**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the right to be free from abuse was provided for 1 of 11 residents reviewed for abuse. (Resident #1) The facility failed protect Resident #1 from abuse when RN A recorded him on 07/26/24 with her personal cellphone while undressed from the waist down. RN A was laughing. RN A showed and sent the video to other staff. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 07/26/24 and ended on 08/30/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for emotional and mental abuse. Findings included: Record review of a face sheet dated 10/22/24 revealed Resident #1 was an [AGE] year-old male and admitted on [DATE] with diagnoses including dementia, depression, and anxiety. Record review of a quarterly MDS dated [DATE] revealed Resident #1 was understood and usually understood others. The MDS revealed a BIMS score of 7, indicating severe cognitive impairment. The MDS indicated Resident #1 required supervision with most ADLs. Record review of Resident #1's physician order dated 08/23/24 indicated a verbal order was obtained to monitor for emotional distress every shift for 3 days. Record review of a care plan last revised on 10/12/24 revealed Resident #1 was at risk for impaired thought processes related to a history of dementia. Resident #1 needed assistance with all decision making. Resident #1 had an ADL self-care performance deficit related to decreased mobility and intermittent confusion. The care plan indicated Resident #1 had potential for a behavior problem as evidenced by inappropriate sexual behaviors. There was an intervention to provide privacy and encourage resident to remain clothed per family request. Record review of a Grievance Resolution Form dated 08/23/24 indicated Resident #1 was involved in a video without his knowledge. The report indicated the compliance department was involved and notified administration. Record review of a Progress Note dated 08/23/24 indicated, SW (Social Worker) visited with resident (Resident #1) this afternoon .SW noticed no change in his mood or behavior after he was notified of the incident. He continues to show confusion, per his usual state. He states I am OK. I am not going to let this effect my life. He is agreeable to speaking with (psych services). SW has sent in a referral for evaluation and spoke with .counselor, re: the incident. SW will continue to monitor resident and will assist further as needed. The note was signed by the Social Worker. Record review of Nurse's notes for Resident #1 dated 08/23/24 - 08/28/24 indicated Resident #1 was monitored for mood and distress. The notes did not indicate Resident #1 had a change in mood or emotional distress. Record review of an Investigation Summary and Timeline report dated 08/30/24 indicated the DON was notified of the allegation of abuse on 08/22/24 at approximately 5:00 p.m. related to the conduct of RN A. The allegation suggested that the nurse had taken an unauthorized video of a resident. RN A was immediately suspended at the time it was reported, pending investigation. During the interview process, it was confirmed that RN A had taken a video of a resident while in his room The resident was not wearing pants and his genitals were visible. The Investigation Summary and Timeline indicated that Resident #1 had been interviewed by Administrator G and had knowledge of the video at the time of the interview. The Investigation Summary and Timeline report indicated RN A was terminated in person on 08/26/24. The report indicated the police were notified and the RP requested to press charges against RN A. Record review of a Provider Investigation Report dated 08/23/24 indicated that on an unknown date RN A took an unauthorized video of Resident #1. The investigation findings were confirmed. Record review of an interview of RN A dated 08/23/24 at 9:30 a.m. indicated she had taken a video of Resident #1. She stated Resident #1 had been in his room with his roommate. She said it had been reported to her by someone in therapy that they smelled smoke in the residents' room. She said she went to the room and Resident #1 was leaning over his roommate and his genitals were rubbing on the roommate. She stated the video showed Resident #1's backside, naked from the waist down. She said she showed the video to LVN C. She said the purpose of filming the video was to show LVN C the residents behavior. She stated, .I shouldn't have done that. I should have verbally told the nurse or done a progress notes. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by RN A. On 10/22/24 at 11:30 a.m., an attempt was made to reach RN A by telephone. There was no answer. A detailed message requesting a return call was left on voicemail. Record review of an interview of LVN C dated 08/23/24 at 10:10 a.m. indicated that she knew about and had seen the video. She said she had seen the video. She said it was of Resident #1 walking over to his roommate. She said Resident #1 only had a shirt on. She said she just saw the back of Resident #1. She said she saw his buttocks. She said he was bending over to do something, and she could see his genitals hanging down. She said RN A had shown her from her phone. She stated RN A said, Oh my God, look what (Resident #1) did. She said RN A thought it was funny. She said she did not report the video. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by LVN C. Record review of an interview of the Transport Aide dated 08/23/24 at 10:20 a.m. indicated the Transport Aide was aware of and had seen the video. She said the video was shown to her by RN A. She said the video was of Resident #1 walking with a shirt on. She said she could see Resident #1's genitals. The interview indicated that the Transport Aide asked RN A why she had the video and RN A said something to her about when he was younger, he probably had big balls. The Transport Aide said she had seen the video weeks ago. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by the Transport Aide. During an interview on 10/22/24 at 3:34 p.m., the Transport Aide said she walked in one morning. She said RN A said to come see the video and said, it's really funny. She said she did not understand why RN A would have even filmed the video. She said she watched the video on RN A's phone, and it was never sent to her. She said she thought the video was shown to her in July 2024. She said the video was inappropriate. She said on the video she saw Resident #1 over by the air conditioner. She said RN A said, Look at his balls going back in forth, I bet when he was younger, he was bigger. Record review of an interview of CNA D dated 08/23/24 at 10:20 a.m. indicated CNA D was aware of the video and that she had seen the video. She said it was both shown to her and sent to her via text by RN A. She stated that on the video Resident #1 was standing by his roommate with no pants or underwear on, just a shirt. Resident #1 leaned over to help his roommate and she saw his buttocks, penis, and scrotum. She said it had been less than a month since she had seen the video. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by CNA D. Record review of an interview of LVN E dated 08/23/24 at 10:20 a.m. indicated LVN E had heard about the video but had not seen the video. He stated it had been about a month since he had heard about the video. He said he heard there was a video of Resident #1's genitalia. He said RN A had told him about the video. