Every finding on record at Willow Ridge Of NC

Based on record reviews and staff interviews, the facility failed to develop accurate care plans when the facility wrote care plans for cognitively impaired residents for activity they were unable to consent to and wrote goals and interventions that would not apply to the residents for 4 of 8 residents whose comprehensive care plans were reviewed (Resident #10, Resident #12, Resident #101, and Resident #104). The findings included: a. Resident #10 was initially admitted to the facility on [DATE] with a readmission date of [DATE]. Resident #10's diagnoses included Alzheimer's disease and unspecified dementia. Resident #12 resided on the secured memory care unit at the time this care plan was developed. A review of Resident #10's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was severely cognitively impaired and had no documented behaviors during the assessment period.A review of Resident #10's active care plan dated [DATE] revealed a focused area which stated in part: Responsible party gave consent for Resident #10 to have intimate relationship with consenting resident partner. The stated goal was Resident #10 would have psychosocial needs and sexual choices/preferences met with dignity and privacy. Interventions included the following: nursing staff provided education in safe sex practices, to include sexually transmitted infection prevention & hygiene. Staff would ensure signage on door to private areas used for intimate activity to ensure privacy and dignity were maintained. Staff would provide private areas for consensual intimate activities upon request. b. Resident #12 was admitted to the facility on [DATE] with diagnoses which included neurocognitive disorder with Lewy bodies (a progressive dementia characterized by accumulation of protein clumps in the brain resulting in cognitive decline). Resident #12 resided on the secured memory care unit at the time this care plan was developed. A review of Resident #12's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was severely cognitively impaired and had verbal aggression and wandering behaviors for 1 to 3 days during assessment period. A review of Resident #12's active care plan dated [DATE] revealed a focused area which stated in part: Resident #12 wishes to have an intimate relationship with consenting resident partner. Family has given approval for Resident #12 developing an intimate relationship with another resident if both residents consent. The stated goal was Resident #12 would have psychosocial needs and sexual choices/preferences met with dignity and privacy. Interventions included the following: nursing staff provided education in safe sex practices, to include sexually transmitted infection prevention & hygiene. Staff would ensure signage on door to private areas used for intimate activity while residents used it to ensure privacy and dignity were maintained. Staff would provide private areas for consensual intimate activities upon request. c. Resident #101 was initially admitted to the facility on [DATE] with a readmission date of [DATE]. Resident #101's diagnoses included Alzheimer's disease. Resident #101 resided on the secured memory care unit at the time this care plan was developed. A review of Resident #101's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #101 was severely cognitively impaired and had verbal aggression, rejection of care, and wandering behaviors 1 to 3 days during assessment period.A review of Resident #101's active care plan initiated [DATE] and revised [DATE] revealed a focused area which stated in part: Resident #101 wished to have an intimate relationship with consenting resident partner. Responsible party was aware and consent given. The stated goal was Resident #101 would have psychosocial needs and sexual choices/preferences met with dignity and privacy. Interventions included the following: nursing staff provided education in safe sex practices, to include sexually transmitted infection prevention & hygiene. Staff would ensure signage on door to private areas used for intimate activity to ensure privacy and dignity were maintained. Staff would provide private areas for consensual intimate activities upon request. d. Resident #104 was initially admitted to the facility on [DATE] with a readmission date of [DATE]. Resident #104's diagnoses included unspecified dementia. Resident #104 resided on the secured memory care unit at the time this care plan was developed. A review of Resident #104's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #104 was severely cognitively impaired and had verbal aggression and wandering behaviors for 1 to 3 days during assessment period.A review of Resident #104's active care plan initiated [DATE] and revised [DATE] revealed a focused area which stated in part: Resident #104 wished to have an intimate relationship with consenting resident partner. Responsible party aware and consent given. The stated goal was Resident #104 would have psychosocial needs and sexual choices/preferences met with dignity and privacy. Interventions included the following: nursing staff provided education in safe sex practices, to include sexually transmitted infection prevention & hygiene. Staff would ensure signage on door to private areas used for intimate activity to ensure privacy and dignity were maintained. Staff would provide private areas for consensual intimate activities upon request. An interview with the Memory Care Unit Coordinator was conducted on [DATE] at 1:41 PM. The Memory Care Unit Coordinator stated that some residents held hands, hugged, and danced but no residents engaged in sexual contact. The Memory Care Unit Coordinator reported that her understanding was that care plans were in place because the responsible parties gave consent for residents to hold hands, hug, and dance. An interview was conducted with the MDS Nurse on [DATE] at 12:12 PM. The MDS Nurse verbalized that she completed resident's care plans with a focused area of intimate relations. The MDS Nurse stated that corporate instructed her to enter the intimate relations care plan for residents but could not recall when or who specifically gave her those instructions. The MDS Nurse verbalized that her understanding was that the residents held hands or danced together but did not engage in sexual behaviors. The MDS Nurse reported that she never questioned if the care plan was appropriate for Resident #10, Resident #12, Resident #101, or Resident #104. An interview was conducted with the Director of Nursing (DON) on [DATE] at 3:15 PM. The DON stated that care plans should be individualized and updated. The DON reported Resident #10 had a history of holding hands and walking with a peer who was now deceased . Resident #12 and Resident #101 were known to be together all the time and held hands frequently. Resident #12 also would hold hands with Resident #104 at times. The care plans were in place because consent from the responsible party was obtained for the residents to hold hands, hug, and dance. The DON verbalized that no sexual activity occurred between residents. An interview was conducted with the Administrator on [DATE] at 4:35 PM. The Administrator stated the care plans should be accurate, appropriate for each resident, be individualized, and up to date.

Based on record review, observation, and resident and staff interviews, the facility failed to provide personal privacy to residents when staff did not knock before entering resident rooms. This deficient practice affected 2 of 6 residents reviewed for privacy (Resident #94 and Resident #31). The findings included:a. Resident #94 was admitted on [DATE].Resident #94's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 was cognitively intact.An interview with Resident #94 was conducted on 3/16/26 at 10:19 AM. Resident #94 stated that staff just barge into my room without knocking. He reported that if staff did knock, it was one single knock as they were already entering the room, and they never announced themselves or waited for him to give permission. He indicated this occurred regardless of whether his door was open or shut. Resident #94 reported that it made him very angry when staff entered without knocking and he had asked staff several times to knock before coming into his room. He stated, I have just given up on having any privacy and I feel like a prisoner with no rights. An observation conducted while sitting with Resident #94 in the resident's room behind a fully closed door on 3/18/26 at 9:35 AM revealed that Nurse #3 opened the door and entered the room without knocking or announcing himself.An interview with Nurse #3 was conducted on 3/18/26 at 10:04 AM. Nurse #3 reported he was not sure why he had walked into Resident #94's room without knocking and that he didn't realize he had even done it. He reported he had received education annually on residents' rights and he knew he was supposed to knock before entering the room for all residents and to wait for permission to enter for residents who were cognitively able to give permission. He reported knocking and waiting for permission was the resident's right to privacy.b. Resident #31 was admitted to the facility on [DATE].Resident #31's quarterly MDS assessment dated [DATE] revealed he was moderately cognitively intact.An observation while sitting with Resident #31 in the resident's room behind a fully closed door on 3/16/26 at 9:45 AM revealed that Nurse Aide (NA) #1 opened Resident #31's door without knocking and entered the room unannounced. Resident #31 began smacking the mattress of his bed and asked NA #1, What the hell are you doing? Resident #31 was then observed pounding his fist on his leg and repeating knock on the door several times to NA #1.An interview with Resident #31 was conducted on 3/16/26 at 9:50 AM. Resident #31 reported that staff never knocked on his door before entering his room. He stated he felt like a child and that the staff had no respect for him. Resident #31 stated staff always came into his room without knocking and it made him angry.An interview was conducted with NA #1 on 3/19/26 at 10:00 AM. NA #1 reported that he knew he was supposed to knock before entering a resident's room but stated that when he was in a hurry, he forgot to knock. NA #1 reported that he had received training on residents' rights, and that part of the training was to knock on residents' doors prior to entering and to wait for the resident to grant permission to enter if they were able to do so.An interview with the Director of Nursing (DON) was conducted on 3/19/26 at 11:50 AM. The DON reported that she expected her staff to do the same thing at the facility as they would do at any home, which included knocking on the door before entering. She reported that staff received training on residents' rights upon hire and annually. She explained that she was not sure why any staff would enter a resident's room without knocking and waiting for permission from residents who were cognitively able to give that permission.An interview with the Administrator was conducted on 3/19/26 at 4:11 PM. The Administrator indicated that she expected all staff to knock on the door of a room, announce themselves, and wait for the resident's permission before entering a resident's room. She reported that staff received training on residents' rights and should know they were required to knock and wait for permission before entering a resident's room.

Based on record review, resident, staff interviews, and Psychiatric Nurse Practitioner (NP) interviews, the facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident with a serious mental health diagnosis for 1 of 3 residents reviewed for PASRR (Resident #5).The findings included:Review of Resident #5's medical record revealed Level I PASRR was completed on [DATE] prior to Resident #5's admission to the facility on [DATE] with a recommendation to resubmit paperwork for Level II PASRR if a mental health diagnosis was suspected or if there was a significant change in the resident's condition. There was no expiration date.Review of the hospital Discharge summary dated [DATE] revealed Resident #5 was discharged from acute care hospital following recent deep vein thrombosis (DVT) left lower leg with ulceration and a fall at home. Discharge diagnoses included bipolar disorder. Resident #5's discharge medications included bupropion XL (an antidepressant extended-release medication) 150 milligrams (mg)/24 hours two tablets daily for mood symptoms of bipolar disorder, duloxetine (an antidepressant medication) 60 mg delayed response capsule 1 capsule daily for mood symptoms of bipolar disorder, rivastigmine (medication used to treat mild to moderate dementia) 1.5 mg oral capsule one (1) capsule twice daily for memory related to dementia and trazodone (an antidepressant medication) 50 mg every night at bedtime for sleep.Resident #5 was admitted to the facility on [DATE] with diagnoses which included bipolar disorder, hypertension, heart failure, diabetes mellitus, and dementia. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was cognitively intact, and her current active diagnoses included bipolar disorder. According to the admission MDS assessment the resident had not been evaluated by Level II PASRR and determined to have a serious mental illness and/or mental retardation or a related condition and was taking antidepressant medications.A psychiatry visit note documented by the Psychiatric NP and dated [DATE] revealed Resident #5 was seen for initial evaluation following recent admission to the facility on [DATE] with acute embolism and thrombosis of deep vein of left lower extremity. Her medical history was significant for diabetes mellitus type II, bipolar disorder and dementia. During the evaluation the resident reported sleeping adequately and described her appetite as fair. Resident #5 denied suicidal and homicidal ideation, auditory hallucinations and visual hallucinations. Mood was reported by resident as stable with no acute behavioral concerns reported by staff. Current psychiatric medications included duloxetine 60 mg daily, bupropion XL 300 mg daily, rivastigmine 1.5 mg, and trazodone 50 mg at bedtime, all of which have been tolerated without reported adverse effects. The plan was for continued psychiatric oversight in the facility to monitor symptom stability, medication effectiveness, and overall safety. Resident #97's care plan dated [DATE] revealed a focus area for the resident being on antidepressant medication related to bipolar disorder and insomnia. The goal was for the resident to be free from discomfort or adverse reactions related to antidepressant therapy through the review date. The interventions included administering antidepressant medications as ordered by the physician and monitor/document side effects and effectiveness every shift, and monitor/document/report as needed adverse reactions to antidepressant therapy. The care plan also revealed a focus area for the resident having a mood problem related to bipolar disorder. The goal was for the resident to have improved mood state through the review date. The interventions included administering medications as ordered and monitoring for side effects and effectiveness, behavioral health consults as needed, monitor/document/report as needed, monitor/document/report as needed any risk for harm to self and monitor/record/report as needed any risk for harming others.Further review of psychiatry visit notes revealed Resident #5 was seen on [DATE] and [DATE] with noted stability of the resident. Continued psychiatric management remained medically necessary due to chronic psychiatric illness and need for structured monitoring in the facility setting. There was no evidence in the medical record that a request was submitted for a Level II PASRR evaluation.Further review of Resident #5's medical record revealed a letter dated [DATE] that stated the resident already had a Level I PASRR and that could be used until it expired but there was no indicated expiration date on the letter.An interview on [DATE] at 10:14 AM with Resident #5 revealed she could not recall when she was first diagnosed with bipolar disorder. She stated her symptoms were off and on and that she often noticed them during the evening when she was tired she experienced increased frustration and closed her self off from others and didn't want to be around anyone. Resident #5 further stated some days she just sat and cried all day without really knowing why. She indicated she had lupus and some days were worse than others with her lupus and that made her feel down on her bad days. Resident #5 indicated her medication for depression seemed to help and that she was seeing a counselor that helped with her medications. She explained that she felt stable at present but said she did have bad days that made her feel down.An interview on [DATE] at 10:40 AM with the Social Work (SW) Director revealed he and the other SW would be responsible for completing Level II PASRR paperwork for residents. The SW Director stated it was his understanding that residents were admitted with a Level I PASRR or Level II PASRR that had been completed prior to admission and said he and the other SW would be responsible for completing and submitting PASRR paperwork when the resident received a temporary Level II that required paperwork be resubmitted after 30, 60, or 90 days or if the resident had received a new mental health diagnosis or had a significant change. The SW Director stated he believed he would be notified during their morning meetings and from the nursing staff of any resident who had received a new mental health diagnosis or had a significant change so the Level II PASRR paperwork could be completed. The SW Director further stated he had submitted paperwork for Resident #5 for a Level I PASRR evaluation but stated he had not included any progress notes from the Psychiatric NP, progress notes from the NP or Medical Director and had not sent in a signed FL2 form (medical document in North Carolina completed by a physician to assess a resident's medical needs, diagnoses, and medications before admission to a facility) because there was nowhere on the system to attach the documents. The facility received a letter back on [DATE] that Resident #5 already had an existing Level I PASRR and that number could be used until it expired. There was no expiration date included on the letter. The SW Director stated after reviewing Resident #5's mental health diagnosis, he believed a Level II PASRR evaluation should have been completed. He stated he could not recall if he was aware of the bipolar disorder diagnosis prior to Resident #5's admission to the facility on [DATE].An interview on [DATE] at 10:59 AM with the Psychiatric NP revealed she was currently seeing Resident #5 for bipolar disorder. She stated she was not aware of the exact date of her bipolar disorder diagnosis but said she was stable at present on her medications. The Psychiatric NP stated that Resident #5 may have needed to be evaluated for a Level II PASRR due to her bipolar diagnosis but said her dementia diagnosis superseded the bipolar diagnosis.During an interview on [DATE] at 4:08 PM with the Administrator, she communicated her understanding that Level II PASRR evaluation should be completed in a timely manner upon admission of a resident with a mental health diagnosis and anytime a resident had a change of condition or received a new mental health diagnosis. The Administrator stated that Resident #5 should have had a Level II PASRR evaluation submitted when the diagnosis of bipolar disorder was noted on her diagnoses list. The Administrator further stated that she did not know why the referral for Level II PASRR evaluation was not submitted for Resident #5.

Based on observations, record review, and staff interviews, the facility failed to ensure a resident's toenails were trimmed and podiatry services were arranged for 1 of 4 resident reviewed for foot care (Resident #94).The findings included:Resident #94 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation and heart failure.Review of the admission nursing assessment dated [DATE] did not reveal any issues with Resident #94's toenails.Review of Resident #94's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 was cognitively intact and required moderate assistance with activities of daily living (ADL) and personal hygiene, and was dependent with bathing and frequently refused care.Review of Resident #94's care plan dated 2/4/26 revealed he had an activity of daily living performance deficit and required staff assistance to complete daily tasks and frequently refused care.An observation and interview were conducted on 3/16/2026 at 10:19 PM. Resident #94's toes revealed long, jagged toenails on both feet. Resident #94's right great toenail had a brownish coloring at the base of the nailbed which had started to extend upward to the middle of the toenail. Resident #94 stated he had asked for his toenails to be trimmed several times and that he had never refused for them to be trimmed. He further reported that he had been told he was going to be seen by the podiatrist but to his knowledge the appointment had not been made. He explained that he had not been able to bend down and take care of his toenails and feet for a long time and that wearing socks was uncomfortable. Review of Resident #94's electronic medical chart (EMR) 94's revealed no documentation of resident being offered or refusing podiatry or toenail care. The EMR did reveal documentation of Resident #94 refusing showers and refusing to have his UNNA boots (compression dressing with zinc oxide paste that treats edema, ulcers and sores). Resident #94's weekly nursing assessments from 1/29/2026 through 3/19/26 revealed no notation that his toenails were long and needed trimmed. Review of the facility's podiatry clinic schedule for February revealed Resident #94 was not seen by the podiatrist and was not on the list to be seen. Resident #94 was not on March's podiatry schedule at the time of review. There were no consultation reports or notations in Resident #94's EMR that he was scheduled to see the podiatrist or that he had been seen by a podiatrist since admission to the facility.An interview was conducted with Nurse Aide (NA) #1 on 03/19/2026 at 9:19 AM who stated that he often provided care for Resident #94. NA #1 stated he had noticed Resident #94's toenails were very long and needed to be trimmed. NA #1 stated he didn't remember if he had told anyone about Resident #94's toenails. NA #1 further explained that he usually reported any concerns or issues to the resident's assigned nurse. NA #1 reported Resident #94 did refuse care from time to time but was not sure if he had ever refused to have his toenails trimmed. NA #1 reported he had not asked Resident #1 about getting his toenails trimmed.An interview was conducted on 3/18/26 at 10:04 PM with Nurse #3. He reported he was familiar with Resident #94 and remembered that he came in with discoloration on his toenails, and the toenails were long, especially the one on the right great toe. Nurse #3 reported he was unsure why he did not document this in the EMR or why he didn't let the provider know. He reported he was also unsure why he had never attempted to trim the resident's nails. Nurse #3 stated social work (SW) was responsible for getting residents a podiatry consultation, but the floor nurses would be expected to tell social work if a resident needed a podiatrist consultation. Nurse #3 stated he had not personally told social work that Resident #94 needed foot care, he reported he was unsure why he had not told anyone.An interview was conducted on 3/18/2026 at 10:55 AM with the Social Work Director. He reported he had spoken with the podiatrist office today to get Resident # 94 on the podiatry list for March. He reported the nurse on the hall had asked him to include Resident #94 on the list for podiatry services to get his toenails trimmed. The Social Work Director reported he was unaware of any podiatry needs for Resident #94 prior to this request. An interview was conducted on 3/19/26 at 3:45 PM with Director of Nursing (DON). The DON stated she was aware of Resident #94's toenails but Resident #94 refused care a lot, including toenail care. She reported she could not remember which nurse made her aware of his toenails or when she was made aware. She indicated she thought Resident #94 had been seen by the podiatrist and was not sure why he had not been seen or his toenails addressed unless he refused the care. She reported that if he had refused care, it should be documented in his electronic medical record.An interview was conducted on 3/19/26 at 4:11 PM with the Administrator. She reported she would expect any resident who had concerns with their feet to be referred to podiatrist. She stated all residents should be receiving basic foot care to include toenail care.

Based on record review and interviews with staff, Registered Dietician (RD), and the Nurse Practitioner, the facility failed to initiate a dietary supplement per the RD's recommendation when the resident experienced a significant weight loss for 1 of 5 residents reviewed for weight loss (Resident #20).The findings included:Resident #20 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease. Review of Resident #20's care plan dated 4/3/2025 revealed a potential for nutritional problems related to having a mechanically altered and therapeutic diet, with interventions that included providing and serving the diet as ordered and having the RD evaluate and recommend diet changes as needed.Resident #20 had an admission weight of 206 lbs. on 4/3/2025.The RD note dated 9/24/2025 documented a 7.8% weight loss in 30 days and a BMI of 36.2 (Normal BMI range is 18.5 to 24.9) and noted weight loss might be beneficial due to obese Body Mass Index (BMI); the RD recommended fortifying foods.On 9/26/2026 Resident #20 had a documented weight of 185 lbs.On 9/29/2025, the physician ordered a fortified nutritional shake 120 milliliters (ml) twice daily for weight loss. Review of Resident #20's quarterly Minimum Data Set (MDS) dated [DATE] revealed she was moderately cognitively impaired, weighed 180 lbs., had experienced a weight loss of 5% or more in the last month or 10% or more in the last 6 months, was not following a physician prescribed weight loss regimen, and was on a therapeutic and mechanically altered diet.On 10/23/2025 Resident #20 had a documented weight of 186 lbs. On 10/27/2025 the fortified nutritional shake 120 ml twice daily was discontinued.The RD note dated 10/30/2025 showed weight loss of 10.8% in 90 days and 10.1% in 180 days, a BMI of 35.1, noted weight loss might be beneficial due to obese BMI and that the resident was up 6 lbs. since last review, and recommended discontinuing the fortified nutritional shake due to weight gain.On 11/25/2025 Resident #20 had a documented weight of 171 lbs. The RD note dated 12/1/2025 indicated a 8.1% weight loss in 30 days, 11.2% in 90 days, and 18% in 180 days, with a BMI of 32.3; the RD noted weight loss might be beneficial due to obese BMI, that Resident #20 was down 15 lbs. since last review, and indicated the resident received the fortified nutritional shake 120 ml twice daily; the RD recommended re weigh and monitoring. Review of the December 2025 Medication Administration Record (MAR) showed no active order for the fortified nutritional shake 120 ml twice daily. On 12/3/2025 Resident #20 had a documented weight of 173.5 lbs.The RD note dated 12/8/2025 noted an 8.1% weight loss in 30 days, 11.2% in 90 days, and 18% in 180 days, with a BMI of 32.3; the RD indicated a supplement of fortified nutritional shake 120 ml twice daily and that Resident #20 was up 3 lbs. since the last review and recommended continuing the plan of care.A progress note dated 12/8/2025 documented discussion in the risk meeting, noted the resident's weight was beginning to level out, and directed continuing the fortified nutritional shake and monitoring.Review of the January 2026 MAR showed no active order for the fortified nutritional shake twice daily.On 1/6/2026 Resident #20 had a documented a weight of 168.5 lbs.The RD annual note dated 1/16/2026 revealed a 9.4% weight loss at 90 days and 19.2% at 180 days, a BMI of 31.8, and indicated Resident #20 received the fortified nutritional shake 120 ml twice daily; the RD noted weight loss might be beneficial due to obese BMI and that Resident #20 was down 3 lbs. since last review, and recommended continuing the plan of care and monitoring.Resident #20's annual MDS dated [DATE] indicated she was moderately cognitively impaired, weighed 169 lbs., had experienced a weight loss of 5% or more in the last month or 10% or more in the last 6 months, was not following a physician prescribed weight loss regimen, and was on a therapeutic and mechanically altered diet.On 2/3/2026 Resident #20 had a documented a weight of 161.5 lbs.A progress note dated 2/9/2026 documented discussion in the risk meeting of a 22.4% weight loss in 180 days and recommended increasing the fortified nutritional shake to 120 ml three times daily.The RD note dated 2/12/2026 documented a 22.4% weight loss at 180 days and a BMI of 30.5; indicated Resident #20 received a the fortified nutritional shake 120 ml twice daily; noted she was down 7 lbs. since last review; and recommended increasing fortified nutritional shake to 120 ml three times daily.Review of the February 2026 MAR showed no active order for the fortified nutritional shake twice or three times daily. During an interview on 3/17/2026 at 1:35 PM, Nurse #1 stated she was familiar with Resident #20 and was not sure if the resident received a supplement during medication pass. Nurse #1 reviewed active orders and verified there was no active order for the fortified nutritional shake. She stated if a resident had an order for a fortified nutritional shake, it appeared on the MAR and nurses administered it during medication pass. Nurse #1 stated weights were reviewed in the risk meeting and explained the risk meeting was a management meeting (Director of Nursing and Unit Coordinators), not floor nurses. She stated she believed supplement orders were entered by the dietician or unit coordinators present at the risk meeting.During an interview on 3/17/2026 at 3:58 PM, the RD stated she was familiar with Resident #20 and had been monitoring weight loss. The RD stated Resident #20's BMI was in the obese range and due to that weight loss could be beneficial, but she monitored Resident #20 to regulate the rate weight loss. The RD stated Resident #20's fortified nutritional shake should have been restarted in December 2025, and it should have been increased in February 2026 per her recommendations. The RD stated the order should have been entered by the RD or the Director of Nursing (DON) within a couple of days. The RD she stated did not know why the fortified nutritional shake was listed on the RD note for 12/1/2025, but it should have been restarted on 12/8/2025. The RD indicated she did not know why the order for the fortified nutritional shake was not entered on 12/8/2025, and that she should have entered the order. During an interview on 3/18/2026 at 9:55 AM, Nurse #2 stated floor nurses did not normally enter orders for nutritional supplements; those orders were entered by the dietician or unit coordinator.During an interview on 3/18/2025 at 10:07 AM, the Memory Care Unit Coordinator stated she believed the dietician entered supplement orders and normally emailed recommendations to the DON. The Memory Care Unit Coordinator stated it must have been a communication error Resident #20's fortified nutritional shake was not restarted in December. She stated during risk meetings the DON read recommendations aloud and unit coordinators and supervisors present at the meeting typed a progress note but did not verify the order had been entered.During an interview on 3/19/2025 at 10:00 AM, the Nurse Practitioner (NP) stated she expected RD recommendations to be followed and entered as orders. The NP stated she expected supplements to be administered as recommended. The NP stated Resident #20 was noted as weight loss being beneficial, but recommended supplements should have been ordered and administered. The NP stated the resident could have experienced more rapid weight loss without supplements, leading to failure to thrive, but stated Resident #20 was able to walk out of her room when encouraged.During an interview on 3/19/2025 at 10:59 AM, the Nurse Supervisor stated she participated in risk meetings and entered progress notes read from RD recommendations. The Nurse Supervisor verified she had signed the note written for the 2/9/2026 risk meeting but stated she did not verify the orders were active. During an interview on 3/19/2025 at 2:27 PM, the DON stated she had been in the DON role since January 2026 and was formerly the Assistant Director of Nursing. The DON stated when the RD's recommendations were read off during the risk meeting the unit coordinators or nurses present would enter a progress note, and as ADON she entered a note on 12/8/2025 for Resident #20. She stated the management team discussed weight loss with the RD during weekly risk meetings. The DON explained that the RD was present at some meetings and emailed the recommendations when not at the meeting in person. The DON indicated she thought the dietician normally entered orders for her recommendations. She stated staff did not verify orders were active when writing progress notes during the risk meeting and stated missing the order for the fortified nutritional shakes for Resident #20 was an oversight or miscommunication. The DON stated Resident #20 was now able to walk and had not had a negative outcome from the weight loss. She stated she expected RD recommendations to be followed.During an interview on 3/19/2025 at 4:04 PM, the Administrator stated the DON handled risk meetings with the RD. The Administrator stated she expected RD recommendations to be followed and administered as recommended.

