility, but was not aware a cloth facemask was not acceptable. During observation and interview on 11/5/2020 at 4:29 PM, Liscensed Practical Nurse (LPN) #1 was observed on the 200 hallway wearing a cloth face mask. LPN #1 stated he was instructed to wear a mask at all times, but thought the thicker cloth masks were acceptable. During an interview with Certified Nurse Aide (CNA) #1 on 11/5/2020, CNA #1 stated he had been educated on universal mask usage while in the facility, but was unable to recall receiving instruction that cloth masks could not be worn. During a telephone interview conducted on 11/6/2020 at 4:48 PM, Registered Nurse (RN) #1 stated she had received PPE training and always wore a surgical mask, but was not aware a cloth mask could not be worn in the facility. During an interview conducted on 11/9/2020 at 1:25 PM, the Dietary Director stated .until end of last week (11/6/2020), was not told we could not wear a cloth mask .we are now wearing surgical masks . During an interview conducted on 11/10/2020 at 12:51 PM, the Director of Clinical Services stated .when no Covid (Covid-19 coronavirus) was in the facility, staff was able to wear cloth masks. Per CDC (Centers for Disease Control and Prevention) guidelines, we have changed over to surgical masks. Staff has been educated on mask usage . During an interview conducted on 11/10/2020 at 4:07 PM, the Director of Nursing (DON) stated staff had been educated on the use of a surgical mask or N95 mask in resident care areas. The DON further stated cloth masks were not to be worn in the resident areas and she was not aware of, nor been informed of any staff wearing a cloth mask.

Based on facility policy review, medical record review, and interview the facility failed to prevent abuse for 2 residents (#4 and #5) of 5 residents reviewed for abuse. The findings include: Review of the facility policy, Abuse Prevention Policy and Procedure, revised 2/26/18 revealed, The scope of this program shall apply to the prevention of abuse committed by anyone, including but not limited to, staff, other residents .This facility shall not condone any acts of resident .physical and/or mental abuse .RESIDENT-TO-RESIDENT ABUSE POLICY .It is the policy of this facility to take all steps reasonable and necessary to protect the residents from harm at all times, including protection from physical .abuse from other residents . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #4's Care Plan dated 3/15/18 (active) revealed .(Resident #4) has agitation towards others, verbally abusive toward staff . Medical record review of Resident #4's Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5 indicating Resident #4 was severely cognitively impaired. Medical record review of Resident #4's Nurse Note dated 9/17/19 revealed .ACCORDING TO RESIDENT (Resident #5) AT APPROXIMATELY 3PM (Resident #4) ENTERED HIS OLD ROOM AND ATTEMPTED TO GET IN HIS OLD BED WHEN (Resident #5) NOW IN THIS ROOM WAS LYIGN (lying) DOWN .(Resident #4) THEN PR[NAME]EEDED TO REMOVE THE BED COVERS AND YELL AT (Resident #5) TO GET OUT OF HIS BED .(Resident #5) DID NOT MOVE AND (Resident #4) BEGAN TO PULL ON HIS CLOTHING UNTIL HE RIPPED (Resident #5's) SHIRT .AT THAT TIME (Resident #5) HIT (Resident #4) IN THE GROIN AND (Resident #4) THEN STARTED TO EXIT ROOM .(Resident #5) CAME TO DOORWAY AND WAS ASKED WHAT HAPPENED TO HIS SHIRT WHEN HE REPORTED THE INCIDENT TO THE 100 HALL NURSE . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #5's Quarterly MDS dated [DATE] revealed the Resident had a BIMS of 15 indicating the resident was cognitively intact. Medical record review of Resident #5's Care Plan dated 9/6/19 (active) revealed .Resident exhibits physically aggressive and socially inappropriate behaviors .attempting to hit, yelling and cursing . Review of facility documentation dated 9/17/19 revealed .(Resident #5) came to doorway and nurse (nurse name) saw . his shirt was ripped and asked what happened .(Resident #5) states that another resident (Resident #4) came into his room and pulled his cover of (off) and told him to get up and out of his bed .(Resident #4) the (then) pulled on his clothes and ripped his shirt when he didn't get up .(Resident #5) states he hit the other resident in the privates and he left the room . Interview with License Practical Nurse (LPN) #1 on 9/24/19 at 2:55 PM, in the conference room, confirmed LPN #1 had interviewed both Residents #4 and #5 following the physical altercation on 9/17/19. Continued interview confirmed resident to resident abuse occurred. Interview with LPN #2 on 9/24/19 at 3:07 PM, in the conference room, confirmed she was the first nurse on the scene after the incident. Continued interview confirmed she noted Resident #5 had a ripped shirt. Further interview confirmed the physical altercation occurred between Residents #4 and #5. Continued interview confirmed the facility failed to prevent abuse for Residents #4 and #5. Interview with Resident #5 on 9/24/19 at 3:21 PM, in the resident's room, confirmed . (Resident #4) tried to get me out of bed .Ripped my shirt I hit Resident #5 . Interview with the Director of Nursing (DON) on 9/24/19 at 3:39 PM, in the conference room, confirmed there was physical contact between Resident #4 and #5. Continued interview confirmed the facility failed to prevent abuse for Residents #4 and #5. Interview with the Administrator (Abuse Coordinator) on 9/24/19 at 3:57 PM, in the conference room, confirmed the facility failed to prevent abuse for Residents #4 and #5.

