**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to initiate an investigation related to allegations of sexual abuse for 1 (Resident #6) of 3 sampled residents. The findings include: 1. Review of the facility policy titled, ABUSE PREVENTION PROGRAM, dated 10/22/2022, revealed, .It is the policy of this facility to prevent resident abuse .The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect or a resident by a 3rd [third] party [a party not primarily involved in a situation] .Any incident or allegation involving abuse or mistreatment will result in an abuse investigation .All personnel must promptly report any incident or suspected incident of resident abuse .Any alleged violations involving mistreatment, abuse .MUST be reported to the Administrator . 2. Review of the medical records revealed Resident #6 was admitted to the facility on [DATE], with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction, Major Depressive Disorder, and Need for Assistance with Personal Care. Review of the Progress Notes for Resident #6 dated 12/2/2024 revealed, .Reported by two staff members suicidal ideation expressed .order from facility provider to send to ER [Emergency Room] for psych [mental health] eval [evaluation] . Review of the Hospital Transfer Form dated 12/2/2024 revealed Resident #6 was transferred to Hospital #1 on 12/2/2024 at 6:00 PM for suicidal ideations/statements. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #6 required maximal assistance with Self-Care for toileting hygiene, bathing, and Personal hygiene. Behavior was coded for no Hallucinations, Delusions, Physical, Verbal and Other behavioral symptoms. During a telephone interview on 1/8/2025 at 12:37 PM, Adult Protective Services (APS) Q stated the Hospital #1 had reported Resident #6 was admitted to the geriatric psychiatric unit for evaluation on 12/2/2024 and had alleged an incident of sexual abuse by staff at the facility where she resided. APS Q stated, .On 12/4/2024 at 12:30 PM, I spoke with [Named Social Services Director-SSD] about the allegations [Named Resident #6] had made when she was admitted to [Named Hospital #1] .[SSD] said they were looking into it and that [Named Resident #6] was on the memory care unit, could be hallucinating . When asked if she had told the SSD about the specific allegations of sexual abuse, APS Q replied, Yes, she understood [Named Resident #6] had reported the allegations to staff at [Named Hospital #1] . During an interview on 1/14/2025 at 12:26 PM, the SSD stated she had been employed by Facility #1 for 3 years and had received abuse training multiple times. The SSD defined sexual abuse as any type of sexual contact without consent. When asked if APS Q had notified the facility regarding allegations of sexual abuse made by Resident #6, the SSD replied, .Yes, [Named Resident #6] was not cognitively intact, she was on the memory care unit .she was only here for a couple of days .I spoke with [Named Administrator] after [Named APS Q] left .he [Administrator] told me he was already looking into it [Resident #6's allegations] . When asked, if she participated in the facility abuse investigations, the SSD stated she conducts interviews with residents. When asked if she had a role in the investigation related to Resident #6's allegations of sexual abuse, the SSD replied, I am sure that I did. During an interview on 1/14/2025 at 1:10 PM, The Administrator was asked for copies of the investigation related to allegations of sexual abuse reported by Resident #6 on 12/2/2024. The Administrator stated he was not aware of any allegations of sexual abuse made by Resident #6. The Administrator was asked if the SSD had notified him related to the allegations of sexual abuse made by Resident #6 when she had been transferred to Hospital #1 for evaluation. The Administrator stated no one had reported the allegations of sexual abuse made by Resident #6 to him and confirmed the facility had not investigated the alleged sexual abuse. The Administrator affirmed he expected all staff to report allegations of abuse immediately to him, the Abuse Coordinator. The Administrator confirmed all allegations of sexual abuse should be reported and investigated thoroughly. During a telephone interview on 1/15/2025 at 9:45 AM, the Social Worker at Hospital #1 stated Resident #6 was admitted to the facility on [DATE] for psychiatric evaluation following suicidal ideations reported by staff at Facility #1. The Social Worker stated the hospital physician documented bruising on Resident #6's arms and under her chin. The Social Worker stated, .The M.D. [Medical Doctor] reported that [Named Resident #6] had made allegations of sexual assault by two white women, nurses who had both put their fingers in her vagina .[Named Resident #6] alleged she had told the women to stop and they would not .[Named Resident #6] stated she did not really have suicidal thoughts, she just wanted to get out of the facility because she was scared . The Social Worker stated she had reported the allegation to Adult Protective Services (APS) and to the local police department.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, video footage review, medical record review, facility document review, and interview, the facility failed to provide an environment that is free from accident hazards over which the facility has control for 1 of 3 (Resident #10) sampled residents reviewed for falls. The findings include: 1. Review of the facility policy titled, GUIDELINES FOR INCIDENTS/ACCIDENTS/FALLS, dated 6/30/2023, revealed, .If a resident is involved in an incident/accident an immediate assessment of the resident will be completed by a nurse .Whether or not the resident can be moved or repositioned will be determined by the assessing nurse . 2. Review of video footage dated 1/3/2025 at 11:34 AM, revealed Resident #10 telling staff she was sliding out of the chair. Certified Nursing Assistant (CNA) K then told CNA L to go get the mechanical lift and the bigger chair. CNA K was standing in front of Resident #10 and CNA M was standing behind the resident. Resident #10 was in the transport chair facing the 600 Hall entrance. CNA K attempted to adjust the sling under Resident #10's legs. Resident #10 was leaning over the right chair arm with her feet on the floor. Resident #10 stated, .I am falling out of this thing [transport chair]. CNA M told Resident #10 to lean back, twice, then Resident #10 stated, .I can only lean back so far . CNA K attempted to adjust Resident #10's legs and Resident #10 stated, .I feel like my leg is falling .I am going to be on the floor in a minute . CNA M called Resident #10 by her first name in a loud voice and proceeded to pull the resident backwards with Resident #10's feet both on the floor. Resident #10 yelled out and stated, .I'm not kidding .I am just on the edge of this chair . CNA M stopped pulling the chair, looked at CNA K and stated, .I am losing my patience .I didn't want to get her up in the first place . Resident #10 stated, .I can't I am going to hit the floor in a second . CNA K disagreed with Resident #10 and Resident #10 screams, .Yes I am . as CNA M pulls the chair again. Resident #10 slid out of the chair on to the foot rest and stated, .I tried to tell you . CNA L attempted to support Resident #10 and CNA K covered Resident #10's exposed lower body with a sheet/blanket. CNA M turned her head to the side, raised her hand in the air and states, .I am just to the point of like, so I'm going to get arrested . and myself at risk, no . CNA K states, .This chair don't need to go in her room no more . CNA L states, .We can lift her up with the lift .we can go get the chair she is supposed to have . CNA L and CNA K attempted to move Resident #10 off of the foot rest. CNA M continued to stand behind the transport chair and raises both hands in the air and declares, .I'm going to go get help . Further review of the video footage revealed Licensed Practical Nurse (LPN) E arrived to the area and assured Resident #10 staff would help lift her. Physical Therapy (PT) arrived shortly after LPN E, and assisted with positioning the sling under Resident #10. Staff raised Resident #10 off of the floor on both sides and raised both legs in order to place the sling. Resident #10 cried out during movement. The video footage revealed no one physically touched the resident to assess for injury. Registered Nurse (RN) C was not in the video footage at any time. 3. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), Generalized Anxiety Disorder, and history of Age-Related Osteoporosis with Current Pathological Fracture. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Resident #10 was coded for total dependence with all mobility and locomotion in wheelchair. Review of the care plan for Resident #10 dated 7/3/2024 revealed, .7/3/2024 .Pain/Comfort .ROM [Range of Motion] .7/19/2024 .[Named Resident #10] has a 'Self Care Deficit' .Ensure proper positioning while in bed and/or chair .Fall: [Named Resident #10] has the potential for serious injury/fall .1/3/25 [2025] Bariatric Wheelchair .Remind resident of safety awareness .OSTEOPOROSIS: [Named Resident #10] is at risk for Fracture R/T [Related/To] dx: [diagnosis] osteoporosis .Avoid exercises that may increase risk for fractures . Review of the facility incident report dated 1/3/2025 revealed, .[Resident #10] slid from wheelchair on to floor in hallway .Predisposing Physiological Factors . Agitated/Anxious .Decreased safety awareness . Review of the Incident Report Checklist for Resident #10 dated 1/3/2025 revealed a statement from CNA K indicating Resident #10 slowly slid out of her chair and was easily guided to the floor. A statement from CNA L indicated Resident #10 had to be pulled backwards in the chair because her feet would not fit on the foot rest of the transport chair. CNA L's statement revealed Resident #10 was slipping out of an inappropriate chair which required the CNAs to ease her to the floor onto blankets and pillows. A statement from CNA M alleged Resident #10 began to slide out of her wheelchair and CNA grabbed the sling that was underneath the resident and gently slid her to the ground. Review of the Multidisciplinary Incident Report Meeting Minutes dated 1/3/2025 at 11:35 AM, revealed a signature page which included a signature of the Administrator, the Medical Director, the Assistant Director of Nursing (ADON), the Wound Care Nurse, the MDS Coordinator, the Social Services Director, and the Therapy staff. The immediate interventions included (Named non-slip material), and replace Resident #10's transport chair with a Bariatric chair. During an interview on 1/16/2025 at 11:11 AM, Resident #10 stated on 1/3/2025 a Certified Nursing Assistant (CNA-M) transferred her to the transport chair (a narrow mobility chair) using a mechanical lift. Resident #10 stated, .I told [CNA M] I wasn't sitting in the chair right and needed to be pulled .she was in a hurry and seemed agitated .[CNA M] said you shouldn't be going anyway .coming back from activities I kept telling [CNA M] I was about to slip out of the chair, then I did .No one took my blood pressure .When therapy puts me in the wheelchair, I do not ever have a problem sliding out, the techs just rush . During an interview on 1/16/2025 at 12:45 PM, Family Member (FM) P stated, .[Named Resident #10] told staff multiple times during activities and going back to her room that she needed to be pulled up because she was sliding off of her chair .[CNA M] appeared agitated, and a couple of times [CNA M] said she didn't want to get her up .her feet were dragging the floor and she lost her shoe .[staff] stopped once when [Named Resident #10] yelled out .one tech said we need to get a lift, the dark haired tech [CNA M] said no we don't and told [Named Resident #10] she wasn't sliding out, then pulled [Resident #10] again and she slid out onto the floor . During a telephone interview on 1/16/2025 at 6:15 PM, the Activities Assistant stated on 1/3/2025 he walked behind staff pulling Resident #10 backwards with her feet dragging the floor when leaving activities. The Activities Assistant affirmed Resident #10 did tell staff she was sliding out of the chair and then [Resident #10] slid from the chair. During an interview on 1/17/2025 at 11:00 AM, CNA M stated on 1/3/2025 stated, .I was paged to activities because [Resident #10] was sliding out of her chair .she had slid down in the chair and the sling [ hammock-like support used to cradle a person's body during a transfer] was dislodged, there was no way to pull her back up .[Resident #10]'s feet were past the foot pedals, on the floor, and I had to pull her backwards .[Named CNA L] and another CNA [CNA K] walked with us down the hall .[Resident #10] said she was sliding out of the chair .no way to use [mechanical lift] in the hall .I was aggravated with the situation .when I got her up in the chair before activities, she complained about being wrong in the chair, I asked her then if she even wanted to go .it isn't safe for her to be in that chair [transfer chair] . When asked why she placed Resident #10 in the transfer chair instead of a wheelchair, CNA M responded, It's her chair, I guess she wants to use it. CNA M stated Resident #10 was sliding out of the chair and staff eased her to the floor then used a mechanical lift to place her in a Bariatric wheelchair (extra wide wheelchair). CNA M stated a nurse assessed the resident and checked vital signs. During an interview on 1/17/2025 at 12:14 PM, CNA K stated, .[Named Resident #10] was not sitting right in her chair .[Resident #10] had slid down and her feet were on the floor .[Named CNA M] came to get her and the resident was yelling because we couldn't get her feet on the foot pedal .[Named CNA M] pulled her backwards out of 600 Hall .[Named Resident #10] kept saying she was sliding out of the chair .I told [Named CNA M] [Resident #10] was sliding out .[Named CNA M] started pulling her backwards again and [Resident #10] slid out into the floor landing on the wheelchair foot pedal . CNA K affirmed she did not recall anyone actually assessing Resident #10 before staff lifted her with the mechanical lift. CNA K concluded the transport chair was not large enough for Resident #10 which caused her to slide out of the chair during transport. During an interview on 1/17/2025 at 12:55 PM, LPN N stated on 1/3/2025 Registered Nurse (RN) C told him to assist the CNAs with Resident #10 after a fall on 200 Hall. LPN N stated RN C was sitting at the nurse station charting when she requested his assistance. LPN N confirmed he did not assess Resident #10 after the fall and did not assist with lifting her from the floor. LPN N conceded the facility protocol required a nurse to perform a head to toe assessment after a fall before moving the resident. During a telephone interview on 1/17/2025 at 4:37 PM, the Physical Therapist (PT) stated on 1/3/2025 he was asked to assist with lifting Resident #10 from the floor after she slid out of her transport chair. The PT stated, .[Named Resident #10] was awake, alert and said nothing was hurting her .I assessed [Resident #10] by applying pressure to her shoulder and both hips .[Resident #10] only complained about the sling bothering her neck .no one has voiced concerns with [Named Resident #10]'s transport chair being too small .no chair ordered because the facility had Bariatric wheelchairs . During a telephone interview on 1/17/2025 at 5:05 PM, RN C stated on 1/3/2025 she did not witness Resident #10 slide out of the wheelchair. RN C stated, .I went to the hall and assessed the resident .I did not obtain vital signs until she was back in bed .I felt of her hips, applied pressure to both hips and lifted her pants leg to look for injuries to her legs .I asked [Named Resident #10] if she was in pain and she denied pain . RN C conceded the facility protocol requires the nurse to perform an assessment prior to moving a resident post fall which includes obtaining vital signs. During an interview on 1/17/2025 at 5:15 PM, CNA L stated on 1/3/2025 the 600 Hall nurse (LPN O) told her Resident #10 was sliding out of her chair and to get a mechanical lift to assist Resident #10 back into a sitting position. CNA L stated CNA M came to take Resident #10 back to her room and pulled her backwards in the transport chair because Resident #10's feet were dragging the floor. CNA L stated, .