Based on record review, observations, and interviews with residents, facility staff, the Medical Director, the Lieutenant from the Police Department, resident's family friend, and the resident's responsible person (RP), the facility failed to protect the resident's right to be free from resident-to-resident abuse for 2 of 3 residents reviewed for abuse (Resident #15 and Resident #57). On 4/12/24 while completing morning rounds, Nurse Aide (NA) #6 found Resident #366 in Resident #15's room, lying on top Resident #15 while she was asleep in her bed, with his brief pulled down and his penis exposed. Resident #15's brief appeared to be sideways, undone on the left side, but was in place between her legs. Resident #366 was placed on one-to-one supervision at this time due to wandering and sexualized behaviors. Both residents were severely cognitively impaired. On 12/18/24 Resident #57 and Resident #36 (Resident #57's roommate) had their call light on and motioned for NA #1 to come into the room. Resident #36 spoke first and reported to NA #1 that Resident #366 came into the room took his pants off and got on top of Resident #57 and raped her. Resident #57 nodded her head in agreement and stated she told them to get off of her and get out of her room and they left. Both residents were assessed as cognitively intact. Resident #366 was supposed to be under one-to-one supervision at the time of the incident on 12/18/24 due to his continued wandering and sexualized behaviors and NA #2 left him unattended. A reasonable person would expect to be free from abuse in their own home and could experience altered mental condition, fear, anxiety, and depressed mood. The findings included: A. Resident #15 was admitted to the facility on [DATE]. Diagnosis included Alzheimer's disease, dementia, and muscle weakness. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #15 was severely cognitively impaired and required substantial assistance for mobility and dependent on staff for transfers and toileting due to being incontinent of bladder and bowel. Resident #15 was also coded for having adequate hearing and vision, usually able to make herself understood, and usually able to understand others. Resident #366 was a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis included a traumatic brain injury (TBI), altered mental status, and cognitive communication deficit. Review of Resident #366's facility face sheet dated 4/14/23 revealed Cleveland County Department of Social Services as his responsible person and guardian. Review of quarterly MDS dated [DATE] revealed Resident #366 was severely cognitively impaired, independent for mobility, supervision for transfers, partial assistance with toileting as he was always continent for bowels with frequent urinary incontinence. Resident #366 was also ambulatory, utilized a wheelchair for long distances, able to make himself understood, able to understand others, adequate vision, and no hearing deficits. Resident #366 was not coded for any wandering or behaviors. A telephone interview with NA #6 on 1/30/25 at 8:30 AM revealed she typically worked 11:00 PM to 7:00 AM on the locked memory care unit and was familiar with Resident #15 and the incident regarding Resident #366. She stated in April 2024 she worked in the locked memory care unit and while completing her morning rounds, she had entered Resident #15's room and saw Resident #366 on top of Resident #15 who was sleeping in her bed. NA #6 revealed Resident #366's pants and brief were pulled down with his penis exposed and Resident #15's brief was sideways, undone on the left side but still in place between her legs, her gown was pulled down, and her breasts were covered. NA #6 stated she immediately removed Resident #366 from Resident #15's bed, called for Nurse #6 to come to Resident #15's room, explained to Nurse #6 what happened and was then instructed for Resident #366 to be placed on one-to-one supervision. NA #6 revealed she assisted Resident #366 back to his room and stayed with him while Nurse #6 assessed Resident #15 and notified the Administrator. NA #6 stated after the incident, Resident #366 was moved from the memory care unit to a room on the regular hall and to her knowledge remained on one-to-one supervision. NA #6 revealed that prior to the incident with Resident #15, she was not aware of Resident #366 having any type of behavior and had never witnessed him display those types of sexualized behaviors. Attempted to contact Nurse #6 who was unable to be reached. Review of interdisciplinary team (IDT) progress note dated 4/12/24 revealed on the morning of 4/12/24 staff found Resident #366 in a severely cognitively impaired female resident's room (Resident #15). Resident #366 was observed lying on top of Resident #15 with his brief pulled halfway down and his penis exposed. Resident #15 was asleep at the time, but her brief was noted to be sideways, undone on the left side, but still in place between her legs. Resident #366 was immediately placed on one-to-one supervision which required him to always be in the staff's line of sight due to the sexualized and wandering behaviors. Resident #366 was also moved off the locked memory care unit to room [ROOM NUMBER] on B hall and one-to-one supervision to remain on-going. Review of the Medical Director progress noted dated 4/12/24 for Resident #15 revealed the following: Examination of Resident #15 due to history of a male resident [Resident #366] being on top of Resident #15 while she was in her bed. The Medical Director noted apparently around 6:30 AM a male resident [Resident #366] was found on top of Resident #15; his penis was out and Resident #15's brief was pulled to the side. According to the nursing staff, Resident #15 was asleep when they found her, was asleep when Medical Director went to see her, and remained asleep during Medical Director exam. Resident #15 had severe dementia. The Medical Director revealed to the best of his knowledge it did not seem that Resident #15 was penetrated at all, there were no scratch marks or other marks visible on Resident #15's hands, body, or in her vaginal area. Review of the Medical Director progress note dated 4/12/24 for Resident #366 revealed the following: Around 6:30 AM, Resident #366 was found on top of a female resident [Resident #15] with his penis exposed and Resident #15's diaper was also possibly pulled to the side. Resident #366 was pulled off Resident #15 immediately and apparently placed on one-to-one. This had never happened with Resident #366 before; he did not seem agitated at the time, and there had been no knowledge of any behaviors leading up to this problem. Resident #366 did have a long mental health history he was being treated for with no recent changes to his medications. Hospital evaluation recommended by psychiatric (psych) services. Resident #366 returned from his evaluation from the local hospital and per their report, Resident #366's computed tomography (CT) scan and bloodwork showed no evidence of any acute abnormalities, and his urinalysis was negative. The Medical Director noted Resident #366 exposed himself on the way back from the hospital which was totally abnormal behavior. Resident #366 presently has one-to-one supervision for safety risks for both residents and staff. The Medical Director revealed he spoke with the psych provider who recommended new medications and agreed with Resident #366's one-to-one supervision for his and other residents' safety. Review of facility 5-day investigation report completed by the previous Administrator dated 4/18/24 revealed their investigative findings included the following: On the morning of 4/12/24 while NA #6 was making her rounds on the locked memory care unit when she entered Resident #15's room and found Resident #366 on top of Resident #15 who was sleeping, with his pants and brief pulled halfway down exposing his penis. Resident #15's gown was on, her breasts were covered, and her brief was sideways, appeared to be undone on the left side, but still in place between her legs. NA #6 notified Nurse #6 and Resident #366 was removed from Resident #15's room, taken back to his room, and immediately placed on one-to-one supervision. Resident #15 was assessed by Nurse #6 with no findings and continued sleeping. Law enforcement, Department of Social Services, State, Medical Director, and Resident #15's RP was notified of the incident. The facility Medical Director completed a physical examination of Resident #15 that included thorough examination of the vaginal and peri areas and found no indication that any sexual contact had occurred. Resident #15's RP declined the facilities offer to send her out to the hospital for any further evaluations. Both Resident #15 and Resident #366 were severely cognitively impaired and resided in the facility locked memory care unit. Resident #366 was not admitted with this type of behavior and prior to this incident had not displayed any types of behaviors that would cause staff to be aware of the potential for this type of behavior. Resident #366 was sent out to the hospital emergency department for evaluation and returned with no issues noted. Resident #366 was removed from the locked memory care unit into a room on a regular hall, remained on one-to-one supervision, monitored by the Medical Director, and was being evaluated and treated by psych services. Resident #15 was monitored for any psychosocial changes, mental anguish, change in her demeanor, or alterations in her daily activities and no issues were noted and Resident #15 remained pleasant and cooperative and appeared to have no negative impact. All facility staff were educated on abuse and neglect policies and procedures, wandering residents, new behaviors, and one-to-one supervision process. The facility was not able to substantiate abuse or neglect against any residents, and the residents involved remained without any physical injury, mental harm, pain, or anguish. Review of Resident #366's care plan initiated on 4/12/24 revealed Resident #366 had exhibited inappropriate sexualized behaviors and was noted to continue sexualized behaviors such as masturbating while in bed with a goal to not exhibit any of these sexual behaviors any further through the next review. Interventions for Resident #366 included allowing privacy for masturbation in his room, new medications ordered for sexual behaviors and send out to emergency room for medical and psych clearance. Resident #366 also had a care plan approach for being an elopement risk and wanderer with goals of not leaving the facility unattended and maintaining his safety through the next review. Interventions for Resident #366 included one-to-one observation, monitoring locations, and documenting wandering behaviors. Attempted to contact the previous Administrator who was unable to be reached. B. Resident #36 was admitted to the facility on [DATE]. Diagnosis included chronic pulmonary obstructive disease (COPD) and muscle weakness. Review of quarterly MDS dated [DATE] revealed Resident #36 was cognitively intact with adequate vision and hearing, able to make herself understood, and able to understand others. Resident #57 was admitted to the facility on [DATE]. Diagnoses included mild dementia, Alzheimer's disease, chronic obstructive pulmonary disease (COPD), and muscle weakness. Review of admission Minimum Data Set MDS dated [DATE] revealed Resident #57 was cognitively intact and required partial assistance with mobility, substantial assistance with transfers, and substantial assistance with toileting as she was always incontinent for both bladder and bowel. Resident #57 was also coded for oxygen use and utilized a wheelchair for mobility, adequate vision and hearing, able to make herself understood, and able to understand others. Resident #102 was admitted to the facility on [DATE]. Diagnosis included COPD and type 2 diabetes. Review of admission MDS dated [DATE] revealed Resident #102 was cognitively intact with adequate vision and hearing, able to make herself understood, and able to understand others. Resident #366 was a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis included a traumatic brain injury (TBI), altered mental status, and cognitive communication deficit. Review of Resident #366's facility face sheet dated 4/14/23 revealed Cleveland County Department of Social Services as his responsible person and guardian. Review of Resident #366's care plan revised on 6/11/24 revealed Resident #366 had exhibited inappropriate sexualized behaviors and was noted to continue sexualized behaviors such as masturbating while in bed with a goal to not exhibit any of these sexual behaviors any further through the next review. Interventions for Resident #366 included allowing privacy for masturbation in his room, new medications ordered for sexual behaviors and send out to emergency room for medical and psych clearance. Resident #366 also had a care plan approach for being an elopement risk and wanderer with goals of not leaving the facility unattended and maintaining his safety through the next review. Interventions for Resident #366 included one-to-one observation, monitoring locations, and documenting wandering behaviors. Review of quarterly MDS dated [DATE] revealed Resident #366 was severely cognitively impaired, independent for mobility, supervision for transfers, partial assist with toileting as he was always continent for bowels with frequent urinary incontinence. Resident #366 was also ambulatory, utilized a wheelchair for long distances, able to make himself understood, able to understand others, adequate vision, and no hearing deficits. Resident #366 was also coded for wandering and for physical and verbal behaviors towards others such as scratching, grabbing, threatening, screaming, cursing, or abusing others sexually. Review of facility incident report completed by the Administrator revealed on 12/19/24 at 1:30 AM the following information was reported: [Resident #36] rang her call bell to alert staff that someone had wandered into their room and attempted to climb onto the bed with her roommate [Resident #57]. [Resident #57] had a BIMS (brief interview for mental status) of 15 and stated no inappropriate touching had taken place. Investigation was underway. [Resident #57] was being placed on one-on-one temporarily. Nursing Home Administrator (NHA) and the Director of Nursing (DON) were in the facility to conduct full investigation and ensure resident's safety. [Resident #57] stated that she felt safe at the facility. The incident report also revealed law enforcement had been contacted on 12/19/24 at 3:00 AM. An interview with Resident #57 on 01/30/2025 at 4:09 PM revealed one night a black woman [Resident #366] had come into Resident #57's room, got on top of her, and tried to feel of her. When Resident #57 told the black woman [Resident #366] to get off and get the hell out of her room initially she would not get off her so Resident #57 used her hands fight to get her off and to leave. Resident #57 stated on that night she was wearing her gown but could not remember if her gown was pulled up or was down and Resident #57 did not recall if she was wearing a brief or not. A telephone interview was conducted with Nursing Aide (NA) #1 on 1/30/25 at 8:49 AM and revealed she was familiar with Resident #57 and the alleged incident regarding Resident #366. She stated on the evening of 12/18/24 she was scheduled to work 11:00 PM to 7:00 AM and was assigned to the A hall which included Resident #57's room. She revealed while reviewing her room assignments at the A hall nurse desk she observed Resident #366 sitting in his wheelchair at the desk with his assigned one on one (NA #3). NA #1 stated when she went down the A hall, she saw that three resident call lights were on including Resident #57's room. She revealed after answering the first two call lights, she went in to answer Resident #57's call light around 11:17 PM and upon entering the doorway to the room she observed both Resident #57 and her roommate Resident #36 to be alert and awake and were motioning for her to come into their room. She stated when she entered the room, she noticed there was a brief lying on the floor near the trash can and a brief lying at the end of Resident #57's bed and she asked both residents what was going on in there. NA #1 revealed Resident #36 then informed her that she saw Resident #366 come into their room, took off his pants, got on top of Resident #57 and raped her and that Resident #57 told Resident #366 to get off of her and get the hell out of their room, so he got up and left. She stated Resident #57 was shaking her head in agreement with what her roommate Resident #36 was saying and then stated, I told them to get off of me and get the hell out of the room and they left. NA #1 revealed she pulled back Resident #57's comforter and observed Resident #57 was not wearing a brief, so she immediately stopped and began yelling out for assistance from the other nursing staff to stay with the residents while she went to inform the nurse what was just reported to her. She stated she was not able to get any other staff to come into the room at that time, so she called the Director of Nursing (DON), which she believed to be around 11:30 PM to let her know what had been reported to her by both residents and that Resident #57 was not wearing a brief. She stated while on the telephone with the DON, she informed her that she was on her way and for NA #1 to stay with the residents, not to leave the room, not to touch anything in the room, and not to provide any type of personal care or incontinence care to Resident #57. She revealed the DON also inquired where Resident #366 was, and she informed her the last time she had seen Resident #366 he was sitting in his wheelchair at the nurse's desk with his assigned one to one. NA #1 stated she stayed in the resident's room until the DON and Administrator arrived and they asked her to step out of the room while they spoke with both residents privately. She revealed as she was leaving the resident's room, Resident #366's roommate (Resident #102) whose room was located directly across from Resident #57 room, motioned for her to come into their room. She stated Resident #102 informed her that earlier in the evening his roommate Resident #366's one on one had left the room and Resident #366 had gotten up out of his bed and attempted to get into bed with him. NA #1 revealed Resident #102 stated he asked Resident #366 what he was doing which seemed to startle Resident #366 and he got up from Resident #102's bed and watched him walk across the hall to Resident #57's room. She stated Resident #102 revealed he saw Resident #366 bend down, remove his pajama pants, get on top of Resident #57 and was moving around. She revealed Resident #102 stated he then heard Resident #57 yell get off of me and to get out of her room and saw Resident #366 get off the bed, put his pajama pants back on, leave Resident #57's room and walk down the hall. NA #1 stated after speaking with Resident #102 she finished her rounds with her other residents, went to the nurse station and notified NA #3 what Resident #57, Resident #36, and Resident #102 had reported and NA #3 informed her that when she had come back from her break a little before 11:00 PM, she had observed Resident #366 walking down the hallway unattended without his one to one. She revealed while at the nurse's station she began writing her handwritten statement about what had been reported to her by the residents and what she had observed, when she was asked to go back into Resident #57 room to sit with her. She revealed when she arrived back at the room, Resident #57 was still not wearing her brief, had used the bathroom on herself and was complaining about feeling wet and her gown and bedding being wet. NA #1 stated she then contacted the DON who was still in the building and asked if she could provide Resident #57 incontinence care and the DON and the Administrator came back into Resident #57 room. She revealed she was asked to step out of the room again but assumed the DON had cleaned and provided Resident #57 incontinence care, because when she returned to Resident #57 room afterwards, she was wearing a clean brief, and her gown and bedding had been changed. Attempted to contact NA #2 by telephone and was unable to be reached. A telephone interview was conducted with NA #3 on 1/30/25 at 9:23 AM revealed she was familiar with Resident #57 and the alleged incident regarding Resident #366. On 12/18/24, NA #3 was scheduled to work 7:00 PM to 7:00 AM on the A hall and her shift assignment was to provide one-to-one supervision for Resident #366. NA #3 revealed resident one-to-one supervision included being within arm's reach while the resident was up or ambulating around the facility and while the resident was in their room or sleeping the one-to-one was to sit outside the room and maintain line of sight. NA #3 stated on the evening of 12/18/24 she had assisted Resident #366 with turning on his TV and getting ready for bed and then asked NA #2 who was agency staff but had worked at the facility for several months and was aware of the one-to-one supervision protocol to come down and relieve her for her break which NA #2 agreed. NA #3 revealed that as she was leaving to go to break at 10:27 PM according to her watch and the time clock she notified the A hall nurse who was sitting at the nurse's desk that she was going on break and NA #2 was covering Resident #366's one-to-one supervision. NA #3 stated when she returned from her break at 10:51 PM and rounded the corner to A hall she observed Resident #366 three doors down from his room, walking the hallway unattended, wearing his pajama pants and a t-shirt. NA #3 revealed she did not see NA #2 anywhere in sight, so she assisted Resident #366 back to his room where she noticed he was not wearing a brief which was not uncommon because he would take them on and off, got him into his wheelchair and took him to sit with her at the A hall nurse's desk. NA #3 stated right after the 11:00 PM shift change while she and Resident #366 were sitting at the nurse's desk, NA #2 came up to the desk and she informed NA #2 that upon her return from break she had found Resident #366 walking around the A hall unattended and NA #2 apologized stating that she had gone to answer another resident's call light and had left Resident #366 unattended. NA #3 revealed that sometime around midnight while she and Resident #366 continued to sit at the nurse's desk, the Administrator and DON came in and went down the A hall and a few minutes later NA #1 came up to her and told her that Resident #36 had reported to her that Resident #366 had come into her and Resident #57's room, removed his pajama pants, got on top of Resident #57 while she was lying in her bed and raped her, Resident #57 yelled at Resident #366 to get off her and to get out of her room and Resident #366 left the room and walked down the hall. NA #3 stated NA #1 reported that Resident #57 had agreed with everything her roommate, Resident #36, was saying. NA #3 reported that as NA #1 was leaving Resident #36 and Resident #57's room, was when Resident #366's roommate (Resident #102) had motioned for NA #1 to come into his room. Resident #102 then reported to NA #1 that when Resident #366's one-on-one left the room, Resident #366 attempted to get into his bed and when he asked him what he was doing he got up and left. Resident #102 stated he saw Resident #366 walk across the hall into Resident #57's room, remove his pants, get on top of Resident #57 who was lying in her bed, move around on top of Resident #57, and when he heard Resident #57 yell at Resident #366 to get off of her and to get out of her room, Resident #102 saw Resident #366 get off Resident #57, put his pants back on, leave the room, and walk down the hall. NA #3 revealed she then informed NA #1 that when she had returned from her break earlier that evening, she had witnessed Resident #366 walking around the A hall unattended 3 doors down from his room. NA #3 also informed NA #1 that NA #2 was supposed to be covering her break and providing one-to-one supervision for Resident #366 but had left him attended while she went to answer a call light. NA #3 recalled a few minutes later after speaking with NA #1, was when NA #1 was asked to go back into Resident #57's room. NA #3 revealed while the Administrator and DON were walking back up the hallway from Resident #57's room was when she informed both about when she had returned from her break, she found Resident #366 walking around the A hall three doors down from his room, he was unattended wearing only his pajama pants, t-shirt, and no brief. NA #3 also reported to the Administrator and the DON that NA #2 was supposed to be covering her break and providing one-to-one supervision to Resident #366, and while providing Resident #366's one-to-one supervision NA #2 went to answer a call light and left Resident #366 unattended. NA #3 stated that after she was informed what Resident #57 had reported, she asked Resident #366 what had happened while he had been walking around the hall, and he stated that he had gone in to get into bed with his wife and he was touching and kissing on her but she didn't like it and told him to get out, so he left. An interview with Resident #36 who on 1/29/25 at 12:40 PM revealed she recalled being roommates with Resident #57. When asked if anything had ever happened while she and Resident #57 had been roommates, she stated she did remember this one time where a black man had come into their room, got on top of Resident #57, she told them to get out and they left. She stated after that she believed Resident #57 moved rooms and nothing ever happened again. Resident #36 could not recall who she had spoken with on the night of the incident or any further details about the incident. A telephone interview with Resident #102 on 1/30/25 at 3:08 PM revealed on the evening of 12/18/24 he was lying in his bed, and his roommate Resident #366 was lying in his bed, when Resident #366's one-to-one staff left the room, Resident #366 got up out of his bed and tried to get into bed with him. Resident #102 stated it seemed to startle Resident #366 when he asked him what he was doing, and that was when Resident #366 got up from Resident #102's bed, left their room, walked across the hall, and into Resident #57's room. Resident #102 stated Resident #57's room was dark, but he was still able to see into the room with the hallway lights. Resident #102 revealed he saw Resident #366 remove his pants, get on top of Resident #57 while she was lying in her bed, and witnessed Resident #366 moving around on top of Resident #57. Resident #102 reported he could not tell if Resident #366 was wearing his brief or not while on top of Resident #57. Resident #102 stated he then heard Resident #57 tell Resident #366 to get off of her and get the hell out of her room and he saw Resident #366 exit off the left side of Resident #57's bed, walk around the end of the bed, put his pants back on, exit Resident #57's room, and walk down the hall. Resident #102 stated he would have used his call light to let staff know what had happened, but his call light had gotten tangled up and he couldn't find it. Resident #102 reported a few minutes later Resident #366's one-to-one came back into their room to get Resident #366's wheelchair, and appeared frazzled, so he did not tell her about what he had witnessed either. Resident #102 revealed a few minutes after Resident #366 one-to-one had come into his room, he saw NA #1 go into Resident #57's room and when he saw her leaving Resident #57 room was when he motioned for NA #1 to come into his room, and he told NA #1 what he had witnessed between Resident #366 and Resident #57, and then repeated this same information to the Administrator, and law enforcement. A telephone interview with Resident #57's friend on 01/30/2025 at 3:50 PM revealed she had been Resident #57 previous caretaker prior to her coming to the facility and continued to visit with her often. She stated on 12/26/24 she was visiting with Resident #57 when she suddenly became quiet, looked at her and said, I have something to tell you. Resident #57's friend stated she asked Resident #57 what she needed to tell her, and she said, I was raped. When asked what she was talking about, Resident #57 stated I was raped by a black woman [Resident #366], she got on top of me, and I had to tell her to get off me and out of my room. Resident #57's friend then asked if anyone had come into her room when this was going on and she said no. When she asked Resident #57 if she was ok and felt safe at the facility she said yes. Resident #57's friend stated she did not ask any further questions about the incident and Resident #57 had seemed fine, but it bothered her to think Resident #57 had gone through something like this. Review of physician progress note written by the Medical Director on 12/20/24 indicated he was asked to see Resident #57 for questions about an incident that happened the night before and was unclear whether Resident #366 had assaulted her. While the Medical Director was talking with Resident #57, she stated that nothing happened, but someone did come into her room. It was really unclear to the Medical Director whether she knew exactly what happened, but the incident was being investigated. Resident #57 did not seem to be more anxious now or change in her mental status from previous. In speaking with Resident #57 today, it did not appear like there had been any trauma that he could think of but obviously the whole incident had to be anxiety provoking, however, he could not get a real history of what happened. Again, there were no signs of believed trauma but certainly wanted her seen by mental health provider and discussed all of this with Resident #57's RP. During an interview with the Medical Director on 1/28/25 at 11:09 AM he stated that he was aware of the alleged incident with Resident #57 and Resident #366. He stated the date of his progress note 12/20/24 was when he was notified, and he assumed the incident had occurred the night before on 12/19/24 and was not made aware the incident had occurred on the evening of 12/18/24. He revealed he did speak with Resident #57's RP on 12/19/24 regarding a sleep medication the RP wanted stopped, but he could not recall if she had mentioned anything to him about the incident, he only recalled that he discontinued Resident #57's sleep medication as requested. The Medical Director stated he was asked on 12/20/24 regarding an incident where Resident #366 had come into Resident #57's room and gotten onto her bed, she asked him to leave her room and he did, and it was unclear if any type of assault had occurred. He revealed that when he saw Resident #57 on 12/20/24 he only attempted to speak with her about the incident, but did not complete any type of physical exam. He stated Resident #57 would not really give him any details about the incident, only that someone had come into her room, but he did not feel that she was showing any signs or symptoms that any type of trauma or injuries had occurred. The Medical Director revealed to his knowledge Resident #57 had never showed any signs of increased anxiety or changes to her mental status and she was followed by psych services, and he was not aware of them noting any issues or concerns stemming from the incident. He stated Resident #366 was supposed to always be on one-to-one supervision due to sexualized behaviors, wandering, and an incident that occurred with another female resident earlier in the year. He revealed it appeared the one-on-one process failed allowing Resident #366 the opportunity to go into Resident #57's room which should have never been allowed to happen, Resident #366 was not suitable for skilled nursing level and not matter how much his medications were increased he would continue to require one-on-one supervision as long as he was at the facility because his sexualized behaviors specifically were unable to be controlled. A telephone interview was conducted with Resident #57's RP on 1/30 [TRUNCATED]

Based on record review, Medical Director, Hospital Case Manager, Resident's Legal Guardian, and staff interviews, the facility failed to allow a resident to return to the first available bed at the facility after being sent to the hospital for a medical and psychiatric evaluation. The resident remained in the hospital for over a month despite being cleared to return to the nursing home after 3 days. A reasonable person would expect once they were medically cleared from the hospital to be allowed back into their home and not being allowed back into their home could cause them to experience altered mental condition, fear, anxiety, and depressed mood. This deficient practice was evidenced for 1 of 3 residents reviewed for transfer and discharge (Resident #366). Findings included: Resident #366 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury (TBI), altered mental status, and cognitive communication deficit. Review of Resident #366's facility face sheet dated 4/14/23 revealed a local Department of Social Services was appointed as his legal guardian. Review of the Medical Director order dated 12/20/24 revealed Resident #366 was to be sent out to hospital in South Carolina (SC) for evaluation and treatment. Review of discharge Minimum Data Set (MDS) dated [DATE] revealed Resident #366 was severely cognitively impaired with wandering, verbal, and physical behaviors towards others. Resident #366's discharge was coded as an unplanned discharge with return anticipated. Review of hospital case manager notes for Resident #366 dated 12/20/24 through 1/22/25 revealed the following: 12/20/24- Resident #366 was brought to the hospital emergency room in SC by his current facility located in North Carolina (NC) for a psychiatric (psych) evaluation regarding his hypersexualized behavior and a complaint from another resident. Resident #366 who had a history of TBI had gotten into bed with another resident thinking she was his wife. 12/21/24- Tele psych consult completed, and initial recommendation was for involuntary commitment (IVC) and psych placement in behavioral unit. 12/23/24- Follow up psych note documented, Psych inpatient facility considered and currently NOT indicated cleared psychiatrically and medically. 12/24/24 - Hospital psych liaison, contacted the Director of Nursing (DON) at Resident #366's current facility of him being cleared by psych and inquired what time for the hospital to bring him back to the facility. The DON referred to the facility Administrator. The hospital psych liaison informed the Administrator Resident #366 was ready to return to the facility, the Administrator stated Resident #366 had been immediately discharged from their facility and was accepted to another facility in NC. 12/26/24 - Hospital case manager spoke with Admissions at the other facility who stated were unable to offer Resident #366 a bed and they had notified his current facility of this fact. 1/7/25 - Resident #366 was transferred from their hospital behavioral unit to a regular hall on their main campus until placement could be found. 1/9/25 - Hospital case manager spoke with Resident #366's guardian who communicated that his current facility was refusing to accept him back and she was working on a new placement in North Carolina. 1/10/25 - Resident #366 was agitated and wandering into other patient rooms; transferred to their only secured unit in the hospital, the Intensive Care Unit (ICU). 1/10/25 - Following transfer to the ICU, the hospital case manager questioned why the nursing home brought Resident #366 across state lines to their hospital in SC. The hospital case manager contacted the hospital in NC to inquire if they offer psych services. The facility Administrator then explained they did not send Resident #366 to their local hospital because they knew he would be evaluated and sent right back to their facility. The hospital case manager explained and advocated Resident #366's needs to return to their facility, but the Administrator continued to refuse to accept him back. 1/13/25- The hospital case manager spoke with Resident #366's guardian and stated Resident #366 current facility transported him across the state lines to their hospital for a psych evaluation which Resident #366's guardian agreed was inappropriate and stated she had filed a report with the State Agency regarding this and the facility's refusal to readmit the resident. 1/17/25- The hospital case manager noted the facility was still unwilling to accept Resident #366 back and the hospital was currently awaiting placement. 1/20/25- Resident #366 was medically stable, ready for discharge, and awaiting placement. A telephone interview with Resident #366's Guardian on 1/27/25 at 3:15 PM revealed she was Resident #366's Guardian through the Department of Social Services. She stated Resident #366 had a history of wandering and sexual behaviors over the past year while at his current facility and some incidents of going into other female resident's rooms and getting into their beds which had required him to be on one-to-one supervision. She revealed after the last incident on 12/18/24 of Resident #366 wandering into a female resident's room and getting into her bed, she received a telephone call on 12/20/24 from the Administrator at the facility stating Resident #366 would be moving to another skilled nursing facility within the day. Resident #366's Guardian stated she informed the Administrator that Resident #366 could not be moved so quickly without her speaking with and touring the other facility. She revealed she contacted the other facility and after discussing Resident #366 with them, the other facility refused to take him on that day and stated they would need to come and assess Resident #366 in person the following week. Resident #366's Guardian stated she contacted the Administrator at Resident #366's current facility and let her know the other facility would not be able to take Resident #366 on 12/20/24 but would be able to assess him in person the following week, and the Administrator stated Resident #366 would not be at their facility next week he would be leaving that day. Resident #366's Guardian revealed a few hours later on 12/20/24, she received a telephone call from the Administrator stating Resident #366 had been taken to the hospital in SC for an in-patient psychiatric hold and evaluation. She stated after that she began communicating with the hospital, Resident #366 was evaluated and on 12/23/24 was psychiatrically and medically cleared and recommended for discharge back to his current facility but the Administrator refused to take him back. Resident #366's guardian revealed both she and the hospital spoke with the Administrator at the facility on numerous occasions begging for them to take Resident #366 back until they could find a more appropriate placement for him and the Guardian offered that the Department of Social Services would pay for a private one-to-one for the resident and the Administrator continued to refuse to take him back. She stated during Resident #366's hospital stay, the hospital had to place him in the intensive care unit because it was the only locked unit in the hospital, and he was trying to wander in and out of patient rooms. Resident #366's Guardian revealed she contacted the State Agency for help with placement for Resident #366 and believed the state must have contacted the Administrator at the facility because a few days after she had spoken with the State Agency, she received a telephone call from the facility stating they would be readmitting Resident #366 to the facility. A telephone interview with the hospital case manager on 1/31/25 at 4:00 PM revealed she was familiar with Resident #366. She stated Resident #366's current facility brought him to their hospital emergency room in SC on 12/20/24 requesting an in-patient psych evaluation. She revealed Resident #366 was admitted to their behavioral unit on 12/21/24 for completion of a psych evaluation. The hospital case manager stated the follow-up recommendations from the behavioral unit on 12/23/24 revealed in-patient psych placement had been considered for Resident #366 and was not indicated. Resident #366 was psychiatrically and medically cleared for discharge. She revealed the hospital contacted Resident #366's current facility and spoke with the Administrator and advised that Resident #366 had been cleared and was ready for discharge and the hospital needed to know when they could schedule transport back to the facility. She stated the Administrator informed the hospital Resident #366 would not be returning to their facility that he had been discharged from their facility and had been accepted to another skilled nursing facility. The hospital case manager revealed the hospital contacted the other skilled nursing facility about Resident #366 and were informed that they had notified Resident #366's current facility they were unable to offer him a bed and would not be admitting him. She stated the hospital also spoke with Resident #366's guardian who informed her Resident #366's current facility was refusing to take him back. The hospital case manager revealed that during Resident #366's hospital stay she contacted Resident #366's current facility numerous times and spoke with the Administrator about Resident #366 needing to return to their facility, and the Administrator continued to refuse to allow Resident #366 to come back to their facility. The hospital case manager stated on 1/20/25 the hospital received a call from Resident #366's current facility stating they would be coming to assess Resident #366 to see if they would be able to accept him back to their facility. She revealed to the Administrator, and the Admissions Director came to the hospital to speak with Resident #366 and then agreed he could come back, and he was discharged back on 1/22/25 after being left at the hospital for over a month. An interview conducted with the Director of Nursing (DON) on 1/30/25 at 4:03 PM revealed she was familiar with Resident #366 and that he required one-to-one supervision due to his wandering and sexual behaviors. She stated there had been an incident on 12/18/24 where Resident #366's one-to-one supervision had left him unattended and he wandered into another female's residents' room, got into her bed.The DON revealed on 12/20/24, Resident #366 was supposed to be transferred to another skilled nursing facility, but that placement apparently fell through. The DON stated that she and the Administrator notified the facility Medical Director about Resident #366's placement to the other facility had fallen through and discussed with the Medical Director about Resident #366 being sent out to the hospital for a psych evaluation. She revealed the Medical Director agreed for Resident #366 to be sent out to the hospital in SC due to the local hospital not having a psych unit. The DON stated that she only spoke with the hospital in SC once which she believed was on 12/21/24, when the doctor from the hospital was requesting information on Resident #366 and stated they would be admitting him for a psych evaluation. The DON revealed she was not aware of the hospital staff or the guardian calling the facility multiple times to notify them Resident #366 was ready to return to the facility and she was not aware of the facility ever refusing to take him back. She stated she believed the facility did receive a telephone call from the State Agency regarding Resident #366's discharge and return to the facility, but to her knowledge the plan had been for him to return to their facility once they were able to assess him and make sure his psych evaluation and recommendations had been completed. She revealed that the facility had been trying to find a more appropriate placement for Resident #366 since last year due to his TBI and his behaviors. An interview was conducted with the Administrator on 1/30/25 at 5:34 PM revealed she was familiar with Resident #366. She stated Resident #366 had a history of wandering and sexual behaviors and had been on one-to-one supervision for safety. She also stated that on 12/18/24, Resident #366's one-to-one supervision had left him unattended, and he wandered into a female resident's room, got into her bed. The Administrator revealed on 12/20/24 Resident #366 was scheduled to transfer to another skilled nursing facility, but that placement fell through, and in the meantime the other facility residents had heard about the incident on 12/18/24 and had started calling Resident #366 a rapist. The Administrator revealed she and the DON had discussed their fears for Resident #366 safety and felt it might be best for him to be sent out to the hospital for a psych consultation due to his wandering and sexual behaviors. She stated she and the DON spoke with the facility Medical Director, they notified him that the other skilled nursing placement for Resident #366 had fallen through and discussed sending Resident #366 out to the hospital for a psych evaluation due to his behavior and for his safety. She revealed the Medical Director agreed for Resident #366 to be sent out to the hospital for an in-patient psych evaluation based on his sexual behaviors and for his own safety. The Administrator stated the facility transported Resident #366 to the hospital in SC because they have a geriatric psych unit, and their local hospital did not have a psych unit and would only provide him with a tele psych visit and send him back to the facility. She revealed while Resident #366 was at the hospital in SC she did speak with the hospital over the telephone and provided them with some diversion activities she thought would help with his behaviors and informed them the facility would assist them with finding other placement. She denied ever refusing to take Resident #366 back and did not have an explanation as to why the hospital had documented the facility's refusals to take him back. The Administrator stated she did receive a telephone call from the State Agency she believed on 1/17/24 advising her of the facility's responsibility to readmit Resident #366. She revealed prior to the State Agency calling the facility, she had already planned to go to the hospital and assess Resident #366 for him to return and was just waiting to make sure his recommended treatment from his psych evaluation had been completed. An interview was conducted with the facility Director of Marketing and Admissions on 1/29/25 at 11:07 AM revealed he was familiar with Resident #366. He stated he was not involved with Resident #366 discharge to the hospital and never spoke with anyone at the hospital regarding Resident #366 not being allowed to return. He revealed on 1/20/25 he was notified by the Administrator to contact the hospital in SC to let them know they would be coming to the hospital to assess Resident #366 to see if they would be able to allow him to return. The Director of Marketing and Admissions stated he accompanied the Administrator to the hospital on 1/20/25 where they assessed Resident #366 and agreed for him to return to the facility, and he assisted with scheduling Resident #366's admission and transport back to the facility on [DATE]. An interview was conducted with the Medical Director on 1/28/25 at 11:09 AM revealed he was familiar with Resident #366. He stated Resident #366 had a history of wandering and sexual behaviors and required one-to-one staff supervision for his safety. He revealed on 12/20/24, Resident #366 was supposed to be transferred to another skilled nursing facility, but that placement fell through. The Medical Director stated after Resident #366's placement fell through; the Administrator and DON spoke with him about concerns for Resident #366's safety facility along with the safety of the other's residents given his sexual behaviors and asked if he could be sent out to the hospital for a psychiatric evaluation. He revealed he agreed with the Administrator and the DON for Resident #366 to be sent out for an evaluation to the hospital in SC. The Medical Director stated that because their local hospital would more than likely have briefly evaluated Resident #366 and sent him back to the facility, he felt the behavioral unit at the hospital in SC would be able to evaluate and assist with locating a more appropriate placement for Resident #366. The Medical Director stated he did not feel Resident #366's current placement was the most appropriate for him given his age, TBI, and his behaviors and was told when he was sent out that he would not be returning to his current facility. He revealed he did speak with the hospital in SC on 12/21/24 to give some medical and background information on Resident #366 but was not aware of any further details of his stay at the hospital. He stated as far as Resident #366 being readmitted to the facility; it was his understanding the facility had received a call from the State Agency saying the facility had to allow him to return until they found him a more appropriate placement.

Based on observation, record review, and interviews with residents and staff, the facility failed to ensure residents could access their light switch located behind the bed for 3 of the 3 residents reviewed for accommodation of needs (Resident #76, Resident #364, and Resident #54). The findings included: a. Resident #76 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] coded Resident #76 with intact cognition and indicated walking between locations inside the room for more than 10 feet was not attempted during the assessment period due to medical condition or safety concerns. During an observation conducted on 01/27/25 at 11:45 AM, the switch for the light fixture behind Resident #76's bed was attached with a broken cord 10 inches in length. It was 5 feet from the floor and 6 feet from Resident #76's bed. Resident #76 was unable to reach the switch cord from the bed if needed. An interview was conducted with Resident #76 on 01/27/25 at 11:48 AM. He could not recall how long the switch cord had been broken. He stated he wanted to switch on the light fixture behind his bed at times, but he could not reach the switch cord. It was very inconvenient for him, and he wanted the switch cord to be fixed immediately. Subsequent observation conducted on 01/28/25 at 10:46 AM revealed the switch cord for the light fixture behind Resident #76's bed remained inaccessible. During joint observation and subsequent interview with Nurse Aide #4 (NA #4) and Nurse #1 on 01/28/25 at 2:33 PM, both nursing staff stated they provided care for Resident #76 frequently in the past few weeks, but they did not notice the switch cord was broken and inaccessible for Resident #76. Both nursing staff acknowledged that it needed to be fixed as soon as possible. b. Resident #364 was admitted to the facility on [DATE]. The Admission MDS assessment dated [DATE] coded Resident #364 with intact cognition and impairment on one side of her lower extremity. The MDS indicated Resident #364 required supervision or touching assistance to walk for more than 10 feet between locations inside the room. During an observation conducted on 01/27/25 at 11:55 AM, the switch for the light fixture behind Resident #364's bed was attached with a broken cord 3 inches in length. It was 5 feet from the floor and 4 feet from the bed. Resident #364 was unable to reach the switch cord from the bed if needed. An interview was conducted with Resident #364 on 01/27/25 at 11:58 AM. Resident #364 stated when she wanted to switch on the light fixture behind her bed at times, she could not stand up to reach the switch cord as she had knee surgery recently. It was very frustrating and inconvenient for her as she had to depend on the staff to switch it on each time. She hoped it could be fixed as soon as possible. Subsequent observation conducted on 01/28/25 at 10:49 AM revealed the switch cord for the light fixture behind Resident #364's bed remained inaccessible. During joint observation and subsequent interview with NA #4 and Nurse #1 on 01/28/25 at 2:33 PM, both nursing staff stated they provided care for Resident #364 frequently in the past few days and added they did not notice the switch cord was broken and inaccessible for Resident #364. Both nursing staff acknowledged that it needed to be fixed as soon as possible. c. Resident #54 was admitted to the facility on [DATE]. The quarterly MDS assessment dated [DATE] coded Resident #54 with moderately impaired cognition. The MDS indicated she could walk in between locations in the corridor up to 150 feet independently. During an observation conducted on 01/27/25 at 3:30 PM, the switch for the light fixture behind Resident #54's bed was attached with a broken cord 10 inches in length. It was 5 feet from the floor and 4 feet from Resident # 54's bed. Resident #54 was unable to reach the switch cord from the bed if needed. An interview was conducted with Resident #54 on 01/27/25 at 3:31 PM. She did not know how long the switch cord had been broken. She could not reach the cord when she was lying in her bed, and it was very inconvenient to her. Subsequent observation conducted on 01/28/25 at 10:51 AM revealed the switch cord for the light fixture behind Resident #54's bed remained inaccessible. During joint observation and subsequent interview with NA #5 and Nurse #5 on 01/28/25 at 2:45 PM, both nursing staff stated they provided care for Resident #54 frequently in the past few weeks. NA #5 stated she did not notice the switch cord was broken and unreachable for Resident #54. Nurse #5 stated she noticed the switch cord was unreachable for Resident #54 on 01/28/25 in the morning and had notified the maintenance staff verbally. She did not know why the issue was not being addressed. Both nursing staff stated the cord needed to be fixed to ensure full accessibility for Resident #54. An interview was conducted with the Maintenance Director on 01/29/25 at 9:43 AM. He stated he walked through the facility at least once daily to identify repair needs. He also depended on nursing staff to report repair needs either verbally or via facility website electronically. He could not recall if he had fixed Resident #54's switch cord on 01/28/25 in the morning. He explained some of the switch cords could be broken again after he had fixed them. He acknowledged that all the broken cords needed to be fixed immediately to accommodate residents' needs. During an interview conducted on 01/29/25 at 1:25 PM, the Administrator expected the staff to be more attentive to residents' living environment and reported repair needs in a timely manner to accommodate residents' needs and ensure full accessibility to their light fixture. An interview was conducted with the Director of Nursing on 01/29/25 at 1:33 PM. She stated it was her expectation for all the residents to have full accessibility to their light fixture all the time to accommodate their needs.

Based on record review, legal guardian, and staff interviews, the facility failed to notify the Resident's legal guardian in writing of a transfer to the hospital in South Carolina for 1 of 3 residents reviewed for discharge (Resident #366). The findings included: Resident #366 was admitted to the facility on [DATE]. Review of Resident #366's facility face sheet dated 4/14/23 revealed a local Department of Social Services was appointed as his legal guardian. Review of the Medical Director order dated 12/20/24 revealed Resident #366 was to be sent out to hospital in South Carolina (SC) for evaluation and treatment. Review of Resident #366's discharge Minimum Data Set (MDS) dated [DATE] revealed the discharge was coded as an unplanned discharge to hospital with return anticipated. Review of Resident #366's electronic medical record revealed no written notification to Resident #366's Guardian of his transfer to the hospital in SC. A telephone interview was conducted with Resident #366's Legal Guardian on 1/27/25 at 3:15 PM revealed she was Resident #366's legal guardian through the Department of Social Services. She stated she received a telephone call on 12/20/24 from the Administrator stating Resident #366 had been taken to the hospital in SC for an in-patient psychiatric hold and evaluation. She stated she did not receive any notification in writing prior to Resident #366 being transferred to the hospital in SC. The Administrator was interviewed on 1/30/25 at 5:30 PM. The Administrator reported on 12/202/4 the facility felt it would be best for Resident #366's safety due to his wandering and sexualized behavior to be sent out to the hospital for an in-patient psychiatric evaluation and treatment. She stated she did not send Resident #366's legal guardian notification in writing regarding Resident #366's transfer to the hospital in SC but did notify her by telephone.