Based on the facility policy review, Social Service Job Description review, medical record review, and interview the facility failed to have Social Services follow up with 2 residents (#4 and #5) of 5 residents reviewed for abuse following a physical altercation between Residents #4 and #5. The findings include: Review of the facility's abuse policy, Abuse Prevention Policy and Procedure, revised 2/26/18 revealed .REPORTING/INVESTIGATION/RESPONSE POLICY .Facility Social Worker is to provide counseling and support to the resident and possibly the family involved .The counseling is to be provided as long as necessary .the psychosocial intervention is to be documented in the resident's clinical record . Review of the Social Service Job description, Social Services, revised 6/2006 revealed General Purpose .Identify and provide for each resident's social, emotional and psychological needs .Essential Job Functions .Provide timely and accurate completion of Social Services .Progress Notes as well as Social Service Assessment .and other forms as required by the Administrator in order to comply with federal and state regulations and facility policies and procedures .Maintain progress notes for each resident as required by company policy and state and federal regulations .Progress notes must reflect progress made regarding problems identified in the Plan of Care . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #4's Care Plan dated 3/15/18 (active) revealed .(Resident #4) has agitation towards others, verbally abusive toward staff . Medical record review of Resident #4's Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5 indicating Resident #4 was severely cognitively impaired. Medical record review of Resident #4's Nurse Note dated 9/17/19 revealed .ACCORDING TO RESIDENT (Resident #5) AT APPROXIMATELY 3PM (Resident #4) ENTERED HIS OLD ROOM AND ATTEMPTED TO GET IN HIS OLD BED WHEN (Resident #5) NOW IN THIS ROOM WAS LYIGN (lying) DOWN .(Resident #4) THEN PR[NAME]EEDED TO REMOVE THE BED COVERS AND YELL AT (Resident #5) TO GET OUT OF HIS BED .(Resident #5) DID NOT MOVE AND (Resident #4) BEGAN TO PULL ON HIS CLOTHING UNTIL HE RIPPED (Resident #5's) SHIRT .AT THAT TIME (Resident #5) HIT (Resident #4) IN THE GROIN AND (Resident #4) THEN STARTED TO EXIT ROOM .(Resident #5) CAME TO DOORWAY AND WAS ASKED WHAT HAPPENED TO HIS SHIRT WHEN HE REPORTED THE INCIDENT TO THE 100 HALL NURSE . Medical record review of Resident #4's General Notes revealed no Social Service documentation from 9/17/18-9/24/19 following a physical altercation related to abuse which occurred on 9/17/19 between Residents #4 and #5. Medical record review revealed Resident #5 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #5's Quarterly MDS dated [DATE] revealed the Resident had a BIMS of 15 indicating the resident was cognitively intact. Medical record review of Resident #5's Care Plan dated 9/6/19 (active) revealed .Resident exhibits physically aggressive and socially inappropriate behaviors .attempting to hit, yelling and cursing . Continued review revealed the residents care plan was updated on 9/17/19 and a new intervention was initiated. Further review revealed .9/17/19 RESIDENT TO RESIDENT CONTACT .RESIDENT EDUCATED ON ASKING FOR HELP FROM STAFF IF HAVING DIFFICULTY WITH ANOTHER RESIDENT INSTEAD OF ENGAGING IN PHYSICAL CONTACT . Review of facility documentation dated 9/17/19 revealed .(Resident #5) came to doorway and nurse (nurse name) saw . his shirt was ripped and asked what happened .(Resident #5) states that another resident (Resident #4) came into his room and pulled his cover of (off) and told him to get up and out of his bed .(Resident #4) the (then) pulled on his clothes and ripped his shirt when he didn't get up .(Resident #5) states he hit the other resident in the privates and he left the room . Medical record review of Resident #4's General Notes revealed no Social Service documentation from 9/17/18-9/24/19 following a physical altercation related to abuse which occurred on 9/17/19 between Residents #4 and #5. Interview with the Social Worker (SW) on 9/24/19 at 11:18 AM, in the conference room, confirmed the SW failed to conduct any follow up services with Resident #4 and #5 after an incident of resident to resident abuse on 9/17/19. Continued interview confirmed the SW was unaware she was responsible for providing counseling and support to Resident #4 and #5 after any allegation or suspicion of resident abuse occurred. Further interview confirmed .I didn't know then but I know now . Interview with the Director of Nursing (DON) on 9/24/19 at 2:37 PM, in the conference room, confirmed there was physical contact between Resident #4 and #5. Further interview confirmed physical abuse had occurred between Residents #4 and #5. Continued interview confirmed the facility failed to have Social Services follow up with Residents #4 and #5 as required by the facility's policy. Further interview confirmed Social Services failed to provide counseling and support to Residents #4 and #5 after the abuse allegation.