[Named CNA K] and I tried to help hold her in the chair going down the hall .[Resident #10] yelled a couple of times saying she was sliding out of the chair and then she did .I think [Named LPN N] assessed her but I don't know about vital signs .I think they did [obtain vital signs] . When asked if CNA M was agitated, CNA L replied, .Yes, she was huffy, short with answers, and making remarks, I am not sure exactly what she said . During a telephone interview on 1/17/2025 at 5:52 PM, LPN E stated, .The day [Named Resident #10] slid out of her chair I went to help get her up from the floor .several of us put the sling under her and lifted her up to a wheelchair .I went back to the nurses station and told [Named RN C] she could get vital signs now, the resident was back to her room . When asked if RN C had assessed Resident #10 prior to her being moved from the floor, LPN E replied, .I do not recall seeing [RN C] assess the resident, she stayed at the desk charting . During an interview on 1/17/2025 at 6:00 PM, the Director of Nursing (DON) stated she was not present in the facility on 1/3/2025, the day Resident #10 slid from her chair while being pulled backwards in the transport chair. The DON affirmed pulling a resident backwards in a wheelchair was not safe and conceded dragging a resident's feet during transport created a skin injury risk in addition to a fall risk. The DON stated she expected nursing staff to complete an assessment after a fall to prevent any potential additional injury to a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the Facility Assessment Tool review, facility policy review, medical record review, and interview, the facility failed to ensure all nursing staff possessed the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being for 1 of 3 (Resident #5) sampled residents. The findings include: 1. Review of the Facility Assessment Tool dated 8/7/2024, revealed, .Diseases/conditions, physical and cognitive disabilities that the facility can accommodate .Respiratory System .Chronic Obstructive Pulmonary Disease (COPD) .Decisions regarding caring for residents with conditions not listed .In the event that a referral for admission is received or a current patient develops a new or unfamiliar diagnosis the clinical chart is reviewed .When considering the patient the IDT [Interdisciplinary Team] shall take into account the clinical capabilities of the staff .Specialized education shall be given to staff as necessary to manage new or less common diagnoses .prior to admission .Special Treatments and Conditions .Suctioning Tracheostomy [surgically created opening and placement of a tube/catheter/cannula in the windpipe/trachea, to help a person breathe] Care . 2. Review of the undated facility policy titled, Tracheostomy Care, revealed, .Tracheostomy care is the process of aseptically cleaning the tracheostomy tube and soma [stoma] site .Review physician's order .Gather the necessary equipment .Suction equipment .Trach care kit .Follow relevant infection control procedures .Suction the trach as necessary-following sterile suction technique .Precautions/Hazards .Accidental decannulation .Infection from poor aseptic technique . 3. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses which included COPD, Tracheostomy Status, and Acquired Absence of Larynx. Review of the physician's orders for Resident #5 revealed, .Trach: site care every shift and as needed as needed AND every shift .Start Date .10/22/2024 .End Date .12/24/2024 .Trach: suction as needed as needed .Start Date .10/22/2024 .End Date .12/24/2024 . Review of the Medication Administration Records dated 10/22/2024- 12-12-2024, for Resident #5 revealed trach site care was documented each shift by nursing staff. Continued review revealed documentation of as needed suctioning provided twice during his stay in the facility. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Continued review revealed Resident #5's primary medical condition category coded as Debility, Cardiorespiratory Conditions. Resident #5 was coded for Special Treatments, Procedures, and Programs which included Tracheostomy care. Review of the comprehensive care plan dated 10/23/2024, for Resident #5 revealed, .at risk for complications R/T [Related/To] tracheostomy .Trach care per MD [Medical Doctor] order .Trach change . Staff alleged Resident #5 provided his own trach care. There was no physician's order for self-care. During an interview on 1/9/2025 at 2:21 PM, Licensed Practical Nurse (LPN) E stated, .I talked to [Named Assistant Director of nursing-ADON and Interim Director of Nursing-DON] the day of [Resident #5's] admission .I told them that I did not have the experience or training to provide care for a trach patient .I never saw a replacement trach tube at [Resident #5's] bedside or in supply .I didn't feel confident to be responsible for a trach patient then and I don't know .We didn't have suction at the bedside and no trach care kits .I was told the admission could not be stopped and [Named Interim DON] called the nurses into the office and provided a quick true/false quiz on trachs .A respiratory consultant came in to set up oxygen for [Resident #5] and I asked him what could I do if the patient lost his airway, he said to call 911 [emergency assistance] and bag [mask bag device used to force air into the lungs] at the trach . LPN E affirmed the brief in-service true/false quiz was the only education on tracheostomy care and precautions provided by the facility. LPN E stated he had minimum training during his LPN course and did not feel it was adequate for hands on care of a tracheostomy. During an interview on 1/13/2025 at 1:55 PM, LPN F stated, .I had [Named Resident #5] on my assignment while he was here .[Resident #5] took care of his trach himself .was not compliant with care, sometimes he would take his trach tube out and leave it open .I don't believe I could put a trach tube back in if I needed to .[Named Interim DON] called us into the office and gave a test on trach care and I googled a video to watch about it [providing care of a tracheostomy] .I believe they handed out a packet of information too .I know there was a care kit at his bedside, not sure if there was a replacement tube in the kit . When asked if she felt the training provided by the facility was adequate to prepare her for Resident #5's care, LPN F replied, No. During a telephone interview on 1/14/2025 at 10:32 PM, LPN G stated, .I received a real quick in-service on trach care .a few questions on a test .I provided suction when [Resident #5] needed it .used a catheter suction .I don't think it [suctioning the trach] is a sterile procedure, I did use clean procedure .[Resident #5] provided his own trach care .I am not really familiar with an emergency kit for trachs . LPN G stated she did not receive an in-service video education related to tracheostomy care and wasn't aware of any type of packet with education provided by the facility. During an interview on 1/15/2025 at 2:53 PM, the ADON stated, .We only had one resident with a trach, [Named Resident #5] .a couple of the nurses were anxious about taking care of his trach .[Named Interim DON] provided some training, I think a video and a post test . When asked if the training was provided to all nursing staff, the ADON replied, I really don't remember. When asked if the video was provided by the DON during the in-service on 10/22/2024, the ADON replied, I'm not sure. The ADON stated there wasn't a specific Staff Development person and affirmed she provided most nursing education. When asked if she had received sufficient training related to tracheostomy care, the ADON replied, I'm not sure. During an interview on 1/16/2025 at 11:43 AM, the Nurse Practitioner (NP) stated, .