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by LVN E. Record review of an interview of the Staffing Coordinator dated 08/23/24 at 11:05 a.m. indicated the Staffing Coordinator became aware of the video on 08/22/24. The Staffing Coordinator stated RN A came to the office and stated that compliance had called her about a video she had taken of one of the residents and she was scared and didn't know what to do. The Staffing Coordinator indicated she had not seen the video and had only heard gossip about the video. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by the Staffing Coordinator. During an interview on 10/22/24 at 11:42 a.m., the Staffing Coordinator said she was in the hallway on a day in August 2024. She did not remember the date. She said RN A pulled her into the office and said compliance had reached out to her and she did not know what to do. The Staffing Coordinator said RN A was scared. The Staffing Coordinator said RN A said, I think they are calling me about the video. The Staffing Coordinator said she had heard rumors about the video but was not sure if those rumors were true. She said she has never seen the video. She said she heard there was a video out of a resident that they had at the time. She said she did not know any details. She said RN A did not tell her what was on the video or show it to her. She said she reported the incident to the DON after RN A had come into her office. During an interview on 10/22/24 at 11:42 a.m., the Staffing Coordinator said she was in the hallway on a day in August 2024. She did not remember the date. She said RN A pulled her into the office and said compliance had reached out to her and she did not know what to do. The Staffing Coordinator said RN A was scared. The Staffing Coordinator said RN A said, I think they are calling me about the video. The Staffing Coordinator said she had heard rumors about the video but was not sure if those rumors were true. She said she has never seen the video. She said she heard there was a video out of a resident that they had at the time. She said she did not know any details. She said RN A did not tell her what was on the video or show it to her. She said she reported the incident to the DON after RN A had come into her office. Record review of a telephone interview of the Treatment Nurse dated 08/23/24 at 11:15 a.m. indicated the Treatment Nurse was aware of and had seen the video. She said it was shown to her right before she went on maternity leave. She said in the video she could see Resident #1's behind and his scrotum between his legs. She said RN A had shown her the video. She said it was on RN A's phone. The Treatment Nurse said she had mentioned the video to Administrator G and ADON H. She said she may have reported it the next day but could not remember. She stated that RN A thought the video was funny and was showing staff. She said she told RN A that the video was inappropriate, and she should not be videoing the residents. The interview was conducted and signed by the DON and the Clinical Resource Nurse. During an interview on 10/22/2024 at 1:06 p.m., the Treatment Nurse said she went on leave in August 2024. She said it would have been the middle of August 2024. She said RN A did show her the video. She said RN A did not send her the video. She said RN A stopped her in the hall and said, Hey look at this. She said you could see Resident #1 and his roommate messing with the air conditioner. She said Resident #1 only had a shirt on. She said you could see his scrotum. She said the video was from behind and she was not sure if you could see the resident's penis. She said it did not appear Resident #1 was aware he was being videoed. She said RN A was laughing about the video. She said she told RN A it was inappropriate, and RN A said, I just thought it was funny. She said she did report it immediately to the previous ADON H that and told Administrator G the same day. She said she told Administrator G on 07/30/24 or 07/31/24. She said Administrator G told her he would address it at the next all staff meeting. Record review of a police Incident Report, dated 08/23/24 indicated Administrator G was the reportee. The report indicated the offense was solicitation to commit - invasive visual recording in bathroom/changing room. The report indicated RN A was the offender. The report indicated the officer spoke with Administrator G and the DON. The report indicated the DON explained that RN A recorded a patient in secret. The report indicated Resident #1 liked to walk around in the nude and RN A had secretly recorded Resident #1 and sent the video through text to RN B and made jokes about Resident #1. RN A showed her co-workers the video while making fun of Resident #1. The officer asked RN B if she still had the video and was told that she had deleted it. The report indicated on 08/27/24 It was concluded by (the facility) that (RN A) had acted inappropriately by recording (Resident #1) and was subsequently terminated for that reason. According to the interviews, (RN A) was distributing the video to other employees and making comments like, When he was younger, he probably had big balls and Look what you're missing out on. RN A herself was interviewed and stated that her reasoning for recording (Resident #1) was to provide his nurse with information on his behavior. During an interview on 10/22/24 at 9:28 a.m. a family member of Resident #1 said the incident of RN A videoing Resident #1 had been reported to the police. He said the investigating officer was Officer J. He said RN A took a video of Resident #1 and shared the video with her co-workers. The family member said they had not personally seen the video. The family said said Officer J had seen the video. He said Officer J had interviewed some of the facility staff at the police department and had taken several phones. The family member said one of the phones had produced the video. The family member said they did not know which one had. The family member said the facility was aware of the incident in July 2024. The family member said they were not notified of the video until the end of August 2024. The family member said Resident #1 had no memory of the incident. The family member said Resident #1 cannot even remember what he had for breakfast. During an interview and observation on 10/22/24 at 1:30 p.m., Officer J said nursing home staff did not report the video to the police department until a month after it was recorded. He said then the following week, Resident #1's family had reported the video to the police department. He said the first report was made on 8/23/2024. He said review of the video indicated a create date of 7/26/24. He said the police department still had custody of CNA D's and RN B's cell phones. He said they each gave consent for their phones to be searched. He said the video was eventually found on RN B's cellphone. He said on some of the phones there were text messages from the staff members and RN A discussing what Resident #1 might have looked like when he was younger. The video was observed in Officer J's office. The video showed Resident #1 from behind. Resident #1's roommate was sitting in a chair. Each resident had their backs to