Based on facility policy review, medical record review, and interview, the facility failed to notify the physician and the resident's family after a fall, and failed to notify the physician of complaints of pain for 1 resident (#76) of 5 residents reviewed for falls, of 20 sampled residents. Resident #76 sustained pelvic fractures, which resulted in Harm. The findings include: Review of the facility's policy Accidents and Incidents, Investigating and Reporting, revised 7/2017, revealed, .all accidents or incidents involving residents .shall be investigated and reported to the Administrator .1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident . Continued review revealed, .The following data, as applicable, shall be included on the Report of Incident/Accident form: .g. The time the injured person's Attending Physician was notified .the date/time the injured person's family was notified and by whom . Medical record review revealed Resident #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a 30 Day Minimum Data Set ((MDS) dated [DATE] revealed Resident #76 scored a 9 on the Brief Interview for Mental Status (BIMS), indicating the resident had moderate cognitive impairment. Continued review revealed the resident required extensive assistance of 1 staff for bed mobility, transfers, dressing, toileting, and hygiene. Review of a facility fall investigation, for a fall on 7/4/19, revealed Resident #76 was observed sitting on the floor at the foot of the bed. Further review revealed no documentation the Physician or the family had been notified of the fall. Medical record review of a nurse's note dated 7/4/19 revealed no documentation the Physician or the resident's family had been notified of the fall on 7/4/19. Medical record review of a nurse's note dated 7/5/19 at 4:50 PM, revealed Resident #76 complained of pain and soreness in the right hip and was offered medication to treat pain. Medical record review of the Physical Therapy (PT) Treatment Encounter Notes dated 7/5/19 revealed, .Pt (patient) declined PT .need for PT .especially after her fall in room last night . Medical record review of a nurse's note dated 7/6/19 at 11:20 AM revealed Resident #76 had increased pain to the right hip and the physician was notified of the increase in pain due to a fall. Medical record review of x-ray results dated 7/6/19 revealed Resident #76 had pelvic fractures. Interview with the Quality Assurance Registered Nurse (RN) #1 on 8/7/19 at 8:40 AM, in the conference room, confirmed the facility failed to notify the Physician, and the family of the fall on 7/4/19. Telephone interview with Licensed Practical Nurse (LPN) #1 on 8/7/19 at 3:09 PM, revealed on 7/4/19 at 6:45 PM, Resident #76 was found in the resident's room sitting on the floor at the foot of the bed. Continued interview revealed Resident #76 complained of .pain in her hip around 4 o'clock (4:00 AM on 7/5/19) . Continued interview confirmed LPN #1 failed to notify the Physician and the family of the fall on 7/4/19 and did not notify the physician of the resident's complaints of increased pain. Further interview revealed .I should have called (the Physician) .but that's my fault . Interview with the Director of Nursing (DON) on 8/7/19 at 10:08 AM, in the DON's office, confirmed the facility failed to notify the Physician and the resident's family after the fall on 7/4/19, which resulted in Resident #76 sustaining pelvic fractures. Refer to F-689