[Named Resident #5] should not have provided his own trach care .I didn't feel confident that the nurses providing [Resident #5's] care were adequately trained for any type of acute airway compromise. I asked the nurses questions related to an acute airway emergency and trach care, the nurses could not answer correctly .I asked the Wound Care Nurse [LPN H] to assist the nurses with [Resident #5] care . The NP stated she voiced concerns related to staff competency in tracheostomy care to the ADON and the interim DON on the day of Resident #5's admission. When asked about Nursing Administration's response, the NP replied, The Interim DON called the nurses on duty into her office and provided a little 5 question quiz on trach care, which was not adequate. During an interview on 1/17/2025 at 5:25 PM, the Wound Care Nurse (LPN H) stated, .The DON talked to some of the nurses in the office when [Resident #5] was admitted .gave a quick questionnaire, watched a video, and I believe there was a packet .we had not had a trach patient here before [Resident #5] .I have never provided trach care to anyone, here or anywhere else .a couple of the nurses voiced concerns about caring for [Resident #5] .I was never present during trach care for [Resident #5] . When asked if she felt confident to provide care for a tracheostomy patient during an acute airway compromise, LPN H did not reply. During an interview on 1/17/2025 at 6:00 PM, the DON was asked if the competency check-off sheet provided for nursing staff was sufficient to ensure staff had the skill set to provide tracheostomy care. The DON stated, .The check off sheet provided during orientation of nursing staff simply determines a basic knowledge of skills .When a resident is admitted with special care needs, such as a tracheostomy, staff need to have a comprehensive in-service to ensure competency in care .nursing staff should be confident when providing care of all residents and be encouraged to request additional training in order to reach competency for resident safety . The DON reviewed the in-service 5-question true/false quiz and confirmed it was not adequate training. The facility provided an in-service record titled, Trach Care, dated 10/22/2024. The documents provided included a sign in sheet for 8 staff nurses and 1 MDS nurse (which did not include all nursing staff assigned to care for Resident #5) and a Tracheostomy Care Quiz. Review of the 5-question true/false quiz revealed, .1. It is not necessary to have a spare tracheostomy cannula at hand, if cannula is dislodged placing cannula back is permitted .2. After tracheostomy decannulation [removal of the tracheostomy tube] oxygenation is of high priority .3. If resident is dependent on tracheostomy cannulation and tracheostomy becomes decannulated, it becomes an emergency .4. If a resident is observed struggling to oxygenate with tracheostomy cannula in place, immediately notify nurse .5. Always have oxygen and suctioning machine available at resident's bedside .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy reviews, medical record review, and interviews, the facility failed to report allegations of suspected abuse within 2 hours for 1 of 2 sampled residents (Resident #1) reviewed for allegations of abuse. The findings include: Review of the policy titled, Abuse Prevention Program Policy, updated on 1/9/2017, revealed, .Abuse Reporting .this policy will define how the investigation of abuse allegations and mistreatment will be conducted and outline the process of reporting .any alleged violations involving mistreatment, abuse .must be reported to the Administrator and Director of Nursing .or person in charge .notify the following persons or agencies of such incident immediately .the investigator will submit a final report of the conclusion of the investigation in writing within five (5) working days of the incident . Review of the undated policy titled, Resident Rights, revealed, .Abuse .you have the right to be free from verbal, sexual, physical or mental abuse .In the event of an alleged violation involving your treatment, the facility is required to report it to the appropriate officials . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Hypertensive Chronic Kidney Disease with Stage 1 Through Stage 4, Type II Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease. During an interview on 3/20/2023 at 2:15 PM, the Assistant Director of Nursing (ADON) stated, Adult Protective Services [APS] came to the facility .investigating a complaint made by [named Resident #1] alleging she was not being taken care of properly. I informed the Director of Nursing [DON] that APS was there to investigate the allegations made by [named Resident #1]. When asked to define the definition of Neglect, the ADON replied, not providing care to the resident. During an interview on 3/21/2023 at 1:37, APS stated, I came to the facility on 1/18/2023 to investigate a complaint of neglect for [named Resident #1]. I spoke with the ADON about the concerns regarding the allegation of neglect for [named Resident #1]. During an interview on 3/22/2023 at 2:02 PM, the Administrator confirmed the allegations of Neglect made by Resident #1 were not investigated by the facility or reported to the State Agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy reviews, medical record review, and interviews, the facility failed to thoroughly investigate an allegation of neglect for 1 of 2 sampled residents (Resident #1) reviewed with allegations of abuse. The findings include: Review of the policy titled, Abuse Prevention Program Policy, updated on 1/9/2017 revealed, .Abuse Reporting .this policy will define how the investigation of abuse allegations and mistreatment will be conducted and outline the process of reporting .any alleged violations involving mistreatment, abuse .must be reported to the Administrator and Director of Nursing .or person in charge of the facility, will notify the following persons or agencies of such incident immediately .the investigator will submit a final report of the conclusion of the investigation in writing within five (5) working days of the incident . Review of the undated policy titled, Resident Rights, revealed, .Abuse .you have the right to be free from verbal, sexual, physical or mental abuse .In the event of an alleged violation involving your treatment, the facility is required to report it to the appropriate officials . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Hypertensive Chronic Kidney Disease with Stage 1 Through Stage 4, Type II Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease. During an interview on 3/20/2023 at 2:15 PM, the Assistant Director of Nursing (ADON) stated, Adult Protective Services [APS] came to the facility .investigating a complaint made by [Resident #1] alleging she was not being taken care of properly. I informed the Director of Nursing [DON] that APS was there to investigate the allegations made by [named Resident #1]. When asked to define the definition of Neglect, the ADON replied, not providing care to the resident. During an interview on 3/21/2023 at 1:37, APS stated, I came to the facility on 1/18/2023 to investigate a complaint of neglect for [named Resident #1]. I spoke with the ADON about the concerns regarding the allegation of neglect for [named Resident #1]. During an interview on 3/22/2023 at 2:02 PM, the Administrator confirmed the allegation of neglect made by Resident #1 was not investigated or reported to the State Agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interviews, the facility failed to develop and implement a baseline care plan to include the instructions needed to provide effective and person-centered care for 1 of 4 sampled residents (Resident #2) reviewed for care plans. The findings include: Review of the facility policy titled, Baseline Care Plan Assessment/Comprehensive Care, revealed, .It is the policy of the facility to ensure that every resident has a Baseline Care Plan completed and implemented within 48 hours of admission .intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan of delivery of care and services by receiving a written summary of the Baseline Care Plan .The Baseline Care Plan Assessment will be completed within 48 hours of admission and will address areas of imminent concern . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses which included COVID-19, Atrial Fibrillation, Muscle Weakness, History of Falling and Thrombocytopenia (low amount of platelets in blood which prevents clotting and can cause excessive bleeding-bruising). Review of the Baseline Care Plan for Resident #2 revealed the following questions were incomplete and/or Not Assessed .advanced directives, eating, personal hygiene, toilet use, dressing, bathing, bed mobility, transfer, and walking in room. Questions regarding urinary and bowel continence, skin risk, mental health and behavioral concerns were also incomplete. The Baseline Care Plan was signed and dated 1/29/2023 by the ADON (Assistant Director of Nursing). No other disciplines signed the Baseline Care Plan. During an interview on 3/20/2023 at 2:37 PM, the ADON stated, The baseline care plan is initiated during the admission process .We have 48 hours for all disciplines to complete the care plan . The ADON confirmed the care plan for Resident #2 was incomplete and areas that were not assessed for interventions. During an interview on 3/22/2023 at 12:15 PM, the Social Services Director (SSD) stated, The baseline care plan will be completed within 48 hours according to the policy .it was not completed [for Resident #2] .I did not go over the plan of care with [Resident #2]'s resident representative .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview the facility failed to notify the responsible party of a room change to a secure unit for 1 of 3 residents (Resident #7) reviewed. The findings include: Review of the facility's undated policy for the special care unit (secure unit) titled, admission and Discharge Policy and Procedure, revealed .The criteria for admission is the standard by which [named facility] selects potential residents and is also the basis for the criteria by which a resident may be discharged from [named facility]. A specialized screening process begins prior to the admission to [named facility] and continues until the time of discharge. If a resident does not meet the admission criteria in one or more of the following areas, the resident may not be selected for admission [to named facility]. 1. Must have a diagnosis of Alzheimer's or Dementia. 2. Must not exhibit behaviors that may result in injury to self or others .5. Must be mobile: ambulatory, self-propelled wheelchair, and must be able to transfer with a 1-2 person assist and weight bear pivot . Review of the facility's undated policy titled, Room Changes-Resident Rights revealed .It is the policy of the facility to conduct any room changes/transfers in compliance with the regulations related to the different specified locations in the facility including the distinct part areas .Resident/responsible party will be informed of their right to refuse to transfer to another room in the purpose of the transfer is to: Relocate a resident of a SNF [skilled nursing facility] from the distinct part of the institution that is a SNF to a part of the institution that is not a SNF . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses which included Myocardial Infarction, Hypothyroidism, and a History of Falling. Review of Resident #7 undated care plan revealed .Alteration in behaviors as evidenced by: [named Resident #7] is resistant with care, verbally aggressive with staff, and physically, aggressive with staff during care. Makes false statements, hallucinates . Review of the Nurse Practioner (NP) Notes dated 7/14/2022 revealed, .She is being seen today for routine follow-up and lab analysis .Patient requiring assistance with personal hygiene, toileting, transfers and mobility. She continues to have anxiety. MHN [Mental health Nurse] NP to see . Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had a Brief Inventory for Mental Status (BIMS) score of 2, indicating severe cognitive impairment. Continued review revealed Resident #7 required extensive assistance from two staff for bed mobility and toileting. Resident #7 was frequently incontinent of bowel and bladder. Review of the Progress Notes dated 7/16/2022 revealed .Resident combative with confusion during any care provided. Will scream out during brief/bed changes/transfers, attempts to hit staff during care, threatens to report all of staff during care . Review of the Progress Notes dated 7/18/2022 revealed, .I have a doctors appointment when this nurse entered resident was attempting to exit the bed. This nurse and CNA [Certified Nursing Assistant] assisted her back in bed in proper alignment. Resident began screaming and pinched this nurses left arm leaving a red mark. Resident reminded that it was 0400 [4:00 AM] and still nighttime and she also did not have an appointment at the time. Resident began to get agitated and accused this nurse of causing the bruising on her arms and legs. Noted no bruising to legs or arms, reminded resident staff is here to assist and care for her. Resident was provided with peri-care, ice water and morning medications. Resident lying in bed with lights on and eyes open, respirations even unlabored . Review of the NP Notes dated 7/18/2022 revealed .She has been anxious. She is here for continued care .She needs help with bathing, grooming, dressing, and toileting . During a telephone interview on 11/15/2022 at 9:30 AM, Family Member #1 stated the facility did not inform Family Member #1 that Resident #7 was moved to a secure unit or of the room change. During a telephone interview on 11/15/2022 at 4:26 PM, License Practical Nurse (LPN) #5 stated she never worked on the secure unit unless an assigned nurse did not come into work. The management decided who was placed in the secure unit. LPN #5 confirmed that the responsible party or the resident, if they were their own responsible party, had to be notified before moving them to another room or unit. During an interview on 11/16/2022 at 10:42 AM, the Social Service Director (SSD) stated that Resident #7 was initially admitted to the 500 halls (non-secure long term care unit). The only residents admitted to the secure unit were residents who wandered, or who had behaviors, a history of falling, Dementia, exit seeking, or a history of elopement. The SSD stated the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) decided for residents to be admitted to the secure unit. The SSD stated that the family should be notified before moving a resident to the secure unit. The SSD confirmed she did not see any documentation in the EHR (electronic health record) of notification to the family for Resident #7 for the transfer to the secure unit. During a telephone interview on 11/16/2022 at 12:20 PM, the NP stated that the facility did not inform her of Resident #7's move to the secure unit, and the NP did not have input on which residents were admitted to the secure unit. The NP stated she would not have written an order for admittance to the secure unit for Resident #7. During an interview on 11/16/2022 at 1:44 PM, the ADON stated that residents were admitted to the secure unit dependent on their prior hospitalization, exit-seeking behaviors, and wandering behaviors. The ADON stated the DON was the decision maker for transferring a resident to the secure unit. The ADON stated the nursing staff did not have to obtain an order from the physician before transferring a resident to the secure unit. THE ADON stated she did not remember why Resident #7 was moved to the secure unit and confirmed she did not see any documentation for the notification of the responsible party to the secure unit for Resident #7.