the camera. Resident #1 had on a polo type shirt. He was naked from the waist down. His buttocks and testicles were visible. At one point in the video, Resident #1 walked over to his roommate and bent over as if to help him with something. When the resident bent over it further exposed his testicles. In the background, there was heard a female voice laughing off and on throughout the video. At one point the female voice said, What is he doing? followed by more laughter. During an observation on 10/22/24 at 2:00 p.m., a video of RN B being interviewed by Officer J revealed RN B stated RN A had sent the video to a few people. RN B said the video was, inappropriate to say the least. RN B said RN A sent the video to her between 07/21/24 to 07/28/24. RN B said she had deleted the video from her phone after she found out that compliance had called RN A. RN B said she had deleted text messages from her phone also. During an interview on 10/23/24 at 8:25 a.m., RN B said she went on vacation for a whole week. She said she then tested positive for Covid and was off another week. She said texted RN A to ask what she had missed at work. She said RN A said, Hey I'm about to send you a video. She said she watched most of the video but not all of it. She said this was normal behavior for Resident #1 and she had seen this behavior daily. She said she felt the video was inappropriate. She said she thought the video was meant to be humorous. She said she thought she typed back, LOL. She said after that she did not think anything else about the video. She said she was sick, and she really did not give it much thought. She said RN A texted her and told her she had sent the video to several other people. She said she did not know the date the video was sent to her, but it was towards the end of July 2024 because she was home sick. She said Resident #1 had a shirt on and nothing below. She said he was walking away from the camera. She said that was as far as she watched. She said she could see his buttocks. She said she did not have her glasses on and did not see his testicles. She said around 8/28/24 she did have a meeting with Compliance. She said she had already deleted the video from her phone. She said now the police had her phone. She said it was sent to forensics and they found the video on the phone. During an observation on 10/22/24 at 2:10 p.m., a video of CNA D was being interviewed by Officer J. CNA D said she was shown the video in the hallway right after RN A had come out of Resident #1's room. CNA D said that at the nurse's station RN A was showing the video to LVN C, LVN E, and herself. During an interview on 10/22/24 at 4:20 p.m., CNA D said RN A sent the video to her the day she recorded the video. She said this date was 7/27/24 on her birthday. She said the resident's roommate was in his wheelchair over by the air conditioner. She said Resident #1 was standing over him with a polo type shirt on and was naked from the waist down. She said she could see his buttocks, testicles, and his penis. She said RN A did not tell her why she took the video. She said she could not remember the context of her conversation with RN A. She said she could not remember if she saw all of the video, but she did feel it was inappropriate. She said she did not report the video to anyone. She said she was not aware of anyone else seeing the video. She said RN A never showed the video to LVN C, LVN E, and herself at the nurse's station. During an interview on 10/22/24 at 2:38 p.m., LVN C said RN A just showed her the video to show her what he was doing. She said the video was just the back of Resident #1 walking over to his roommate with just a shirt on. She said you could not see his face. She said you could see his testicles from behind. She said the video was never sent to her. She said she was at her medication cart when RN A showed her the video. She said LVN E and CNA D were at the facility but were not present when she watched the video. She said the resident's behavior was not a shock to her because he did stuff like that all the time. She said the video was inappropriate and was not necessary. She said RN A was laughing and said, I can't believe this, look at him. She said she was not sure of the date the video was taken. She said she felt RN A showed it to her immediately after it was recorded. She said Resident #1 had dementia and would not remember the incident. She said one time he had even walked down the hall with only a shirt on. During an interview on 10/22/24 at 3:24 p.m., PTA L said she was aware RN A took a video of Resident #1. She said RN A showed her the video on her phone. She said she saw Resident #1 in his room naked from the waist down. She said he had only a shirt on. She said he was walking around the room. She said as soon as she saw it, she quit watching the video. She said she did not know if it was the day, RN A took the video. She said when RN A showed her the video she was laughing. She thought it was funny. She said Resident #1 was not aware the incident happened. During an interview on 10/22/24 at 3:56 p.m., Administrator G said what occurred was HR K informed him that a video was going around. He said that was either 7/31/2024 or 8/2/2024. He said he thought it was in August 2024. He said he could not remember if she gave him details of the video. He said the allegation did not hit his abuse and neglect radar. He said about two weeks later the DON was informed of the video and communicated the details the video to him and it was reported. He said RN A was suspended immediately and never brought back from suspension. He said he did send a text to the Treatment Nurse on 08/02/24. He said he did say the video was inappropriate. He said he just did not realize how bad the video was or the response would have been completely different. He said he had never seen the video. He said he left the facility sometime in August 2024. He said he was given the option to resign. During an interview 10/22/24 at 4:12 p.m., the Social Worker said she was not even aware of the video until compliance got involved. She said she usually did a checkup with residents after any incident. She said she did safe surveys and there were no concerns. She said she did talk to Resident #1. She said Administrator G had just come out of his room, so the incident was fresh on Resident #1's mind. She said he did not seem upset. She said he did say, I just don't know why someone would do something like that. I'm not going to let it affect me. She said she did get an order for psychology services to check on him. During an interview on 10/23/24 at 9:14 a.m., HR K said she found out about the video on 8/2/24. She said ADON H told her about the video. She said, and still nothing was done. She said she never saw the video. She said she was told by multiple people it did exist and what it consisted of. During an interview on 10/23/24 at 9:31 a.m., the DON said she first became aware of the video approximately 2 days before she reported the incident to the state. She said HR K told her but did not tell her any details about the video. She said prior to 8/21/24 she had not even heard of the video. She said she was on vacation 7/30/24 - 8/5/24. She said the video was not reported to her during that time. She said on 8/22/24 she became of aware of the content of