Based on observation, record review, and staff interviews, the facility failed to secure an opened tube of topical paste for 1 of 1 Resident reviewed for medication storage. (Resident #99). The findings included: Resident #99 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] coded Resident #99 with severely impaired cognition. During an observation conducted on 01/27/25 at 12:32 PM, one opened tube of zinc oxide paste (a topical paste for treating or preventing skin irritation) with the concentration of 15% was left unattended on top of the left bedside table in Resident #99's room. It contained approximately 75 grams of zinc oxide and was ready to be used. An interview was conducted with Resident #99 on 01/27/25 at 12:35 PM. She did not know how long the tube of zinc oxide paste had been left unattended in her room. She could not provide any additional information related to the zinc oxide paste. During an interview conducted on 01/27/25 at 12:39 PM, Nurse #5 stated the zinc oxide paste should be kept in the medication cart instead of leaving unattended in Resident #99's room. She did not notice the tube of zinc oxide paste was in Resident #99's room when she did medication pass on 01/27/25 in the morning. An interview was conducted with Nurse Aide #4 on 01/27/25 at 12:41 PM. She stated she had provided care for Resident #99 frequently in the past few weeks. She did not notice the tube of zinc oxide was left unattended on Resident #99's bedside table when she rounded her on 01/27/25 in the morning. During an interview conducted with the Director of Nursing (DON) on 01/27/25 at 12:55 PM, she stated Resident #99's daughter could have brought the zinc oxide paste to the facility for Resident #99. She stated zinc oxide paste should be kept in the medication cart. It was her expectation for all the nursing staff to be more attentive to residents' room when providing care to ensure none of the medications were left unattended in the facility. An interview was conducted with the Administrator on 01/27/25 at 4:02 PM. She expected nursing staff to pay attention to residents' room when providing care. It was her expectation for the facility to remain free of unattended medications at all time.

Based on record review and staff interviews, the facility failed to complete the Care Area Assessment Summary (CAAS) of the Minimum Data Set (MDS) comprehensively to address the underlying causes and contributing factors of the triggered areas for 2 of 6 sampled residents reviewed for unnecessary medications (Residents #48 and Resident #82). The findings included: a. Resident #48 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety disorder, and depression. The MDS assessment dated [DATE] coded Resident #48 with moderately impaired cognition. A review of the CAAS revealed 8 care areas were triggered for Resident #48. Other than listing medications received by Resident #48, the facility did not provide any information in analysis of findings for 6 of the 8 triggered areas to describe the nature of Resident 48's problems, possible causes, contributing factors, risk factors related to the care areas, and reasons to proceed with care planning for the following triggered care areas: 1. Cognitive loss/dementia 2. Activities of daily livings functional/Rehabilitation potential 3. Falls 4. Dental care 5. Pressure ulcer/injury 6. Psychotropic drug usage b. Resident # 82 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, bipolar disorder, and chronic pain. The quarterly MDS assessment dated [DATE] coded Resident #82 with intact cognition. A review of the CAAS of the annual MDS assessment date 03/29/24 revealed 5 care areas were triggered for Resident #82. Other than listing medications received by Resident #82, the facility did not provide any information in analysis of findings for all 5 triggered areas to describe the nature of Resident 82's problems, possible causes, contributing factors, risk factors related to the care areas, and reasons to proceed with care planning for the following triggered care areas: 1. Activities of daily livings functional/Rehabilitation potential 2. Falls 3. Nutritional status 4. Pressure ulcer/injury 5. Psychotropic drug use During an interview conducted on 01/29/25 at 1:19 PM, MDS Coordinator #2 confirmed 6 of the 8 triggered care areas for Resident #48's MDS dated [DATE] and all 5 triggered care areas for Resident #82's MDS dated [DATE] were submitted without providing pertinent information in the analysis of findings in the CAAS. She explained she started to work as the MDS Coordinator last July and both MDS assessments were submitted by the former MDS Coordinator. She did not know how both incidents occurred and acknowledged that it was an error to submit an annual MDS without completing analysis of findings for all the triggered areas comprehensively. An interview was conducted with the Administrator on 01/29/25 at 1:25 PM. She stated it was her expectation for all the CAAS to be completed comprehensively to include at least the underlying causes, contributing factors, and reasons to proceed with care planning. On 01/29/25 at 1:33 PM an interview was conducted with the Director of Nursing. She stated all the CAAS must be individualized and completed comprehensively. It was her expectation for the MDS Coordinators to complete the analysis of findings for all the triggered areas in the CAAS before submission.

Based on record review and staff interviews, the facility failed to provide report an allegation of resident to resident abuse to the State Agency, law enforcement, and Adult Protective Services (APS) within the required timeframe and to ensure the report to all agencies included accurate information. The facility learned of an allegation of rape on 12/19/24, did not provide the information to law enforcement, and did not report the information to the State Agency until the investigation report was submitted on 12/26/24. This deficient practice affected 1 of 3 residents reviewed for abuse (Residents #57). Findings included: A review of the facility's abuse policy entitled Abuse, Neglect, Exploitation, and Misappropriation, last revised 6/13/21 revealed if an incident of suspected abuse occurs, the facility shall report immediately, but not later than 2 hours after forming the suspicion, if the events that caused the suspicion resulted in bodily harm, and no later than 24 hours if the events that caused the suspicion did not result in bodily harm to designated state agencies. Review of facility initial report completed by the Administrator indicated the incident date was 12/19/24 and the facility became aware of the incident on 12/19/24 at 1:30 AM. The fax date and time revealed the report was submitted on 12/19/24 at 3:24 AM. The initial report revealed the following information: [Resident #36] rang her call bell to alert staff that someone had wandered into their room and attempted to climb onto the bed with her roommate [Resident #57]. [Resident #57] has a BIMS [brief interview for mental status] of 15 and states no inappropriate touching took place. Investigation underway. [Resident #57] is being placed on [one-on-one] temporarily. [The Administrator] and [the Director of Nursing] were in facility to conduct full investigation and ensure resident's [safety]. The report indicated Resident #57 stated that she felt safe at the facility and that law enforcement had been contacted on 12/19/24 at 3:00 AM. It did not indicate if APS had been contacted. An interview was conducted with the Director of Nursing (DON) on 1/30/25 at 4:03 PM. She indicated she received a telephone call from nursing staff around 11:34 PM on 12/18/24 stating Resident #57 and her roommate (Resident #36) had alleged a Resident #366 came into their room, sat down on Resident #57 bed, and when Resident #57 asked him to get out of the room he (Resident #366) left. She stated she immediately notified the Administrator and they both agreed to come into the facility to start their investigation and begin interviewing both residents and staff. The DON revealed she and the Administrator arrived at the facility sometime between 12:30 AM and 1:00 AM on 12/19/24 and immediately began interviewing residents so they could determine what type of incident had occurred and to begin their investigation. Review of the Police Department report dated 12/24/24 revealed on 12/22/24 detectives responded to the facility in reference to a past tense assault. Upon arrival they spoke with the Administrator who advised they had an incident that occurred on 12/19/24 around 3:00 AM and they had contacted the police department and spoke with a patrolman regarding the incident of a male resident entering the room of a female resident, sitting on the female resident's bed, and then leaving the room. The Administrator advised there was no nudity and no contact between the male (Resident #366) and female (Resident #57) resident. The Administrator stated the female resident had instructed the male resident to leave when he entered the room, and he left. As the detectives continued to receive the story of the incident from the rest of the staff there, as well as speaking with the patrolman about what was initially reported to him, it was concluded the male resident had crawled into bed with the female resident prior to getting him out of her room. This was information the Administrator did not mention to law enforcement during the initial interview about the situation. An interview conducted with the Lieutenant at the Police Department on 1/30/25 at 3:30 PM revealed on 12/19/24 at 3:00 AM they received a report from the Administrator at the facility regarding resident-to-resident abuse. The Administrator reported Resident #366 had walked into Resident #57's room, sat down on the bed, and then left the room. The Lieutenant revealed he was later notified on 12/22/24 by Resident #57's responsible person that Resident #57 had alleged she was raped. He stated he then went to the facility to take the report regarding Resident #57's allegation of rape. The Lieutenant revealed he interviewed the Administrator, and she stated on the evening on 12/18/24, Resident #366 had entered Resident #57's room, removed his pants, and got on top of Resident #57 while she was lying asleep in her bed. The Administrator revealed Resident #57 told Resident #366 to get off of her and to get out of her room, Resident #366 put his pants back on and left the room. The Lieutenant revealed this was a different story than what was initially reported on 12/19/24. He stated he attempted to interview Resident #57, but she would not really speak with him about the matter, and he also attempted to contact the staff that were working that night but none of them would return his call. He revealed the Administrator denied Resident #57 reporting to her that she was raped and the first time she had heard that word was when Resident #57's responsible person had mentioned it. Review of facility 5-day investigation report completed by the Administrator dated 12/26/24 revealed their investigative findings included the following information: Resident #102 witnessed the entire incident citing Resident #366's confusion and wandering behaviors. There was no willful intent noted on behalf of Resident #366 as evidenced by the fact that he also attempted to get into his roommate's bed just prior to the incident. There was no evidence of sexual intercourse observed during completed skin assessment and per resident reports. Resident #57's responsible person (RP) alleged Resident #57 had stated to her (the RP) that she (Resident #57) was raped. The Administrator and law enforcement attempted to interview Resident #57 about the allegation of rape, but she was not able to provide any further information. There were no reports that indicate abuse from staff interviews, or other resident interviews. The facility did not substantiate abuse, and Resident #57 remained without any physical injury, mental harm, pain, or anguish. Review of an intake letter from Adult Protective Services (APS) dated 12/31/24 revealed they had received the facility's 5-day investigation report on 12/26/24 related to the incident involving Resident #57 and Resident #366. The letter also revealed APS would not be following up on the intake report and were sending the report to the state for further review. An interview conducted with the Administrator on 1/30/25 at 5:34 PM revealed she had completed the initial and 5-day investigation reports regarding the incident between Resident #57 and Resident #366. She stated she was contacted by the DON around midnight on 12/18/24 informing her of an alleged incident that occurred regarding Resident #57 and a male resident, who was later identified as Resident #366, coming into the room, sitting on Resident #57's bed, and then leaving the room. The Administrator revealed she and the DON arrived at the facility she believed between 12:30 AM and 1:00 AM on 12/19/24 to begin interviewing the residents. She stated that was why the initial report had was dated for 12/19/24 at 1:30 AM because that was when she was able to arrive at the facility, begin interviewing the residents, and receive the information needed for the report. The Administrator revealed based on the initial information that was provided to her by Resident #57 she did not have reason to believe anything further had happened than Resident #366 coming into Resident #57's room, getting on top of her bed, touching her shoulder area, Resident #57 telling him (Resident #366) to get out, and him leaving. She revealed the information that was initially provided to law enforcement on 12/19/24 was the information she had received after interviewing Resident #57 and the staff who were working that night. The Administrator stated it was not until later into the day on 12/19/24, after the incident had occurred on 12/18/24, that Resident #57's RP notified her that Resident #57 had said she was raped. The Administrator revealed Resident #57's RP did not provide her with any further information and when she attempted to interview Resident #57 again, she would not give her any further information. She revealed she addressed the rape allegation in the 5-day report and was not aware that she should have sent in a new report regarding that information and was also not aware that she should have contacted APS prior to the 5-day investigation since they had no information to show any alleged abuse had taken place.

Based on record review, and Legal Guardian and staff interviews, the facility failed to communicate with the Resident's Legal Guardian and obtain authorization from the Legal Guardian prior to the Resident being transferred across state lines to a hospital in South Carolina (SC) for 1 of 3 residents reviewed for discharge (Resident #366). The findings included: Resident #366 was admitted to the facility on [DATE]. Review of Resident #366's facility face sheet dated 4/14/23 revealed a local Department of Social Services was appointed as his legal guardian. Review of the Medical Director order dated 12/20/24 revealed Resident #366 was to be sent out to hospital in South Carolina (SC) for evaluation and treatment. Review of Resident #366's discharge Minimum Data Set (MDS) dated [DATE] revealed the discharge was coded as an unplanned discharge to hospital with return anticipated. Review of Resident #366's electronic medical record revealed no written notification to Resident #366's Legal Guardian of his transfer to the hospital in SC. A telephone interview was conducted with Resident #366's Legal Guardian on 1/27/25 at 3:15 PM revealed she was Resident #366's legal guardian through the Department of Social Services. She stated she received a telephone call on 12/20/24 from the Administrator at the facility stating Resident #366 would be moving to another skilled nursing facility within the day. Resident #366's Legal Guardian stated she informed the Administrator that Resident #366 could not be moved so quickly without her speaking with and touring the other facility. Resident #366's Legal Guardian revealed a few hours later on 12/20/24, she received a telephone call from the Administrator stating Resident #366 had been taken to a hospital in SC for an in-patient psychiatric hold and evaluation. She stated she did not receive any notification in writing or verbal notification prior to Resident #366 being transferred to the hospital in SC. Resident #366's Legal Guardian revealed she would like to have been notified prior to Resident #366 being transferred to the hospital but especially to a hospital across state lines when there was a local hospital a few minutes away that was equipped to treat him. The Administrator was interviewed on 1/30/25 at 5:30 PM. The Administrator reported on 12/20/24 that the facility felt it would be best for Resident #366's safety due to his wandering and sexualized behavior to be sent out to the hospital for an in-patient psychiatric evaluation and treatment. She stated the facility transported Resident #366 to the hospital in SC because they have a geriatric psych unit, and their local hospital did not have a psychiatric unit and would only have provided him with a tele psychiatric visit and sent him back to the facility. The Administrator revealed she did not notify Resident #366's legal guardian prior to his transfer to the hospital in SC but did notify the Legal Guardian by telephone after Resident #366 had left the facility.

Based on record review and staff interviews, the facility failed to complete a thorough investigation of an allegation of resident-to-resident abuse for 1 of 3 residents reviewed for abuse (Residents #57). Findings included: The facility's Abuse Investigation and Reporting policy revised 6/13/21 indicated: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/ or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. The role of the investigator included: - Review the completed documentation forms. - Resident the residents medical record to determine events leading up to the incident. - Interview the person reporting the incident. - Interview any witnesses to the incident. - Interview the resident. - Interview the residents Attending Physician as needed to determine the resident's current level of cognitive function. - Interview the resident's roommate, family members and visitors. - Interview other residents to whom the accused employee provided care or services. - Review all events leading up to the alleged incident. The following guidelines will be used when conducting interviews: - Each interview will be conducted separately in a private location. - Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it. Resident #57 was admitted to the facility on [DATE]. Resident #57's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. Resident #366 was admitted to the facility on [DATE]. Resident #366's quarterly MDS assessment dated [DATE] revealed he was severely cognitively impaired. Resident #36 was admitted to the facility on [DATE]. Resident #36's quarterly MDS assessment dated [DATE] revealed she was cognitively intact. Review of Nurse Aide (NA) #1's signed statement typed by the Administrator dated 12/18/24 revealed NA #1 answered call light from Resident #36's room, she (Resident #36) called her to her bedside and stated she had seen someone come into the room and get on her roommates Resident #57's bed. Resident #36 stated it had been a black person that looked like a man. Review of NA #2's verbal statement via telephone and typed by the Administrator dated 12/18/24 revealed NA #3 asked me to watch Resident #366 while she went on break. NA #2 was sitting at the nurse's station so she could see the hall, she did however answer a few call lights while NA #3 was on break. Review of NA #3's signed statement typed by the Administrator dated 12/19/24 revealed NA #3 went to break around 10:25 PM (12/18/24) and asked NA #2 to take over one-to-one with Resident #366. When NA #3 returned she saw Resident #366 walking down the hallway near the A station dining room. Review of facility initial report completed by the Administrator indicated the incident date was 12/19/24 and the facility became aware of the incident on 12/19/24 at 1:30 AM. The fax date and time revealed the report was submitted on 12/19/24 at 3:24 AM. The initial report revealed the following information: [Resident #36] rang her call bell to alert staff that someone had wandered into their room and attempted to climb onto the bed with her roommate [Resident #57]. [Resident #57] has a BIMS [brief interview for mental status] of 15 and states no inappropriate touching took place. Investigation underway. [Resident #57] is being placed on [one-on-one] temporarily. [The Administrator] and [the Director of Nursing] were in facility to conduct full investigation and ensure resident's [safety]. Review of facility 5-day investigation report completed by the Administrator dated 12/26/24 revealed their investigative findings indicated Resident #102 witnessed the entire incident citing Resident #366's confusion and wandering behaviors. There was no willful intent noted on behalf of Resident #366 as evidenced by the fact that he also attempted to get into his roommate's bed just prior to the incident. There was no evidence of sexual intercourse during thorough skin assessment or per resident reports, and there were no reports that indicate abuse from the two resident eyewitnesses, staff interviews, or other resident interviews. Typed statements for Resident #57 and her roommate, Resident #36, were included in the investigation. The investigation did not include a resident statement from Resident #366 and no assessments were documented for either Resident #57 or Resident #366. On 1/30/25 at 4:03 PM an interview was conducted with the Director of Nursing (DON). The DON stated she assisted the Administrator with the investigation regarding the incident that occurred on 12/18/24 between Resident #57 and Resident #366. She stated she did not have anything to do with collecting the nursing staff's witness statements. She explained that the Administrator handled those statements. She stated she believed the Administrator had stated that due to the staff's written statements being hard to read, the Administrator had re-typed the staff statements and had staff to sign them. The DON revealed she had no knowledge of Resident #366 being interviewed and she was never asked to assess Resident #366. She stated she had completed a skin assessment on Resident #57 and was not aware that she needed to complete and document a more thorough physical assessment. A review of the facility investigation file and interview with the Administrator were conducted on 1/30/25 at 5:35 PM. The Administrator stated she was aware of and had completed the incident and 5-day investigation reports regarding the incident that occurred on 12/18/24 between Resident #57 and Resident #366. She revealed that two of the three nursing staff from that night provided her with their handwritten statements. She indicated after reviewing those statements, she explained to staff that some of the statements were not legible, had too much detail, only needed to include the facts, and did not need to include any resident interviews. She explained she then took the nursing staff's hand-written statements and typed up new statements and then had the staff to sign them. She stated she did offer the staff to come into her office with her while she typed up the statements and they declined. The Administrator revealed she did not keep the staff's original handwritten statements. The Administrator further revealed Resident #366 was not assessed, but she did speak with him about the incident with Resident #57, and he told her that he was going to see his wife to give her a back massage. She stated she was not aware that she needed to type up an interview statement for Resident #366 or that he should have been assessed. She revealed the DON assessed Resident #57 and completed a skin assessment, but she was not aware the DON needed to complete and document a more thorough physical assessment.

Based on record review, and interviews with the staff, Consultant Pharmacist, and Medical Director (MD), the Consultant Pharmacist failed to identify drug irregularities related to the use of as needed (PRN) psychotropic drug (drug that affects mental state) and provide recommendations for 1 of 7 residents reviewed for unnecessary medications (Residents #25). The findings included: Resident #25 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #25 with moderately impaired cognition and indicated she had received antianxiety medications in the 7-day assessment periods. A physician's order dated 11/26/24 indicated- 1 tablet of Ativan 0.5 milligrams (mg) by mouth every twelve hours as needed for anxiety was ordered for Resident #25. This active order did not have a stop date and the rationales for extended therapy beyond 14 days were not found in Resident #25's medical records. A review of the medication administration record (MAR) revealed Resident #25 had received 4 doses of PRN Ativan in January 2025. A review of medical records revealed the Consultant Pharmacist had conducted a medication regimen review (MRR) for Resident #25 on 11/18/24 and 12/30/24. She did not identify any drug irregularities. The only recommendation from 12/30/24 MRR was to discontinue PRN meds due to non-use which included Ativan, Senna, Preparation H, and albuterol. During a phone interview conducted on 01/28/25 at 4:08 PM, the Consultant Pharmacist confirmed she had completed MRRs for Resident #25 on 11/18/24 and 12/30/24. She stated she did not notice the drug irregularities related to the PRN Ativan order without a stop date and attributed the error to her oversight. During an interview conducted on 01/28/24 at 11:50 AM, the Medical Director was familiar with Resident #25 but did not remember the specifics of the exact order. The Medical Director stated he did not write stop dates on his orders, and stated he wrote his orders with no refills then reviewed the medication when a refill was requested before a new order was given. He stated he wrote his orders that way they would not last more than 30 days. He stated he was bad at writing stop dates. He stated he was not aware of a 14-day duration for PRN psychotropic medication. An interview was conducted with the Director of Nursing (DON) on 01/29/25 at 2:16 PM. She expected the Consultant Pharmacist to identify the drug irregularities and report the findings to the facility and provider in a timely manner. During an interview conducted on 01/29/25 at 2:37 PM, the Administrator stated it was her expectation for the Consultant Pharmacist to identify the drug irregularities and report it in a timely manner.

Based on record review and interviews with residents, staff, and the Medical Director (MD), the facility failed to ensure physician's orders for as needed (PRN) psychotropic drug (drug that affects mental state) was time limited in duration and provided rationales for therapy exceeding 14 days for 1 of 7 sampled residents reviewed for unnecessary medications (Resident #25). The findings included: Resident #25 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #25 with moderately impaired cognition and indicated she had received antianxiety in the 7-day assessment periods. A physician's order dated 11/26/24 indicated 1 tablet of Ativan 0.5 milligrams (mg) by mouth every twelve hours as needed for anxiety was ordered for Resident #25. This active order did not have a stop date and the rationales for extended therapy beyond 14 days were not found in Resident #25's medical records. Attempts to interview Nurse #4 who confirmed the order on 11/26/2024 were unsuccessful. A review of the December 2024 and January 2025 Medication Administration Records (MARs) revealed Resident #25 had received 4 doses of PRN Ativan in January 2025. 1/11/25 - 2 doses 1/14/25- 1 dose 1/17/25- 1 dose On 01/27/25 02:24 PM an attempt to interview Resident #25 was unsuccessful. She was unable to engage in the interview. During an interview on 01/29/25 at 12:17 PM Nurse #1 stated PRN orders for psychotropic medications were to be written for 14 days. Nurse #1 stated she would ask the Doctor for clarification if PRN psychotropic medications were written without a stop date. An interview was conducted with the Director of Nursing (DON) on 01/29/25 at 2:16 PM. The DON stated she expected orders for PRN psychotropic medications to be written per the facilities policy. The DON expected the orders to be reviewed by 3rd shift nurses for accuracy. The DON also stated during morning management meetings all orders were reviewed by being read off and double checked. The DON was unsure how the order for a PRN psychotropic with no stop date was not caught during the review process. During a telephone interview on 01/30/25 at 09:20 AM Nurse #2, who worked 3rd shift after the order on 11/26/2024 was written, stated she did know she was supposed to, and had never reviewed the orders for accuracy while working third shift at the facility. During a telephone interview on 01/30/25 at 09:43 AM Nurse #3, who worked 3rd shift after the order on 11/26/2024 was written, stated she had never reviewed orders for accuracy while working third shift, and stated she did not know that was expected. During an interview conducted on 01/29/25 at 2:37 PM, the Administrator stated she expected orders for PRN psychotropic meds to be written per the facilities policy. During an interview conducted on 01/28/24 at 11:50 AM, the Medical Director was familiar with Resident #25 but did not remember the specifics of the exact order. The Medical Director stated he did not write stop dates on his orders, and stated he wrote his orders with no refills then reviewed the med when a refill was requested before a new order was given. He stated he wrote his orders so they would not last more than 30 days. He stated he was bad at writing stop dates. He stated he was not aware of a 14 day duration for PRN psychotropic medication.

Based on observations and staff interviews the facility failed to post daily nurse staffing in a prominent location that was readily accessible to residents on 4 of 5 days during the survey (01/27/2025, 01/28/2025, 01/29/2025, and 01/30/2025). The findings included: An observation on 01/27/2025 at 9:00 AM revealed the daily nurse staff posting was located on the wall in the front lobby. The daily nurse staffing sheet was a white, 8 by 10-inch piece of paper enclosed in a hard plastic display holder. The lobby was only accessible to the residents by entering through a closed door which had a keypad access. The facility staff had the access code for the keypad. The daily nurse staff posting was not readily visible or accessible for the residents to view. Additional observations on 01/28/2025 at 8:15 AM, 01/29/2025 at 8:15 AM, and 01/30/2025 at 7:45 AM of the facility's daily nurse staff posting revealed it was located on the wall in the front lobby and was not readily visible or accessible for residents to view. An interview was conducted with the Scheduler on 01/30/2025 at 11:34 AM. The Scheduler revealed that she had worked in her current role for [AGE] years and she was responsible for posting the daily nurse staffing. The Scheduler also stated the daily staff posting had been located in the lobby for quite a long while. An interview was conducted with the Director of Nursing (DON) on 01/30/2025 at 12:30 PM. The DON revealed that the residents could view the daily staff posting if they entered the lobby. She further stated the residents had to ask a staff member to enter the keypad code to unlock the door for the residents to enter the lobby and view the daily staff posting. An interview was conducted with the Administrator on 01/30/2025 at 1:40 PM. The Administrator revealed the facility's daily staff posting should be placed in an area that was readily accessible and visible for residents to view. She also stated the daily staff posting had been displayed in this area since she had been with the facility and was not readily accessible to residents.