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to inform a resident's representative/responsible party of an identified pressure ulcer and failed to consult with the resident's physician of a significant decline requiring transfer to the secure unit for 1 of 3 (Resident #7) sampled residents. The findings include: Review of the facility's undated policy titled, Changes in Residents Condition or Status, revealed .It is the policy of the facility to ensure that the resident's attending physician and Representative are notified of changes in the resident's condition or status . Review of the facility's undated policy titled, Preventative Skin Care revealed .It is the intent of the facility that the facility provide preventive skin care through careful washing, rinsing, and drying to keep residents clean, comfortable, well groomed, and free from pressure sores . Review of the facility's undated policy for the special care unit (secure unit) titled, admission and Discharge Policy and Procedure, revealed .The criteria for admission is the standard by which [named facility] selects potential residents and is also the basis for the criteria by which a resident may be discharged from [named facility]. A specialized screening process begins prior to the admission to [named facility] and continues until the time of discharge. If a resident does not meet the admission criteria in one or more of the following areas, the resident may not be selected for admission [to named facility]. 1. Must have a diagnosis of Alzheimer's or Dementia. 2. Must not exhibit behaviors that may result in injury to self or others .5. Must be mobile: ambulatory, self-propelled wheelchair, and must be able to transfer with a 1-2 person assist and weight bear pivot . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses which included Myocardial Infarction, Hypothyroidism, and a History of Falling. Review of Resident #7 undated care plan revealed .[named Resident #7] has an alteration in skin integrity and is at risk additional and/or worsening of skin integrity issues related to: Impaired cognition, Incontinence of bowel, Impaired Mobility Status, Comorbidities, and Resistance to ADL [activities of daily living] Care . Review of the Weekly Wound Evaluation dated 7/12/2022 revealed Resident #7 had a Stage 2 pressure ulcer to the coccyx documented as present upon admission. The measurements of the Stage 2 pressure ulcer on 7/12/2022 was 8.0 centimeters (cm) in length, 7.0 cm in width, and 0.5 cm in depth. Resident #7 had a suspected deep tissue injury to the right heel documented as present upon admission. The measurements of the suspected deep tissue injury were 1.3 cm in length and 2.1 cm in width. The Wound Care Nurse documented, Upon admission, skin assessment completed. Discoloration noted to R [right] heel and SDTI [Suspected Deep Tissue Injury]/open area coccyx .NP [Nurse Practitioner]/DON [Director of Nursing] aware of skin integrity . The Wound Care Nurse documented Resident #7 was self responsible, and she updated Resident #7 on the status of the wound. There was no documentation found that the resident's representative/responsible party was notified of the identification of a pressure wound or the wound status. Review of the admission Agreement dated 7/13/2022 revealed that Family Member #1 was the representative/responsible party for Resident #7. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had a Brief Inventory for Mental Status (BIMS) score of 2, indicating severe cognitive impairment. Continued review revealed Resident #7 required extensive assistance from two staff for bed mobility and toileting. Resident #7 was frequently incontinent of bowel and bladder. During a telephone interview on 11/15/2022 at 9:30 AM, Family Member #1 stated he could not remember when he was told about the wound but was told on 7/20/2022 Resident #7 was being discharged because the wound had declined. During an interview on 11/16/2022 at 4:12 PM, the Wound Care Nurse stated she did not remember if she contacted the family regarding the wound upon discovery at admission. Review of Resident #7 undated care plan revealed .Alteration in behaviors as evidenced by: [named Resident #7] is resistant with care, verbally aggressive with staff, and physically, aggressive with staff during care. Makes false statements, hallucinates . Review of the Nurse Practioner (NP) Notes dated 7/14/2022 revealed, .She is being seen today for routine follow-up and lab analysis .Patient requiring assistance with personal hygiene, toileting, transfers and mobility. She continues to have anxiety. MHN [Mental health Nurse] NP to see . Review of the Progress Notes dated 7/16/2022 revealed .Resident combative with confusion during any care provided. Will scream out during brief/bed changes/transfers, attempts to hit staff during care, threatens to report all of staff during care . Review of the Progress Notes dated 7/18/2022 revealed, .I have a doctors appointment when this nurse entered resident was attempting to exit the bed. This nurse and CNA [Certified Nursing Assistant] assisted her back in bed in proper alignment. Resident began screaming and pinched this nurses left arm leaving a red mark. Resident reminded that it was 0400 [4:00 AM] and still nighttime and she also did not have an appointment at the time. Resident began to get agitated and accused this nurse of causing the bruising on her arms and legs. Noted no bruising to legs or arms, reminded resident staff is here to assist and care for her. Resident was provided with peri-care, ice water and morning medications. Resident lying in bed with lights on and eyes open, respirations even unlabored . Review of the NP Notes dated 7/18/2022 revealed .She has been anxious. She is here for continued care .She needs help with bathing, grooming, dressing, and toileting . During a telephone interview on 11/15/2022 at 4:26 PM, License Practical Nurse (LPN) #5 stated she never worked on the secure unit unless an assigned nurse did not come into work. The management decided who was placed in the secure unit. During an interview on 11/16/2022 at 10:42 AM, the Social Service Director (SSD) stated that Resident #7 was initially admitted to the 500 halls (non-secure long term care unit). The only residents admitted to the secure unit were residents who wandered, or who had behaviors, a history of falling, Dementia, exit seeking, or a history of elopement. The SSD stated the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) decided for residents to be admitted to the secure unit. During a telephone interview on 11/16/2022 at 12:20 PM, the NP stated that the facility did not inform her of Resident #7's move to the secure unit, and the NP did not have input on which residents were admitted to the secure unit. The NP stated she would not have written an order for admittance to the secure unit for Resident #7. During an interview on 11/16/2022 at 1:44 PM, the ADON stated that residents were admitted to the secure unit dependent on their prior hospitalization, exit-seeking behaviors, and wandering behaviors. The ADON stated the DON was the decision maker for transferring a resident to the secure unit. The ADON stated the nursing staff did not have to obtain an order from the physician before transferring a resident to the secure unit. THE ADON stated she did not remember why Resident #7 was moved to the secure unit. During a telephone interview on 12/2/2022 at 9:14 AM, the Medical Director stated he did not recall giving verbal or written orders for admittance to the secure unit because he had over 20 buildings with residents that he sees.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview the facility failed to ensure 1 (#66) of 94 residents was free from abuse. Facility policy review Resident Rights & Facility Responsibilities, undated, revealed .The right to live in a caring environment free from abuse, mistreatment and neglect . Facility policy review Abuse Prevention Program, dated 1/19/17, revealed .It is the policy of this facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property .This facility will not tolerate resident abuse or mistreatment by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies, family members, legal guardians, friends or other individuals . Review of facility investigation initiated on 11/11/19 revealed Resident #24 was observed with his hand on Resident #66's torso. Continued review revealed Resident #24 was removed and placed on 1 on 1 supervision and both residents were assessed by staff with no skin issues noted. Resident #24 was sent to local hospital for further evaluation with medication adjustments made; upon return to facility the resident was moved to a different unit to a private room. Continued review revealed staff were educated on abuse from 11/11/19 through 11/22/19. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses which included Dementia without Behaviors. Continued review revealed the resident received a diagnosis of Sexual Disorders on 8/14/19. Medical record review of Resident #24's Order Summary Report dated November 2019 revealed .Depakote Sprinkles 125 MG [milligram] give 1 tablet at bedtime for sexual impulsivity 11/15/19 .Flutamide 250 mg one time daily at bedtime for sexual inappropriate behaviors 11/12/19 . Medical record review of Resident #24's History and Physical dated 11/12/19 revealed .Pt [patient] is being seen per nursing request. Pt has had an episode of sexually inappropriate behavior with another resident. Pt sent to ED [emergency department] for evaluation. He was found to have mild PNA [pneumonia] and is taking Levaquin 750 mg by mouth daily. He returned back to the facility and has been moved to another wing away from other resident . Medical record review of Resident #24's Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 6 indicating the resident had severe cognitive impairment. Continued review revealed the resident exhibited physical behaviors directed toward others 1-3 days of the 7 day look back period. Medical record review of Resident #24's comprehensive care plan dated 5/5/19 and revised on 10/15/19 revealed .the resident exhibits sexually inappropriate behavioral symptoms related to dementia. Behavioral symptoms are manifested by: making inappropriate comment toward staff members, attempting to get females to lie down in bed with him, grabbing staff members during care. Grabs nurses and sexual remarks . Medical record review revealed Resident #66 was admitted to the facility on [DATE] with diagnoses which included Dementia, Anxiety, Bipolar Disorder and Depression. Medical record review of Resident #66's MDS dated [DATE] revealed the resident was severely impaired for decision making. Continued review revealed the resident exhibited no behaviors. Medical record review of Resident #66's comprehensive care plan revealed the resident had communication impairment. Medical record review of an incident note for Resident #24 and #66 dated 11/11/19 revealed .around 17:20 - 17:25, I walked by female resident's room [Resident #66] (she was lying in bed) and noticed the resident [Resident #24] was in her room sitting in his w/c [wheel chair] beside the bed. The lights were off, so I turned the lights on as I walked in. the blanket was at the female resident's waist, her gown was around her neck and the resident had his left hand on her left breast. I immediately pulled him away, pulled the female resident's gown down and covered her with the blanket. I comforted and reassured the female resident, she was unable to tell me what happened, no obvious skin injury or other injury noted . Continued review revealed Resident #24 was taken to the nurse station and placed on 1 on 1 supervision. Interview with Resident #24 on 12/16/19 at 12:08 PM in his room revealed when asked if he touched Resident #24 on her breast he stated no, I don't remember that. Interview with the Administrator on 12/17/19 at 8:15 AM in her office revealed the facility unsubstantiated the allegation of abuse between Residents #24 and #66 due to both residents' cognition and there was no intent identified. Continued interview revealed the facility deemed the incident as a wandering, rummaging type of behavior. Telephone interview with Licensed Practical Nurse (LPN) #2 on 12/17/19 at 11:32 AM confirmed I was walking down the hall past [named] Resident #66's room when I saw another resident sitting in her room in a wheelchair beside her bed; I went into the room and turned on the light and she had her gown up close to her neck and [named] Resident #24 had his left hand on her left breast; I addressed him and he moved his hand. Continued interview she stated she removed the male resident to the hall way and assessed the female resident's skin with no issues identified. Continued interview revealed she placed the male resident in the main nurse station and notified the Assistant Director of Nursing. Continued interview revealed Resident #24 was placed on 1 on 1 supervision and was transferred to the hospital for further evaluation. Interview with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) on 12/17/19 at 1:14 PM in the DON's office revealed staff notified them of the incident on 11/11/19 with Resident #24 and #66. Continued interview the ADON confirmed [named] LPN #2 came to me and reported she found [named] Resident #24 in [named] Resident #66's room with his hand on her chest with her covers pulled back; I immediately notified the DON and the Administrator; [named] Resident was placed on 1 on 1 supervision and then sent to the hospital for evaluation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to accurately assess 1 (#87) resident of 32 residents reviewed for Minimum Data Set (MDS) accuracy. The findings include: Medical record review revealed Resident #87 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes and Hypertension. Medical record review of Resident #87's physician order dated 11/29/19 revealed .D/C [discharge] home 11/29/19 . Medical record review of Resident #87's Care Plan Summary Progress Note dated 11/27/19 revealed .Care plan meeting held .resident is scheduled for discharge on Friday . Medical record review of Resident #87's Progress Note dated 12/2/19 revealed Resident discharged home Friday [11/29/19] . Medical record review of Resident #87's Discharge MDS dated [DATE] revealed .Discharge Status .acute hospital . Interview with the MDS Coordinator on 12/18/19 at 9:24 AM in her office confirmed Resident #87's discharge MDS was coded to reflect the resident was discharged to the hospital; she stated I just miscoded it.

Based on facility policy review, observation, and interview, the facility failed to serve hot food at or greater than 135 degrees Fahrenheit (F) for 1 of 5 halls. The findings include: Review of the facility policy dated 12/16/06 .Resident Dining Services revealed .Hot foods are served at 135 degrees or higher . Review of the resident council minutes dated 12/3/18 revealed .Dietary Food being served cold . Interview with the Resident Council on 1/7/18 at 10:30 AM in the dining room revealed hall 400 was served cold food. Observation on 1/7/19 at 1:09 PM on hall 400 revealed 18 trays on the meal cart. Further observation revealed the test tray consisted of chicken, mashed sweet potatoes, and mixed vegetables. Further observation at 1:11 PM revealed the Assistant Dietary Manager obtained the temperature of the mixed vegetables which were 112 degrees Fahrenheit. Interview with Resident #85 on 1/7/19 at 2:52 PM in her room stated .when meals are served on hall 400 they are not hot and always cold when delivered to her room . Interview with the Dietary Manager on 1/8/19 at 10:01 AM in her office confirmed .the food should be appealing, accommodating, and hot foods should be hot .