Based on facility policy review, medical record review, observation, and interviews, the facility failed to implement a care plan intervention to prevent falls for 2 residents (#12, #76) of 5 residents reviewed for falls. The facility's failure to implement a fall intervention resulted in actual Harm when Resident #12 and Resident #76 sustained fractures following a fall. The findings include: Review of the facility policy, Care Planning-Interdisciplinary Team revised on 9/2013 revealed .care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team . Medical record review revealed Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum Data Set ((MDS) dated [DATE], revealed the resident scored a 9 on the Brief Interview for Mental Status (BIMS), indicating the resident had moderate cognitive impairment. Continued review revealed the resident required extensive assist of 2 staff for bed mobility, transfers, dressing, and toileting. Medical record review of Resident #12's Comprehensive Care Plan dated 8/2/19 revealed .at risk for fall related injury as evidenced by history of previous fall .hx (history) of falls .6/26/18-Dycem (nonslip pad to prevent slipping/sliding) to chair . Observation of Resident #12 on 8/5/19 at 10:07 AM, in the resident's room, revealed the resident sitting in the wheelchair watching television. Further observation revealed the resident slid from the wheelchair onto the floor and landed on his right side. Further observation revealed the fall intervention of Dycem pad to the wheelchair was not in place at the time of the fall. Medical record review of an acute care emergency room record dated 8/6/19 revealed Resident #12 had a right [MEDICAL CONDITION] that required surgery to repair. Interview with Licensed Practical Nurse (LPN) #3 on 8/6/19 at 12:04 PM, in the resident's room, confirmed the fall intervention of Dycem pad to the wheelchair was not in place at the time of the fall. Interview with the Director of Nursing (DON) on 8/6/19 at 2:50 PM, in the DON's office, confirmed the care plan intervention of Dycem pad to the wheelchair was active on the care plan and should have been in place at the time of the fall. Further interview confirmed the facility failed to implement the care plan intervention of Dycem pad to the wheelchair. Resident #12's fall resulted in a [MEDICAL CONDITION]. Medical record review revealed Resident #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Comprehensive Care Plan dated 6/13/19 revealed Resident #76 was at risk for falls. Continued review of the care plan revealed .appropriate footware (footwear) . Medical record review of a 30 Day MDS dated [DATE], revealed Resident #76 was moderately cognitively impaired and required the extensive assistance of 1 staff for bed mobility, transfers, dressing, toileting, and hygiene. Medical record review of a nurse's note dated 7/2/19 revealed the resident had a fall from her bed .resident states that she was trying to get he (her) shoes and slide (slid) out of the bed . Review of the facility fall investigation dated 7/2/19 revealed the facility initiated the following intervention after the fall .non skid socks when shoes off . Review of a facility fall investigation for Resident #76 revealed the resident had a fall on 7/4/19 at 6:45 PM in her room when Resident #76 attempted to get a night gown from her closet. Continued review revealed, .Footwear at time of fall .socks . Medical record review of a nurse's note dated 7/6/19 revealed .Resident continues to complain of increased pain to right hip post fall unrelieved .requesting x-ray . Medical record review of X-Ray results dated 7/6/19 revealed the resident had pelvic fractures. Interview with the Quality Assurance Registered Nurse (QA/RN) #1 on 8/7/19 at 8:40 AM, in the conference room, confirmed the facility failed to implement the fall intervention of nonskid socks at the time of Resident #76's fall on 7/4/19. Interview with the Director of Nursing (DON) on 8/7/19 at 10:08 AM, in the DON's office, revealed the intervention of appropriate footwear initiated on Resident #76's admission to the facility included the use of nonskid socks. Continued interview revealed after the resident's fall on 7/2/19 the only intervention the facility initiated after the resident's fall was nonskid socks. Further interview with the DON confirmed Resident #76 did not have on appropriate footwear or nonskid socks at the time of the resident's fall on 7/4/19. Further interview confirmed the facility failed to implement the intervention of nonskid socks resulting in Resident #76 sustaining a pelvic fracture. Refer to F-689