Based on observations, record review and resident, family member (RP), staff and Medical Director (MD) interviews, the facility failed to ensure safe securement per manufacturer recommendations of a resident during a van transport. Resident #1 flipped backwards in his wheelchair, hitting the van floor while being transported in the facility's transportation van when the transportation van drove over a speedbump located along the steep driveway leading to the facility. Resident #1 sustained a hematoma to the back of his head, a skin tear to his right hand and skin tear to his right wrist. This practice had the high likelihood of causing serious injury for 1 of 3 residents reviewed for accidents (Resident #1). The immediate jeopardy began on 12/21/23 when Resident #1 flipped backwards in his wheelchair hitting the transportation van floor. The immediate jeopardy was removed on 1/6/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity D (no actual harm that is immediate jeopardy) to ensure monitoring systems are put into place are effective. The findings included: Review of the manufacturer's instructions for the 4-point wheelchair securement system (the system used on the facility's transport van to secure residents who are seated in wheelchairs during transport) indicated the following instructions were to be followed: 1)center the wheelchair facing forward in the securement zone and lock wheelchair brakes, 2) attach 4 retractors into floor anchorage points and lock them in place with an approximate distance of 48-54 between the front and rear retractors. 3) completely pull out the arch webbing and attach J-hooks and compliant chair securement points near seat level at a 45-degree angle. 4) move wheelchair forward and backwards to remove webbing slack or manually tension webbing with retractor knobs. 5) make sure the chair's pelvic belt is buckled over the occupants hips 6) attach shoulder belt pin connector to pin located on the shoulder belt height adjuster 7) pull shoulder belt over occupants chest and attach shoulder belt pelvic connector to pin on pelvic belt and adjust shoulder belt height so it rest on the shoulder belt. 8) attach shoulder belt pin connector to pin on rear retractor closest to the wall 9) attach the removeable pelvic belt pin connector to pin on rear retractor closest to the aisle. 10) Pull the shoulder belt over the occupant's chest and buckle shoulder belt pelvic connector to remove pelvic belt. Resident #1 was admitted to the facility on [DATE] with diagnoses that included aftercare following surgery for acquired absence of the left lower extremity below the knee (surgical amputation), osteoarthritis and diabetes. A quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #1 was cognitively intact and required assistance for transfers and locomotion of his wheelchair. A nurse progress note dated 12/20/23 indicated Resident #1 was scheduled for a follow-up visit with the general surgeon on 12/21/23 at 4:40 PM. A nurse progress note dated 12/21/23 written by Nurse #1 indicated following the completion of a full body assessment, post a fall in the facility van, the on-call provider was notified of the injuries to Resident #1's head and right upper extremity. The on-call provider provided Nurse #1 with new orders to contact Resident #1's responsible party (RP) to determine if he/she wished to have further evaluation of Resident #1's injuries to include a computed tomography (CT) or be sent to the emergency room (ER). The note further indicated after Nurse #1 spoke to Resident #1 and his RP about the orders from the on-call provider, they both agreed to have Resident #1 monitored in the facility and not transfer him to the ER at that time. An incident report completed by Nurse #1 dated 12/21/23 at 5:30 PM indicated Resident #1 had returned to the facility following transport from an appointment. The report revealed Nurse #1 was notified that Resident #1 fell back in his wheelchair and landed on his back while in the parking lot of the facility. It further indicated Resident #1 notified Nurse #1 he fell out of his wheelchair backwards when something that held his wheelchair inside the van snapped out. The report detailed that Resident #1 was placed in a lift sling and placed back into his wheelchair and transported into the facility for further evaluation. A skin note dated 12/21/23 written by Nurse #2 indicated Resident #1 was assessed by herself and Nurse #1 which revealed a raised area at lower back of head that measured 2cm x 1.5cm without discoloration. A 2.5cm x2cm x 0.1cm superficial skin tear on top of his right hand that had scant amount of bleeding and a 1cm x 0.5cm x 0.1cm skin tear above right wrist area. Medication nurse aware and treatment was initiated. A document titled investigation questions handwritten by Nurse #2 dated 12/21/23 indicated Resident #1 fell while on the van on 12/21/23. It revealed Nurse #2 was in her car in the parking lot when the transportation van pulled up and she was notified by the Transportation Aide that Resident #1 had fallen due to the seatbelt on van which had snapped. An interview with Nurse #2 on 1/5/24 at 11:59 AM revealed she was present in her car in the facility parking lot speaking to Resident #1's RP and another staff member (she could not recall the staff member's identity) when the facility van containing Resident #1 pulled up near the traditional van parking spot outside the front door of the facility where she noticed the Transportation Aide exited the driver side of the van and yelled for her assistance when she stated, he fell . Nurse #2 stated she exited her car and quickly approached the facility van where she saw Resident #1 lying on his back with his wheelchair tipped backwards onto the van floor and his right foot dangling in the air. Nurse #2 indicated she started to assess Resident #1 and saw and felt a raised hematoma on the back of Resident #1's head near the base of his skull but saw no bleeding present at the time along with a skin tear to Resident #1's right hand and another skin tear to his wrist with minimal bleeding present. Nurse #2 explained following her assessment of Resident #1 she requested Nurse #1's assistance in the van. Then, she removed the wheelchair from beneath Resident #1's body and sat it in an upright position in the van. Nurse #2 indicated she finished her assessment before Nurse #1 arrived and requested the total body mechanical lift be brought to the van, then both she and Nurse #1 placed the lift sling under Resident #1's body, slid him to the edge of the van, secured his body in the mechanical lift and placed him back into his wheelchair then lowered him from the lift gate in his wheelchair and wheeled him to his room where a thorough assessment was completed and treatments were initiated, followed by notification of the on-call provider. Nurse #2 stated Resident #1 remained alert and oriented during the entire assessment and was assuring his RP that he was going to be okay and was not in any pain related to the fall. Nurse #2 stated while she was in the van, she was focused on performing an assessment of Resident #1's condition and did not notice the floor securement device placement but noticed the rear straps were loosely attached to the rear of the wheelchair (which she removed); however, she did notice a seatbelt looking thing hanging down from the top of the van that was not attached to the resident or his wheelchair. An interview with Nurse #1 on 1/5/24 at 11:59 PM revealed a staff member whom she could not identify notified her that Resident #1 had fallen in the transportation van and Nurse #2 had requested her assistance. Nurse #1 indicated she went to the front of the building and approached the transportation van where she saw Resident #1 lying on his back with Nurse #2 next to him. Nurse #1 stated Nurse #2 notified her Resident #1 had a knot (hematoma) on the back of his head and needed to be transferred via total body mechanical lift back to his room for further examination. Nurse #1 explained she and Nurse #2 placed the lift sling under Resident #1 and using the mechanical lift placed Resident #1 back into his wheelchair and transported him to his room and placed him in the bed. Nurse #1 stated she obtained Resident #1's vital signs and began neurological checks then notified the on-call provider. Nurse #1 explained the on-call provider gave orders that Resident #1 could have a CT performed or be transferred to the ER if Resident #1 or his RP requested further evaluation or if a change of condition occurred. Nurse #1 clarified the instructions with Resident #1 and his RP who chose not to go to the ER at that time. Nurse #1 further explained she stayed with Resident #1 for approximately 30 minutes following the incident without any change of condition, complaints of pain, or abnormal neuro checks. An interview with the Transportation Aide on 1/5/24 at 1:00 PM revealed she was the primary staff assigned for all resident transports for the facility since late November 2023. The Transportation Aide recalled on the early evening of 12/21/23, she transported Resident #1 from a surgical follow-up appointment to the facility; however, while driving up the inclined driveway to the facility, she passed over a speedbump and heard a [NAME] and Resident #1 yell out. The Transportation Aide stated she immediately looked in her mirror located above her head and noticed Resident #1was no longer secured upright in his wheelchair but was lying on his back with his foot in the air. The Transportation Aide explained she asked Resident #1 if he saw any bleeding and when Resident #1 notified her, he did not see any obvious blood present, she told him she would move the transportation van closer to get assistance. The Transportation Aide stated without exiting the van to visualize Resident #1, she pulled the van to the top of the hill just outside the facility's front door where she saw Nurse #2 sitting in her parked car. The Transportation Aide stated she yelled at Nurse #2 for assistance and stated Nurse #2 immediately exited her car and approached the van where she began assessing Resident #1 who had a raised hematoma on the back of his head and a couple bleeding skin tears to his right hand and arm. The Transportation Aide stated when she got to the back of the van where Resident #1 was lying on his back, partially in his wheelchair, she noticed the floor securement straps were no longer attached to Resident #1's wheelchair and Resident #1 had partially came out of his wheelchair and was leaning on his side. The Transportation Aide indicated she thought, but could not be certain, before she began the transportation back to the facility, she had secured all straps (both shoulder and floor straps) tightly and that Resident #1's wheelchair was secured to the van. An observation with the Transportation Aide on 1/5/24 at 1:00 PM The Transportation Aide attempted to perform a reenactment of the steps that occurred which led to Resident #1's fall in the facility van on 12/21/23. The Transportation Aide made an attempt to secure a wheelchair (identified not to be Resident #1's personal wheelchair used on 12/21/23) containing a state surveyor to the van floor of which revealed the floor securement straps were placed on a declining bar along the bottom of the wheelchair in the front and back with difficulty as she struggled to be able to get around the lower extremities of the surveyor which were placed on the wheelchair pedals in order to reach the securement straps on the right side. The Transportation Aide attempted to attach the rear right strap from the left front portion of the wheelchair instead of from behind the chair. and she did not lock the right hand break which was obstructed by a folded bench seat on the right side of the wheelchair which allowed the front wheels of the wheelchair to be elevated off the floor with minimal force. A demonstration of how Resident #1 was positioned on the floor in the van reenacted by the Transportation Aide revealed Resident #1's wheelchair had tilted completely on its back pad and Resident #1's head was located near a metal locking groove strip near the lift gate at the rear of the van. The Transportation Aide acknowledged the wheelchair should not move when it is properly secured per manufacturers' guidelines. The Transportation Aide indicated her training was provided by a Former Transportation Aide briefly back in August 2023; however, she had not transported for several months following her training before she took over as the primary transpiration aide and she had not received any formal training with manufacturer's guidelines included. An interview with Resident #1 on 1/4/23 at 4:15 PM revealed he was lying in his bed following a urology appointment where he had been transported in the facility van by the Transportation Aide. Resident #1 elaborated that he had been transported by the Transportation Aide to a urology appointment since the incident on 12/21/23 and verified that an additional nurse aide (or another facility staff member) per IDT recommendations had not been present for the transport. Resident #1 explained he recalled the fall in the facility van on 12/21/23 following his follow-up visit to the surgeon office. Resident #1 stated when the van began to start up the incline hill outside the facility, it hit a speed bump going too fast and the straps from his wheelchair fell off the chair and he fell backwards striking his head on the floor of the facility van. An Interdisciplinary Team (IDT) progress note written by Nurse #2 dated 12/22/23 indicated the van was inspected by maintenance and the Administrator following the incident on 12/21/23. IDT recommended a nurse aide be with the transporter while transporting to all appointments. A typed note dated 12/21/23 signed by the Maintenance Assistant indicated he inspected the van and the securement devices in the van and did not find any deficiencies in the integrity of the equipment. An observation and interview with the Maintenance Assistant on 1/5/24 at 2:15 PM revealed he was present on 12/21/23 after the fall by Resident #1 occurred. The Maintenance Assistant indicated he made an observation of the van and the securement equipment for functioning on 12/21/23. The Maintenance Assistant indicated he did not find any concerns about the equipment and believed human error (straps were not placed in proper position and secured per manufacturer's guidelines by the Transportation Aide) in the attachment had occurred during the transport which caused the incident. The Maintenance Assistant demonstrated the proper attachment of the device to the wheelchair used on the date of the incident. The Maintenance Assistant ensured bilateral hand brakes on the wheelchair were firmly locked in place, then he tightly secured four locking straps to the bottom frame of the wheelchair then placed a seatbelt like wrapping device across the surveyor and locked it to an extension belt near the rear floor of the van. When all straps were secured, the wheelchair did not allow for movement by the surveyor who was seated to represent Resident #1 for demonstration. The Maintenance Assistant indicated he had provided driver training to both the Transportation Aide and the Maintenance Director following the incident on 12/21/23. The Maintenance Assistant said he was trained by the former Transportation Aide on how to place the securement system to a wheelchair. An interview with the Maintenance Director on 1/5/24 at 3:45 PM revealed he had been the Maintenance Director since November 2023 but had no direct involvement in the incident which occurred on 12/21/23 involving Resident #1. The Maintenance Director stated he did not inspect the van for proper function following the incident and had not been asked to ride with the Transportation Aide before nor after the incident on 12/21/23 to monitor her driving or passenger securement safety. The Maintenance Director indicated that he received his driver and securement training from the Maintenance Assistant and had watched videos on the proper application of the securement system a week following the incident which occurred on 12/21/23. An interview with the Administrator on 1/5/24 at 2:15 PM revealed she was present at the facility on 12/21/23 when the incident involving Resident #1 occurred. The Administrator indicated she was immediately made aware of the incident and notified the Maintenance Assistant so proper inspection could be completed. The Administrator stated she and the interdisciplinary team (IDT) determined the accident was caused by an error in securement of each strap per the manufacturer's guidelines by the Transportation Aide. She indicated she expected all transports to be performed in a safe and secure manner. The Administrator indicated she was unaware that the intervention was included that a NA would be on all transports with the van driver and thought since the Transportation Aide was a NA that was sufficient. An interview with Resident #1's Responsible Party (RP) on 1/16/24 at 9:00 AM revealed she was present in the facility parking lot when the facility transport van returned Resident #1 from his surgical follow-up appointment on the evening of 12/21/23 as she was present at the appointment. Resident #1's RP stated she noticed the van begin up the driveway outside the facility and abruptly stop before it reached the normal parking area located adjacent to the front lobby of the building. The RP said she initially thought it was a little unusual but then the van proceeded on towards the top of the hill as normal. The RP explained when the van arrived and began to proceed towards the turn in just before reaching the front entrance, the van again abruptly stopped and she saw the Transportation Aide get out of the van and yell across the parking lot at a staff nurse who was in the parking lot. Resident #1's RP said she heard the Transportation Aide screaming He fell , Help, He fell . Resident #1's RP said she and the staff nurse both ran towards the facility van asking if Resident #1 was hurt. Resident #1's RP said she was on the phone with her daughter when the nurse opened the rear lift gate so she could get to Resident #1. Resident #1's RP said Resident #1 was lying on his back with his wheelchair partially under him with his one leg in the air. She said Resident #1's right portion of his torso was located adjacent to the metal lift gate and she stated his head was lying on the floor of the facility van but could not give details as to the location or recall the positioning upon her visualization. The RP stated she recalled snapping a picture of Resident #1 immediately following the accident and sending it to another family member, but the photo had since been deleted from her telephone. Resident #1's RP stated the staff nurses looked him over, then put him in his chair and took him to his room to put him to bed. Resident #1's RP said Resident #1 had a raised place on the back of his head and a couple gashes to his right hand, but he made the decision not to go for further evaluation and she respected his decision at that time. An interview with the Medical Director (MD) on 1/10/23 at 5:37 PM revealed he was made aware on 1/9/24 of the fall in the transportation van which occurred on 12/21/23. The MD indicated Resident #1 had the potential to sustain significant injury when involved in a motor vehicle accident (MVA). The facility Administrator was notified of immediate jeopardy on 1/5/24 at 12:21 PM. The facility provided the following plan for IJ removal. Credible Allegation of IJ Removal Plan for F 689 Accident and Hazards - Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On 12/21/23 at approximately 5:00 p.m. Resident #1 was on the facility van returning from an appointment, when the Van Driver was coming up the hill of the parking lot when she went over the speed bump resident #1 went over backward in his wheelchair. Charge Nurse was notified that resident fell back in his wheelchair in the facility van. Van was sitting in the parking lot stopped. Resident was on his back with the wheelchair under his back and legs. The securement straps were noted to be loose at this time. The wheelchair was unlocked at base from van hooks then the wheelchair was gently moved out from under resident. Resident then assessed for injuries. He was alert and oriented x 3 the entire time. Resident was transferred back into the wheelchair with use of total lift, while on the van. Then Resident # 1 was assisted off the van and into his room, to bed for full body assessment. Resident assessed by nurse and suffered a skin tear to right hand measuring 2.5cm X 2.0cm x 0.1cm and a skin tear to his right wrist measuring 1.0 cm x 0.5 cm x 01 cm as well as a knot to the back of his head measuring 2 cm x 1.5 cm. First aid provided. Neuro checks were initiated on 12/21/23 at approximately 5:30 p.m. and continued until 12/25/23 without any negative findings. The physician was notified of the incident on 12/21/23 by the staff nurse. Recommendations received to continue to monitor, send resident to emergency department with condition change. Resident # 1 had a provider assessment completed on 12/28/23 with no new orders. Resident's responsible party was notified of the incident on 12/21/23 by staff nurse. The transport van was removed from service on 12/21/23 at 5:00 pm until it could be checked to ensure no broken parts or failures and a road test with the same wheelchair was conducted. The Maintenance Assistant completed this evaluation and road test immediately following the incident and found no issues or deficits noted with the securement system. No damage was noted to the straps of the securement system. The van was put back into service on 12/21/23 at approximately 6:00 pm. Immediately following the incident on the evening of 12/21/23 a return demonstration was completed with the Van Driver and the Administrator; it was determined that the root cause of the event was that the driver had failed to apply the securement system straps in the proper location on the wheelchair. Immediately following the incident on 12/21/23, the Van Driver received 1:1 education from the Maintenance Assistant, who is an alternate trained driver on proper resident securement, and she provided return demonstration of procedure (process for applying the securement system straps to the wheelchair). Training was per the manufacturer's driver training modules and included applying the securement system straps in the proper location on the wheelchair as outlined in the driver training modules. All residents that are transported in the facility van are at risk. An audit was completed on December 22, 2023, by DON of all residents who were transported in the last 30 days. Residents with BIMs greater than 11 were interviewed regarding transportation and any concerns related to safety during wheelchair van transportation. All residents who were transported within the last 30 days with a BIMs of 10 or lower had skin checks completed to ensure no injuries were noted. No concerns were identified through these interviews/audits. No other residents or concerns were identified as having any circumstances resulting in falls in the van. - Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 12/22/23, The Maintenance Assistant trained the Van Driver and the Maintenance Director on proper resident securement and resident safety. Training was per the manufacturer's driver training modules and included applying the securement system straps in the proper location on the wheelchair. All drivers (Van Driver, Maintenance Director and Maintenance Assistant) completed the Driver Training Program on 12/22/2023. Training was provided by the Regional Director of Operations. Training included review of policy and procedure for resident securement, proper handling of vehicles, use of safety equipment on board the vehicle, passenger safety and securement of passengers in vehicle. Training was per the manufacturer's driver training modules. The Van Driver resumed her duties after training and return demonstration on 12/21/23, however, on 1/5/24, the Van Driver completed return demonstration of resident securement and during this demonstration, sufficient securement was not ascertained due to the securing straps not being tight and the resident chair still moving while restrained with safety equipment. Following this failed return demonstration, the driver was removed from her responsibilities of driving the facility van. On 1/5/24, the two remaining drivers (The Maintenance Director and Maintenance Assistance) were educated by the Administrator on the process of securing a wheelchair into the van. This procedure now includes a 2-step process for ensuring the chair is immobile when preparing for transport. The 2 steps are as follows: - Test each of 5 straps by pulling on both the top and bottom of each strap to confirm that the strap is taut. - Attempt to move wheelchair forward, backward, and side to side to confirm that wheelchair does not move. If during either of the 2 steps the chair is mobile, the driver will cinch the securing straps to create more tension and complete the 2-step process again to ensure that the chair does not move prior to placing the vehicle in motion. The two remaining drivers (the Maintenance Director and Maintenance Assistant) were able to complete the new 2-step process effectively on 1/5/24. This was verified by the Administrator. No transportation occurred until the completion and validation of this training. Administrator will validate 5 resident transports weekly X 8 weeks to ensure the new 2-step process is utilized correctly and that proper securing of residents/wheelchairs in the transport van occurs prior to departure from the center. Alleged date of IJ removal: 1/6/24. On 1/16/24, the corrective action plan for immediate jeopardy removal effective 1/6/24 was validated by the following: Interviews with the Maintenance Staff revealed they were performing facility transports when additional assistance was needed, and an outside transportation company was now scheduled due to the former Transportation Aide being relived from her duties as Transportation Aide. The Maintenance Staff indicated they had received formal training on how to properly secure residents for a safe transport for manufacturer's guidelines and for each transport conducted by a member of the Maintenance Staff a Nurse Aide has been required to ride in the facility van for additional safety reasons. An observation was made of the local transportation company pick up a resident from the facility and a nurse aide accompanied the resident to their appointment. Transportation audit tools were reviewed and confirmed resident safety and securement in the transport van were completed by the Administrator.

Based on observations, record reviews and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following recertification and complaint investigation surveys completed on 11/12/21 and 11/3/23. This failure was for one deficiency in the area of supervision to prevent accidents that was subsequently recited on the current complaint investigation and revisit survey of 01/16/24. The repeat deficiency during three federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. The findings included: This tag is cross referred to: F689- Based on observations, record review, Medical Director (MD), resident, family member (RP), and staff interviews, the facility failed to ensure safe securement per manufacturer recommendations of a resident during a van transport. Resident #1 flipped backwards in his wheelchair, hitting the van floor while being transported in the facility's transportation van. The transportation van drove over a speedbump located along the steep driveway leading to the facility when the wheelchair flipped backwards. Resident #1 sustained a hematoma to the back of his head, a skin tear to his right hand and skin tear to his right wrist. This practice had the high likelihood of causing serious injury for 1 of 3 residents reviewed for accidents (Resident #1). During the recertification and complaint investigation survey conducted on 11/3/23, the facility failed to safely assist a resident without causing injury to 1 of 5 residents reviewed for accidents. The Resident was left standing without assistance in her room and fell . The Resident sustained a laceration to the head and a right fractured hip. During the recertification and complaint investigation survey conducted on 11/12/21, the facility failed to secure smoking materials, failed to provide a smoking apron, and failed to supervise 1 of 2 residents reviewed for smoking. During an interview with the Administrator on 1/16/24 at 10:00 AM, she reported her quality assurance team met monthly and included the Medical Director, Director of Nursing, Assistant Director of Nursing, Treatment Nurse, Dietary Manager, Pharmacist (quarterly), Registered Dietician (quarterly), Social Worker, Activities Director, and a rotating staff member. The Administrator stated she felt like they had resolved the issue of supervision to prevent accidents because she had no further falls with major injuries from being left unattended and did not think to include the potential for a fall in a motor vehicle in the plan.

Based on observation, record review, staff and physician assistant interviews, the facility failed to safely assist a resident without causing injury to 1 of 5 residents (Resident #86) reviewed for accidents. Resident #86 was left standing without assistance in her room and fell . Resident #86 sustained a laceration to the head and a right fractured hip. The findings included: Resident #86 was admitted to the facility on [DATE] with diagnoses that included Alzheimer ' s, hypertension, anxiety, age related osteoporosis, muscle weakness, and adult failure to thrive. Resident #86 resided in the facility ' s memory care unit. Review of Resident #86's care plan revised on 02/21/23 revealed the resident was at increased risk for falls due to deconditioning, poor communication, psychoactive drug use, and unaware of safety needs. The goal was for Resident #86 to not sustain serious injury through the review date. Interventions included anticipate and meet the resident's needs, ensure that the resident is wearing appropriate footwear when ambulating, and follow facility fall protocol. Review of Resident #86's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #86 was severely cognitively impaired and required extensive assistance with one person assist for bed transfers, walk in corridor, and walk in room. The MDS further revealed that under balance during transitions and walking Resident #86 was coded for not being steady but able to stabilize without staff assistance. Review of Resident #86's undated Kardex (a written plan of care for staff to know the needs of a resident). revealed Resident #86 was extensive assistance with one person assist for transfer and mobility. Review of incident report completed by Nurse #3 dated 10/25/23 revealed NA #3 ambulated Resident #86 to her room when NA #3 turned to shut the door and Resident #86 lost balance and fell on her right side. The report further revealed Resident #86 sustained a cut above right eyebrow measuring approximately 3 centimeters (CM) by 1/2 CM. The cut had a small amount of bleeding with light purple bruising and was cleaned and strips were applied. The report indicated Resident #86 remained at her baseline neurological status and unable to voice pain due to cognition during assessment. The note revealed Resident #86 was assessed and assisted to bed and neurological checks were initiated. The responsible party and Assistant Director of Nursing (ADON) were notified, and the resident was placed in the book to be followed up by the provider the next day. The report revealed immediate action taken was Resident #86 was assessed for injuries, wound care applied to laceration above right eye, and neurological check initiated. Predisposing physiological factors indicated Resident #86 was confused and had impaired memory. Review of progress note completed by Nurse #3 dated 10/25/23 revealed Nurse Aide #3 ambulated Resident #86 to her room when NA #3 turned to shut the door and Resident #86 lost balance and fell on her right side. The note further revealed Resident #86 sustained a cut above right eyebrow measuring approximately 3 centimeters (CM) by 1/2 CM. The cut had a small amount of bleeding with light purple bruising and was cleaned and strips were applied. The note indicated Resident #86 remained at her baseline neurological status and unable to voice pain due to cognition during assessment. The note revealed resident #86 was assessed and assisted to bed and neurological checks were initiated. The RP, on call provider, and Assistant Director of Nursing (ADON) were notified. The indicated Resident #86 was not sent out but was placed in the book to be followed up by the provider the next day. Review of progress note completed by the ADON dated 10/26/23 revealed Resident #86 was assessed by the provider and was ordered an x-ray of right arm and shoulder and was sent to the hospital. The note further revealed IDT recommended educating staff about safe transfers. Review of the x-ray results completed at the hospital on 10/27/23 revealed Resident #96 sustained a transverse fracture at the right femoral neck seen at its base with slight angulation and displacement. The note further revealed osteopenia is noted, bony pelvic structures appear intact, and left hip appeared to be normal. Review of hospital progress note dated 10/27/23 revealed Resident #86 was admitted to the hospital and was diagnosed with a right femur fracture and laceration above the right eye. The note further revealed Resident #86 ' s resident representative (RR) indicated Resident #86 was not ambulatory before the fall. Review of progress note dated 10/27/23 revealed Resident #86 was transferred back to the facility from the hospital and the resident sustained a hip fracture and urinary tract infection (UTI). The note further revealed Resident #86 is in bed and had a follow up appointment in 4 to 6 weeks with orthopedic. Review of progress note dated 10/29/23 revealed Resident #86 was admitted to hospice. Review of progress note completed by the Medical Director (MD) on 10/30/23 revealed Resident #86 was transported to the hospital for a fall. The note further revealed the resident was found to have a right sided hip fracture and would not be managed operatively and would return to the facility. The note indicated Resident #86 would be followed by hospice and all medicines had been discontinued other than comfort measures. An observation was conducted on 10/30/23 at 11:00 AM revealed Resident #86 was in bed with with her eyes closed. Observation further revealed laceration over the resident ' s right eyebrow to have green and purple bruising with three steri strips on it. An interview conducted with NA #3 on 11/02/23 at 3:50 PM revealed on 10/25/23 she had assisted Resident #86 back to her room to put her in the bed. NA #3 further revealed Resident #86 had a good day and was walking with little assistance. NA #3 was an extensive assistance with one person support which meant to have hands on the resident assisting them. NA #3 indicated she walked Resident #86 into her room and stopped at the sink and left Resident #86 unattended to close the bedroom door because the resident had a good day and seemed stable to stand alone. NA #3 indicated she does not recall why she did not assist Resident #86 to the bed before shutting the bedroom door. NA #3 stated as she closed the door Resident #86 lost balance and fell to the ground on her right side. NA #3 revealed Nurse #3 assessed Resident #86 and the resident showed no signs of pain or injury other than the laceration above the right eye. NA #3 on 10/26/23 Resident #86 was assessed by the provider in the facility and Resident #86 started to show signs of discomfort and was sent to the hospital to be further assessed. An interview conducted with Nurse #3 on 11/01/23 at 11:10 AM revealed Resident #86 was an extensive assist with one person for ambulating. Nurse #3 indicated Resident #86 ' s health and memory had declined in the last couple months. Nurse #3 further revealed on 10/25/23 NA #3 had assisted resident #86 to her room and left Resident #86 unassisted standing when shutting the resident's door. Nurse #3 indicated at that time Resident #86 fell to the floor on her right side. Nurse #3 revealed she was called to Resident #86's room and observed Resident #86 on her right side near the bathroom door. Nurse #3 revealed she assessed Resident #86, and the resident sustained a laceration above the right eyebrow but did not show indications of pain or other injuries. Nurse #3 indicated Resident #86 was assisted back to bed and the Medical Director (MD), RR, and ADON were notified. Nurse #3 stated Resident #86 did not complain of pain and neurological assessments were completed. An interview conducted with the ADON on 11/01/23 at 11:10 AM revealed she was not present at the time of the incident. The ADON further revealed Resident #86 was extensive assistance with one person assist for ambulating and transfers. The ADON stated NA#3 should have not left the resident unattended in her room. The ADON indicated prior to the incident on 10/25/23 Resident #85's health was declining and had become weaker. An interview conducted with the Director of Nursing (DON) on 11/01/23 at 1:45 PM revealed Resident #86 was unstable and required extensive assistance with one person for ambulation and transfers. The DON further revealed NA #3 should have not left Resident #86 unassisted while closing the bedroom door. An interview conducted with the Physician Assistant (PA) on 11/03/23 at 12:25 PM revealed Resident #86 ' s health had declined rapidly since the residents fall on 10/25/23. The PA further revealed Resident #86 had been admitted to hospice before and could not state the fall had caused the resident ' s rapid health decline. The PA indicated Residents #86's weakness and dementia had progressed prior to the incident on 10/25/23. An interview conducted with the Administrator on 11/03/23 at 12:25 PM revealed if Resident #86 was coded and documented for extensive with one person assist then NA #3 should not have left the resident unattended. The Administrator indicated she expected nursing staff to follow the Kardex and what each Resident was coded for.

Based on observations, record review, resident and facility staff interviews, the facility failed to protect a cognitively impaired resident from physical abuse from an employee when a nurse aide (NA #5) put her hands on the resident's shoulders to get her to a seated position and slapped the resident on the side of her shoulder for 1 of 2 residents reviewed for abuse (Resident #57). NA #5 slapped Resident #57 in response to Resident #57 slapping at NA #5 resulting in Resident #57 holding her left arm as NA #5 walked away stating, I'm not going to take this off anyone. Immediate Jeopardy began on 08/11/22 when Resident #57, who had severe cognitive impairment, was physically abused by NA #5. The immediate jeopardy was removed on 10/26/22 when the facility provided and implemented an acceptable credible allegation. The facility remains out of compliance at a lower scope and severity of a D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective. The findings included: Resident #57 was admitted to the facility on [DATE] with diagnoses that included dementia without behaviors. A review of Resident #57's quarterly Minimum Data Set assessment dated [DATE] revealed her to be severely impaired with no psychosis, behaviors, rejection of care, or instances of wandering. Resident #57 was coded as requiring extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. She needed limited assistance with transfers, walking in the room, walking in the corridors, locomotion on and off the unit, eating, and bathing. Resident #57 was coded as having had 2 or more falls with no injury since her previous assessment. A review of the facility's investigation completed on 08/12/22 revealed Housekeeper #1 came to the Administrator on 08/12/22 stating she had witnessed NA #5 slap Resident #5 after trying to get her to sit down for the evening meal service on 08/11/22. The facility's investigation indicated the allegation to be unsubstantiated due to Housekeeper #1's lack of knowledge regarding Resident #57's behaviors and fall risks and that NA #5 was trying to get Resident #57 to sit down for her own safety. Review of Housekeeper #1's written statement from the investigation dated 08/12/22 read [Resident #57] was in the dining room at around 5:30 [PM] was standing up in the dining room. [NA #5], the CNA [Certified Nursing Assistant] told [Resident #57] to sit down. [Resident #57] stated she didn't want to sit down. [NA #5] assisted [Resident #57] in sitting down. [Resident #57] reached back and slapped [NA #5]'s arm [NA #5] then slapped [Resident #57] on the arm. During a telephone interview with Housekeeper #1 on 10/24/22 at 3:20 PM, she reported she was working on the hall where Resident #57 resided on the evening of 08/11/22. She stated she had walked into the dining room to gather trash and noticed NA #5 assisting Resident #57 in sitting down. She stated Resident #57 was telling NA #5 she did not want to sit down but eventually did and once Resident #57 sat down, she slapped NA #5. She stated NA #5 immediately slapped Resident #57 on the side of her left shoulder. Housekeeper #1 reported she heard the slap and stated she observed Resident #57 to hold her left arm. She stated NA #5 then walked out of the room and stated aloud, I'm not going to take that off of anybody. She reported she went home, was upset about what she had witnessed, spoke with a family member who worked at the facility who told her she needed to report it and stated she reported the incident the following day to the Administrator. During an interview with NA #5 on 10/20/22 at 3:18 PM, she reported she usually worked on the locked unit where Resident #57 resided. She stated she was aware of the allegation against her and denied slapping Resident #57. NA #5 reported she did try to encourage Resident #57 to remain seated due to her behaviors of attempting to get up and wander. She stated Resident #57 had a history of falling, so all staff had to keep a close eye on her. NA #5 reported Resident #57 had been up and down a lot that day and was refusing verbal requests by NA #5 to sit down and stay seated. She stated in trying to get Resident #57 to remain seated, she placed her hands on Resident #57's shoulders and stated, Come on [Resident #57], let's sit down. NA #5 reported Resident #57 sat down and swung her hand at her so NA #5 reported she thought to herself forget it and walked away and told Nurse #3 about the behavior. NA #5 provided a hands-on reenactment of the incident. During this reenactment NA #5 started by saying [Resident #57] time to sit down for dinner. She then proceeded to walk over to the surveyor, place both her hands on top of each of the surveyor's shoulders, tapping on the left shoulder and saying, Come on [Resident #57], let's sit down. NA #5 then reported Resident #57 sat down and slapped at her at which time, NA #5 reported thinking to herself, forget this and then stated she walked out of the dining room. During an interview with Nurse #3 on 10/20/22 at 6:43 PM, she verified she was working at the time the incident occurred. She reported she was unaware about the incident until the following day when she was questioned by the Administrator. She also reported NA #5 never reported any behaviors regarding Resident #57 to her on 08/11/22. During an interview with the Administrator on 10/20/22 at 1:53 PM, she reported she was made aware of the allegation on 08/12/22 in the afternoon when Housekeeper #1 came to her with the previous Environmental Services Director. She stated Housekeeper #1 reported she believed she had seen NA #5 slap Resident #57, however, the Administrator reported there were inconsistencies in the slap portion of the reported allegation. She stated she immediately began an investigation into the incident and unsubstantiated the allegation based on an interview with NA #5, the inability to find anyone else to corroborate what Housekeeper #1 had reported, and Housekeeper #1's lack of knowledge regarding Resident #57, her behaviors, and fall risk. The Administrator was notified of the immediate jeopardy on 10/24/22 at 7:30 PM The facility provided the following Credible Allegation of immediate jeopardy removal. o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance * On 8/11/22 the facility failed to protect a resident with severe cognitive impairment from physical abuse during an interaction in the dining room. * Housekeeper #1 reported on 8/12/22 that in the dining room, she observed Resident #57 hitting Nurse Aide #5. Housekeeper #1 also reported that she then observed Nurse Aide #5 slap Resident #57 on the arm. *All other residents are at risk from suffering from the deficient practice, and residents with dementia and behaviors are at increased risk for abuse. On 10/24/22, all staff in all departments were interviewed by members of the interdisciplinary team (IDT) that consists of Administrator, Director of Nursing (DON), Assistant Director of Nursing, Unit Managers (ADON), Social Worker, Activities Director, Business Office Manager, Admissions Director, Rehab Manager, and Office Assistant, to determine if any other resident may have been affected and if they had observed and not reported any resident abuse. The interview included questioning whether staff members have any knowledge of resident abuse - (defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) and that they understand the immediate reporting requirements to the Administrator and the Director of Nursing (DON) in the Administrator's absence. On 10/24/22, an audit of all residents with a Brief Interview of Mental Status (BIMS) of 10 or above, was completed by the Social Worker of designee to determine if they have experienced any type of resident abuse. No concerns were found. On 10/21/22 - 10/25/22, an audit consisting of thorough skin assessment of all residents with a BIMS of 9 or less was completed by licensed nurses to determine if there is evidence of abuse. No concerns were found. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete 0n 10/24/22, education was provided to the Administrator and DON by the Corporate Consultant, District Director of Operations, regarding the definition of abuse as defined in the abuse policy, the resident's right to be free from abuse. On 10/24/22, after being reeducated as outlined above, education for all staff was completed in person and via phone by the Administrator and DON. The education consisted of the following: The definition of abuse, neglect and misappropriation of property and the need to immediately notify their supervisor of all issues related to these infractions. Supervisors must inform the Administrator or DON immediately in person by phone and immediately separate the victim from and perpetrator, and that dementia residents are at increased risk of being the victim of these problems. Progressive characteristics of dementia (disorientation, withdrawal, mood and personality changes, and anxiety about symptoms), clinical challenges such as identifying pain, hunger, thirst, inability to express needs/wants, and other communication related symptoms of dementia that could cause a resident to have negative behaviors In addition to identification of these challenges, the education focused on tactics to deal with difficult behavior such as walking away to allow for de-escalation, providing time/place orientation, using a soothing tone of voice, providing gentle tactile cueing, use of gestures, offering distractions such activities, music, or person-centered strategies (pictures, personal memorabilia) Signs and symptoms of abuse in a dementia resident such as physical abnormality, withdrawal, loss of appetite, and general changes in patterns and psychosocial well-being Identification of caregivers who appear stressed or need a break from working in the dementia environment should also be brought to the immediate attention of the supervisor This training will be provided by the Administrator or the Human Resource Director to all agency staff and new employees upon hire during orientation. All facility staff in all departments, including as-needed and agency staff, received this training on 10/24/22-10/25/22 and all staff will continue to receive the training yearly thereafter. The Administrator and Human Resource Director were notified by the Regional Director of Operations of the need to provide this training to new hires on 10/25/22. Alleged IJ removal date is 10/26/22. On 10/27/22, the credible allegation of Immediate Jeopardy removal date of 10/26/22 was validated by onsite verification through facility staff interviews. The interviewed staff across all disciplines including nursing, office, housekeeping, dietary, and therapy revealed they had received in-service training regarding spotting, identifying, and reporting abuse. The also received in-service training regarding dementia care and how to handle adverse or difficult behaviors from residents with diagnoses of dementia.