the video. She said she was told by the Staffing Coordinator. She said the Staffing Coordinator told her there was a video of Resident #1 with his genitals exposed and that RN A had taken the video. She said she suspended RN A immediately. She said she began the investigation herself on 8/23/24. She said her investigation concluded that RN A had taken the video of Resident #1 and had shown multiple co-workers. She said RN A was terminated on 08/26/24. She said she had not seen the video. She said all staff that had knowledge of or saw the video was given final written warnings for failure to report. She said once she heard the content of the video, she felt it was abuse. She said she felt it should have been reported and investigated right from the very beginning. She said she did talk to Resident #1 about the video. She said he did not remember the incident unless it was brought up by staff. She said she did feel like this was a dignity issue. She said he had been the mayor at one time. She said he was a photographer. She said he could not help his behavior. During an interview on 10/23/24 at 2:21 p.m., a family member of Resident #1 said in the condition of dementia or Alzheimer's they would not know if this had happened to them. The family member said if they did know, they would feel it was demeaning or demoralizing and against all privacy. They said they thought the whole thing horrible. They said Resident #1 had been a very private but public person. The family member said Resident #1 was the mayor at one time. The family member said Resident #1 never discussed the birds and bees with them because he was a private person. The family member said Resident #1 would not have liked this at all. During an interview on 10/23/24 at 4:21 p.m., the Clinical Resource Nurse said she learned of the video during one of her weekly visits. She said it was probably on 08/22/24 or 08/23/24. She said she was told there was a nurse that had taken an inappropriate video of a resident not fully dressed and that it was sent to a staff member that was not on duty that day. She said she interviewed RN A. She said RN A was off that day and she was told she had to come to the facility to be interviewed. She said RN A admitted to taking the video. She said during interview RN A said, there was no reason for taking the video. She RN A said during that interview she had shown the video to no one. The Clinical Resource Nurse said she never saw the video. She said RN A told her the video was no longer on her phone, and she had deleted the video. She said every staff member was in-serviced. She said there were some one-on-one in-services. She said these were with the people that were disciplined. She said RN A was suspended that day. She said RN A's license were referred to the state. She said if this happened to her, she would be humiliated. She said it would be humiliating regardless of her age. She said she was angry and very emotional about what happened. She said it was just disgusting. She said she had assisted with safe surveys and with Resident #1 and he had no concerns. She said she did know Administrator G had interviewed the resident. She said Administrator G told her the resident did not recall the incident. She said Administrator G was asked to resign or he would be terminated. Record review of a Counseling/Disciplinary Notice dated 08/22/24 indicated an allegation of abuse was identified and RN A was suspended pending investigation. RN A was notified at 5:08 p.m. by the DON. Record review of a Counseling/Disciplinary Notice dated 08/26/24 indicated RN A was discharged from employment and her last day worked was 08/20/24. The notice indicated, It was determined that the nurse, (RN A), was responsible for the recording and distributing inappropriate video of a resident to multiple staff members. This is against our Abuse Policy as it classifies as Mental Abuse. Staff member is to be terminated for violation of Abuse Policy. The notice was signed by Administrator G and RN A on 08/27/24. Record review of a Termination Form dated 08/27/24 indicated RN A was terminated with a termination date of 08/27/24 for gross misconduct. The Termination Form was signed by the DON. Record review of an undated Employer Report Form to the Texas Board of Nursing Regarding Violations of the Nursing Practice Act, Other Statutes, and Board Rules indicated, It was reported that (RN A) had taken inappropriate video of the resident (Resident #1) and was distributing the video to her co-workers via multimedia message. Upon investigation, it was identified that (RN A) had videoed the resident nude from the waist down while he ambulated in his room and shown multiple coworkers on her phone, as well as sent it via text message to at least 2 coworkers. Through investigation it was determined that there was no reason medical indication for the video to be taken. It has been determined through this investigation that the nurse mentally abused the resident by taking and distributing this video. CMS defines mental abuse as, abuse that is facilitated or caused by nursing home staff taking or using photographs or recording in any manner that would demean or humiliate a resident (Ref. S&C16-33-NH). Employment has been terminated at this facility due to this crime. Record review of a Social Media facility policy dated December 2020 indicated, .An employee's use of social media, both during work time and non-work time, may subject the employee to discipline if their conduct violates company policies or law . Record review of an Abuse: Prevention of and Prohibition Against facility policy dated 11/2017 indicated, .It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Facility staff are prohibited from taking, keeping, using or distributing photographs or video recordings of Facility residents in any manner that would demean or humiliate a resident, regardless of whether the resident provided consent and regardless of the resident's cognitive status. This includes using any type of equipment (e.g., cameras, smart phones, or other electronic devices) to take, keep, or distribute inappropriate photographs or recordings on social media. The Facility will provide oversight and monitoring to ensure that staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse, neglect, misappropriation of resident property, and exploitation .