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide adequate supervision to prevent falls for 2 residents (#12, #76) of 5 residents reviewed for falls. Resident #12 sustained a right [MEDICAL CONDITION] and Resident #76 sustained pelvic fractures, which resulted in actual Harm to Residents #12 and #76. The findings include: Review of the facility policy Accidents and Incidents Investigating and Reporting, revised 7/2017, revealed, .The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident .The Nurse Supervisor/Charge Nurse .shall complete a Report of Incident/Accident form and submit .within 24 hours of the incident . Review of the facility policy Falls and Fall Risk, Managing, revised on 3/2018, revealed, .identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .implement a resident-centered fall prevention plan to reduce risk .implement interventions .to try to minimize serious consequences of falling . Review of the facility document Post Fall Checklist, undated, revealed, .Complete Fall Description Details . Immediate interventions implemented . Medical record review revealed Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #12 was moderately cognitively impaired and required the extensive assitance of 2 staff for bed mobility, transfers, dressing, and toileting. Medical record review of the Nursing Risk assessment dated [DATE] revealed Resident #12 scored a 20 on the Falls Risk Assessment, indicating the resident was high risk for falls. Medical record review of Resident #12's care plan dated 8/2/19, revealed a fall intervention of a Dycem, a nonslip pad to prevent slipping or sliding from the chair, was implemented 6/26/18. Observation of Resident #12 on 8/5/19 at 10:07 AM, in the resident's room, revealed the resident seated in the wheelchair watching television. Further observation revealed the resident slid from the wheelchair onto the floor and landed on his right side. Continued observation revealed Certified Nursing Assistant (CNA) #1 walked into the resident's room, observed the resident on the floor, and yelled for assistance. Further observation revealed the Dycem pad was not in place in the wheelchair at the time of the fall. Review of the facility fall investigation dated 8/5/19, revealed Resident #12 was admitted to the hospital with [REDACTED]. Medical record review of an acute care emergency room record dated 8/6/19 revealed .patient (Resident#12) is having right hip pain .RIGHT femoral neck (hip) fracture .operate tomorrow (8/7/19) . Interview with Licensed Practical Nurse (LPN) #3 on 8/6/19 at 12:04 PM, in Resident #12's room, revealed, .(Resident #12) is in (the hospital) set to have surgery for [REDACTED]. Further interview confirmed the facility failed to implement the intervention of Dycem to the wheelchair. Interview with the Director of Nursing (DON) on 8/6/19 at 2:50 PM, in the DON's office, confirmed the intervention of Dycem to the wheelchair should have been in place at the time of Resident #12's fall. Further interview confirmed the facility failed to implement the intervention of Dycem to the wheelchair, which resulted in Resident #12 sliding from the wheelchair and sustaining a [MEDICAL CONDITION]. Interview with the Physical Therapist Manager on 8/7/19 at 8:41 AM, in the therapist's office, revealed, .we typically order Dycem to wheelchairs to assist residents who are at risk for sliding out of chairs . Further interview confirmed the facility's failure to implement the Dycem to the wheelchair resulted in the resident sliding out of the wheelchair and sustaining a [MEDICAL CONDITION]. Medical record review revealed Resident #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Comprehensive Care Plan dated 6/13/19 revealed Resident #76 was at risk for falls with the following intervention .appropriate footware (footwear) .review information on past falls and attempt to determine cause of falls . Medical record review of the Certified Nurse's Assistant (CNA) Care Plan, undated, revealed no documentation of fall interventions for Resident #76. Medical record review of a 30 Day MDS dated [DATE], revealed Resident #76 scored a 9 on the BIMS, indicating the resident had moderate cognitive impairment. Continued review revealed the resident required extensive assistance of 1 staff for bed mobility, transfers, dressing, toileting, and hygiene. Medical record review of a nurse's note dated 7/2/19 revealed, .resident states that she was trying to get he (her) shoes and slide (slid) out of the bed . Review of the facility fall investigation dated 7/2/19 revealed, .slide (slid) out of bed landing on her bottom . Continued review revealed the fall interventions initiated after the 7/2/19 fall were .non skid socks when shoes off, bed low position . Medical record review of Nursing Risk assessment dated [DATE] revealed the resident scored an 11 on the facility Nursing Risk Assessment, indicating Resident #76 was a high risk for falls. Medical record review of a Physical Therapy (PT) Treatment Encounter Note dated 7/4/19 revealed Resident #76 presented with no signs of pain. Continued review revealed, .