Based on record review and staff interview the facility failed to implement their abuse policies and procedures when a housekeeper observed physical abuse of a resident by nurse aide (NA) #5 and did not immediately report the abuse to a supervisor or any member of the administrative team, failed to protect the residents by allowing NA #5 to work the remainder of that shift and the following day, failed to complete a thorough of investigation of an allegation of abuse, and failed to report the allegation of abuse to the State Agency, local law enforcement, and adult protective services within the required timeframe for 1 of 2 residents reviewed for abuse (Resident #57). Immediate jeopardy began on 08/11/22 when Housekeeper #1 failed to report abuse to her supervisor or administrative team immediately after she observed NA #5 slap Resident #57. The immediate jeopardy was removed on 10/26/22 when the facility provided and implemented an acceptable credible allegation. The facility remains out of compliance at lower scope and severity of a D (isolation with no actual harm with potential for more than minimal hard that is not immediate jeopardy) to complete education and ensure monitoring system put into place are effective. Example 1.b. below is cited at lower scope and severity of a D. The findings included: 1a. Review of the facility's policy titled Abuse and Neglect Protocol last revised on 06/13/21 revealed the following steps to be taken in the event potential abuse was observed: Any staff member or personal affiliated with this facility who has witnessed or who believes that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense shall immediately report, or cause a report to be made of, the mistreatment or offense. The policy further stated, Employees of this facility who have been accused of resident abuse shall be suspended from duty until the results of the investigation have been reviewed by the Director of Nursing/Designee or Administrator. The facility's abuse policy further stated Upon receiving reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the resident. Findings of an examination must be recorded in the resident's medical record. Regarding the investigation, the facility's policy stated The individual conducting the investigation will, at a minimum: e. Review the completed documentation forms; f. Review the resident's medical record to determine events leading up to the incident; g. Interview the person(s) reporting the incident; h. Interview any witnesses to the incident; i. Interview the resident as medically appropriate); j. Interview the resident's attending physician as needed to determine the resident's current level of cognitive function and medical condition; k. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; l. Interview the resident's roommate, family members, and visitors; m. Interview other residents to whom the accused employee provides care or services; and n. Review all events leading up to the alleged incident. o. Preserve all audio and video recordings of incident, if available/applicable. Resident #57 was admitted to the facility on [DATE] with diagnoses that included history of falling, muscle weakness, and dementia without behaviors. A review of the facility's investigation completed on 08/12/22 revealed Housekeeper #1 came to the Administrator on 08/12/22 stating she had witnessed NA #5 slap Resident #5 after trying to get her to sit down for the evening meal service on 08/11/22. The facility's investigation indicated the allegation to be unsubstantiated due to Housekeeper #1's lack of knowledge regarding Resident #57's behaviors and fall risks and that NA #5 was trying to get Resident #57 to sit down for her own safety. There was no documented assessment of Resident #57, or any other resident NA #5 had contact with on 08/11/22. There was a lack of interviews and statements from staff and residents regarding NA #5 and any other potential abuse that may have occurred. The investigation also failed to include statements or interviews from Resident #57's family and visitors. Review of Housekeeper #1's written statement from the investigation dated 08/12/22 read; [Resident #57] was in the dining room at around 5:30 [PM] was standing up. NA #5 told [Resident #57] to sit down. [Resident #57] stated she didn't want to sit down. [NA #5] assisted [Resident #57] in sitting down. [Resident #57] reached back and slapped [NA #5]'s arm [NA #5] then slapped [Resident #57] on the arm. An interview with Housekeeper #1 on 10/24/22 at 3:20 PM, she reported she saw NA #5 slap Resident #57 on 08/11/22 after Resident #57 slapped NA #5 around 5:30 PM. She stated she did not report the incident until the following day because she did not know she needed to. She stated once she got home from her shift, she spoke with her daughter who told her she needed to tell the Administrator what she observed. Housekeeper #1 stated she informed the Administrator the following day when she came in for her shift at 2:00 PM about the incident. She stated she had not received any training prior to the incident regarding reporting guidelines for allegations of abuse. Review of in-service logs for Housekeeper #1 provided by the facility revealed she completed an in-service training titled Patient/Residents' Rights Abuse Neglect and Elder Justice Act Inservice in May of 2022. During an interview with NA #5 on 10/20/22 at 3:18 PM, she reported she usually worked on the locked unit where Resident #57 resided. She stated she was aware of the allegation against her and denied slapping Resident #57. NA #5 reported she did try to encourage Resident #57 to remain seated due to her behaviors of attempting to get up and wander. She stated Resident #57 had a history of falling, so all staff had to keep a close eye on her. NA #5 reported Resident #57 had been up and down a lot that day and was refusing verbal requests by NA #5 to sit down and stay seated. She stated in trying to get Resident #57 to remain seated, she placed her hands on Resident #57's shoulders and stated, Come on [Resident #57], let's sit down. NA #5 reported Resident #57 sat down and swung her hand at her so NA #5 reported she thought to herself forget it and walked away and told Nurse #3 about the behavior. During a follow up interview with NA #5 on 10/24/22 at 4:39 PM, she verified she finished her shift on 08/11/22 which ended at 11:00 PM. She also reported she worked the following day (08/12/22) from 3:00 PM until 11:00 PM. Review of NA #5's statement within the investigation dated 08/12/22 read I was trying to get [Resident #57] to sit down for supper several times. One of the times [Resident #57] elbowed me. I put my hands on her shoulders to get her to sit down, that's when she elbowed me, and I walked off. During an interview with the Director of Nursing on 10/20/22 at 10:47 AM, she reported the facility was made aware on 08/12/22 of an allegation by Housekeeper #1 that NA #5 was observed being a little rough with Resident #57. She reported she was not a part of the investigation and that it was completed by the Administrator. The Director of Nursing reported she believed the allegation was unsubstantiated and referred to the Administrator for further information. During an interview with the Administrator on 10/20/22 at 1:53 PM, she reported she was initially informed of the allegation when Housekeeper #1 came to her office with the previous Environmental Services Director on the afternoon of 08/12/22. The Administrator stated Housekeeper #1 informed her she had observed NA #5 slap Resident #57 on 08/11/22 at the dinner meal service after trying to get her to sit down. The Administrator stated she began an investigation immediately after being informed of the incident taking a statement from Housekeeper #1, NA #5, and speaking with Nurse #3. She also had the facility staff complete an in-service education on reporting guidelines and timeframes since the alleged slap occurred on 08/11/22 and was not reported until the following afternoon. The Administrator reported she asked Housekeeper #1 why she waited to report what she saw and was told that Housekeeper #1 went home, thought about the incident further and then decided she needed to report what she saw when she arrived for her shift on 08/12/22. She reported she investigated the allegation as an incident, and indicated it was not investigated as an allegation of abuse. The Administrator reported she was able to complete the investigation before NA #5 returned to the facility for her shift on 08/12/22 and stated she unsubstantiated the allegation due to Housekeeper #1 wavering in her description of the incident and the Administrator's belief that Housekeeper #1 was not aware of Resident #57's care needs and behaviors. The Administrator verified she did not report the allegation to local law enforcement or adult protective services and NA #5 completed her shift on 08/11/22 until 11:00 PM. An interview with the Housekeeping Director at the time of the incident was attempted by telephone call due to them being out of the facility at the time of the investigation but was unsuccessful. During an interview with Nurse #3 on 10/20/22 at 6:43 PM, she verified she was working on the hall where Resident #57 resided on 08/11/22 when the incident occurred. She reported no one came to her at any time and reported the alleged abusive behavior by NA #5 towards Resident #57. She stated any allegations of that nature should immediately be reported to her, the Director of Nursing, or the Administrator. The Administrator was notified of the immediate jeopardy on 10/24/22 at 7:30 PM On 10/26/22 at 5:27 PM, the facility provided the following Credible Allegation of Compliance: F607 o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance On 8/11/22, the facility failed to follow the abuse policy in the areas of prevention, protection, reporting and training. *The facility failed to implement their abuse policies and procedures for preventing, reporting, protection, and training when in the dining room, Housekeeper #1 observed Resident #57 hitting Nurse Aide #5. Housekeeper #1 also stated that she then observed Nurse Aide #5 slap Resident #57 on the arm but did not report this incident to her supervisor until the next day. The perpetrator continued to work her shift in the special care unit. *All residents are at risk from suffering from the deficient practice, and residents with dementia and behaviors are at increased risk for abuse. On 10/24/22, an audit was completed by interviewing all residents with a Brief Interview of Mental Status (BIMS) of 10 or above by social worker and designees to determine who could alert staff to instances of abuse. Residents were interviewed for unreported abuse occurrences. No other residents were identified as being abused and not reported. On 10/21/22 - 10/25/22, an audit consisting of thorough skin assessment of all residents with a BIMS of 9 or less was completed by licensed nurses and designees to determine if there is evidence that they have experienced any abuse, including bruises of unknown origin or other unknown skin impairments. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete On 10/24/2022, all staff in all departments were interviewed by members of the interdisciplinary team (IDT) that consists of Administrator, Director of Nursing (DON), Assistant Director of Nursing, Unit Managers (ADON), Social Worker, Activities Director, Business Office Manager, Admissions Director, Rehab Manager, and Office Assistant, to determine if any other resident may have been affected and if they had observed and not reported any abuse. No concerns identified. Administrator was also reeducated on all components of the facility's abuse policy and how to identify abuse on 10/24/2022 by the District Director of Operations. Education included the definition of abuse, reporting requirements, the need to identify if other cognitively impaired residents had been abused, the need to protect other cognitively impaired residents by implementing skin assessments and monitoring for psychosocial changes by qualified individuals, as well as immediately separating the victim from the alleged abuser. The administrator was also educated on the progressive characteristics of dementia (disorientation, withdrawal, mood and personality changes, and anxiety about symptoms), clinical challenges such as identifying pain, hunger, thirst, inability to express needs/wants, and other communication related symptoms of dementia that could cause a resident to have negative behaviors. In addition to identification of these challenges, the education focused on tactics to deal with difficult behavior such as walking away to allow for de-escalation, providing time/place orientation, using a soothing tone of voice, providing gentle tactile cueing, use of gestures, offering distractions such activities, music, or person-centered strategies (pictures, personal memorabilia). Identification of caregivers who appear stressed or need a break from working in the dementia environment should also be brought to the immediate attention of the supervisor. The administrator was educated that this training should be completed with all new employees during the orientation process and with all staff on a yearly basis. On 10/24/22 and 10/25/22, after being reeducated as outlined above education for all staff was completed by the Administrator and DON. The education consisted of the following: The definition of abuse, neglect and misappropriation of property and the need to immediately notify the Administrator or DON of all issues related to these infractions. If Administrator or DON are not present in facility, supervisors must be notified, and they must inform the Administrator or DON immediately in person or by phone Staff members who observe situations of abuse should immediately intervene to prevent continued potential abuse to residents. The perpetrator should be removed from the situation and placed under 1:1 supervision until they can be removed from premises. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator or Director of Nursing. The following information should be reported: a. The name(s) of the resident(s) to which the abuse or suspected abuse occurred b. The date and time that the incident occurred c. Where the incident took place d. The name(s) of the person(s) allegedly committing the incident, if known e. The name(s) of any witnesses to the incident f. The type of abuse that was committed (i.e., verbal, physical, sexual, neglect, etc.) g. Any other information that may be requested by management. Signs and symptoms of abuse in a dementia resident such as physical abnormality, withdrawal, loss of appetite, and general changes in patterns and psychosocial well-being The progressive characteristics of dementia (disorientation, withdrawal, mood and personality changes, and anxiety about symptoms), clinical challenges such as identifying pain, hunger, thirst, inability to express needs/wants, and other communication related symptoms of dementia that could cause a resident to have negative behaviors. In addition to identification of these challenges, the education focused on tactics to deal with difficult behavior such as walking away to allow for de-escalation, providing time/place orientation, using a soothing tone of voice, providing gentle tactile cueing, use of gestures, offering distractions such activities, music, or person-centered strategies (pictures, personal memorabilia). Identification of caregivers who appear stressed or need a break from working in the dementia environment should also be brought to the immediate attention of the supervisor. This training will be provided by the Administrator or the Human Resource Director to all agency staff and new employees upon hire during orientation. All facility staff in all departments, including as-needed and agency staff, received this training on 10/24/22-10/25/22 and all staff will continue to receive the training yearly thereafter. The Administrator and Human Resource Director were notified by the Regional Director of Operations of the need to provide this training to new hires on 10/25/22. Alleged IJ removal date is 10/26/22. On 10/27/22, the credible allegation of Immediate Jeopardy removal date of 10/26/22 was validated by onsite verification through facility staff interviews. The interviewed staff across all disciplines including nursing, front office, housekeeping, dietary, therapy, and maintenance, revealed the had all received in-service training regarding identifying and reporting allegations of abuse immediately. The facility had completed skin assessments of cognitively impaired residents and had completed interviews with cognitively intact residents. 1b. Review of the facility's policy titled Abuse and Neglect Protocol last revised on 06/13/21 revealed the following steps to be taken in the event potential abuse was observed: Any staff member or personal affiliated with this facility who has witnessed or who believes that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense shall immediately report, or cause a report to be made of, the mistreatment or offense. The policy also specified reporting times, stating If an incident of suspected abuse occurs, facility shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury to the state agency. An immediate investigation will be made and a copy of the findings of such investigation will be provided to the state agency within 5 working days or as designated by state law. During an interview with the Administrator on 10/20/22 at 1:53 PM, she reported she was informed by a staff member that NA #5 had been aggressive towards Resident #57 and had slapped her. She reported she believed the Housekeeper was not aware of Resident #57's behaviors of constantly trying to stand up and pace, along with her fall risk, and may have misinterpreted NA #5's actions. The Administrator stated she investigated the allegation as an incident and not an allegation of abuse. She also verified she did not complete an initial report to send in, to the State Agency. The Administrator stated because she investigated the allegation as an incident and had resolved it, she did not believe she needed to notify the State Agency, law enforcement, or adult protective services, in writing, of the allegation.

Based on record review and staff, Nurse Practitioner, Medical Director #1, and Medical Director #2 interviews, the facility failed to provide necessary medical attention when staff were aware of signs and symptoms of a possible cardiac event. Medical Director #1 instructed Nurse #1 to administer a pain medication along with his regular scheduled morning medications. The resident experienced cardiac arrest and subsequently passed away. This occurred for 1 of 2 resident reviewed for death (Resident #407). Immediate jeopardy began on [DATE] when Resident #407 experienced signs and symptoms of a cardiac event and necessary emergent medical interventions were not provided. The immediate jeopardy was removed on [DATE] when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of Level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education was in place and monitoring systems that were put into place were effective. The findings included: Resident #407 was admitted to the facility on [DATE]. His diagnoses included fracture of T9-T10 (T= thoracic, the area of the body between the neck and abdomen) vertebra (small bones forming the backbone), atherosclerotic (build-up of fat, cholesterol, and other substances in and on the artery walls) heart disease and pain. He was admitted for rehabilitation services. Review of the medical record revealed Resident #407 had an order dated [DATE] for full code cardiopulmonary resuscitation (CPR). Review of Resident #407's hospital discharge summary dated [DATE] revealed Resident #407 had a past medical history of coronary artery disease and a past surgical history of 3 vessel coronary artery bypass grafting (CABG) and cardiac stents. He was discharged on the following blood pressure, blood thinner and pain medications: clopidogrel (blood thinner) 75 milligrams (mg) by mouth once a day, lisinopril (used to decrease blood pressure) 20mg by mouth once a day, and metoprolol succinate (used to lower blood pressure) 100mg by mouth every night at bedtime and tramadol for pain. The discharge summary indicated that Resident #407 had fallen at home and fractured his thoracic vertebra and was discharged to the facility for therapy Review of Resident #407's admission Minimum Data Set (MDS) dated [DATE] revealed he was moderately cognitively impaired. Resident #407 was also coded for having no pain and no oxygen therapy was used during the assessment reference period. Review of Resident #407's care plan revealed he had a care plan in place for coronary artery disease and hypertension initiated on [DATE]. Interventions included monitor vital signs and administer medications as ordered. A telephone interview was conducted with Nurse #1 on [DATE] at 1:11 PM. Nurse #1 stated she remembered Resident #407 and recalled he had fallen at home prior to coming to the facility and fractured his back. Resident #407 was at the facility for therapy and had to wear a back brace when he was out of the bed. She revealed on the day Resident #407 coded ([DATE]) she had been passing medications on her hall, at approximately 9:30 AM, and the Receptionist advised her that Resident #407's family had called the facility and said that he was having difficulty breathing. Nurse #1 stated she immediately got her vital sign equipment and went to Resident #407's room where Resident #407 was on the telephone and did not appear to be in any distress. She took his vital signs, and his blood pressure was 140's over 80's, his respirations were a little high at 22, his pulse was 103 and his oxygen levels were low at ,d+[DATE]%. Nurse #1 stated that Resident #407 had normal color to his skin, he was not diaphoretic and said that he felt like he couldn't breathe. He was grimacing a little bit, but was not clutching his chest, rubbing his arm or his jaw. Resident #407 told Nurse #1 that his back brace was uncomfortable. Nurse #1 stated to Resident #407 that she was going to speak to Medical Director #1 (MD) and was anything bothering him. Resident #407 stated that he had chest pressure that felt like an elephant was sitting on his chest. Nurse #1 stated she reported to Medical Director #1 and Nurse Practitioner (NP), who were both in the building, what Resident #407 had told her along with his vital signs that she had taken and the reports of having trouble breathing. She stated Medical Director #1 and NP discussed among themselves and Medical Director #1 asked her if Resident #407 had any pain medication. Nurse #1 stated she told Medical Director #1 that Resident #407 had an order for Tramadol for pain as needed. Medical Director #1 instructed Nurse #1 to give Resident #407 a Tramadol and monitor him. Nurse #1 stated she asked for clarification twice from Medical Director #1 that he only wanted her to give Resident #407 a Tramadol and both times was told yes, by Medical Director #1. She stated she told Medical Director #1 again that Resident #407 stated he felt like an elephant was sitting on his chest and again Medical Director #1 stated to give Resident #407 the Tramadol and he would see him later that day. Nurse #1 stated she heard the NP state to Medical Director #1 that this was the resident Nurse #1 was talking about, the NP was pointing at a name on the list of patients that needed to be seen that day and that instructed Medical Director #1 to go and see Resident #407. Nurse #1 stated she went back to the medication cart and got Resident #407's morning medications, and a Tramadol and administered them to Resident #407, he took them without difficulty. Nurse #1 stated that she again took Resident #407's vital signs and his respirations had come down a little bit to 21. She stated that Resident #407 told her that he felt better. He was not grimacing or sweating or complaining of pain. Nurse #1 asked Resident #407 if he could use his call light if he needed her and he said yes, and she told him that she would be outside his room and would watch for the call light as she passed medications to other residents. Nurse #1 revealed that around 11:00 AM the Physical Therapy Assistant (PTA) and Occupational Therapy Assistant (COTA) came to her medication cart and advised her that Resident #407 had a large emesis, but they had cleaned him up and assisted him back to bed and that Resident #407 felt better after he vomited. Nurse #1 stated she had charted the emesis and about ,d+[DATE] minutes later she had finished her medication pass and passed his room, she could see that he was breathing, his color was normal, he was not sweating, and his call bell was next to him. She stated she went to the nursing station and was charting when a family member came to the desk at around 12:00 PM and informed her that Resident #407 would not wake up and he was cold. She immediately got up and went to Resident #407's room. Upon entering the room, she felt Resident #407's chest, he was not breathing, and she listened to his heart with a stethoscope, and she could not hear a heartbeat. She stated she left the room and the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were coming out of a room, next door to Resident #407's room. She advised them that Resident #407 did not have a heartbeat. They immediately checked his code status, obtained the crash cart, and Cardiopulmonary Resuscitation (CPR) was initiated. Code Blue (called when resident is without heartbeat) was announced overhead and 911 was called. She stated she did not see Medical Director #1 go into Resident #407's room prior to the Code blue. She did see the NP respond to the code blue and talk to the family. Nurse #1 stated Medical Director #1 called off the code blue after talking to the family in the hallway. Nurse #1 indicated that she was 100% sure that she had told both Medical Director #1 and the NP that Resident #407 had chest pain that felt like an elephant was sitting on his chest. Nurse #1 revealed if Medical Director #1 or NP had not been in the facility at the time that Resident #407 had complained of chest pain, she would have called 911 and sent him to the emergency room to be evaluated, but she had followed her chain of command. An interview was conducted with Nurse #2 on [DATE] at 11:04 AM. Nurse #2 stated she had completed her morning medication pass on her residents and went to assist Nurse #1 with her medication pass on [DATE]. She revealed during the medication pass a Nurse Aide came and advised her and Nurse #1 that Resident #407 had chest pain. Nurse #1 went and notified the NP and Medical Director #1, who were both in the facility. Nurse #1 stated that she had received an order from Medical Director #1 to administer Resident #407's regular medications and Tramadol. Nurse #2 stated she asked Nurse #1 why they were not administering nitroglycerin (common cardiac medication) to Resident #407, because it was her understanding if someone was experiencing chest pain a nitroglycerin was usually administered. Nurse #1 told her, The Doctor said to give tramadol and his routine medications. The routine medications and the Tramadol were administered between 10:30 AM- 11:00 AM. Nurse #2 stated she was not aware of Resident #407's medical history and had not taken care of him. She stated she went back to her hall after the medication pass was completed. An interview was conducted with the Physical Therapy Assistant (PTA) and Certified Occupational Therapy Assistant (COTA) on [DATE] at 11:21 AM. The PTA stated that he and the COTA had gotten Resident #407 up for the first time since his admission for therapy on [DATE] around 9:30 AM. They assisted him from laying down to sitting on the side of the bed. They applied his back brace and then Resident #407 transferred from the side of the bed to the wheelchair. He required very little assistance. Resident #407 did not complain of chest pain or shortness of breath at that time. Resident #407 was advised by the PTA that he and the COTA would be back in about an hour to assist Resident #407 back to bed. When they returned to the room approximately ,d+[DATE] minutes later, they observed a large amount of emesis on the floor. The PTA and COTA assisted Resident #407 back to bed, cleaned him up and positioned him for comfort. Resident #407 never complained of chest pain or shortness of breath. His color was normal, and he was not sweating. Resident #407 stated he felt better after he had vomited. The PTA and COTA notified Nurse #1 of Resident #407's emesis and she came in and took his vital signs, which were all normal. Review of the progress notes revealed a note dated [DATE] at 12:30 PM by Nurse #1, Patient not feeling well after therapy got him up this morning for the first time. Vital signs obtained and Nurse #1 spoke with the (former) Nurse Practitioner and Medical Director #1. Received an order to give regular medications and Tramadol (non-narcotic pain reliever) for discomfort from brace and getting up. Approximately ,d+[DATE] minutes later Nurse #1 rechecked Resident #407 and he advised Nurse #1 that he was not in pain. At approximately 11:00 AM, therapy advised Nurse #1 that Resident #407 had an emesis (vomit) and they laid him back down. Review of the progress note by the DON dated [DATE] at 1:03 PM revealed, During this shift at approximately 12 noon, called to Resident #407's room due to code blue status. Upon entering the room, resident found to be pulseless and non-breathing. CPR initiated immediately. Respirations being delivered via ambu-bag (self-inflating bag to provide positive pressure ventilation to patients who are not breathing) with high flow oxygen. NP in and aware of current situation. Family in building are aware of situation. CPR stopped at 12:19 PM after confirmation to stop CPR by NP. Resident pronounced dead at this time. Medical Director (Medical Director #1) in house and spoke with family regarding same. An interview was conducted with the DON on [DATE] at 3:24 P. The DON stated she remembered Resident #407 as she had admitted him to the facility on [DATE]. She stated she had been at a meeting when she heard code blue called over the loudspeaker, she responded to the code blue in Resident #407's room. His code status was verified, and he was a full code and CPR was initiated. The DON stated that the NP had come into the room during the code and was relaying messages from the family to the team that was performing the code blue. 911 was called and they responded but were not needed as the family decided to stop CPR. Medical Director #1spoke to the family after the code, she did not remember seeing Medical Director #1 in the room during the code. The DON stated per Nurse #1's written statement, Nurse #1 had told the MD #1 and NP that Resident #407 was experiencing chest pain that felt like an elephant was sitting on his chest, and that Nurse #1 had heard the NP tell the MD #1 that Resident #407 was on his list of residents to be seen that day. The DON indicated that routine practice was if someone had a significant cardiac history and was experiencing chest pain, that she would immediately call for help, apply oxygen and call for an ambulance. An interview was conducted with the ADON on [DATE] at 11:12 AM and confirmed she was familiar with Resident #407. The ADON revealed she had been in a meeting in a room next to Resident #407's room on the morning of [DATE] when Nurse #1 came in the room and asked her to come to his room, that she was unable to find a pulse on Resident #407. Upon entering Resident #407's room, she observed a male visitor attempting to find a pulse on Resident #407. She stated she checked for a pulse and was not able to auscultate (hear) a pulse. She checked Resident #407's code status and he was a full code, CPR was initiated. ADON indicated that the NP was present during CPR and spoke with the family. She stated she did not see the MD #1 during CPR. A telephone interview was conducted with Medical Director #1 on [DATE] at 10:03 AM. He stated he had been the Medical Director for the facility since [DATE] through [DATE]. Medical Director #1 stated he made rounds at the facility once a week and had been at the facility on [DATE] when Resident #407 had a cardiac arrest but had not evaluated Resident #407 prior to the code. He stated that Resident #407 was on his list to be seen that day for an admission assessment. Medical Director #1 stated he had reviewed Resident #407's medical record after the code and he had a significant cardiac history but had no cardiac notes or evaluation of his cardiac history. Medical Director #1 revealed when Nurse #1 came and told him that Resident #407 had pain, he was not the only resident that had to be seen, and that he had thought the pain was coming from the back brace and getting up with therapy. He stated, I was not the first person that the Nurse should have reported Resident #407's pain to, there was the DON, NP, other Nurses, and Nurse Aides that she should have reported to first. Medical Director #1 stated that all the residents in a nursing home had pain and he had other residents to see. He revealed he could not recall the exact events of Resident #407's cardiac event, but remembered he had a back brace. Medical Director #1 revealed he could not remember if Nurse #1 had told him that Resident #407 had chest pain that felt like an elephant was sitting on his chest and had emesis but recalled back pain. He stated he did not address every pain because he had a lot to do, and he was only there once a week. Medical Director #1 further stated he saw Resident #407 during the code and after, but not before, and spoke to the family twice after the code. He revealed if he had known prior to Resident #407's cardiac arrest that he had a significant cardiac history, he would have had the nurse call 911, because there was very little he could do outside of the hospital during a cardiac arrest, there was no epinephrine (cardiac drug) in the facility to use in a code, but he would have got Emergency Medical Services (EMS) involved and sent him to the hospital. Review of the Nurse Practitioner (NP) note dated [DATE] revealed Code Blue initiated at approximately 12:00 PM due to patient having no pulse or respirations. Facility staff performed CPR (cardio-pulmonary resuscitation) and EMS (Emergency Medical Services) were requested. After approximately 15 minutes of CPR, while family members that were present spoke with patient's responsible party via telephone, it was requested that facility staff stop CPR. A telephone interview was conducted with the Nurse Practitioner (NP) on [DATE] at 11:12 AM. The NP stated she had been the facility's Nurse Practitioner for about a year and saw residents in the facility Monday-Friday. She stated she thought she had seen Resident #407 at least once prior to his cardiac event on [DATE]. She explained that upon Resident #407's admission she had briefly seen him and reconciled his medication, but it was the Medical Directors responsibility to conduct a History and Physical on Resident #407. She stated on [DATE], while she and Medical Director #1 were discussing which residents had to be seen that day, Nurse #1 came into the room and advised them that Resident #407 was having chest pain, what his vital signs were and that he had just gotten up for the first time with therapy with a back brace on. The NP stated Medical Director #1 advised Nurse #1 to give him some pain medication and that he would see Resident #407 that day. She revealed she did not evaluate Resident #407 prior to his cardiac event, because she had her own list of residents to see that day and she thought Medical Director #1 was going to evaluate him. She stated she pointed to the list of resident names and to Resident #407's name, and said, see this is the man she is talking about, you need to see him first. The NP stated she believed that Resident #407 needed to be seen immediately and pointed to the list of resident's names. The NP stated she left to go and see her assigned residents and responded to the code blue when it was an overhead page. The NP stated she had wrongly assumed Medical Director #1 would go see Resident #407 first, and since they were in the building, they should have gone to Resident #407's bedside and evaluated him. The NP stated that Nurse #1 had responded appropriately to Resident #407's chest pain, by reporting it to the Medical Director #1 and NP that were in the building. The NP stated that the classic signs of a cardiac event was chest pain, diaphoresis (sweating profusely) and emesis. NP revealed these signs or symptoms could have been a side effect of the tramadol, but that either way, it required a bedside evaluation of the resident and listening to the resident's heart with a stethoscope. Review of a statement the NP executed on [DATE] indicated that the NP was working at the facility on [DATE] and was familiar with Resident #407 who had been admitted to the facility for rehabilitation following a vertebral fracture. The NP confirmed she was present when Nurse #1 reported Resident #407 was expressing that he had unspecified pain. The NP declared that Nurse #1 did not convey to her on [DATE] that Resident #407 had chest pain or pain that felt like an elephant was sitting on his chest. The NP confirmed that she was interviewed by state surveyor on [DATE]. During the interview with the state surveyor the NP explained it had not been conveyed that Resident #407 was complaining of chest pain specifically and could not offer an opinion on whether Resident #407's outcome could have been different if he would have been seen immediately. In the declaration the NP stated that Nurse #1 or other staff did not alert her to the urgency of Resident #407's pain complaints. The NP indicated no one at the facility asked for Resident #407 to be sent out to the hospital for further evaluation or treatment. An interview was conducted with Medical Director #2, by telephone, on [DATE] at 12:26 PM. The MD stated she had only been the Medical Director for a few days, and she was not familiar with Resident #407. She revealed that one of the first things that needed to be done when a resident complained of chest pain was to go and do a bedside assessment. Medical Director #2 stated she would have checked his blood pressure, pulse, oxygen saturation level, and description of his pain. If the resident was hemodynamically stable, then she would send the resident to the emergency room for an evaluation and if not, then provide urgent care at the bedside. Medical Director #2 further stated the best procedure was to send the resident to the emergency room for an evaluation. She stated the resident needed to be assessed well, and that it depended on the resident, their medical history, the assessment on whether to administer nitroglycerin or another pain medication. The Administrator was notified of the immediate jeopardy (IJ) on [DATE] at 6:54 PM. The facility provided the IJ removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On [DATE] at approximately 9:00am, Resident #407 complained of heaviness in chest and trouble breathing. The licensed nurse notified the medical providers that were in the facility. Pain medication was given as ordered by the medical provider. Shortly after medication given, the resident expressed that he felt better. Approximately 9:20am, the physical therapist placed the residents TLSO -Thoracis Lumbar Sacral Orthoses (Back brace) on and the resident was assisted out of bed by the physical therapist and the resident tolerated the transfer without complaints. 10:50am the licensed nurse observed that the resident had vomited. The resident was assisted back to bed by the licensed nurse and the physical therapist and the TLSO brace was removed. The resident was repositioned in bed with head of bed elevated and the resident's upper body and face were bathed. At approximately 11:04am, the licensed nurse left the room, and the resident was resting comfortably with no further complaints of pain or discomfort. The family came to visit at approximately 12 noon and notified the nurse that the resident would not wake up. The licensed nurse assessed the resident and determined that he was not breathing and did not have a pulse. CPR (Cardio/Pulmonary Resuscitation) was initiated by the licensed nurses and the resident subsequently passed away and pronounced at 12:19pm. - All residents who exhibited a decline in condition at the facility and were not sent out who expired were at risk of being affected by the alleged deficient practice. An audit of all residents who had expired at the facility was completed by the Regional Director of Clinical Services at 7:44 pm. 3 other residents were identified as expiring at the facility in the 30 days prior to the incident and through today. [DATE] through [DATE]. A review of the medical record of those residents revealed that two were hospice residents and one with general decline refusing dialysis with significant past medical history. There are no current residents exhibiting cardiac symptoms. This reveals no other residents have been affected by the alleged deficient practice. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. - All facility physicians and extenders, Nurse Practitioner and physician assistants received training on [DATE] by the Chief Medical Officer, to include how to respond and initiate medical treatment for residents that express and exhibit signs and symptoms of a cardiac event including an assessment by provider when possible or a transfer to another level of care. Medical Practitioners hired after [DATE] will receive education upon hire during new hire orientation by the physicians group Associate Director of Quality and Education. Regional Director of Clinical Services educated the Director of Nursing on [DATE], to include how to respond and initiate medical treatment for residents that express and exhibit signs and symptoms of a cardiac event such as chest pain that may feel like pressure, tightness, pain, squeezing or aching, pain or discomfort that spreads to the shoulder, arm, back, neck, jaw, teeth or sometimes the upper belly, cold sweat, and nausea/vomiting, including an assessment by provider when possible or a transfer to another level of care. The nurse may act independently and send the resident to the hospital in an emergency. All licensed personnel including Licensed Practical nurses and registered nurses were provided the information to include Identifying signs and symptoms of a possible cardiac event such as chest pain that may feel like pressure, tightness, pain, squeezing or aching. pain or discomfort that spreads to the shoulder, arm, back, neck, jaw, teeth or sometimes the upper belly, cold sweat, and nausea/vomiting, including an assessment by provider when possible or a transfer to another level of care. The nurse may act independently and send the resident to the hospital in an emergency. This education was completed on [DATE] by the Director of Nursing. Licensed nurses, to include agency staff and newly hired nurses will be educated prior to accepting assignment and/or during new hire orientation. The Director of Nursing was advised by the Regional Director of Clinical Services on [DATE] that all staff who had not been educated would need to be required to have the above in-service education prior to the start of their next scheduled shift. The Director of Nursing will be required to monitor and ensure all licensed staff receive this education by maintaining a log of education. All nurse aides and non-nursing staff to include contracted and agency staff present were educated by the Director of Nursing, ADON and nursing supervisor on [DATE], to continue to immediately report any complaints of pain or changes in condition to the licensed nurse. Contracted staff, nurse aides and agency staff will be educated prior to accepting assignment and/or during new hire orientation. The Director of Nursing was advised by the Regional Director of Clinical Services on [DATE] that all staff who had not been educated would need to be required to have the above in-service education prior to the start of their next scheduled shift. The Director of Nursing will be required to monitor and ensure all licensed staff receive this education by maintaining a log of education. Alleged date of IJ removal: [DATE]. Medical Practitioner interviews revealed they had been re-educated on how to appropriately respond to cardiac situations and watched a video again reiterating the steps to take when a resident was experiencing cardiac issues. All clinical staff and non-clinical staff verbalized understanding of signs and symptoms of residents experiencing cardiac issues. All staff were able to verbalize the signs of symptoms and who to report them to if a resident should experience them and how to respond if the appropriate medical attention was not delivered to call emergency medical services. The education sign in sheets were reviewed as well as the audits conducted to ensure no other residents were affected by the deficient practice. The facility's IJ removal date of [DATE] was validated.