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Mental Abuse includes, but is not limited to humiliation . The facility had corrected the noncompliance on 08/30/24 by the following: - Termination of RN A who was responsible for the abuse - Resignation of Administrator G who was responsible for not reporting or investigating the abuse. - Final Written Warnings for the failure to report alleged abuse to supervisor or abuse coordinator dated 08/23/24 were given to Transport Aide, the Staffing Coordinator, CNA D, LVN E, LVN C, and RN B. PTA L was given a Final Written Warning for the failure to report alleged abuse to supervisor or abuse coordinator on 08/29/24. - Safe surveys of all the residents in the facility initially and weekly for 90 Days. (on-going at the time of exit) - 100% staff in-service on Code of Conduct, Photographing or Videoing a resident (Abuse and Neglect), Abuse: Prevention of and Prohibition Against, and Abuse Coordinator - 100% staff knowledge checks on Abuse and Neglect Prevention and Reporting - 100% staff Abuse Prevention & Reporting Skills Check - 100% staff on-line training on Knowing the Resident Rights, HIPPA Refresher (TO), Abuse Neglect and Exploitation, Obligation to Report Abuse - Psychological Services were provided to Resident #1 beginning 8/27/24 Record review of an Ad Hoc Quality Assurance (QA) Meeting Sign-in Sheet dated 08/23/24 indicated the facility had an QA meeting addressing the incident. The QA Meeting Sign-in Sheet indicated the DON, ADON, Medical Director, Marketing Representative, Admissions Coordinator, LVN N, Maintenance Director, Activity Director MDS Nurse, Medical Records staff member, Resource Therapist, the Treatment Nurse, and Operations Manager. Record review and interview of the sampled residents (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, and Resident #11) revealed they had not been abused or witnessed any abuse of other residents. They each said to their knowledge they had not been photographed or videoed by any staff members. All staff interviewed (RN B, LVN C, CNA D, LVN E, ADON F, HR K, PTA L, LVN O, the Staffing Coordinator, the Transport Aide, the Treatment Nurse, the Social Worker, CNA P, the Activ[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation, or mistreatment of residents for 1 of 11 residents (Resident #1) reviewed for abuse and neglect. The facility failed to prevent Resident #1 from being abused when on 07/26/2024 RN A entered his room and filmed him with her cellphone. Resident #1 was naked from the waist down. RN A shared the video with other staff. The facility failed to protect Resident #1 from potential further abuse after the allegation. RN A was allowed to work from the date of the incident until she was suspended on 08/22/24. The facility staff (RN B, LVN C, CNA D, LVN E, the Staffing Coordinator, the Transport Aide, PTA L) failed to report abuse immediately to the Abuse Coordinator after they had viewed or became aware of the video. Facility Administrator G failed to investigate and to report an allegation of abuse to the state agency after he became aware of the video on 07/31/24. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 07/26/24 and ended on 08/30/24. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for continued abuse and neglect due to inappropriate interventions and failure to report the allegations of abuse timely. Findings included: Record review of an Abuse: Prevention of and Prohibition Against facility policy dated 11/2017 indicated, .It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Facility staff are prohibited from taking, keeping, using or distributing photographs or video recordings of Facility residents in any manner that would demean or humiliate a resident, regardless of whether the resident provided consent and regardless of the resident's cognitive status. This includes using any type of equipment (e.g., cameras, smart phones, or other electronic devices) to take, keep, or distribute inappropriate photographs or recordings on social media. The Facility will provide oversight and monitoring to ensure that staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse, neglect, misappropriation of resident property, and exploitation .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Mental Abuse includes, but is not limited to humiliation .All personnel, residents, visitor, etc. are encouraged to report incidents and grievance without the fear of retribution. The Facility will act to protect and prevent abuse and neglect from occurring with the Facility by .Supervising staff to identify and correct any inappropriate or unprofessional behavior .Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur .Facility staff with knowledge of an actual or potential violation of this policy must report the violation to his or her supervisor or the Facility administrator immediately .This includes taking, keeping, using or distributing photographs or video recordings of Facility resident in any manner that would demean or humiliate a resident .with any type of device .All identified events are reported to the Administrator immediately .After receiving the allegation, and during and after the investigation, the Administrator will ensure that all residents are protected from physical and psychosocial harm .All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigate by the Administrator or his/her designee .Upon receiving a report or allegation of a potential violation of this policy involving the taking, keeping, using, or distributing photos or video recordings, the Administrator or his or her designee will analyze the allegations and determine whether the conduct at issue implicated resident privacy or security as protected by the Health Insurance Portability and Accountability Act (HIPPA) .The investigation will include .an interview with the person(s) reporting the incident .an interview with the resident(s) .Interviews with any witnesses to the incident, including the alleged perpetrator, as appropriate .a review of the resident's medical record .An interview with staff members (on all shifts) who may have information regarding the alleged incident .Interviews with other residents to whom the accused employee provides care or services or who may have information regarding the alleged incident .an interview with staff members (on all shifts) having contact with the accused employee and a review of all circumstance surrounding the incident .To the extent there is evidence that could be sued in a criminal investigation, staff will immediately notify the Administrator or his/her designee .The investigation, and the results of the investigation, will be documented .If an allegation of abuse .is reported, discovered or suspected, the Facility will take the following steps to protect all residents .respond immediately to protect the alleged victim and the integrity of the investigation .examine the alleged victim for any sign of injury, including a physical examination and psychosocial assessment .Increase supervision of the alleged victim and residents .make room or staffing changes .provide emotional support and counseling to the resident during and after the investigation .immediately remove the employee from the care of any resident .Suspend the employee during the pendency of the investigation . All allegations of abuse .should be reported immediately to the Administrator .Allegations of abuse .will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations .At the conclusion of the investigation, the Facility will take action, as necessary, in light of the information gathered which may include but is not limited to . Record review of a face sheet dated 10/22/24 revealed Resident #1 was an [AGE] year-old male and admitted on [DATE] with diagnoses including dementia, depression, and anxiety. Record review of a quarterly MDS dated [DATE] revealed Resident #1 was understood and usually understood others. The MDS revealed a BIMS score of 7, indicating severe cognitive impairment. The MDS indicated Resident #1 required supervision with most ADLs. Record review of Resident #1's physician's orders indicated on dated 08/23/24 indicated a verbal order was obtained to monitor for emotional distress every shift for 3 days. Record review of a care plan last