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, and interview, the facility failed to prevent abuse/exploitation for 1 residents (#81) of 5 resident reviewed for abuse. The findings included: Review of facility policy, Cell Phone Policy, undated, revealed .It is Facility's policy that representatives of our organization do not use cell and /or smart phones while performing work tasks. Further, video and or pictures should not be taken of residents, PHI [Protected Health Information] and ePHI [electronic Protected Health Information] . Medical record review revealed Resident #81 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Displaced Supracondylar Fracture with Intracondylar Extension of Lower End of Left Femur, Dyspnea, Chronic Obstructive Pulmonary Disease, Acute on Chronic Combined Systolic and Diastolic Heart Failure, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Chronic Atrial Fibrillation, Chronic Pain Syndrome, Heart Failure, Pleural Effusion, Gastroparesis, Hyperlipidemia, Panic Disorder, Major Depressive Disorder, Anxiety Disorder, Hypertension, Irritable Bowel Syndrome and Gastro-Esophageal Reflux Disease without Esophagitis. Resident #81 discharged from the facility on 7/28/17. Medical record review of the Quarterly Minimum Data Set, dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 15, indicating she was cognitively intact. Review of the facility investigation revealed a written statement from Certified Nurse Aide (CNA) #2 dated 6/27/17 .I was shown a picture by [CNA #1]. It was an inappropriate picture of the resident in 408B. I also witnessed [CNA #1] showing the picture at the nurse's station one night & laughing about it . Telephone interview with CNA #1 on 10/11/17 at 6:35 PM revealed she admitted taking a picture of Resident #81 while the resident was transferring from the bedside commode to the bed. It was unknown when this picture was taken. Further interview revealed the resident was not clothed from the waist down. Further interview revealed approximately 2 months later the CNA sent the picture to CNA #2 and denied showing the picture to any other staff. Interview with the Administrator on 10/11/17 at 4:30pm in her office revealed confirmed the facility failed to prevent abuse/exploitation for Resident #81.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, and interview, the facility failed to thoroughly investigate 2 allegations for 1 resident (#81) of 5 residents reviewed for abuse. The findings included: Review of facility policy, Abuse Prevention Program, dated 1/19/17 revealed .Once the Administrator or designee determines that there is a reasonable cause for suspecting abuse, the Administrator or designee will investigate the allegation and obtain a copy of any documentation relative to the incident . Medical record review revealed Resident #81 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Displaced Supracondylar Fracture with Intracondylar Extension of Lower End of Left Femur, Dyspnea, Chronic Obstructive Pulmonary Disease, Acute on Chronic Combined Systolic and Diastolic Heart Failure, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Chronic Atrial Fibrillation, Chronic Pain Syndrome, Heart Failure, Pleural Effusion, Gastroparesis, Hyperlipidemia, Panic Disorder, Major Depressive Disorder, Anxiety Disorder, Hypertension, Irritable Bowel Syndrome and Gastro-Esophageal Reflux Disease without Esophagitis. Resident #81 discharged from the facility on 7/28/17. Medical record review of the Quarterly Minimum Data Set, dated [DATE] revealed Resident #81 had a Brief Interview for Mental Status score of 15, indicating she was cognitively intact. Review of the facility investigation regarding abuse/exploitation of Resident #81 revealed no statement from the identified staff who took the picture or from Resident #81. Review of the facility investigation of an undated hand written document revealed .Res [resident] reported to nurse that $80 was missing fr [from] wallet. It has been 2-3 days since she saw it . Further review of the facility's investigation revealed 5 witness statements were obtained from staff. Interview with the Administrator on 10/11/17 at 4:30 PM in her office revealed the resident was having hallucinations when she reported the money missing. The Administrator stated the hallucinations worsened as the day progressed, resulted in the resident being sent to local hospital for evaluation. The Administrator confirmed no additional witness statements were obtained nor was a statement obtained from Resident #81. The Administrator confirmed she wrote the hand written document in the investigation. The Administrator confirmed the facility failed to thoroughly investigate 2 allegations of abuse/exploitation and misappropriation of funds for Resident #81. Interview with the Assistant Director of Nursing (ADON) on 10/11/17 at 4:45 PM in the conference room revealed the statements in the investigations were obtained by the Director of Nursing, the Administrator and the ADON. The ADON confirmed no additional statements were obtained from any additional staff, from the identified staff who took the picture of Resident #81 or from Resident #81 about either investigation. The ADON confirmed the facility failed to thoroughly complete both investigations. The facility failed to obtain statements from staff who worked prior to the money being reported missing and from Resident #81 thus the facility failed to completed a thorough investigation of the missing money per the facility. The facility failed to obtain statements from the identified staff who took the picutre of Resident #81 and from the resident thus the facility failed to complete a thorough investigation of abuse/exploitation per the facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to accurately assess the oral status of 1 resident (#34) of 20 residents reviewed. The findings included: Medical record review revealed Resident #34 was admitted to the facility on [DATE] and readmitted on [DATE] and 11/9/15 with diagnoses including Alzheimer's Disease, Abnormal Posture, Urinary Tract Infection, Autonomic Neuropathy in Diseases, Restless Legs Syndrome, Vitamin D Deficiency, Acquired Hemolytic Anemia, Anxiety Disorder, Major Depressive Disorder, Dementia without Behavioral Distrubance and Hypertension. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE], the Annual MDS dated [DATE], and the Quarterly MDS dated [DATE] of the Oral/Dental Status section revealed the resident had no concerns. Observation on 10/10/17 at 9:53 AM in the Main Dining Room, on 10/10/17 at 12:40 PM in the 600 Hall area, and on 10/11/17 at 7:20 AM in the 600 Hall dining area revealed Resident #34 had several missing front teeth at the top and bottom of the mouth. Interview with the MDS Corrdinator on 10/11/17 at 12:10 PM in her office revealed she was responsible for completing the dental status section of the MDS for Resident #34. The MDS Cordinator confirmed Resident #34's dental status section on the Quarterly MDS dated [DATE], the Annual MDS dated [DATE] and the Quarterly MDS dated [DATE] were not coded accurately.

Based on review of facility policy, observation, and interview, the facility failed to safeguard medical record information against loss or unauthorized use. The findings included: Review of facility policy, Controlled Substance Prescriptions, undated revealed .In compliance with applicable state and federal regulations, and to prevent diversion of controlled substances, the following steps must be taken when a provider completes and signs a prescription for a controlled substance in the skilled nursing facility: .Original paper prescription to be placed in a sealed envelope and delivered to pharmacy . Observation on 10/10/17 at 4:00 PM at the 600 Hall nurses station revealed the station door open, the desk top computer was logged into a resident's chart and a paper prescription for Lortab was stored on the desk. Further observation revealed no facility staff in the nurses station or the immediate area. Observation and interview on 10/10/17 at 4:02 PM at the 600 Hall nurses station, with the Assistant Director of Nursing (ADON) present, revealed the station door open, the desk top computer was logged into a resident's chart and a paper prescription for Lortab was stored on the desk. Interview with the ADON confirmed it was not facility procedure for the computer to be logged on and the paper prescription to be stored on the desk without facility staff present. Further interview confirmed the facility failed to safeguard the medical record information against loss or unauthorized use.