Based on record review, staff, Resident, Pharmacist, and Facility Nurse Practitioner, Rheumatology Nurse Practitioner and Physician interviews the facility failed to administer five of six doses of a [MEDICAL CONDITION] arthritis medication that was ordered to be injected on a weekly basis for 1 of 3 sampled residents reviewed for unnecessary medications (Resident #2). Resident #2 experienced increased pain in her left shoulder and right knee. Immediate Jeopardy began on 08/14/20 when Resident #2 did not receive five of six doses of a [MEDICAL CONDITION] arthritis medication which was ordered to be given subcutaneously every week. Immediate Jeopardy was removed on 09/27/20 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level E (no actual harm with the potential for more that minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems in place are effective. The findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A telephone order given by the Rheumatology Nurse Practitioner (RNP) dated 07/29/20 indicated, Resident #2 was to receive Orencia Solution (a biologic medication that reduces the pain and swelling of moderate to severe [MEDICAL CONDITION] arthritis and can help stop further joint damage) 125 milligrams (mg) per 1 milliliter (ml) injection, 1 ml subcutaneously once a week. The telephone order also indicated, the order was faxed to the pharmacy by Nurse #3. Nurse #3 was no longer employed by the facility and unable to be interviewed. The Care Plan revised on 04/09/20 revealed, Resident #2 was at risk for pain related to [MEDICAL CONDITION] arthritis. The goal for Resident #2 was to verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the next review by administering [MEDICATION NAME] per the physician's orders [REDACTED]. The recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed, Resident #2 had intact cognition and required extensive assistance with the help of two staff for bed mobility, transfers and toilet use. The MDS indicated, Resident #2 received a scheduled and a prn (as needed) pain medication for pain described as frequent and moderate. The MDS also indicated, the Resident received an opioid pain medication and did not receive an injection during the seven day look back period. Review of Resident #2's September 2020, physician's orders [REDACTED]. *Orencia Solution 125 mg/ml subcutaneously one time a day every Friday for pain related to [MEDICAL CONDITION] arthritis ordered 07/29/20. *[MEDICATION NAME] Extended Release (ER) 40 mg give one tablet by mouth one time a day for pain, scheduled for 8:00 AM ordered on [DATE]. *[MEDICATION NAME] ER 30 mg give one tablet by mouth one time a day for pain, scheduled for 9:00 PM ordered 10/24/19. *[MEDICATION NAME] 5 mg give one tablet by mouth every two hours as needed for pain. May take with [MEDICATION NAME] if patient desired ordered 07/03/20. On 09/15/20 at 2:30 PM during a telephone interview with Resident #2 she explained, she was started on a medication for her [MEDICAL CONDITION] arthritis by the Rheumatologist but had not received the medication in several weeks. Resident #2 stated, the pain in her right knee, left shoulder and back was getting worse and there were nodules on her elbows that were painful when she laid her arms down on a flat surface, like her mattress, or when she tried to push herself up to a standing position using her arms. The Resident explained, when she did receive her arthritis injection, she could tell a major difference in her pain level in that now her pain level would get as high as a ten and when she took the prn pain medication, it would only relieve the pain for about two hours before her pain level started to increase. Resident #2 remarked, she was pretty much miserable all the time since she had not been receiving her arthritis pain medication. Resident #2's July, August and September 2020 Electronic Medication Administration Records (eMAR) revealed, there were no administration dates scheduled on the July 2020 eMAR. However, the [MEDICAL CONDITION] arthritis medication was scheduled to be administered on 08/07/20, 08/14/20, 08/21/20, 08/28/20, 09/04/20, and 09/11/20. The eMAR further revealed, the only date the Orencia was initialed as being administered was on 08/07/20. The eMAR indicated, Nurse #1 documented the #9 for the dates of 08/14/20, 08/28/20 and 09/11/20 and Nurse #2 documented the #9 for the dates of 08/21/20 and 09/04/20 which indicated Other/Progress Notes on the chart codes. Review of Resident #2's Progress notes revealed: *08/14/20 indicated pharmacy to deliver written by Nurse #1 *08/21/20 indicated med not in stock written by Nurse #2 *08/28/20 indicated called the pharmacy to deliver tonight written by Nurse #1 *09/04/20 indicated not in stock written by Nurse #2 *09/11/20 indicated pharmacy to deliver written by Nurse #1 On 09/15/20 at 2:13 PM a telephone interview was conducted with Nurse #1 who confirmed, he was the Nurse who worked on 08/14/20 at 8:00 AM and who documented he did not give Resident #2 the Orencia injection because he did not have the medication on hand and had to order the Orencia from the pharmacy. Nurse #1 stated, he reported to the oncoming 7:00 PM - 7:00 AM B Station (the hall Resident #2 resided on) Nurse which was Nurse #4 that he was not able to give the Orencia and that Nurse #4 should give Resident #2 the Orencia when the pharmacy delivered the medications that evening. When asked if Nurse #1 followed up the next day to confirm the medication had been given to Resident #2, he stated he did not because he was assigned to a different hall. Nurse #1 added, he could not confirm whether he was the Nurse who worked on 08/28/20 or 09/11/20 but he knew there were other dates that the injection was not available, and he had to order the Orencia from the pharmacy. Nurse #1 offered no indication that the pharmacy could not deliver Resident #2's arthritis medication. On 09/15/20 at 2:50 PM during a telephone interview with Nurse #4 she explained, she was not assigned to work B Station on 08/14/20 7:00 PM - 7:00 AM and therefore, Nurse #4 did not know anything about Resident #2's Orencia injection. Nurse #5 was assigned to work 08/14/20 7:00 PM - 7:00 AM and several attempts were made to obtain an interview. The attempts were unsuccessful. Nurse #2 was an agency Nurse who no longer had a contract with the facility and was unable to be interviewed. Nurse #6 who worked on 08/15/20 7:00 AM - 7:00 PM was on leave of absence and was unable to be interviewed. Attempts to interview Nurse #7 who worked on 08/29/20 7:00 AM - 7:00 PM were unsuccessful. Review of several pharmacy delivery sheets for Resident #2's Orencia revealed: *On 07/30/20 Orencia Solution Prefilled Syringes of 125 mg/ml, 2 syringes were delivered. *On 08/14/20 Orencia Solution Prefilled Syringes of 125 mg/ml, 2 syringes were delivered. *On 08/28/20 Orencia Solution Prefilled Syringes of 125 mg/ml, 2 syringes were delivered. On 09/15/20 at 10:45 AM during a telephone interview with the Pharmacist she confirmed, the pharmacy had delivered Resident #2's Orencia Solution 125 mg/ml, 2 syringes on 07/30/20, 08/14/20 and 08/28/20 to the facility. The Pharmacist also shared, the prescriber had approved the Orencia in June of 2020 and the prior approval was effective through 06/2021. Review of the Nurse Practitioner's Progress Notes dated 09/14/20 revealed, Resident #2 presented with the following assessment: severe joint deformities in her bilateral hands; severe ulnar deviations of her fingers; tenderness in her knees, ankles, wrists and hands; nodules along her radius and near the elbows; no acute joint redness or swelling and her right knee and left shoulder were particularly tender. On 09/15/20 at 10:10 AM a telephone interview was conducted with the Facility Nurse Practitioner (FNP) who stated, she had assessed Resident #2 the previous evening on 09/14/20. The FNP explained, Resident #2 complained of increased pain in her right knee and left shoulder and stated she was not getting her arthritis injection that the Rheumatologist ordered for her. The FNP continued to explain, that Resident #2 was ordered to receive Orencia injections by the RNP once a week to prevent her [MEDICAL CONDITION] arthritis flare ups and after research the FNP discovered that the last dose of the Orencia injection was given on 08/07/20. The FNP stated, she had not been made aware that Resident #2 was not receiving the medication or that she had missed five doses. The FNP explained, if Resident #2 did not receive the Orencia soon that she would have to start Resident #2 on course of steroids. The FNP shared, the Orencia required a prior authorization approval from the prescriber and that approval had already been completed. On 09/16/20 at 4:21 PM a telephone interview was conducted with the Rheumatology Nurse Practitioner who explained, Resident #2 had been a patient of the clinic for years. The RNP confirmed, in late July 2020 she had given an order for [REDACTED].#2 not receiving the ongoing treatment for [REDACTED]. During an interview with Resident #2's Physician on 09/16/20 at 9:50 AM he explained, he was made aware of the situation with Resident #2's Orencia injections not being given on Thursday (09/10/20) as he was leaving the facility and thought he would address the situation when he was back in the facility on 09/17/20. He stated, the NP saw Resident #2 more than he did, and the NP had not indicated to him that Resident #2 was not receiving her arthritis medication nor had the facility informed him that the medication had not been given. The Physician added, if the Orencia was currently an active order, then it should have been given as ordered. A telephone interview was conducted with the Director of Nursing (DON) on 09/17/20 at 12:00 PM. During the interview the DON confirmed, Resident #2's Orencia was charted as not given on 08/14/20, 08/21/20, 08/28/20, 09/04/20 and 09/11/20 with follow up progress notes that indicated the medication was either not in stock or that the medication was ordered from the pharmacy. The DON explained, the nurses should have notified her that the medication was not available so that she could have followed up with the pharmacy herself. The DON stated, when she investigated the situation, she found two syringes of Resident #2's Orencia medication in the medication room on A Station which was not the medication room in which Resident #2's medication was stored. The DON shared, she did not know why the nurses did not follow up with giving the medication when it was delivered from the pharmacy. On 09/17/20 at 2:30 PM during a follow up telephone interview with the DON she explained, that she had educated the nurses multiple times to notify her when a medication was not available from the pharmacy so that she could follow up with the pharmacy herself and that by the nurses not notifying her when Resident #2's Orencia was not available was an error on their part. During a telephone interview with the Administrator on 09/17/20 at 4:50 PM he stated, he expected the doctor's orders to be followed as they were written, and the nurses should have notified the DON when Resident #2's medication was not available from the pharmacy so that she could have followed up with the pharmacy. The Administrator and Regional Clinical Director were notified of Immediate Jeopardy on 09/26/20 at 8:18 PM. The facility provided the following credible allegation of Immediate Jeopardy removal for F 760: 1. Identify those recipients who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance. Based on record review, staff, Resident, Pharmacist, and Nurse Practitioner interviews the facility failed to administer five of six doses of a rheumatologist ordered medication that was to be injected on a weekly basis to treat [MEDICAL CONDITION] arthritis for 1 of 3 sampled residents reviewed for unnecessary medications (Resident #2) because the nurse failed to retrieve the medication from the medication refrigerator, and instead, documented that the medication was not available. They failed to alert the Director of Nursing or Nursing Supervisor. While Nurse #1 and Nurse #2 both had progress notes for the five missed doses and indicated the medication was not in stock or the pharmacy would deliver, the root cause was that they documented this without checking the refrigerator which was where the medication was located. Further, the Nursing Supervisor failed to identify the medication as missed within the electronic medical record system. This information should have been reviewed in the daily clinical meeting which is held five days per week. The weekend Supervisor monitors this information on the weekends. The Physician was notified on 9/14/20, by the Director of Nursing regarding the missed medication, Orencia 125mg/ml for Resident #2 for the dates of 8/14, 8/21, 8/28, 9/4 and 9/11/20. The Director of Nursing stated, when she investigated the situation, she found two syringes of Resident #2's Orencia medication in the medication room on A Station which was not the medication room in which Resident #2's medication was stored. The medication was received by a Licensed Nurse who took the medications and placed them in the A nurse's station refrigerator. The other medications were also located in that same refrigerator. It was found during the investigation that the medications were received and stored in the location where the Resident had originally resided. The facility has since changed to a centralized location where all refrigerated medications are received. The Nurses were made aware of this change via telephone or in person on September 27th by the Director of Nursing and Administrator. Resident #2 received an injection on 9/16/20 and again on 9/23/20. The Physician assessed and reviewed the Resident's medications on 9/24/20 and wrote an order to hold the medication until 10/01/20 due to the medication can weaken the immune system. The Physician also documented that the Resident's pain was fairly controlled with her pain medications of [MEDICATION NAME] and [MEDICATION NAME]. Current facility residents were at risk to be affected by the alleged deficient practice of failure to receive medications as ordered. The Director of Nursing completed an audit of current facility residents' Medication Administration Record [REDACTED]. There was one Resident identified that did not receive the scheduled dose of [MEDICATION NAME] on 9/22/20 at 8:00 AM. The Nurse Practitioner was notified on 9/27/20 by the Licensed Nurse. No new orders were received. There were no adverse effects identified. The Director of Nursing and Charge Nurses completed an audit comparing the ordered medications to what was on the cart on 9/27/20, to validate that medications were available to be administered as ordered. All medications were available. 2. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. The Director of Nursing and the Nursing Supervisors completed education for current Licensed Nurses on 9/27/20, regarding the protocol for obtaining medications and process for notification if a medication was not available to be administered as ordered. When a medication order is written, the Licensed Nurse will input the order in the electronic medical record and the order will be received by the pharmacy to be filled and sent to the facility. During the medication pass, if the medication is not available on the medication cart, the Licensed Nurse should look in the back up medication room and if not available there, the Licensed Nurse should get the medication out of the Emergency Stat safe kit. If the medication is not available in the kit and is not available from the back up pharmacy, the Licensed Nurse will notify the Physician and an order will be written for a medication that is available or hold the order until the medication was available. The Licensed Nurse will notify the Director of Nursing regarding the needed medication 24/7. The Medication Availability Form which is a new form will be kept on each medication cart for the Licensed Nurse to document the steps taken to obtain the medication. This new form was provided to all licensed staff, including current agency staff, with education to the new process. All new staff will be educated by the Director of Nursing or Unit Coordinators to the new procedure during orientation prior to taking an assignment. The Director of Nursing and or the Nursing Supervisor will review the Medication Availability list daily seven days a week to assure medications were available as ordered. No Nurse will be allowed to work until educated. Newly hired Licensed Nurses will be educated during the new hire orientation. The Supervisors have been informed of this responsibility. The Director of Nursing and or the Nursing Supervisors will run a report from the electronic medical record daily seven days a week to identify medications that were documented as missed or not given. The Director of Nursing and or the Nursing Supervisors will follow up when it is identified that a medication was not given or not signed out as given, to determine the reason and assure the medication is available and given as ordered. If the medication was not given as ordered the Licensed Nurse will notify the Physician for further orders. The Nursing Supervisors were informed of this responsibility as provided by the training provided on 09/27/2020 by the Director of Nursing. The facility alleges the removal of the Immediate Jeopardy on 09/27/20. On 10/02/20 the facility's credible allegation for Immediate Jeopardy removal was validated by the following: Review of in-service training records included twenty-four individuals from the nursing department which included floor nurses, supervisors, unit managers, and the management team. The topic of the education was on medication availability that included new processes regarding medication unavailability, ordering medications, notifying physicians of unavailable medication and notifying the Director of Nursing of unavailable medications. The new system introduced a new form titled Medication Availability which would be utilized in the event of unavailable medications and would be monitored by the management team. The Director of Nursing and the Administrator conducted the in-services which were held both by person and via telephone. Interviews with the facility and agency nurses revealed they received the education on 09/27/20 or on hire and could describe the new processes and the nurses could explain the reason and intent of the new Medication Availability form. Observations of the medication carts revealed the new Medication Availability form was present on the medication carts and medications that required refrigeration was noted to be stored in the centralized medication room as indicated by the new system. The facility's date of Immediate Jeopardy removal of 09/27/20 was validated.

Based on observation, record review, review of manufacturer's instructions, and staff, resident, Family Nurse Practitioner, and manufacturer representative interview, the facility failed to secure the front two wheelchair tie down retractors in a manner to prevent slack in the securement system and prevent a wheelchair from moving during a van transport for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #2). Resident #2's wheelchair fell backwards onto the floor of the van which resulted in Resident #2 striking his head on the van floor and caused a left lateral 8th rib fracture. Resident #2 was taken to the hospital for evaluation and returned to the facility the same day. Finding included: The undated manufacturer's instructions for the securement system used in the facility's transport van to secure residents who were seated in wheelchairs during transport was made up of: 4 wheelchair tie downs, 1 occupant lap belt, 1 occupant shoulder belt and floor anchorages. The instructions read in part, attach tie downs into floor anchorages and ensure they are locked in. Ensure all tie downs are locked and properly tensioned. If necessary, rock wheelchair back and forth or manually tension retractor knobs (if present) to take up additional webbing slack. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 expired at the facility on [DATE]. The Nursing Admission Assessment (NAA) dated [DATE] indicated, Resident #2 was alert and oriented to person, place, time and situation. The NAA also indicated, Resident #2 was totally dependent for transfers. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set assessment dated [DATE] revealed, Resident #3 had moderately impaired cognition. Resident #3 was discharged on [DATE]. The facility's Incident Report (IR) dated [DATE] at 4:10 and completed by Nurse #1 indicated, the Van Driver (VD) called Nurse #1 to the transport van which was parked outside the facility. The VD stated the front straps on Resident #2's wheelchair unlocked when he drove over the first speed bump in the parking lot which caused his wheelchair to fall backwards. The Nurse observed Resident #2 sitting upright in his wheelchair holding his left flank area and complained of pain in his back, head and between his shoulders. Resident #2 who was alert and verbally responsive stated, his wheelchair fell backwards, and he hit his head and back. Resident #2 was taken to his room and Nurse #1 notified the Family Nurse Practitioner (FNP) of the incident who gave an order for [REDACTED].#2 was transferred to the hospital via the Emergency Medical Services (EMS). The IR continued to explain, that Resident #3 was also on the van and stated, they were going slowly over the first bump when the latches released and Resident #2's wheelchair fell straight backwards, then the VD stopped and checked on Resident #2. The Administrator interviewed Resident #2 on [DATE]. The typed interview indicated, Resident #2 was asked what happened and Resident #2 replied, that he did not know except that on the way up the driveway his chair flipped. The Administrator asked Resident #2 if he could recall if he and Resident #3 was restrained with the front restraint straps and Resident #2 replied yes, with all the straps including the shoulder harness. The Administrator asked Resident #2 how the ride back to the facility was and the resident stated it was good with no problem. The typed statement was signed by Resident #2. The Administrator also interviewed Resident #3 on [DATE]. The typed interview indicated, the Administrator asked Resident #3 what happened and Resident #3 stated they were headed back to the facility when the van went over the speed bump and Resident #2's chair flipped over. The Administrator asked Resident #3 if he could recall if he and Resident #2 was restrained and Resident #3 replied yes, they were both restrained appropriately, and he did not understand why Resident #2's chair flipped. The typed statement was signed by Resident #3. The Emergency Department (ED) report dated [DATE] revealed, Resident #2 was examined for multiple trauma/fall after the transportation van he was riding in went over a speed bump and caused his wheelchair to fall backwards and caused him to hit the back of his head and his left lateral chest wall. Resident #2 complained of pain and denied loss of consciousness. Resident #2 received a computerized tomography (CT) scan w/o contrast of the chest which resulted in a nondisplaced left lateral 8th rib fracture and a head CT w/o contrast that resulted in no acute finding. Resident #2 explained, he had recently been started on a pain medication at the nursing home and was given one dose of pain medication while at the hospital before he was discharged back to the nursing home that same day. During a telephone interview with the Van Driver (VD) on [DATE] at 1:05 PM he confirmed, he was driving the facility's transportation van on [DATE] when Resident #2 fell backwards in his w/c. The VD explained, he picked Resident #2 and Resident #3 up from [MEDICAL TREATMENT] and secured them in the van by way of his normal routine. He stated, he parked Resident #2 behind the passenger side of the van and locked the brakes on his wheelchair then continued to secure the front two tie downs before he secured the back two tie downs. The VD stated, he checked the tie down straps for slack and the wheelchair for stability by rocking the wheelchair back and forth before he applied the seatbelt and shoulder strap. He continued to explain, that when the front two wheels of the van went over the speed bump in the driveway of the facility parking lot, he heard a noise then Resident #2 said he was falling backwards, and the VD pulled the van over to go back to check on Resident #2. The VD found Resident #2 lying on his back still seated in his wheelchair with his seatbelt and shoulder strap in place. The back two tie down straps were secure, but the front two tie down straps had released enough tension to allow the wheelchair to fall backwards. The VD stated, when he asked Resident #2 what happened, he stated his prosthesis must have hit the latches and he fell backwards. The VD explained, Resident #2 was trying to get the wheelchair back in upright position but could not by himself and insisted the VD sit him upright. The VD stated, he called into the facility to inform the Administrator of what happened, and Nurse #1 came out to the van and assessed Resident #2 before they sat him upright. He stated, he hooked Resident #2 back up and he moved the van up to the where he usually parked the van while the Nurse stayed in the back of the van with the residents. The VD stated, after the incident the same day he had to reenact the securement process for the Administrator and the Maintenance Supervisor (MS) using Resident #2's wheelchair. He stated, the only explanation he had was that Resident #2's footrests or his prosthesis hit the red release lever on the top of the tie downs when he went over the speed bump which caused enough slack in the front straps and allowed the wheelchair to fall backwards. The VD explained, when he was hired the MS trained him to drive the van which consisted of 3 days of reviewing videos of the securement system, return demonstration of loading and unloading residents and performing the procedures with the MS present. He stated, he had to complete a check off list of procedures before he could drive the van by himself without supervision. A telephone interview was conducted with Nurse #1 on [DATE] at 10:55 AM who confirmed, she was the Nurse who assessed Resident #2 on [DATE]. The Nurse explained, she was called out to the van which was parked in the van's usual parking spot and observed Resident #2 sitting upright in his wheelchair holding his left side and he complained of pain in his head, back and between his shoulders. The Nurse stated, she notified the FNP who gave her an order to send Resident #2 to the hospital for evaluation and Resident #2 was transported to the hospital by EMS. The Nurse reported, Resident #2 returned the same day with rib fractures. The Nurse explained, the only thing she knew about how the incident happened was what the VD reported to her that when the van went over the speed bump Resident #2's wheelchair fell backwards. The Nurse also reported, Resident #3 was also a passenger on the van but did not have any issues related to the incident. On [DATE] at 3:00 PM a telephone interview was conducted with the Maintenance Supervisor (MS) who explained, that he was called to the facility on the afternoon of [DATE] because of an incident with the van and Resident #2. The MS stated, he checked the tie downs, and the straps and could not find anything visibly wrong with them. He stated, he then had the VD to reenact the securement procedure using Resident #2's personal wheelchair. He explained, the only thing they could possibly conclude was that the leg rests on the wheelchair rested at the release point which was at the red lever on top of the tie downs and the leg rests could have hit the levers when the van went over the speed bump and caused them to release enough tension on the straps that Resident #2's wheelchair fell backwards. The MS stated, he could not be sure of the exact cause because he was not present when the incident happened. The MS explained, that since they were unable to identify the exact reason for the incident, the facility opted to purchase new tie downs to replace the ones used for Resident #2 and the facility took the van out of service until the new tie downs were installed. He stated, the van was out of service for about 4 days and the facility had to utilize EMS for the transports. He explained, in the meantime they reeducated all the van drivers which included videos, securement process installment and conducting audits that lasted for several months because the facility initiated a self-directed plan of correction that was addressed in the monthly Quality Assurance (QA) meetings. A telephone interview was conducted with the Administrator on [DATE] at 9:00 AM. The Administrator confirmed there was an incident on [DATE] where Resident #2's wheelchair fell backwards in the facility van while being transported from [MEDICAL TREATMENT]. The Administrator explained, as the van was going up the hill into the facility parking lot and went over the speed bump the VD heard a noise and observed a wheelchair had fallen over. The VD stopped the van and went to the back to find Resident #2 in his wheelchair and the wheelchair was lying on its back on the floor of the van. The Resident was still harnessed in his wheelchair with his seatbelt and shoulder strap secured in place. Resident #2 insisted on the VD sitting him upright so the VD, in fear of getting hit by another vehicle because he stopped the van in the road on the hill, assisted Resident #2 to upright position and secured the front straps before he proceeded to the front of the facility. The VD called into the facility to notify the Administrator and the Nurse of the incident. By the time the Administrator had arrived at the van, Resident #2 had already been taken to his room by the VD but Resident #3 was still in the van. The Administrator questioned Resident #3 about the incident and the Resident stated, he did not know what happened because he watched the VD tie Resident #2's wheelchair down with all the tie downs the way he always tied him down and Resident #2 just flipped backwards. Resident #3 added, Resident #2 did not come out of his wheelchair. The Administrator continued to explain, that when he went to Resident #2's room Nurse #1 had already assessed him and he complained of side pain and that he hit his head. When the Administrator asked Resident #2 what happened he stated, he did not know but the VD secured him in the correct way, and he was just on the floor. The Administrator stated, about that time the EMS arrived to take Resident #2 to the hospital, where he was evaluated and treated and returned to the nursing home same day. The Administrator explained, that also on [DATE] the MS and the Administrator had the VD to demonstrate for them the procedure he used to secure Resident #2 with the tie downs using Resident #2's personal wheelchair but they could not determine a root cause of the incident so they opted to err on the side of caution and replaced the tie downs. The Administrator stated, the van was taken out of service until the new tie downs were replaced. The Administrator added, he completed the summary of investigation and the plan of correction that was put into place on [DATE] with the assistance of the Director of Nursing who was no longer employed by the facility. The Director of Nursing at the time of the incident on [DATE] was no longer employed by the facility and unable to be interviewed. A follow up telephone interview was conducted with the Van Driver (VD) on [DATE] at 5:00 PM. The VD explained, that he had misspoken during his first interview when he stated that Nurse #1 came out to the van to check on Resident #2 when the van was parked in the driveway and that the Nurse helped him sit Resident #2 upright in his wheelchair. He stated, it had been a long time since the incident happened and he did not have his notes in front of him when he was asked about the event. The VD stated, he wanted to clarify that Resident #2 insisted that the VD sit him upright and he was trying to get up by himself and because had stopped the van in the driveway he was concerned that the van could be hit by another vehicle. Therefore, the VD sit the wheelchair upright and secured the front two tie downs then drove the van up to the building where the Nurse came out assessed Resident #2 before he took him to his room. The VD explained, that after the incident all the van drivers had to go through the whole training process again which included classroom work, videos, demonstration performance and conducting audits for several months afterwards. During a follow up telephone interview with the Administrator on [DATE] at 6:05 PM he acknowledged, he provided via email the detailed Quality Assurance/Process Improvement Plan (QAPI) along with the documentation of proof for the QAPI related to the [DATE] incident. The Administrator stated the QAPI continued until the [DATE] Quality Assurance QA meeting and that he was responsible for compliance. A telephone interview was conducted with the Family Nurse Practitioner (FNP) on [DATE] at 11:35 AM. The FNP explained, her laptop was not available to her at that time of the interview but stated, she remembered the van incident with Resident #2 and requested the IR be read to her. The FNP then confirmed, that Nurse #1 notified her on [DATE] because Resident #2 had fallen in the van and was complained of side pain and that he hit his head so she gave Nurse #1 an order to send Resident #2 to the hospital for evaluation. The FNP continued to explain, that Resident #2 had scans at the ED that determined he had rib fractures and since he was already on pain medication for his other health conditions, he was given one dose of pain medication for his rib pain in the ED and sent back to the nursing home on the same day. The FNP confirmed, Resident #2 sustained the rib fracture as a result from his fall in the van on [DATE]. On [DATE] at 4:54 PM the Administrator confirmed in an email that the Van Driver was suspended during the investigation of the incident on [DATE]. During a follow up interview with the Maintenance Supervisor (MS) on [DATE] at 9:50 AM he explained, the same securement system had been used during his employment. The MS continued to explain, that the last time he inspected the van was [DATE] and provided a document that indicated a vehicle safety inspection was conducted on [DATE] by the MS who deemed the tie downs were secure to the floor, not frayed, and in good working condition. The MS stated, that he along with the Human Resource Director (HRD) were responsible for reeducation on the securement system and performance procedures for the van drivers and he was also responsible for the routine monitoring and auditing of the van that was outlined in the self-directed plan of correction. The HRD was unavailable for interview. An interview was conducted on [DATE] at 3:05 PM with a representative of the manufacturer of the securement system utilized by the facility on [DATE]. The representative explained, the securement system was designed for the tension (slack) from the tie downs to automatically tighten, after they were correctly applied to the wheelchair, by rocking the wheelchair back and forth and the only way to release the tension was to manually press the release button on top of the tie downs. Therefore, the representative stated, if the user applied the securement system the correct way the video instructed, the tie downs would not have released the tension that would have allowed the wheelchair to fall backwards. The facility's corrective actions implemented after the incident to prevent a reoccurrence included the following: All items listed on this self-imposed action plan have been completed and implemented on [DATE] with ongoing monitoring to ensure compliance. This concludes the action plan and any potential citation associated with this action plan should be considered past noncompliance as of [DATE]. The statement was signed by the Director of Nursing and Administrator and dated [DATE]. CORRECTIVE ACTION THAT WILL BE ACCOMPLISHED: -[DATE] Resident #2 was assessed by the Licensed Nurse following a fall in the van. -[DATE] Physician was notified, and Resident #2 was transferred to the hospital for evaluation. Resident #2 returned to the facility on [DATE] with [DIAGNOSES REDACTED]. -[DATE] The van was taken out of use on following the incident until checked out by an approved van dealership to assure straps were functioning properly. -[DATE] As a precautionary measure the facility will replace the straps as it may be the contributing factor. -[DATE] The van will remain out of service until the new straps have been installed. -[DATE] The van was checked by an approved dealership and validated that all straps were working properly. -[DATE] The new straps were installed in the van and inspected. All were working properly. IDENTIFICATION OF OTHER RESIDENTS: -There was one other resident in the van when the incident occurred on [DATE]. Resident #3 was interviewed by the Administrator on [DATE] and he stated he observed the driver attach the straps on his and Resident #2's wheelchair. Resident #3 stated he did not know what happened. -On [DATE] the DON and the HRD interviewed other residents in the facility that were interviewable and had been transported in the facility van within the last 14 days to identify any concerns related to proper securement in the van during the transport process. There were no concerns voiced or identified. MEASURES FOR SYSTEMIC CHANGE: -[DATE] The van will remain out of service until the new straps have been installed as the potential for strap malfunction may have caused the incident. -[DATE] and [DATE] The facility van drivers were re-educated via the manufacturer's video and return demonstration regarding the use of the van and proper securement of residents and wheelchairs inside the van. No van driver will be permitted to transport residents until the re-education has been completed. -[DATE] All van drivers will continue to complete the pre-trip checklist each morning prior to the first transport. -[DATE] The Maintenance Director will complete a safety inspection of the van twice a month. HOW CORRECTIVE ACTION WILL BE MONITORED: -[DATE] The Maintenance Director and/or Administrator will observe 10 transports a week for 4 weeks then 5 transports a week for 2 months to validate the straps are working functioning properly and properly attached to the wheelchair. -[DATE] The Maintenance Director or the Administrator will review the audits monthly to identify any patterns or trends and will adjust the plan to maintain compliance. -[DATE] The Maintenance Director or the Administrator will review the plan during the monthly QAPI meeting, and the audits will continue at the discretion of the QAPI committee. The Administrator was responsible for compliance. The date for the decision to QA and monitor was [DATE] End of QAPI/POC ,[DATE] The Performance Improvement Project (PIP) was a self-imposed action plan for the van was reviewed in the QAPI meeting for [DATE]. The interdisciplinary team determined that since no further incidents have occurred, the audit was determined to be satisfactory and no further monitoring was required. On [DATE] at 10:45 AM, during the Extended Survey, an observation was made of the Van Driver (VD) who demonstrated how he connected the securement system to Resident #2's wheelchair while the Maintenance Supervisor (MS) was seated in the wheelchair. The VD followed the manufacturer's instructions when he placed all four J hooks, two in the front and two in the back, to the lowest part of the wheelchair connection and rocked the wheelchair back and forth to allow the tie downs to automatically take up the slack in the straps. After the VD applied the seatbelt and shoulder strap, he again rocked the wheelchair back and forth the ensure the wheelchair was unable to move. The VD insisted that he applied the securement system the same way on the day of the incident with Resident #2's wheelchair but could not definitely explain how both of the tie downs released tension at the same time which allowed Resident #2's wheelchair to fall backwards. On [DATE] at 11:10 AM the facility's plan for past noncompliance was validated by the following: 1) Review of in-service training records revealed all five van drivers had been in-serviced on the van's securement system including return demonstrations on [DATE] and [DATE]. 2) Interviews were completed with current van drivers. There was one van driver hired after [DATE] who confirmed she received all necessary training that included watching videos, safety inspection of the transportation van, return demonstration of the safe application of the securement system, and demonstration of transporting a resident in the van with the instructor present. 3) The interviews validated the van drivers had undergone training regarding the safe application of the securement system. 4) A review of the facility's audits verified they were completed as specified in their self-imposed action plan. 5) Compliance was achieved on [DATE] when all van drivers had been reeducated regarding the van securement system.