revised on 10/12/24 revealed Resident #1 was at risk for impaired thought processes related to a history of dementia. Resident #1 needed assistance with all decision making. Resident #1 had an ADL self-care performance deficit related to decreased mobility and intermittent confusion. The care plan indicated Resident #1 had potential for a behavior problem as evidenced by inappropriate sexual behaviors. There was an intervention to provide privacy and encourage resident to remain clothed per family request. Record review of text messages dated 08/02/24 at 6:14 p.m., indicated texts between HR K and Administrator G. The texts indicated HR K wrote, .And ANOTHER note, I don't know who, how or where it originated from but there has been a video taken of (Resident #1) with no pants on and making its way around the building. Administrator G responded, Oh no! If you're still there, will you mention to one or two of the staff at the nurse's station that any videos taken of residents against their will can give family members a foot hold to sue whoever has the video. HR K responded, I left unfortunately but I was told over the phone, not in person at the facility or I would have said just that and how it's not funny. Administrator G responded, Mmm, ok. I'll mention it to (the Treatment Nurse). Record review of a text message dated 08/02/24 at 6:38 p.m. to the Treatment Nurse from Administrator G indicated, Hey, I just got word that there's an inappropriate video of (Resident #1) going around the facility. Will you mention to the staff that any videos taken of residents against their will can give family members a foot hold to sue whoever has the video. It has happened to our sister facility . Record review of a Grievance Resolution Form dated 08/23/24 indicated Resident #1 was involved in a video without his knowledge. The report indicated the compliance department was involved and notified administration. Record review of a Progress Note dated 08/23/24 indicated, SW (Social Worker) visited with resident (Resident #1) this afternoon .SW noticed no change in his mood or behavior after he was notified of the incident. He continues to show confusion, per his usual state. He states I am OK. I am not going to let this effect my life. He is agreeable to speaking with (psych services). SW has sent in a referral for evaluation and spoke with .counselor, re: the incident. SW will continue to monitor resident and will assist further as needed. The note was signed by the Social Worker. Record review of Nurse's notes for Resident #1 dated 08/23/24 - 08/28/24 indicated Resident #1 was monitored for mood and distress. The notes did not indicate Resident #1 had a change in mood or emotional distress. Record review of an Investigation Summary and Timeline report dated 08/30/24 indicated the DON was notified of the allegation of abuse on 08/22/24 at approximately 5:00 p.m. related to the conduct of RN A. The allegation suggested that the nurse had taken an unauthorized video of a resident. RN A was immediately suspended at the time it was reported, pending investigation. During the interview process, it was confirmed that RN A had taken a video of a resident while in his room The resident was not wearing pants and his genitals were visible. The Investigation Summary and Timeline indicated that Resident #1 had been interviewed by Administrator G and had knowledge of the video at the time of the interview. The Investigation Summary and Timeline report indicated RN A was terminated in person on 08/26/24. The report indicated the police were notified and the RP requested to press charges against RN A. Record review of a Provider Investigation Report dated 08/23/24 indicated that on an unknown date RN A took an unauthorized video of Resident #1. The investigation findings were confirmed. Record review of an interview of RN A dated 08/23/24 at 9:30 a.m. indicated she had taken a video of Resident #1. She stated Resident #1 had been in his room with his roommate. She said it had been reported to her by someone in therapy that they smelled smoke in the residents' room. She said she went to the room and Resident #1 was leaning over his roommate and his genitals were rubbing on the roommate. She stated the video showed Resident #1's backside, naked from the waist down. She said she showed the video to LVN C. She said the purpose of filming the video was to show LVN C the residents behavior. She stated, .I shouldn't have done that. I should have verbally told the nurse or done a progress notes. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by RN A. On 10/22/24 at 11:30 a.m., an attempt was made to reach RN A by telephone. There was no answer. A detailed message requesting a return call was left on voicemail. Record review of an interview of LVN C dated 08/23/24 at 10:10 a.m. indicated that she knew about and had seen the video. She said she had seen the video. She said it was of Resident #1 walking over to his roommate. She said Resident #1 only had a shirt on. She said she just saw the back of Resident #1. She said she saw his buttocks. She said he was bending over to do something, and she could see his genitals hanging down. She said RN A had shown her from her phone. She stated RN A said, Oh my God, look what (Resident #1) did. She said RN A thought it was funny. She said she did not report the video. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by LVN C. Record review of an interview of the Transport Aide dated 08/23/24 at 10:20 a.m. indicated the Transport Aide was aware of and had seen the video. She said the video was shown to her by RN A. She said the video was of Resident #1 walking with a shirt on. She said she could see Resident #1's genitals. The interview indicated that the Transport Aide asked RN A why she had the video and RN A said something to her about when he was younger, he probably had big balls. The Transport Aide said she had seen the video weeks ago. The interview indicated the Transport Aide did not report the video to anyone and when asked why she said, I know I should have. I don't know why I didn't. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by the Transport Aide. During an interview on 10/22/24 at 3:34 p.m., the Transport Aide said she walked in one morning. She said RN A said to come see the video and said, it's really funny. She said she did not understand why RN A would have even filmed the video. She said she watched the video on RN A's phone, and it was never sent to her. She said she thought the video was shown to her in July 2024. She said the video was inappropriate. She said on the video she saw Resident #1 over by the air conditioner. She said RN A said, Look at his balls going back in forth, I bet when he was younger, he was bigger. Record review of an interview of CNA D dated 08/23/24 at 10:20 a.m. indicated CNA D was aware of the video and that she had seen the video. She said it was both shown to her and sent to her via text by RN A. She stated that on the video Resident #1 was standing by his roommate with no pants or underwear on, just a shirt. Resident #1 leaned over to help his roommate and she saw his buttocks, penis, and scrotum. She said it had been less than a month since she had seen the video. She said she did not report the video to anyone. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by CNA D. Record review of an interview of LVN E dated 08/23/24 at 10:20 a.m. indicated LVN E had heard about the video but had not seen the video. He stated it had been about a month since he had heard about the video. He said he heard there was a video of Resident #1's genitalia. He said RN A had told him about the video. He said he thought he should have reported the video but did not report the video. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by LVN E. Record review of an interview of the Staffing Coordinator dated 08/23/24 at 11:05 a.m. indicated the Staffing Coordinator became aware of the video on 08/22/24. The Staffing Coordinator stated RN A came to the office and stated that compliance had called her about a video she had taken of one of the residents and she was scared and didn't know what to do. The Staffing Coordinator indicated she had not seen the video and had only heard gossip about the video. She said the staff that were gossiping did explain what was in the video. She said she did not report what was in the video because it was just gossip. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by the Staffing Coordinator. During an interview on 10/22/24 at 11:42 a.m., the Staffing Coordinator said she was in the hallway on a day in August 2024. She did not remember the date. She said RN A pulled her into the office and said compliance had reached out to her and she did not know what to do. The Staffing Coordinator said RN A was scared. The Staffing Coordinator said RN A said, I think they are calling me about the video. The Staffing Coordinator said she had heard rumors about the video but was not sure if those rumors were true. She said she has never seen the video. She said she heard there was a video out of a resident that they had at the time. She said she did not know any details. She said RN A did not tell her what was on the video or show it to her. She said she reported the incident to the DON after RN A had come into her office. Record review of a telephone interview of the Treatment Nurse dated 08/23/24 at 11:15 a.m. indicated the Treatment Nurse was aware of and had seen the video. She said it was shown to her right before she went on maternity leave. She said in the video she could see Resident #1's behind and his scrotum between his legs. She said RN A had shown her the video. She said it was on RN A's phone. The Treatment Nurse said she had mentioned the video to Administrator G and ADON H. She said she may have reported it the next day but could not remember. She stated that RN A thought the video was funny and was showing staff. She said she told RN A that the video was inappropriate, and she should not be videoing the residents. The interview was conducted and signed by the DON and the Clinical Resource Nurse. During an interview on 10/22/2024 at 1:06 p.m., the Treatment Nurse said she went on leave in August 2024 . She said it would have been the middle of August 2024. She said RN A did show her the video. She said RN A did not send her the video. She said RN A stopped her in the hall and said, Hey look at this. She said you could see Resident #1 and his roommate messing with the air conditioner. She said Resident #1 only had a shirt on. She said you could see his scrotum. She said the video was from behind and she was not sure if you could see the resident's penis. She said it did not appear Resident #1 was aware he was being videoed. She said RN A was laughing about the video. She said she told RN A it was inappropriate, and RN A said, I just thought it was funny. She said she did report it immediately to the previous ADON H that and told Administrator G the same day. She said she told Administrator G on 07/30/24 or 07/31/24. She said Administrator G told her he would address it at the next all staff meeting. Record review of a police Incident Report, dated 08/23/24 indicated Administrator G was the reportee. The report indicated the offense was solicitation to commit - invasive visual recording in bathroom/changing room. The report indicated RN A was the offender. The report indicated the officer spoke with Administrator G and the DON. The report indicated the DON explained that RN A recorded a patient in secret. The report indicated Resident #1 liked to walk around in the nude and RN A had secretly recorded Resident #1 and sent the video through text to RN B and made jokes about Resident #1. RN A showed her co-workers the video while making fun of Resident #1. The officer asked RN B if she still had the video and was told that she had deleted it. The report indicated on 08/27/24 It was concluded by (the facility) that (RN A) had acted inappropriately by recording (Resident #1) and was subsequently terminated for that reason. According to the interviews, (RN A) was distributing the video to other employees and making comments like, When he was younger, he probably had big balls and Look what you're missing out on. RN A herself was interviewed and stated that her reasoning for recording (Resident #1) was to provide his nurse with information on his behavior. During an interview on 10/22/24 at 9:28 a.m. a family member of Resident #1 said the incident of RN A videoing Resident #1 had been reported to the police. He said the investigating officer was Officer J. He said RN A took a video of Resident #1 and shared the video with her co-workers. The family member said they had not personally seen the video. They said Officer J had seen the video. He said Officer J had interviewed some of the facility staff at the police department and had taken several phones. The family member said one of the phones had produced the video. The family member said they did not know which one had. The family member said the facility was aware of the incident in July 2024. The family member said they were not notified of the video until the end of August 2024. The family member said Resident #1 had no memory of the incident. The family member said Resident #1 cannot even remember what he had for breakfast. During an interview and observation on 10/22/24 at 1:30 p.m., Officer J said nursing home staff did not report the video to the police department until a month after it was recorded. He said then the following week, Resident #1's family had reported the video to the police department. He said the first report was made on 8/23/2024. He said review of the video indicated a create date of 7/26/24. He said the police department still had custody of CNA D's and RN B's cell phones. He said they each gave consent for their phones to be searched. He said the video was eventually found on RN B's cellphone. He said on some of the phones there were text messages from the staff members and RN A discussing what Resident #1 might have looked like when he was younger. The video was observed in Officer J's office. The video showed Resident #1 from behind. Resident #1's roommate was sitting in a chair. Each resident had their backs to the camera. Resident #1 had on a polo type shirt. He was naked from the waist down. His buttocks and testicles were visible. At one point in the video, Resident #1 walked over to his roommate and bent over as if to help him with something. When the resident bent over it further exposed his testicles. In the background, there was heard a female voice laughing off and on throughout the