(Resident #76) performed standing side stepping with (aide). Standing at the bar, she performed hip abduction, marching in place, and heel raises . Review of a facility fall investigation for Resident #76 revealed the resident had a fall on 7/4/19 at 6:45 PM in the resident's room. Resident #76 was observed sitting on the floor at the foot of the bed. Continued review revealed interventions of appropriate footwear initiated on 6/13/19 and the fall intervention of nonskid socks initiated after the fall on 7/2/19 were not in place at the time of the fall on 7/4/19. Continued review revealed the falls investigation for the fall on 7/4/19 was not initiated until 7/29/19 (25 days after the fall) and the facility did not implement any new fall interventions after the fall on 7/4/19. Medical record review of a Physical Therapy Treatment Encounter Note dated 7/5/19 revealed, . Pt (patient) declined PT 2x (times) .need for PT .especially after her fall in room last night .returned to (patient) room a 3rd time and found (Resident #76) in bed .numerous refusals by (Resident #76) despite extensive education of the benefits of PT . Medical record review of a Physical Therapy Treatment Encounter Note dated 7/6/19 revealed, .due to increased amount of pain to RLE (right lower extremity) unable to perform at this time. Spoke with resident's nurse this date to aid with comfort measures, and per nurse x-rays ordered this morning to assess extent of injury to RLE from recent fall. Therapy session ended this date due to significant pain experienced by resident . Continued review revealed, .Pain with movement 9/10 (scale of 0-10, 0 = no pain, 10 = worst pain possible) . Medical record review of a nurse's note dated 7/6/19 at 11:20 AM revealed Resident #76 had increased pain to the right hip after the fall on 7/4/19 and the physician was notified with orders to obtain an x-ray. Medical record review of a Physician's Order dated 7/6/19 revealed .XRay R (Right) Hip .post fall . Medical record review of X-Ray results obtained on 7/6/19 revealed .subacute fractures .lateral right superior pubic rami and medial inferior pubic rami (pelvic fractures) . Medical record review of a nurse's note dated 7/9/19 revealed, .recent xrays abnormal revealing a pelvic fracture .(orthopedic physician) was consulted .continue to keep resident non weight bearing . Medical record review of Physical Therapy Progress Report dated 7/11/19 reveaeld prior to Resident #76's fall on 7/4/19 the resident was participating in therapy and had shown improvement .goal .will ambulate 750 (feet) with least restrictive assistive device .baseline 6/5/19 unable/dependent .6/28/19 (Resident #76) is able to walk around 200 (feet) with (caregiver) but remains fearful of walking . Further review revealed .Progress and Response to tx (treatment) .7/11/19 . Resident is currently NWB (non weight-bearing) in RLE (right lower extremity) and is awaiting further directions on (weight bearing) from ortho (orthopedic physician) . Interview with LPN #4 on 8/6/19 at 2:23 PM, at the nurse's station, revealed LPN #4 was not aware Resident #76 had any fall interventions. Interview with the Quality Assurance Registered Nurse (QA/RN) #1 on 8/7/19 at 8:40 AM, in the conference room, confirmed the fall intervention of nonskid socks or appropriate footwear was not in place at the time of the fall on 7/4/19. Interview with CNA #2 on 8/7/19 at 8:48 AM, in the conference room, revealed CNA #2 was not aware of Resident #76's fall interventions. Telephone interview with LPN #1 on 8/7/19 at 3:09 PM, revealed on 7/4/19 at 6:46 PM, Resident #76 was found in the resident's room sitting on the floor at the foot of the bed. Continued interview revealed Resident #76 was not wearing nonskid socks or appropriate footwear at the time of the fall. Further interview confirmed LPN #1 failed to initiate a fall investigation promptly after the fall on 7/4/19 and failed to implement interventions to prevent further falls after the fall on 7/4/19. Interview with the Director of Nursing (DON) on 8/7/19 at 10:08 AM, in the DON's office, revealed the intervention of appropriate footwear (implemented 6/13/19) included nonskid socks (intervention after fall on 7/2/19). Continued interview confirmed the facility failed to ensure the fall interventions of nonskid socks or appropriate footwear were implemented after the fall on 7/2/19, which resulted in the resident sustaining pelvic fractures after another fall on 7/4/19, and failed to implement any fall interventions after the fall on 7/4/19.