Based on observations, record review and staff interviews, the facility failed to supervise and implement interventions for 2 of 10 residents, (Residents #122 and #101), who were non-compliant regarding the facility's smoking rules. In addition the facility failed to keep chemicals out of the reach of the residents residing on 1 of 3 units. (Unit C). Immediate Jeopardy began on 04/30/14 when Resident #122, with a known history of unsafe smoking behaviors, smoked on the facility's premises in a nondesignated smoking area and unsupervised while having an oxygen tank, located on the back of his wheelchair, turned on and the nasal cannula hanging on the wheelchair. Immediate Jeopardy was removed on 09/24/14 at 7:00 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency, no actual harm with potential for more than minimal harm, that is not immediate jeopardy) to complete education and to ensure monitoring systems put into place are effective related to resident smoking and for noncompliance for examples #2 and #3. The findings included: The facility's undated Resident Smoking Policy stated "All smoking materials are required to be maintained at the nursing station", "Residents must be assisted at all times when smoking by either a family member or an employee", "Smoking will be allowed at designated times, as determined by Administration and the Smoking Committee." 1. Resident #122 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan dated 08/09/13 identified the problem of Resident #122 not abiding by the smoking policy, smoking without staff supervision and during non-smoking times. Interventions were to monitor him closely when observed going to the smoking area during non-smoking times, alert the supervisor, advise him if caught smoking against the rules that he is non-compliant with smoking rules and his smoking times would be suspended. An additional intervention included to ask the resident if he had any tobacco products on his person or if he was in possession of a lighter. A smoking assessment dated [DATE], signed by Social Worker (SW) #1 included that Resident #122 did not extinguish smoking materials in an ashtray, smoked in non-designated areas, and had been observed giving smoking materials to and /or from peers. The conclusion was "Resident can responsibly handle smoking materials." This assessment included that a care plan would indicate he needed supervision. Review of social service notes revealed Resident #122 smoked against the rules as follows: *On 11/04/13 it was reported to the SW the resident was sitting on the patio with another resident smoking. When approached, the resident dropped his cigarette down by his side. Explained to the resident he was smoking unattended and at a time that was not designated. The residents were sitting in an area where there were no ash trays, they were sharing cigarettes and had cigarettes and a lighter on them. Due to violating the smoking policy, Resident #122's smoking privileges were suspended for 24 hours. Reviewed the smoking policy and the smoking behavior contract with the resident. Resident #122 stated his understanding. *On 11/13/13 after all the smokers ended their designated smoke break, Resident #122 was noted off to the side of the building with his oxygen tank on the back of his wheelchair smoking a cigarette. The nurse was notified and took the cigarette and lighter from him. This was his second offense and under the policy his smoking privileges were to be revoked. Will arrange to have his room searched for more cigarettes and lighters. *On 11/27/13 Resident #122 was observed by the Administrator outside smoking in the B station patio. This was the resident's third offense. Explained the dangers of smoking with oxygen. His room was searched and cigarettes and a lighter were found. A cigarette was found in the resident's jacket pocket. Administrator explained he would be issued a 30 day discharge notice. Interview with SW #2 on 09/22/14 at 2:05 PM revealed that Resident #122 had his smoking privileges taken away at least twice and the former Administrator would always give him back the privileges. He was unable to provide any time frames or documentation of when the resident's smoking privileges were removed or reinstated. Interview on 09/22/14 at 4:01 PM with SW #1 revealed the Administrator was supposed to give the resident a 30 day notice but never did. She stated that during a search of his room, unknown date, a lighter and cigarette was found. After this, nurse aides were to search his room but SW #1 did not know of any set schedule or set person responsible for searches. Interview on 09/23/14 at 11:39 PM with SW #2 and SW #1 revealed no discharge notice was ever given to Resident #122 because no alternative placement for him could be located and then looking for alternative placement was dropped. On 12/04/13 the smoking care plan for Resident #122 was reviewed with no changes to the interventions. The care plan reviewed on 12/04/13 was not changed to reflect his smoking privileges had been revoked. The smoking assessment was reviewed on 12/10/13 with no changes . The Care plan conference note dated 12/11/13 noted he was caught smoking in his room recently. This note made no mention of interventions related to his unsafe smoking. The Minimum Data Set, a quarterly dated 03/10/14, coded Resident #122 as cognitively intact, having no delirium, no behaviors, and needing supervision to limited assistance with most activities of daily living skills. He utilized a wheelchair for mobility and was on oxygen. No changes were made to the care plan in relation to smoking issues. The smoking assessment was not reviewed at this time. Nursing notes dated 04/30/14 at 6:44 PM revealed at 5:05 PM while out of the facility at a friend's house, Resident #122 had his oxygen on while smoking. He returned to the facility with burns to the left and right side of his face next to his nose and a burn noted to the tip of his nose. Additional nursing notes dated 05/01/14 at 12:26 AM revealed that at approximately 6:15 PM (on 04/30/14) Resident #122 asked to go outside and sit for a few minutes. The resident was directed to go to the B station patio. Before he went outside the nurse asked if he had any cigarettes in his pocket, which he denied. Approximately 10 minutes later he was observed smoking a cigarette with an oxygen tank on his wheelchair and his nasal cannula removed from his nose. Resident #122 stated he found the cigarette on the ground already burning. He was re-educated on smoking in nondesignated areas and the risk of smoking with oxygen. The care plan was updated on 05/01/14 for burning himself while smoking. New interventions included Resident #122's smoking privileges were revoked, periodic room checks for contraband in relation to smoking were to be completed, and the resident was educated on revoking his smoking privileges. The care plan was updated on 05/01/14 noting Resident #122 had smoking privileges revoked. Review of physician orders [REDACTED]. A physician progress notes [REDACTED]. The note stated the resident's smoking privileges were then revoked as he "is obviously a danger." The smoking assessment was reviewed on 05/02/14 with no changes made. Social notes dated 05/02/14 at 11:39 AM revealed the DON, Administrator and unit manager met with Resident #122 and told his smoking privileges were revoked indefinitely and his room and person would be subject to periodic searches for any smoking material, lighters and/or matches. Interview with SW #2 on 09/22/14 at 2:28 PM revealed upon his return with the burns, his room was searched and a lighter and cigarettes were found and removed. she was unsure if the room was ever searched again. Interview with SW #2 on 09/22/14 at 2:38 PM revealed he was unaware if the room was ever searched after he burned himself. Interview with the Director of Nursing on 09/23/14 at 11:24 AM revealed the Administrator was responsible for the daily rounds and checking on Resident #122's smoking paraphernalia and she would check a couple of times per week. An inservice for all nursing staff was held on 05/14/14 to review the smoking policy, smoking areas and inform the staff a camera was placed at B station to ensure smoking policies were being followed. The quarterly MDS dated [DATE] coded Resident #122 as cognitively intact and having no behaviors. The care plan was updated 06/05/14 to monitor closely during smoking times to ensure he does not place tobacco products on his person. Monitor smoking area randomly during non-smoking times to ensure he is not smoking. If seen smoking when he is not supposed to approach him and explain the violation. Another addition was that his smoking privileges were revoked indefinitely on 05/02/14. No documentation of room or personal searches for contraband were found in the medical record or provided by staff. There was no documentation of monitoring of the nonsmoking area or the smoking area at non designated times in the medical record. SW #1 stated on 09/22/14 at 2:28 PM that as of 05/01/14, Resident #122 was never allowed to smoke again on facility premises. At that time he had a nicotine patch, used skoal and vapor cigarettes. The Medication Administration Record revealed Resident #122 had refused the nicotine patch on 06/25/14, 06/26/14 and on 06/27/14. Physician orders [REDACTED]. Nursing notes dated 07/06/14 at 7:12 PM stated at approximately 6:00 PM Resident #122 was outside on the patio off B station with one cigarette lit. The nurse went out, explained concern he was smoking with oxygen on. This nurse noted she did not find any other cigarettes on him. Telephone interview on 09/23/14 at 10:41 AM with the nurse who observed this (Nurse #1) revealed she had heard him ask someone to pick him up some cigarettes earlier in the shift. She became suspicious when he was being pushed around in his wheelchair by another resident and went to check on him while he was outside B station patio. The second check she made on him was when she observed him smoking. She stated the nasal cannula was off his face, however, the oxygen tank was turned on and running. Nurse #1 stated she told the other nurses and reported it to the oncoming nurse. She did not tell the Administrator or the Director of Nursing. She further stated she never checked his room for additional cigarettes or lighters. A social service note dated 07/07/14 at 11:07 AM stated SW #2 observed Resident #122 sitting in his wheelchair on the sidewalk outside B hall. The SW noted he observed smoke coming from the resident's mouth. As the social worker approached, the resident dropped the cigarette on the ground and stepped on it then quickly replaced his oxygen nasal cannula. Interview with SW #2 on 09/22/14 at 4:01 PM revealed he could not recall if the oxygen tank was running at the time he was caught smoking. At this time, the new administrator who came to work on 07/07/14 instructed SW to discharge Resident #122. Resident #122 was discharged from the facility on 07/09/14. On 09/23/14 at 11:39 AM, SW #1 and #2 were interviewed. This conversation revealed that Resident #122 did not want to quit smoking. His smoking privileges were revoked multiple times but the previous administrator reinstated the privileges multiple times. Interview with the Administrator and Director of Nursing (DON) on 09/22/14 at 4:01 PM revealed that as soon as the new Administrator started working, the DON told her Resident #122 had to be discharged . The Administrator immediately told the SWs to find an alternative placement for Resident #122. The Administrator stated that she met with all the residents who smoke in the facility. The rules and behavior contracts were reviewed and the residents were informed that the smoking rules would be strictly enforced. Both the Administrator and the DON revealed that they were aware of no other times a resident was observed smoking unsupervised or in a nondesignated area since Resident #122 was discharged on [DATE]. Both stated the issue was resolved based on Resident #122 being discharged . Credible Allegation of Compliance for F323 The facility provides the following information to show that all the residents at Willow Ridge Rehabilitation and Living Center are safe from the discrepancies identified. RESIDENT IDENTIFIED 1. Resident #122 no longer resides at this facility. 2. On 7/7/14, the Administrator became aware that Resident #122 was caught smoking after his smoking privileges had been revoked. 3. On 7/7/14, the Administrator met with Resident #122 and informed him that he would be being issued a 30 day notice for failure to adhere to the facilities Smoking Policy. He was informed at that time that the facility had found placement for him at another facility. He was given the option of the 30 day notice or placement at another facility. The resident choose placement at another facility and was discharged to that facility on 7/9/14. 4. On 7/7/14, 7/8/14 and 7/9/14, Resident #122 had a room search completed by the Administrator and Director of Nursing for smoking material- no smoking material was found during those searches. 5. On 7/7/14, 7/8/14 and 7/9/14, Resident 122 was frequently monitored every hour during business hours by the Administrator and Director of Nursing- There were no further smoking incidents identified. 6. On 7/7/14, the Resident Smoking Policy was enforced and resident 122 had immediate discontinuation of his smoking privileges. IDENTIFYING OTHER RESIDENTS AT RISK 1. On 7/7/14, the Administrator reviewed the Resident Smoking Policy, the Resident Smoking Behavior Contract and the Resident Smoking Schedule. In addition, the Administrator ensured all resident smoking material was kept behind lock and key in the medication room, the Administrator visualized the " smoking box " and went out to the " smoking area " to ensure staff were present during the resident ' s smoke break, " designated smoking area " and " no oxygen in use " signs were posted, how staff distributed and collected the smoking paraphernalia and how residents disposed of cigarettes butts. In addition, the Administrator ensured the facility had a fire blanket and smoking aprons available for resident use. 2. On 7/9/14, the Administrator, Director of Nursing and Social Service Worker met with all the facility residents who smoke and reviewed the Resident Smoking Policy, the Resident Behavior Contract, Resident Smoking Schedule and answered all questions regarding the enforcement of the Resident Smoking Policy. It was stressed to all of the residents who smoke that the facilities Resident Smoking Policy would be enforced from here on out. 3. On 9/22/14, the Resident Smoking Assessment was updated to read " has the resident been observed giving/selling/offering smoking material to and/or from peers " . The word " offering " was added to the assessment and would be considered an unsafe behavior. 4. On 9/23/14, an audit was started by the facilities Social Service Workers to ensure all residents whom smoke were re-assessed for smoking safety and have reviewed and signed the Resident Behavior Contract regarding the Resident Smoking Policy. The audit was completed on 9/24/14. 5. On 9/23/14, all residents whom use oxygen have had a sign placed on their wheelchair which states " No Smoking " . Any ambulatory residents will have a " No Smoking " sign placed on their portable oxygen E-tanks. o The facility has 13 residents who smoke. Out of those 13 residents- 1 resident uses a BiPAP at night, two residents use oxygen in their room as needed and one resident returned from the hospital on [DATE] with a new order for continuous oxygen. For the residents who use oxygen, when they go outside to smoke the oxygen will be left inside the facility while they are smoking. 6. On 9/24/14, the nursing notes and the social service notes from 9/23/14 at 6:00 AM through 9/24/14 at 6:00 AM, were reviewed by the Director of Clinical Services. No concerns were identified with residents smoking inside the facility and/or smoking while wearing oxygen and/or unsupervised. PROCESSES IMPLEMENTED TO PREVENT FURTHER OCCURRENCES 1. In-servicing for all staff was started on 9/23/14, by the facility Staff Developer Coordinator. At this point 67 out of 146 have been in-serviced. Facility staff will not be able to work until they are in-serviced. The in-service addressed the following: a. Resident Smoking Policy, which included steps taken for violation of policy b. Resident Smoking Behavior Contract, which included resident acknowledgement and understanding of the facilities Resident Smoking Policy c. Resident Smoking Schedule d. Smoking Assessment, which will be completed quarterly e. Hazards of smoking, which included smoking with oxygen f. Smoking material to be kept behind lock and key g. Staff are to smoke in designated staff smoking areas only h. Staff to ensure their personal belongings, including but not limited to smoking material are kept out of the reach of the residents at all times. i. Reporting incidents, in which residents and/or staff fail to follow the facilities Smoking Policy to the Administrator and/or Director of Nursing immediately, via in person or by phone 24/7 and documenting the incident in the medical record. 2. The Facility Department Heads were in-serviced by the Director of Clinical Services on 9/24/14 on the following: a. Follow-up on Incident/Accidents is the responsibility of the Administrator and/or Director of Nursing. b. As well as all areas in 1a-1i above. 3. For those residents assessed as requiring supervision during smoking staff will distribute and light their cigarettes during the scheduled smoke breaks. For those residents assessed as being safe to smoke independently staff will distribute cigarettes and smoking paraphernalia as requested by the resident- the resident will return the paraphernalia when they are finished smoking. a. There are 13 residents who smoke in the facility. All 13 of the residents are assessed as being unsafe to smoke independently. 4. The facilities Admission Coordinator will ensure prior to admit that the resident and their responsible party are aware of the Resident Smoking Policy, Resident Smoking Behavior Contract, Resident Smoking Schedule and Smoking Assessment. 5. The facilities Social Service Workers will ensure all new admissions have had a Smoking Assessment completed at time of admit and have received the Resident Smoking Policy, Resident Smoking Schedule and have signed the facilities Resident Smoking Behavior Contract. 6. The Director of Nursing or the nurse management team will review the shift to shift 24 hour daily report ongoing in AM clinical meeting (Monday - Friday) to ensure any smoking incidents have been reported to the Administrator and/or Director of Nursing immediately. 7. The Administrator and/or Director of Nursing will ensure all smoking incidents have been reported, investigated and have appropriate follow up, including but not limited to revoking smoking privileges, if indicated. The facility alleges the immediacy of these discrepancies have been abated on 9/24/14. Immediate Jeopardy was removed on 09/24/14 at 7:00 PM when interviews with nursing staff and residents confirmed they had received inservice training on the facility's smoking policy and procedures and the expected action to take when a resident was found to not follow the smoking policy. Record reviews confirmed that all current residents who smoke had updated smoking assessments and care plans. Observations confirmed that all smoking materials were secured, smoking was supervised per individual smoking assessments and in the designated area. 2. Resident # 101 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #101's most recent assessment was a significant change Minimum Data Set ((MDS) dated [DATE] which indicated he was cognitively intact for daily decision making. The MDS indicated he had no behavioral symptoms or rejection of care, was independent with transfers, walking in his room and locomotion on and off the unit. A Care Area Assessment (CAA) summary dated 07/14/14 addressing cognitive loss indicated Resident # 101 smoked and routinely attended supervised smoking times. The summary did not mention that he had a history of [REDACTED]. A Care Plan for Resident # 101 which was last updated 07/10/14 addressed risk of elopement and indicated Resident was forgetful, required information or facts to be repeated, had poor insight and judgment, impaired cognition, limited mental functioning, was impulsive at times and had poor insight to safety. Interventions included: Nurse Aide (NA) - remind Resident of smoking rules and times, when warranted; Social Services - observe Resident closely to ensure he is complying with smoking policy and rules. Remind him of smoking times. Involve family if needed, as well as make referrals. Provide supervision when able, during smoking times. The Care Plan also indicated he was at risk for burns from smoking. Interventions included: Nursing Staff - Supervise during smoke breaks at all times, report unsafe environment to supervisor, encourage use of aprons, Resident not allowed to use lighter. Do not allow Resident to pick up cigarette butts off the ground. Supervise Resident closely, and only allow him one cigarette to smoke at a time. Remind him of rules, and continue to discourage him from picking up butts, explaining that it is staff's responsibility to clean smoking area. Explain health risks of picking up other's used cigarette butts. Social Services - review smoking policy per protocol. Remind him of scheduled smoking times, when forgetful. Remind him that no cigarettes or lighters are allowed on his person or in room. Praise Resident for being compliant and cooperative. Repeat smoking rules, as needed. Review of Smoking Assessments from 09/05/13 - 07/15/14, which were completed by SW # 1 indicated Resident # 101 was assessed as a safe smoker and could responsibly handle smoking materials. The assessment dated [DATE] indicated Resident did not need a safety device such as a smoking apron. The smoking assessment completed 09/23/14 indicated Resident # 101 appeared to understand the facility's rules/restrictions on smoking. It also indicated he had asked others for cigarettes and had picked up butts from floor and ashtray. It indicated Resident was not able to responsibly handle smoking materials because he asked others for cigarettes and picked up butts and that he required supervision with smoking. Further review of Resident #101's medical record revealed a note dated 06/24/14 at 2:32 PM by Social Worker (SW) # 2 which indicated Resident # 101 was observed in the courtyard that morning smoking without staff supervision before the designated smoking time. According to the note, the SW advised Resident # 101 that he had violated the smoking policy and that his smoking privileges were being suspended for 24 hours. Review of the Nurse's Notes revealed an entry dated 07/26/14 at 6:26 PM which indicated Resident # 101 was observed smoking in a non-designated area (the hallway) at a non-designated time. The note further stated the Resident had a lit cigarette in the hallway and stated someone lit it for him. The note indicated staff did not locate a lighter in Resident # 101's possession. Review of a 24 hour Nursing Report dated 07/26/14 revealed the following notation: "(Resident # 101's Name) - smoking in hall." On 09/18/14 at 1:50 PM during an interview with Resident # 101, he stated he could go out and smoke any time he wanted to go but had to have a staff member go with him. When asked if staff were available when he wanted to go out, he stated they had been so far. He also stated he could smoke in his room if he wanted to if he had a cigarette. He stated staff kept his cigarettes behind the desk and he didn't know why they kept them but thought it was probably to keep him from smoking in his room. When asked if he was allowed to have cigarettes and lighters in his room, he stated he could keep them in his room. During an interview on 09/23/14 at 3:17 PM with the Administrator she was asked how she addressed the problem with residents violating the facility's smoking policy. The Administrator stated she did an inservice with all residents who smoked on 07/09/14 and all the residents who smoked were at the inservice. She stated Social Worker # 1 made sure they were all there. She stated she did not have a list of the residents who were at the inservice. She stated she reviewed the smoking policy and emphasized to them that the policy would be enforced. An additional interview on 09/23/14 at 5:45 PM with the Administrator revealed she had not provided any inservices to staff about the smoking policy until 09/22/14 and 09/23/14 when the Staff Development Coordinator did an inservice with staff on the smoking policy and procedures. On 09/24/14 at 9:00 AM a second interview was done with Resident # 101. When asked if there were certain times he could smoke, he stated he could smoke anytime he wanted to. When asked if there was a particular place designated for smoking, he stated: "No. I can smoke in here or go outside." When asked if there were any rules about smoking, he stated: "Not that I know of." When asked if he remembered going to a meeting with the Administrator about the smoking rules, he stated: "I remember going to a meeting but it's been a long time." When asked if he remembered what she said, he stated: "No, not really." When asked where he kept his cigarettes and lighter, he stated: "I don't have a lighter but I keep my cigarettes in my drawer." When asked to show surveyor, he opened his drawer and stated: "I don't have any right now." Then, he stated: "We go outside at 10:00 AM to smoke. I probably have some in the box." On 09/24/14 at 11:35 AM an interview with NA # 10 about the incident of Resident # 101 smoking at a non-designated time without staff supervision on 06/24/14 revealed she recalled the incident. When asked what the facility protocol was for addressing a violation of the smoking policy: NA # 10 stated she brought the Resident back in the building and notified SW # 2. She stated SW #2 talked to the Resident. When asked how she was made aware of the smoking policy, NA # 10 stated the smoking policy was reviewed during orientation. NA # 10 stated the door to the designated smoking area was kept locked at all times but they were told that someone had given the code to a family member who in turn had given the code to the Resident. NA # 10 stated the key code was changed that same day and hasn't been changed since that time. When asked if there were any inservices done throughout the year, NA # 10 stated there were periodic inservices throughout the year and also any time there was an incident, such as violation of the smoking policy. On 09/24/14 at 12:20 PM an interview with Nurse # 5 about the incident on 07/26/14 with Resident # 101 smoking inside the facility revealed she was unable to determine where he got the cigarette and lighter. Nurse # 5 stated she and a NA searched him and didn't find any cigarettes or lighter. She stated the Resident came out of the activity room and around the nurse's station with a lit cigarette. Nurse # 5 said she asked him where he got a lighter and he said someone lit it for him. She said it was a small part of a cigarette, less than half a cigarette and she thought he might have picked it up off the ground because staff said he had a habit of doing that. Nurse # 5 stated she reported it to the DON. Nurse # 5 said she told Resident # 101 that he was losing his smoking privileges for 24 hours, as she was instructed to do by the DON. When asked if she had received any training on the facility's smoking policy, Nurse # 5 stated she was told that residents must have staff with them when they go outside to smoke; there are 4 designated smoking times; residents are allowed 2 cigarettes per time; cigarettes and lighters are kept locked in the Medication room at A nurses station. When asked how suspension of smoking privileges was communicated to staff, Nurse # 5 stated she put a note on top of the smoking box where residents cigarettes are kept. She stated residents' family members bring cigarettes to the desk when they bring them in for the resident. Nurse # 5 stated the Administrator met with all the residents who smoke so they knew the rules. Nurse #5 stated Resident # 101 didn't remember being caught smoking in the facility when she informed him that his smoking privileges had been suspended. During an interview on 09/24/14 at 1:03 PM Interview with the Administrator and DON, both were asked if there had been any other incidents of unsafe smoking and how they determined if there had been. The Administrator stated she had talked to Department. Managers, NAs and nurses yesterday (09/23/14) and today and asked if they were aware of any incidents of unsafe smoking since July. She stated staff told her there had not been any other incidents as far as they could recall. When asked if any type of audit had been completed to determine if the residents who currently smoke had a history of [REDACTED]. When asked where she expected incidents of unsafe smoking to be documented, she stated she expected whichever discipline observed the behavior to document it. When asked if she expected smoking violations to be listed on the 24 hour report, she stated she did expect them to be listed on the 24 hour report regardless of which discipline was involved. When asked who reviewed 24 hour reports, the DON stated until the first week in August it was the Unit Managers. The DON stated since second week of August, she had been checking 24 hour reports every morning Monday through Friday. When asked if they were aware of any incidents involving Resident # 101 violating the smoking policy, both the DON and Administrator stated they weren't aware of any violations. When the DON was asked if she was aware of the incident on 06/24/14 involving Resident # 101, she stated she didn't recall knowing about the incident. When the DON and Administrator were asked if they were aware of the 07/26/14 incident of Resident # 101 smoking in the facility, both stated they weren't aware of the incident. When asked how cognitively impaired residents are being monitored to prevent unsafe smoking, the Administrator stated they were supervised when smoking. 3. Observations of the locked dementia unit in the facility included the following: The nurses station was circular shaped and had a counter which was just below chest level (to the average person standing) and approximately 1 1/2 foot wide. The interior of the nurses station contained a work desk which adjoined the wall of the counter, but was below the counter level. The majority of the residents on the locked dementia unit were observed to be ambulatory and often congregated at the nurses station. On 09/15/14 at 3:00 PM a container of Microkill was stored on the nurses work desk, at the edge of the counter. The Microkill container had a bright red top and was easily visible and accessible to residents standing outside the nurses station. The MicroKill container at the nurses station was a pop top type dispenser with pre-saturated cloths that pull out of the top of the container. The manufacturer label on the container included the following precautionary statements: Warning: Causes substantial, but temporary eye injury. Do not get in eyes or

Based on staff interviews and record review, the facility failed to assure that four (4) of five (5) sampled cognitively impaired female residents had an environment that was free from sexual abuse. The facility had not consistently identified the victims, had not conducted investigations and had not implemented effective preventative measures to protect the female residents from actual and potential sexual abuse. Facility staff had knowledge of the inappropriate sexual behaviors of one male resident (Resident #2) toward four (4) sampled female residents (Residents #1, 8, 9, and 10). Immediate jeopardy began on 1/29/2012 when staff became aware of Resident #2 inappropriately touching Resident #8. The administrator was notified of the immediate jeopardy on 02/8/2012 at 9:50 AM. Immediate jeopardy was removed on 02/10/2012 when the facility provided and implemented an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems put in place are effective. The findings are: Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was identified as cognitively intact, able to understand and make himself understood with no behaviors identified. The MDS also identified the resident as once assisted into his wheelchair being able to move about the facility independently. Review of current care plans reviewed in December 2011 revealed no care plans related to resident behaviors. Resident #2 was observed exhibiting inappropriate sexual behaviors towards female residents on the following dates: A. Sunday 01/29/12: Review of nursing notes on 01/29/12 at 3:49 PM revealed Licensed Nurse (LN) #1 documented Resident #2 was observed by Activity Assistant (AA) #1 touching a female resident's breast. The note stated this behavior was documented in the Physician's communication book. Review of the Physician's communication book revealed an entry by LN #1 dated 01/29/12 (no time) which stated staff noted Resident #2 touching Resident #8's breast. Review of nursing notes on 01/29/12 at 11:12 PM, LN #2 documented Resident #2 was seen touching female residents on their upper arms and trying to hold their hands. One resident yelled at him, told him not to touch her and he let go. The nurse reminded him it was inappropriate to touch other residents without their consent. Review of the "Manager's on Duty" report dated 01/29/12 included in part: LN #2 reported Resident #2 was found in Resident #8's room holding her hand. Subsequent interviews with staff concerning these incidents revealed: An interview was conducted with activity assistant (AA) #1 on 02/07/12 at 10:00 AM. AA #1 stated she observed Resident #2 touch Resident #8's breast over her clothing around lunch time on 01/29/12. AA #1 further stated that she immediately reported the incident to Licensed Nurse (LN) #1 who was Resident #2's and Resident #8's licensed nurse on this shift. The interview further revealed the nursing assistants (NAs) stated they were not aware of Resident #2 inappropriately touching other residents prior to 01/29/12. A telephone interview on 02/07/12 at 11:00 AM with LN #1 revealed that AA #1 told her that she observed Resident #2 touch Resident #8's breast over her clothing around lunch time on 01/29/12. LN #1 recalled Resident #2 was removed from the hall near the nurse's station and assisted to bed by a nursing assistant. LN #1 stated she documented the incident in the Physician's communication book, her nurse's note, and passed the information on to the second shift (3:00 PM to 11:00 PM) nurse (LN #2). No other interventions were put into place. During a telephone interview on 02/06/12 at 5:35 PM, LN #2 revealed on 01/29/12 she reported to the Activity Director (AD) (manager on duty), that Resident #2 was touching female residents. LN #2 revealed the AD told her that she would inform the DON and Administrator. On 02/07/12 at 10:10 AM the Activity Director (AD) confirmed she was the Manager on Duty on 01/29/12. The AD revealed LN #2 reported Resident #2 was holding female residents' hands and staff was having a hard time keeping him out of female residents' rooms. The AD stated she did not address Resident #2's behavior herself on 01/29/12 but made sure it was discussed during the facility's morning meeting on 01/30/12. The AD stated the conclusion at the 01/30/12 morning meeting was staff would monitor Resident #2 for inappropriate behaviors. B. Monday 01/30/12: Nursing notes dated 01/30/12 at 11:32 AM revealed LN #4 documented Resident #2 had constantly gone up to several female residents this morning and tried to touch them. Review of the physician verbal orders dated 01/30/12 revealed an order for [REDACTED].#2 received the [MEDICATION NAME] at 9:00 AM starting on 01/31/12 and 02/01/12. Subsequent interviews with staff concerning this incident revealed: During interview on 02/06/12 at 12:46 PM, LN #4 revealed Resident #2's behaviors started on 01/29/12 and continued on 01/30/12, but she could not recall who Resident #2 was approaching those days. During interview on 02/06/12 at 1:20 PM, the Director of Nursing (DON) stated she was aware Resident #2 was "having behaviors" on 01/30/12 and asked the social worker to "look into it." She further stated she did not follow up on the report about Resident #2's behaviors. C. Wednesday 02/01/12: Review of the nursing notes revealed the only documentation of Resident #2's behaviors was documented by LN #5 on 02/01/12 at 10:15 PM. LN #5 documented Resident #2 was observed wandering the halls grabbing female residents' breasts and groins. Resident #2 was redirected several times and cursed at staff. Resident #2 was assigned a Nursing Assistant (NA) for observation when he threatened to punch staff in the head and told another resident that he was "trying to be bad." The Director of Nursing (DON) was notified. Facility record review revealed no documentation regarding one on one supervision provided on 02/01/11 and no incident report was completed. Subsequent interviews with staff concerning this incident revealed: During an interview on 02/06/12 at 12:05 PM, nursing assistant (NA) #1 revealed, that on 02/01/12, while working on the first shift she had pulled Resident #2 in his wheelchair away from Resident #8 four times. NA #1 stated she reported to LN #4, that Resident #2 had been rubbing the leg of Resident #8 up to her groin. NA #1 further revealed later that day the Director of Nursing (DON) came to the nursing station. She informed the DON of what happened. NA #1 was instructed by the DON to "keep an eye" on Resident #2 and not let him around the female residents. LN #4 stated on 02/06/12 at 3:25 PM that on 02/01/12 the NAs (she did not recall whom) reported to her they had observed Resident #2 inappropriately touching female residents, including Resident #1 and Resident #8. LN #4 further revealed she considered Resident #2's behaviors as sexual abuse, so on 02/01/12 she reported it to the DON per facility policy. The DON told her to chart Resident #2's actions under behaviors in the resident's medical record. An interview on 02/06/12 at 3:20 PM with LN #5 revealed Resident #2 was observed on 02/01/12 during the 3:00 PM to 11:00 PM shift grabbing female residents' (Resident #1 and Resident #8) breasts and groins over their clothing. LN #5 stated Resident #2 was redirected, the DON was notified and a NA was assigned to sit with Resident #2. LN #5 was not aware of how long the one to one supervision continued after she left that evening. LN #5 further stated she asked the DON if she needed to fill out an incident report and was instructed only to document her findings in the behavior section of the medical record. D. Thursday 02/02/12: Review of nursing notes dated 02/02/12 at 3:18 PM revealed LN #4 documented Resident #2 had frequently touched female residents inappropriately this shift. Review of physician verbal order dated 02/02/12 revealed a new order for [MEDICATION NAME] (antidepressant) 5mg every day and [MEDICATION NAME] (female hormone) 1mg every day, both "for sexual behaviors." Review of the MAR indicated [REDACTED]. Review of Resident #2's Social Service Notes, a late entry dated 02/03/12 revealed on 02/02/12 the social worker spoke directly with Resident #2 regarding "his sexually inappropriate touching of staff, as well as residents." The note stated Resident #2 verbally agreed to not touch residents in a sexual manner. Review of nursing notes dated 02/02/12 at 11:13 PM revealed LN #2 documented staff had attempted to constantly watch Resident #2 due to him touching female residents inappropriately. The nurse aides observed him rubbing on a female resident's shoulder in the main dining room during supper and redirected Resident #2 away from her. In addition, another female resident had to be moved out into the hall due to Resident #2's numerous attempts to touch her. The social worker was in this evening to talk to him about his inappropriate touching of female residents. Review of the 24 hour shift report for 02/02/12 revealed during the first shift Resident #2 continued "to touch" female residents; during the second shift Resident #2 required constant watching to keep him from touching female residents; and during third shift Resident #2 continued "to touch" female residents. Subsequent interviews with staff concerning these incidents revealed: An interview with Licensed Nurse Unit Manager (LNUM) #2 on 02/07/12 at 11:20 AM revealed that LN #4 informed her on 02/02/12 that Resident #2 was behaving inappropriately and trying to touch other residents. She further stated she did not ask for specific details regarding Resident #2's behaviors at that time. LNUM #2 also stated she did not notify the Director of Nursing or the Administrator because she did not know the extent of his behaviors. She further stated she did not follow up with staff regarding Resident #2's behavior. During an interview on 02/07/12 at 4:30 PM the Social Worker (SW) stated Resident #2 grabbed at staff members and was combative with care when he was first admitted to the facility. The SW further stated Resident #2's behaviors were discussed during the facility's morning meeting on 02/02/12 and the Administrator asked her to meet with Resident #2 and discuss his sexually inappropriate behavior. SW further stated she met with Resident #2 late in the afternoon on 02/02/12. E. Friday 02/03/12: Nursing notes dated 02/03/12 at 6:56 AM revealed LN #3 documented Resident #2 continued to touch female residents inappropriately. He watched for the nurse to go into a room then he moved closer to the female resident. Resident #2 was kept in sight of the nurse since he got up at 5:00 AM. Nursing notes on 02/03/12 at 3:04 PM revealed LN #4 documented Resident #2 continued to touch several female residents inappropriately frequently during this shift. Nursing notes dated 02/03/12 at 4:48 PM revealed LN #2 documented Activities Assistant (AA) #1 reported to the nurse Resident #2 was seen by a visitor touching Resident #10's breasts. AA #1 separated Resident #10 and Resident #2. The nurse documented she notified the social worker (SW) and the DON of this incident and assigned all staff on A hall to monitor Resident #2 and know where he was. Review of nursing notes dated 02/03/12 at 11:48 PM revealed LN #2 documented AA #2 reported at 8:21 PM she saw Resident #2 in Resident #9's room with his hand on the resident's groin. AA #2 attempted to remove Resident #2 from the room and Resident #2 became combative and tried to hit her. Resident #2 was removed from the room and placed at the nurse's desk. LN #2 contacted the Nurse Practitioner (NP) about Resident #2's behaviors who subsequently called the DON. The DON called LN #2 back and was told to have an NA with Resident #2 at all times. Resident #2's physician (MD) called at 10:30 PM. LN #2 explained Resident's #2's behavior had escalated on 02/03/12. The MD asked for the DON's phone number. The MD called LN #2 back at 10:50 PM with new orders for an antipsychotic and antianxiety medication. Also the MD stated the DON would be calling in the morning (02/04/12) to arrange for Resident #2's transfer to a hospital. Review of the physician verbal orders dated 02/03/12 revealed [MEDICATION NAME] was discontinued and the [MEDICATION NAME] was increased to 20mg every day. In addition, an antipsychotic medication, [MEDICATION NAME] 1mg IM (intramuscular) was ordered now, then 1mg either by mouth or IM every 8 hours on schedule. An antianxiety medication, [MEDICATION NAME] 0.5 mg was ordered now and every 6 hours as needed. Review of facility documentation revealed one on one supervision was started on 02/03/12 at 11:00 PM and continued until 02/08/12 at 12:05 PM when Resident #2 was transferred to the hospital. Subsequent interviews with staff concerning these incidents revealed: During a telephone interview on 02/07/12 at 2:55 PM, LN #3 stated at approximately 6:00 AM on 02/03/12, she observed Resident #2 with his hand on Resident #9's stomach. LN #3 further stated she redirected Resident #2 to his room and kept Resident #9 with her. She stated she did not fill out an incident report but did report this information to the oncoming nurse (LN #4). During an interview on 02/07/12 at 4:30 PM the Social Worker (SW) explained she shared her meeting with Resident #2 on 02/02/12 during the facility's 02/03/12 morning meeting and staff discussed the need for a family meeting. During interview on 02/07/12 at 10:00 AM, AA #1 stated that on 02/03/12 a visitor reported Resident #2 was touching Resident #10's breast over her clothing while they were seated in the dining room. AA #1 stated that she moved Resident #10 to another table and reported the incident to LN #2. During a telephone interview on 02/06/12 at 5:35 PM, LN #2 stated that on 02/03/12 she told the DON Resident #2 was observed inappropriately touching Resident #10's breasts. LN #2 asked the DON if she should fill out an incident report and the DON told her to document Resident #2's behaviors in the chart. She further stated the DON called back after 9:00 PM, after being contacted by the nurse practitioner (NP), and instructed staff to put Resident #2 on one on one supervision. During the interview on 02/06/12 at 12:50 PM, the MD revealed the facility physician on call contacted him at home on Friday (02/03/12) evening about Resident #2 exhibiting inappropriate sexual behaviors. The MD stated he called the DON on 02/03/12 and told her it would be best to send Resident #2 to the hospital for a psychiatric evaluation. During continued interview the MD noted he had ordered "sedatives" until the next morning when Resident #2 could be sent to the hospital. The DON stated on 02/06/12 at 1:20 PM, she and the Administrator decided to place the resident on one on one supervision on Friday night (02/03/12). H. Saturday 02/04/12: Review of the 02/04/12 MAR indicated [REDACTED]. There were no documented behaviors for which these as needed medications were administered. Subsequent interviews with staff concerning this incident revealed: During continued interview on 02/06/12 at 1:20 PM, the MD revealed he called the facility on the afternoon of 02/04/12 to see if Resident #2 had been sent out to the hospital and was told by nursing staff that the DON was "working on it." I. Sunday 02/05/12: Review of nursing notes dated 02/05/12 at 5:53 AM revealed Resident #2 was up at long intervals. He was noted to be agitated, cursing, and threatened to hit staff. Review of the MAR for 02/05/12 revealed Resident #2 received [MEDICATION NAME] at 1:30 AM, 1:05 PM and 6:17 PM in addition to his regularly scheduled medications. Review of the physician communication book revealed an entry on 02/05/12 documenting Resident #2 was still having "aggressive sexual behaviors." Review of nursing notes dated 02/05/12 at 9:21 PM revealed Resident #2 was trying to approach Resident #10. The nursing note stated Resident #2 was redirected, was on one on one supervision and received as needed medication. J. Monday 02/06/12: Review of the Social Service Notes dated 02/06/12 revealed the Administrator requested a family meeting to be scheduled immediately due to Resident #2's ongoing sexually inappropriate behavior. Subsequent interviews with staff concerning this incident revealed: During an interview on 02/06/12 at 3:50 PM, the Administrator explained prior to 02/03/12 at 10:30 PM, her understanding was Resident #2 had been holding hands and touching female resident's legs. The Administrator stated she did not usually review the 24 hour reports, nursing notes or Physician communication book but expected her clinical staff to inform her of any changes in resident's condition. The administrator was notified of the immediate jeopardy on 02/8/12 at 9:50 AM. The facility provided a credible allegation of compliance on 02/10/12 at 4:24 PM. The following interventions were put into place by the facility to remove the Immediate Jeopardy: Credible Allegation of Compliance: 02/03/12 at 11:00 pm, resident #2 was assigned a staff member to be with him at all times. The intervention continued until resident #2 was transferred from the facility to the hospital on [DATE] at 12:05 p.m. 02/08/12 Administrator called the County Sheriffs Office to report a possible crime, related to the inappropriate behavior of resident #2. PROCESS TO IDENTIFY OTHER RESIDENTS AT RISK 1. 2/6/12 and 2/8/12 the Social Worker completed interviews, with thirty four (34) alert and interviewable residents, to ascertain if there were any other incidents of inappropriate resident to resident contact noted. They were asked if they felt safe or if anyone had made them feel uncomfortable. No additional concerns were identified. 2. On 2/6/2012 complete body audits done by the Unit Charge Nurses to assess any obvious physical injury, on residents #1, #8, #9 and #10, who were identified as being inappropriately touched by resident #2. Results of this audit revealed no visible bruising or signs of physical trauma. 3. On 2/6/2012, residents # 1, #8, #9, and #10 ' s families/responsible parties were contacted by the Director of Nursing to notify them of their family member being inappropriately touched . They were asked by the Director of Nursing if they were aware of any other instances of resident inappropriate behavior. No additional concerns were identified. 4. 2/7/12 and 2/8/12 The Nursing staff were instructed by the Director of Nursing to observe resident ' s #1, #8, #9 and #10, for and signs, such as crying, increased anxiety, new behaviors, physical injuries, such as bruising, etc., Observations will be on-going. No changes have been noted in theses resident ' s behaviors or demeanor. 5. 2/9/12- Twenty- Nine (29) Resident families/responsible parties were selected at random and contacted by the DON, MDS nurse or Social Worker, to determine if they were aware of any inappropriate resident to resident contact/abuse and educated to immediately report any concerns. Messages were left with 11 additional families. No family contacted reported any concerns. 6. 2/8/12 and 2/9/12 - Ninety-two employees were interviewed by department heads, and asked if they have observed any inappropriate resident to resident contact. All staff members who were not available for interview will be removed from the schedule until such interview is completed by the department head. No additional concerns were identified. PROCESSES IMPLEMENTED TO PREVENT FURTHER OCCURRENCES 1. On 2/7 and 2/8/12 all available persons employed by this facility were in-serviced. All department heads were in-service by the Regional Vice President of Operations. Staff Development Coordinator, Nurse Managers, in-service the nurses. All other staff was in-serviced by their department managers. In-services contained the following: a. The facility ' s Abuse policy and procedure states that abuse can be considered physical touching that is inappropriate, if it is uninvited by the person being touched. b. Immediately protect all residents when inappropriate resident to resident contact is identified, by staying with the resident to protect them. You must immediately notify the administrator. c. Immediately report all events of inappropriate resident to resident contact to the Administrator. If the Administrator is not available, the employee reporting the alleged abuse should report it to his/her supervisor who contacts the Administrator or Director of Nursing. d. 2/8/12 Abuse policy revised to state nurses are to immediately fill out an incident report and submit it to the DON; call the physician; notify family/responsible party and the administrator at the time of the occurrence. In-service was conducted by the Unit Managers, DON, department heads on 2/8/12. e. All staff should report to their immediate supervisor and expect feedback from that supervisor that an investigation has been initiated, if feedback not provided, staff should contact Administrator directly. The Administrators contact information is posted at every Nurses station and in every ancillary department. f. Any staff member that is unable to attend the Abuse in-service will not be allowed to work until they receive this in-service by the Unit Manager or Department Head or Staff Development Nurse. g. The Administrator or DON will immediately report any allegations of abuse to the Regional Vice President of Operations or Chief Clinical officer for proper guidance. The Administrator of Director of Nursing will report to the proper authorities within 2 hours if serious bodily injury occurs, or within 24 hours of a suspicion of crime. h. The 24 hour report is a reflection of any unusual changes in resident ' s conditions and behaviors in the last 24 hours. Effective 2/9/2012,the Director of Nursing and Unit Managers and Weekend Supervisor will review the 24 hour nurses report daily to note any instances of behavior changes and/or occurrences of inappropriate resident to resident contact. On 2/9/12 nurses were in serviced on including more information on resident behaviors. Any Allegations of abuse that are on the 24 hour report identified will be immediately reported to the Administrator. 2. On 2/9/12 a Quality Assurance Tool will be started. This tool will have department heads make rounds 5 times per week, monitoring for inappropriate behaviors, interviews with staff and residents related to this topic, for the next 3 weeks. After that, should no occurrences of abuse be reported, rounds will be made weekly. This information will be monitored by the Quality Assurance Committee monthly and any necessary actions taken. The Quality Assurance Tool instructs the staff member to observe, and question residents and staff to see if there was any inappropriate resident to resident contact; heard any resident/family complaints; observe or receive a report of inappropriate resident to resident contact. They will ask 2 employees the first thing they are to do when they observe or hear of inappropriate resident to resident contact, ask employee to whom they should report this. This will be conducted on all shifts. The Quality Assurance Tool will gather the relevant information, which will be taken to the morning meeting, where it will be discussed and any negative responses will be handled immediately by the administrator or Director of Nursing. 3. Beginning on 2/9/12 any residents displaying inappropriate behaviors will be assessed and have their care plans reviewed and updated for appropriate actions within 24 hours of occurrence. Corrections or additions will be made. This will be completed by the MDS nurses. MONITORING 1. The DON and Unit Managers will continue review the facility ' s 24 hour report to for any documented instances Of inappropriate resident to resident contact or any allegations of abuse. Further Education and possible disciplinary action will occur as needed. 2. The Department heads will continue to complete the daily Quality Assurance rounds for abuse until substantial compliance is obtained. At that time the Quality Assurance committee will review this process and these rounds will determine the frequency that rounds are to continue to be completed as a Quality Assurance process. 3. All allegations of Abuse will be immediately reported to the Administrator. The allegations will Be fully investigated and reported per regulations. The Administrator will notify the Regional Vice President And/or the Chief Clinical Officer for guidance and to ensure that the facility ' s policy has been followed. 4. The results of the Quality Assurance monitoring tool, 24 hour report, and investigations of any inappropriate resident contact will be reviewed and analyzed in the monthly Quality Assurance Committee meeting for three months and quarterly thereafter until deemed resolved by the committee. The immediate jeopardy was removed on 02/10/12 at 5:15 PM following interviews with administrative, licensed and direct care staff on all three shifts related to mandatory education on abuse; interviews with residents; interviews with families; review of in-service rosters on education of staff on abuse; review of revised abuse policy; review of the 24 hours communication sheets; and review of the quality assurance tool put into place.

Based on observations, staff interviews, and record review the facility failed to implement abuse policies and procedures related to identification, prevention, protection, investigation and reporting for four (4) of five (5) cognitively impaired residents. (Resident #1, #8, #9, and #10) Immediate jeopardy began on 1/29/2012 when staff became aware of Resident #2 inappropriately touching Resident #8. The administrator was notified of the immediate jeopardy on 02/8/2012 at 9:50 AM. Immediate jeopardy was removed on 02/10/2012 when the facility provided and implemented an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems put in place are effective. Findings include: The facility abuse policy dated 7/27/11 reads in part: POLICY STATEMENT The Facility and its staff are committed to maintaining a safe and abuse-free environment for all residents. IDENTIFICATION During orientation and throughout the year, staff will be educated on observation and reporting important information about resident care, condition or behavior. Staff and vendors are mandated to report, intervene in situations in which abuse and neglect has occurred or suspicion of occurrence. Staff is to immediately report allegations and or observations of abuse and neglect. Administrative and supervisory staff will supervise staff to identify inappropriate behaviors. PREVENTION Provide staff information on how and to whom they may report concerns, incidents, and grievances without the fear of retribution; and provide feedback regarding the concerns that have been expressed. The facility will review reports of abuse and neglect and incidents in an effort to identify trends/patterns and to maintain a safe environment for residents and staff. PROTECTION The facility will immediately protect the resident, identify the perpetrator, remove the resident from the resident care area and notify the Administrator and Director of Nurses. Other residents who may have potentially been affected or at risk will be identified and a plan of care will be developed or revised as appropriate to ensure their safety. INVESTIGATION All Abuse allegations and actual or suspicious crimes will be reported and investigated. REPORTING Report all alleged Abuse violations and all substantiated incidents to the State Agency and to all other required agencies as required, and take all necessary corrective actions depending on the results of the investigation. Report to the State agency and local law enforcement agency any suspicion of a crime. 1. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the latest Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was not ambulatory and totally dependent on staff for transfers and all Activities of Daily Living (ADL). In addition the MDS revealed Resident #1 had range of motion limitations and was impaired bilaterally in both upper and lower extremities. She was identified on the MDS with severely impaired cognition. Review of the nursing progress notes for Resident #1 revealed the following documentation: 02/06/12 at 10:51 PM Occurrence type: Inappropriately touched by male resident, (Resident #2) as a late entry for: 02/01/12 at 9:30 PM Resident #1 was sitting in the hallway in her wheelchair when the occurrence happened. Also noted the Physician was notified on 02/02/12, family RP will be notified in AM on 02/07/12. 02/08/12 at 2:42PM family RP notified at 9:00 AM. An interview on 02/06/12 at 3:20 PM with LN #5 revealed Resident #2 was observed on 02/01/12 during the 3:00 PM to 11:00 PM shift grabbing female residents' (Resident #1 and Resident #8) breasts and groins over their clothing. LN #5 stated Resident #2 was redirected, the DON was notified and a NA was assigned to sit with Resident #2. LN #5 was not aware of how long the one to one supervision continued after she left that evening. LN #5 further stated she asked the DON if she needed to fill out an incident report and was instructed only to document her findings in the behavior section of the medical record. LN #4 stated on 02/06/12 at 3:25 PM that on 02/01/12 the NAs (she did not recall whom) reported to her they had observed Resident #2 inappropriately touching female residents, including Resident #1 and Resident #8. LN #4 further revealed she considered Resident #2's behaviors as sexual abuse, so on 02/01/12 she reported it to the DON per facility policy. The DON told her to chart Resident #2's actions under behaviors in the resident's medical record. Review of the facility abuse investigations since the last survey revealed no abuse investigations on file for this occurrence involving Resident #1. The DON was interviewed on 2/6/2012 at 1:20 PM. During the interview the DON revealed she knew of Resident #2's behaviors on 1/30/12 and had the SW look in to it but did not follow up on the behaviors. The DON stated she and the Administrator decided on Friday (02/03/12) night to address the situation on 2/6/2012 as Resident #2 was on one on one supervision. The DON noted Resident #2 had been on one on one supervision over the past weekend and the MD was now trying to get a referral for a psychiatric evaluation. The DON further stated she had not yet started her investigation of Resident #2's inappropriate behaviors. The DON confirmed that neither she nor the Administrator came by the facility during the weekend of 02/04/12 through 02/05/12. During an interview on 02/06/12 at 3:50 PM the Administrator stated that prior to the phone call from the DON at 10:30 PM on 02/03/12 she did not understand Resident 2's behaviors as sexually inappropriate. The Administrator further stated when abuse is identified she would expect the resident(s) to be protected, an incident report to be filed, a full investigation to be completed, family and physician to be contacted, resident(s) to be observed for change in behaviors or demeanor and interventions put into place. Review of the facility documents revealed the twenty-four (24) hour initial report to the North Carolina Health Care Personnel Registry was faxed on 02/06/12 at 9:46 PM by the DON and the Sheriff's office was notified by the Administrator on 02/08/12 at 10:45 AM. 2. Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the latest Minimum Data Set ((MDS) dated [DATE] revealed Resident #8 was not ambulatory and required extensive assistance for Activities of Daily Living (ADL). In addition the MDS revealed Resident #8 was impaired bilaterally on lower extremities. She was identified on the MDS with severely impaired cognition. Review of the nursing progress notes for Resident #8 revealed the following documentation: 02/06/12 at 10:47 PM Occurrence type: Inappropriately touched by male resident, (Resident #2) as a late entry for: 02/01/12 at 9:30 PM Resident #8 was sitting in the hallway in her wheelchair when the occurrence happened. Also noted the Physician was notified on 02/02/12, family RP notified on 2/6/12 at 9:10 PM. 02/06/12 at 10:48 PM Occurrence type: Inappropriately touched by male resident, (Resident #2) as a late entry for: 01/29/12 at 3:49 PM Resident #8 was sitting in the hallway when the occurrence happened. Also noted: "physician notified put on MD book for review on 01/30/12." family RP notified on 2/6/12 at 9:10 PM. Review of the Physician's communication book revealed an entry by LN #1 dated 01/29/12 (no time) which stated staff noted Resident #2 touching Resident #8's breast. Review of the "Manager's on Duty" report dated 01/29/12 included in part: LN #2 reported Resident #2 was found in Resident #8's room holding her hand. During an interview on 02/06/12 at 12:05 PM, Nursing Assistant (NA) #1 revealed, that on 02/01/12, while working on the first shift she had pulled Resident #2 in his wheelchair away from Resident #8 four times. NA #1 stated she reported to LN #4, that Resident #2 had been rubbing the leg of Resident #8 up to her groin. NA #1 further revealed later that day the Director of Nursing (DON) came to the nursing station. She informed the DON of what happened. NA #1 was instructed by the DON to "keep an eye" on Resident #2 and not let him around the female residents. An interview on 02/06/12 at 3:20 PM with LN #5 revealed Resident #2 was observed on 02/01/12 during the 3:00 PM to 11:00 PM shift grabbing female residents' (Resident #1 and Resident #8) breasts and groins over their clothing. LN #5 stated Resident #2 was redirected, the DON was notified and a NA was assigned to sit with Resident #2. LN #5 was not aware of how long the one to one supervision continued after she left that evening. LN #5 further stated she asked the DON if she needed to fill out an incident report and was instructed only to document her findings in the behavior section of the medical record. LN #4 stated on 02/06/12 at 3:25 PM that on 02/01/12 the NAs (she did not recall whom) reported to her they had observed Resident #2 inappropriately touching female residents, including Resident #1 and Resident #8. LN #4 further revealed she considered Resident #2's behaviors as sexual abuse, so on 02/01/12 she reported it to the DON per facility policy. The DON told her to chart Resident #2's actions under behaviors in the resident's medical record. Subsequent interviews with staff concerning these incidents revealed: An interview was conducted with activity assistant (AA) #1 on 02/07/12 at 10:00 AM. AA #1 stated she observed Resident #2 touch Resident #8's breast over her clothing around lunch time on 01/29/12. AA #1 further stated that she immediately reported the incident to Licensed Nurse (LN) #1 who was Resident #2's and Resident #8's licensed nurse on this shift. A telephone interview on 02/07/12 at 11:00 AM with LN #1 revealed that AA #1 told her that she observed Resident #2 touch Resident #8's breast over her clothing around lunch time on 01/29/12. LN #1 recalled Resident #2 was removed from the hall near the nurse's station and assisted to bed by a nursing assistant. LN #1 stated she documented the incident in the Physician's communication book, her nurse's note, and passed the information on to the second shift (3:00 PM to 11:00 PM) nurse (LN #2). No other interventions were put into place. Review of the facility abuse investigations since the last survey revealed no abuse investigations on file for this occurrence involving Resident #8. The DON was interviewed on 2/6/2012 at 1:20 PM. During the interview the DON revealed she knew of Resident #2's behaviors on 1/30/12 and had the SW look in to it but did not follow up on the behaviors. The DON stated she and the Administrator decided on Friday (02/03/12) night to address the situation on 2/6/2012 as Resident #2 was on one on one supervision. The DON noted Resident #2 had been on one on one supervision over the past weekend and the MD was now trying to get a referral for a psychiatric evaluation. The DON further stated she had not yet started her investigation of Resident #2's inappropriate behaviors. The DON confirmed that neither she nor the Administrator came by the facility during the weekend of 02/04/12 through 02/05/12. During an interview on 02/06/12 at 3:50 PM the Administrator stated that prior to the phone call from the DON at 10:30 PM on 02/03/12 she did not understand Resident 2's behaviors as sexually inappropriate. The Administrator further stated when abuse is identified she would expect the resident(s) to be protected, an incident report to be filed, a full investigation to be completed, family and physician to be contacted, resident(s) to be observed for change in behaviors or demeanor and interventions put into place. Review of the facility documents revealed the twenty-four (24) hour initial report to the North Carolina Health Care Personnel Registry was faxed on 02/06/12 at 9:46 PM by the DON and the Sheriff's office was notified by the Administrator on 02/08/12 at 10:45 AM. 3. Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #9 was non ambulatory and required extensive assistance for activities of Daily Living (ADL). She was identified on the MDS with severely impaired cognition. Review of the nursing progress notes for Resident #9 revealed the following documentation: 02/06/12 at 10:55 PM Occurrence type: Inappropriately touched by male resident, (Resident #2) as a late entry for: 02/03/12 at 8:21 PM Resident #8 was sitting in the hallway when the occurrence happened. Also noted the Physician was notified on 02/02/12, family RP notified on 02/06/12 at 9:00 PM. Review of nursing notes dated 02/03/12 at 11:48 PM revealed LN #2 documented AA #2 reported at 8:21 PM she saw Resident #2 in Resident #9's room with his hand on the resident's groin. AA #2 attempted to remove Resident #2 from the room and Resident #2 became combative and tried to hit her. Resident #2 was removed from the room and placed at the nurse's desk. LN #2 contacted the Nurse Practitioner (NP) about Resident #2's behaviors who subsequently called the DON. The DON called LN #2 back and was told to have an NA with Resident #2 at all times. Resident #2's physician (MD) called at 10:30 PM. LN #2 explained Resident's #2's behavior had escalated on 02/03/12. The MD asked for the DON's phone number. The MD called LN #2 back at 10:50 PM with new orders for an antipsychotic and antianxiety medication. Also the MD stated the DON would be calling in the morning (02/04/12) to arrange for Resident #2's transfer to a hospital. Subsequent interviews with staff concerning these incidents revealed: During a telephone interview on 02/07/12 at 2:55 PM, LN #3 stated at approximately 6:00 AM on 02/03/12, she observed Resident #2 with his hand on Resident #9's stomach. LN #3 further stated she redirected Resident #2 to his room and kept Resident #9 with her. She stated she did not fill out an incident report but did report this information to the oncoming nurse (LN #4). Review of the facility abuse investigations since the last survey revealed no abuse investigations on file for this occurrence involving Resident #9. The DON was interviewed on 2/6/2012 at 1:20 PM. During the interview the DON revealed she knew of Resident #2's behaviors on 1/30/12 and had the SW look in to it but did not follow up on the behaviors. The DON stated she and the Administrator decided on Friday (02/03/12) night to address the situation on 2/6/2012 as Resident #2 was on one on one supervision. The DON noted Resident #2 had been on one on one supervision over the past weekend and the MD was now trying to get a referral for a psychiatric evaluation. The DON further stated she had not yet started her investigation of Resident #2's inappropriate behaviors. The DON confirmed that neither she nor the Administrator came by the facility during the weekend of 02/04/12 through 02/05/12. During an interview on 02/06/12 at 3:50 PM the Administrator stated that prior to the phone call from the DON at 10:30 PM on 02/03/12 she did not understand Resident 2 ' s behaviors as sexually inappropriate. The Administrator further stated when abuse is identified she would expect the resident(s) to be protected, an incident report to be filed, a full investigation to be completed, family and physician to be contacted, resident(s) to be observed for change in behaviors or demeanor and interventions put into place. Review of the facility documents revealed the twenty-four (24) hour initial report to the North Carolina Health Care Personnel Registry was faxed on 02/06/12 at 9:46 PM by the DON and the Sheriff's office was notified by the Administrator on 02/08/12 at 10:45 AM. 4. Resident #10 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #10 was not ambulatory and required extensive assistance for activities of Daily Living (ADL). She was identified on the MDS with severely impaired cognition. Review of the nursing progress notes for Resident #10 revealed the following documentation: 02/06/12 at 10:54 PM Occurrence type: Inappropriately touched by male resident, (Resident #2) as a late entry for: 02/03/12 at 2:45 PM Resident #10 was sitting in the dining room when the occurrence happened. Also noted the Physician was notified on 02/03/12, family RP notified on 02/06/12 at 9:15 PM. Nursing notes dated 02/03/12 at 4:48 PM revealed LN #2 documented Activities Assistant (AA) #1 reported to the nurse Resident #2 was seen by a visitor touching Resident #10's breasts. AA #1 separated Resident #10 and Resident #2. The nurse documented she notified the social worker (SW) and the DON of this incident and assigned all staff on A hall to monitor Resident #2 and know where he was. Subsequent interviews with staff concerning these incidents revealed: During interview on 02/07/12 at 10:00 AM, AA #1 stated that on 02/03/12 a visitor reported Resident #2 was touching Resident #10's breast over her clothing while they were seated in the dining room. AA #1 stated that she moved Resident #10 to another table and reported the incident to LN #2. During a telephone interview on 02/06/12 at 5:35 PM, LN #2 stated that on 02/03/12 she told the DON Resident #2 was observed inappropriately touching Resident #10's breasts. LN #2 asked the DON if she should fill out an incident report and the DON told her to document Resident #2's behaviors in the chart. She further stated the DON called back after 9:00 PM, after being contacted by the nurse practitioner (NP), and instructed staff to put Resident #2 on one on one supervision. Review of nursing notes dated 02/05/12 at 9:21 PM revealed Resident #2 was trying to approach Resident #10. The nursing note stated Resident #2 was redirected, was on one on one supervision and received as needed medication. Review of the facility abuse investigations since the last survey revealed no abuse investigations on file for this occurrence involving Resident #10. The DON was interviewed on 2/6/2012 at 1:20 PM. During the interview the DON revealed she knew of Resident #2's behaviors on 1/30/12 and had the SW look in to it but did not follow up on the behaviors. The DON stated she and the Administrator decided on Friday (02/03/12) night to address the situation on 2/6/2012 as Resident #2 was on one on one supervision. The DON noted Resident #2 had been on one on one supervision over the past weekend and the MD was now trying to get a referral for a psychiatric evaluation. The DON further stated she had not yet started her investigation of Resident #2's inappropriate behaviors. The DON confirmed that neither she nor the Administrator came by the facility during the weekend of 02/04/12 through 02/05/12. During an interview on 02/06/12 at 3:50 PM the Administrator stated that prior to the phone call from the DON at 10:30 PM on 02/03/12 she did not understand Resident 2's behaviors as sexually inappropriate. The Administrator further stated when abuse is identified she would expect the resident(s) to be protected, an incident report to be filed, a full investigation to be completed, family and physician to be contacted, resident(s) to be observed for change in behaviors or demeanor and interventions put into place. Review of the facility documents revealed the twenty-four (24) hour initial report to the North Carolina Health Care Personnel Registry was faxed on 02/06/12 at 9:46 PM by the DON and the Sheriff's office was notified by the Administrator on 02/08/12 at 10:45 AM. The administrator was notified of the immediate jeopardy on 02/8/12 at 9:50 AM. The facility provided a credible allegation of compliance on 02/10/12 at 4:24 PM. The following interventions were put into place by the facility to remove the Immediate Jeopardy: Credible Allegation of Compliance: 02/03/12 at 11:00 pm, Resident #2 was assigned a staff member to be with him at all times. The intervention continued until resident #2 was transferred from the facility to the hospital on [DATE] at 12:05 p.m. 02/08/12 Administrator called the County Sheriffs Office to report a possible crime, related to the inappropriate behavior of resident #2. PROCESS TO IDENTIFY OTHER RESIDENTS AT RISK 1. 2/6/12 and 2/8/12 the Social Worker completed interviews, with thirty four (34) alert and interviewable residents, to ascertain if there were any other incidents of inappropriate resident to resident contact noted. They were asked if they felt safe or if anyone had made them feel uncomfortable. No additional concerns were identified. 2. On 2/6/2012 complete body audits done by the Unit Charge Nurses to assess any obvious physical injury, on residents #1, #8, #9 and #10, who were identified as being inappropriately touched by resident #2. Results of this audit revealed no visible bruising or signs of physical trauma. 3. On 2/6/2012, residents # 1, #8, #9, and #10's families/responsible parties were contacted by the Director of Nursing to notify them of their family member being inappropriately touched . They were asked by the Director of Nursing if they were aware of any other instances of resident inappropriate behavior. No additional concerns were identified. 4. 2/7/12 and 2/8/12 The Nursing staff were instructed by the Director of Nursing to observe resident ' s #1, #8, #9 and #10, for and signs, such as crying, increased anxiety, new behaviors, physical injuries, such as bruising, etc., Observations will be on-going. No changes have been noted in theses resident's behaviors or demeanor. 5. 2/9/12- Twenty- Nine (29) Resident families/responsible parties were selected at random and contacted by the DON, MDS nurse or Social Worker, to determine if they were aware of any inappropriate resident to resident contact/abuse and educated to immediately report any concerns. Messages were left with 11 additional families. No family contacted reported any concerns. 6. 2/8/12 and 2/9/12 - Ninety-two employees were interviewed by department heads, and asked if they have observed any inappropriate resident to resident contact. All staff members who were not available for interview will be removed from the schedule until such interview is completed by the department head. No additional concerns were identified. PROCESSES IMPLEMENTED TO PREVENT FURTHER OCCURRENCES 1. On 2/7 and 2/8/12 all available persons employed by this facility were in-serviced. All department heads were in-service by the Regional Vice President of Operations. Staff Development Coordinator, Nurse Managers, in-service the nurses. All other staff was in-serviced by their department managers. In-services contained the following: a. The facility's Abuse policy and procedure states that abuse can be considered physical touching that is inappropriate, if it is uninvited by the person being touched. b. Immediately protect all residents when inappropriate resident to resident contact is identified, by staying with the resident to protect them. You must immediately notify the administrator. c. Immediately report all events of inappropriate resident to resident contact to the Administrator. If the Administrator is not available, the employee reporting the alleged abuse should report it to his/her supervisor who contacts the Administrator or Director of Nursing. d. 2/8/12 Abuse policy revised to state nurses are to immediately fill out an incident report and submit it to the DON; call the physician; notify family/responsible party and the administrator at the time of the occurrence. In-service was conducted by the Unit Managers, DON, department heads on 2/8/12. e. All staff should report to their immediate supervisor and expect feedback from that supervisor that an investigation has been initiated, if feedback not provided, staff should contact Administrator directly. The Administrators contact information is posted at every Nurses station and in every ancillary department. f. Any staff member that is unable to attend the Abuse in-service will not be allowed to work until they receive this in-service by the Unit Manager or Department Head or Staff Development Nurse. g. The Administrator or DON will immediately report any allegations of abuse to the Regional Vice President of Operations or Chief Clinical officer for proper guidance. The Administrator of Director of Nursing will report to the proper authorities within 2 hours if serious bodily injury occurs, or within 24 hours of a suspicion of crime. h. The 24 hour report is a reflection of any unusual changes in resident ' s conditions and behaviors in the last 24 hours. Effective 2/9/2012,the Director of Nursing and Unit Managers and Weekend Supervisor will review the 24 hour nurses report daily to note any instances of behavior changes and/or occurrences of inappropriate resident to resident contact. On 2/9/12 nurses were in serviced on including more information on resident behaviors. Any Allegations of abuse that are on the 24 hour report identified will be immediately reported to the Administrator. 2. On 2/9/12 a Quality Assurance Tool will be started. This tool will have department heads make rounds 5 times per week, monitoring for inappropriate behaviors, interviews with staff and residents related to this topic, for the next 3 weeks. After that, should no occurrences of abuse be reported, rounds will be made weekly. This information will be monitored by the Quality Assurance Committee monthly and any necessary actions taken. The Quality Assurance Tool instructs the staff member to observe, and question residents and staff to see if there was any inappropriate resident to resident contact; heard any resident/family complaints; observe or receive a report of inappropriate resident to resident contact. They will ask 2 employees the first thing they are to do when they observe or hear of inappropriate resident to resident contact, ask employee to whom they should report this. This will be conducted on all shifts. The Quality Assurance Tool will gather the relevant information, which will be taken to the morning meeting, where it will be discussed and any negative responses will be handled immediately by the administrator or Director of Nursing. 3. Beginning on 2/9/12 any residents displaying inappropriate behaviors will be assessed and have their care plans reviewed and updated for appropriate actions within 24 hours of occurrence. Corrections or additions will be made. This will be completed by the MDS nurses. MONITORING 1. The DON and Unit Managers will continue review the facility's 24 hour report to for any documented instances Of inappropriate resident to resident contact or any allegations of abuse. Further Education and possible disciplinary action will occur as needed. 2. The Department heads will continue to complete the daily Quality Assurance rounds for abuse until substantial compliance is obtained. At that time the Quality Assurance committee will review this process and these rounds will determine the frequency that rounds are to continue to be completed as a Quality Assurance process. 3. All allegations of Abuse will be immediately reported to the Administrator. The allegations will Be fully investigated and reported per regulations. The Administrator will notify the Regional Vice President And/or the Chief Clinical Officer for guidance and to ensure that the facility's policy has been followed. 4. The results of the Quality Assurance monitoring tool, 24 hour report, and investigations of any inappropriate resident contact will be reviewed and analyzed in the monthly Quality Assurance Committee meeting for three months and quarterly thereafter until deemed resolved by the committee. The immediate jeopardy was removed on 02/10/12 at 5:15 PM following interviews with administrative, licensed and direct care staff on all three shifts related to mandatory education on abuse; interviews with residents; interviews with families; review of in-service rosters on education of staff on abuse; review of revised abuse policy; review of the 24 hours communication sheets; and review of the quality assurance tool put into place.

Based on staff interviews and record review, the facility failed to assure that four (4) of five (5) sampled cognitively impaired female residents had an environment that was free from sexual abuse. The facility had not consistently identified the victims, had not conducted investigations and had not implemented effective preventative measures to protect the female residents from actual and potential sexual abuse. In addition, the facility administration failed to implement their abuse policy to identify, prevent, protect and investigate an allegation of abuse. Facility staff had knowledge of the inappropriate sexual behaviors of one male resident (Resident #2) toward four (4) sampled female residents (Residents #1, 8, 9, and 10). Immediate jeopardy began on 1/29/2012 when staff became aware of Resident #2 inappropriately touching Resident #8. The administrator was notified of the immediate jeopardy on 02/8/2012 at 9:50 AM. Immediate jeopardy was removed on 02/10/2012 when the facility provided and implemented an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems put in place are effective. The findings are: 1. Cross Reference F223. Based on staff interviews and record review, the facility failed to assure four of five cognitively impaired residents (Residents #1, 8, 9, 10) were protected following an allegation of abuse. Facility staff had knowledge of the inappropriate sexual behaviors of one male resident (Resident #2) toward four (4) sampled female residents (Residents #1, 8, 9, and 10). 2. Cross Reference F226. Based on staff interviews and record review, the facility failed to implement abuse policies and procedures for four (4) of five (5) cognitively impaired residents. (Resident #1, #8, #9, and #10) resident's condition. The administrator was notified of the immediate jeopardy on 02/8/12 at 9:50 AM. The facility provided a credible allegation of compliance on 02/10/12 at 4:24 PM. The following interventions were put into place by the facility to remove the Immediate Jeopardy: Credible Allegation of Compliance: 2/3/12 at 11:00 pm, resident #2 was assigned a staff member to be with him at all times. The intervention continued until resident #2 was transferred from the facility to the hospital on [DATE] at 12:05 p.m. 2/8/12 Administrator called the County Sheriffs Office to report a possible crime, related to the inappropriate behavior of resident #2. B. For residents#1, #8, #9, and #10: On 2/6/2012 complete body audits done by the Unit Charge Nurses to assess any obvious physical injury, on resident #1, #8, #9 and #10, who were identified as being improperly touched by resident #2. On 2/6/2012, residents # 1, #8, #9, and #10's families were contacted by the Director of Nursing to notify them of their family member being inappropriately touched . They were asked by the Director of Nursing if they were aware of any other instances of resident inappropriate behavior. No additional instances were reported. On 2/7/12 and 2/8/12 The Nursing staff were instructed to observe resident's #1, #8, #9 and #10, for and signs, such as crying, increased anxiety, new behaviors, physical injuries, such as bruising, etc., Observations will be on-going. No changes have been noted in theses resident's behaviors or demeanor. PROCESS TO IDENTIFY OTHER RESIDENTS AT RISK 1. 2/6/12 and 2/8/12 the Social Worker completed interviews, with all thirty four (34) alert and interviewable residents, to ascertain if there were any other incidents of inappropriate resident to resident contact noted. They were asked if they felt safe or if anyone had made them feel uncomfortable. No additional concerns were identified. 2. On 2/6/2012 body audits done by the Unit Charge Nurses to assess any obvious physical injury, on residents #1, #8, #9 and #10, who were identified as being inappropriately touched by resident #2. Results of this audit revealed no visible bruising or signs of physical trauma. 3. On 2/6/ , residents #1, #8, #9 and #10's families/responsible parties were contacted by the Director of Nursing to notify them of their family member being inappropriately touched. They were asked by the Director of Nursing if they were aware of any other instances of resident inappropriate behavior. No additional concerns were identified. 4. On 2/7/2012 and 2/8/2012 the Nursing staff were instructed by the Director of Nursing to observe resident's #1, #8, #9, #10, for signs, such as crying, increased anxiety, new behaviors, physical injuries, such as bruising, etc.. Observations will be on-going. No changes have been noted in these resident's behaviors or demeanor. 5. 2/9/12- Twenty- Nine (29) Resident families/responsible parties were contacted by the DON, MDS nurse or Social Worker, to determine if they were aware of any inappropriate resident to resident contact/abuse and educated to immediately report any concerns. Messages were left with 11 additional families. No family contacted reported any concerns. 6. 2/8/12 and 2/9/12 - Ninety-two employees were interviewed by department heads, and asked if they have observed any inappropriate resident to resident contact. All staff members who were not available for interview will be removed from the schedule until such interview is completed by the department head. No additional concerns were identified. PROCESSES IMPLEMENTED TO PREVENT FURTHER OCCURANCES 1. On 2/7 and 2/8/12 all available persons employed by this facility were in-serviced. All department heads were in-service by the Regional Vice President of Operations. Staff Development Coordinator, Nurse Managers, in-service the nurses. All other staff was in-serviced by their department managers. In-services contained the following: A. Identification: - Staff and vendors are mandated to report, intervene in situations in which abuse and neglect based on facility reporting policy, - Staff is to immediately report allegations and/or observations of abuse and neglect based on facility reporting policy, - The facility will facilitate assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect based on individualized assessment. B. Prevention: - Provide resident, families, and staff information on how and to whom they may report concerns, incidents, and grievances without fear of retribution; and provide feedback regarding the concerns that have been expressed. - The facility will review reports of abuse and neglect, injury of unknown origins, incidents in an effort to identify trends/patterns and to maintain a safe environment for residents and staff. Analysis and corrective/responsible action plans will be coordinated with the Quality Assurance Committee. C. Protection - When abuse or a crime is witnessed the 1ST that has to be done is to protect the resident and all other residents from further abuse or crimes. - Once you as the employee suspect abuse or a crime you must stay with the resident in the situation to protect them. - You then must then contact help to report "who" the alleged perpetrator is. - This can be reported to a charge nurse or department head. - You must not leave the resident while the reporting occurs. - Once the Nurse or Department head arrives, report what you observed and who is the alleged perpetrator. - The Nurse/Department Head must then immediately locate the perpetrator and immediately remove them from area of all residents. - You must not leave the abused perpetrator alone. - You must then immediately notify the Administrator of the situation. - From this point you follow the direction of the Administrator. D. Investigate: - The Administrator or Director of Nursing will immediately begin the investigative process to include: - Interview the residents involved - Interview of staff that had contact with the residents involved in the allegation of abuse - Interview other alert and oriented residents who had the opportunity to observe the alleged abuse. - Interview any known witness. - assess all involved residents for signs and symptoms of abuse. E. Reporting - The Administrator or Director of Nursing will be responsible for reporting the abuse allegation to all State and Local Authorities per required time frames as mandated by regulation. F. 2/8/12 Abuse policy revised to state nurses are to immediately fill out an incident report and submit it to the DON; call the physician; notify family/responsible party and the Administrator at the time of the occurrence. In-service was conducted by the Unit Managers, DON, department heads on 2/8/12. G. All staff should report to their immediate supervisor and expect feedback from that supervisor that an investigation has been initiated, if feedback not provided, staff should contact Administrator directly. The Administrators contact information is posted at every Nurses station and in every ancillary department. H. Any staff member that is unable to attend the Abuse in-service will not be allowed to work until they receive this in-service by the Unit Manager or Department Head or Staff Development Nurse. I. The Administrator or DON will immediately report any allegations of abuse to the Regional Vice President of Operations or Chief Clinical officer for proper guidance. The Administrator or Director of Nursing will report to the proper authorities within 2 hours if serious bodily injury occurs, or within 24 hours of a suspicion of crime. J. The 24 hour report is a reflection of any unusual changes in resident ' s conditions and behaviors in the last 24 hours. Effective 2/9/2012, the Director of Nursing and Unit Managers and Weekend Supervisor will review the 24 hour nurses report daily to note any instances of behavior changes and/or occurrences of inappropriate resident contact. On 2/9/2012, nurses were in-serviced on including more information on resident behaviors. Any allegations of abuse that are on the 24 hour report identified will be immediately reported to the Administrator. K. A Directed in-service will be conducted by the Ombudsman on Abuse. The facility has been unable to schedule a date as of this writing, but no later than February 17,, 2012. 2. On 2/9/12 a Quality Assurance Tool will be started. This tool will have department heads make rounds 5 times per week, monitoring for inappropriate behaviors, interviews with staff and residents related to this topic, for the next 3 weeks. After that, should no occurrences of abuse be reported, rounds will be made weekly. This information will be monitored by the Quality Assurance Committee monthly and any necessary actions taken. The Quality Assurance Tool instructs the staff member to observe, and question residents and staff to see if there was any inappropriate resident to resident contact; heard any resident/family complaints; observe or receive a report of inappropriate resident to resident contact. They will ask 2 employees the first thing they are to do when they observe or hear of inappropriate resident to resident contact, ask employee to whom they should report this. This will be conducted on all shifts. The Quality Assurance Tool will gather the relevant information, which will be taken to the morning meeting, where it will be discussed and any negative responses will be handled immediately by the administrator or his/her designee. 3. Beginning on 2/9/12 any residents displaying inappropriate behaviors will be assessed and have their care plans reviewed and updated for appropriate actions within 24 hours of occurrence. Corrections or additions will be made. This will be completed by the MDS nurses. MONITORING 1. The DON and Unit Managers will continue review the facility's 24 hour report to for any documented instances Of any allegations of abuse. Further Education and possible disciplinary action will occur as needed. 2. The Department heads will continue to complete the daily Quality Assurance rounds for abuse until substantial compliance is obtained. At that time the Quality Assurance committee will review this process and these rounds will determine the frequency that rounds are to continue to be completed as a Quality Assurance process. 3. All allegations of Abuse will be immediately reported to the Administrator. The allegations will be fully investigated and reported per regulations. The Administrator will notify the Regional Vice President and/or the Chief Clinical Officer for guidance and to ensure that the facility's policy has been followed. 4. The results of the Quality Assurance monitoring tool, 24 hour report, and investigations of any inappropriate resident contact will be reviewed and analyzed in the monthly Quality Assurance Committee meeting for three months and quarterly thereafter until deemed resolved by the committee. The immediate jeopardy was removed on 02/10/12 at 5:15 PM following interviews with administrative, licensed and direct care staff on all three shifts related to mandatory education on abuse; interviews with residents; interviews with families; review of in-service rosters on education of staff on abuse; review of revised abuse policy; review of the 24 hours communication sheets; and review of the quality assurance tool put into place.