video. At one point the female voice said, What is he doing? followed by more laughter. During an observation on 10/22/24 at 2:00 p.m., a video of RN B being interviewed by Officer J revealed RN B stated RN A had sent the video to a few people. RN B said the video was, inappropriate to say the least. RN B said RN A sent the video to her between 07/21/24 to 07/28/24. RN B said she had deleted the video from her phone after she found out that compliance had called RN A. RN B said she had deleted text messages from her phone also. During an interview on 10/23/24 at 8:25 a.m., RN B said she went on vacation for a whole week. She said she then tested positive for Covid and was off another week. She said texted RN A to ask what she had missed at work. She said RN A said, Hey I'm about to send you a video. She said she watched most of the video but not all of it. She said this was normal behavior for Resident #1 and she had seen this behavior daily. She said she felt the video was inappropriate. She said she thought the video was meant to be humorous. She said she thought she typed back, LOL. She said after that she did not think anything else about the video. She said she was sick, and she really did not give it much thought. She said RN A texted her and told her she had sent the video to several other people. She said she did not know the date the video was sent to her, but it was towards the end of July 2024 because she was home sick. She said Resident #1 had a shirt on and nothing below. She said he was walking away from the camera. She said that was as far as she watched. She said she could see his buttocks. She said she did not have her glasses on and did not see his testicles. She said around 8/28/24 she did have a meeting with Compliance. She said she had already deleted the video from her phone. She said now the police had her phone. She said it was sent to forensics and they found the video on the phone. During an observation on 10/22/24 at 2:10 p.m., a video of CNA D was being interviewed by Officer J. CNA D said she was shown the video in the hallway right after RN A had come out of Resident #1's room. CNA D said that at the nurse's station RN A was showing the video to LVN C, LVN E, and herself. During an interview on 10/22/24 at 4:20 p.m., CNA D said RN A sent the video to her the day she recorded the video. She said this date was 7/27/24 on her birthday. She said the resident's roommate was in his wheelchair over by the air conditioner. She said Resident #1 was standing over him with a polo type shirt on and was naked from the waist down. She said she could see his buttocks, testicles, and his penis. She said RN A did not tell her why she took the video. She said she could not remember the context of her conversation with RN A. She said she could not remember if she saw all of the video, but she did feel it was inappropriate. She said she did not report the video to anyone. She said she was not aware of anyone else seeing the video. She said RN A never showed the video to LVN C, LVN E, and herself at the nurse's station. During an interview on 10/22/24 at 2:38 p.m., LVN C said RN A just showed her the video to show her what he was doing. She said the video was just the back of Resident #1 walking over to his roommate with just a shirt on. She said you could not see his face. She said you could see his testicles from behind. She said the video was never sent to her. She said she was at her medication cart when RN A showed her the video. She said LVN E and CNA D were at the facility but were not present when she watched the video. She said the resident's behavior was not a shock to her because he did stuff like that all the time. She said the video was inappropriate and was not necessary. She said RN A was laughing and said, I can't believe this, look at him. She said she did not report the incident. She said at the time she did not think RN A was going to do anything with it. She said at the time she did not think about it reporting it. She said she was not sure of the date the video was taken. She said she felt RN A showed it to her immediately after it was recorded. She said Resident #1 had dementia and would not remember the incident. She said one time he had even walked down the hall with only a shirt on. During an interview on 10/22/24 at 3:24 p.m., PTA L said she was aware RN A took a video of Resident #1. She said RN A showed her the video on her phone. She said she saw Resident #1 in his room naked from the waist down. She said he had only a shirt on. She said he was walking around the room. She said as soon as she saw it, she quit watching the video. She said she did not know if it was the day, RN A took the video. She said she worked at different facilities and was not sure of the day. She said residents across the hall had complained about Resident #1 walking around naked. She said she told RN #1 about the complaint and that was when she showed her the video. She said after viewing the video she did not report it to anyone. She said she did not know why. She said the video made her uncomfortable. She said, I just didn't. I don't know why. I just didn't want that in my brain. She said when RN A showed her the video she was laughing. She thought it was funny. She said Resident #1 was not aware the incident happened. During an interview on 10/22/24 at 3:56 p.m., Administrator G said what occurred was HR K informed him that a video was going around. He said that was either 7/31/2024 or 8/2/2024. He said he thought it was in August 2024. He said he could not remember if she gave him details of the video. He said the allegation did not hit his abuse and neglect radar. He said about two weeks later the DON was informed of the video and communicated the details the video to him and it was reported. He said RN A was suspended immediately and never brought back from suspension. He said he did send a text to the Treatment Nurse on 08/02/24. He said he did say the video was inappropriate. He said he just did not realize how bad the video was or the response would have been completely different. He said he had never seen the video. He said he left the facility sometime in August 2024. He said he was given the option to resign. During an interview 10/22/24 at 4:12 p.m., the Social Worker said she was not even aware of the video until compliance got involved. She said she usually did a checkup with residents after any incident. She said she did safe surveys and there were no concerns. She said she did talk to Resident #1. She said Administrator G had just come out of his room, so the incident was fresh on Resident #1's mind. She said he did not seem upset. She said he did say, I just don't know why someone would do something like that. I'm not going to let it affect me. She said she did get an order for psychology services to check on him. During an interview on 10/23/24 at 8:50 a.m., ADON H said she quit working at the facility on approximately 8/12/24. She said she became aware of the video in July 2024 on a Wednesday. She said the Treatment Nurse had told her. She said she told the Treatment Nurse that she needed to report the video to the DON and Administrator G. ADON H said she reported the video to Compliance on 8/3/24 at 2:00 a.m. She said therefore she was told about the video on 7/31/24. ADON H said she never saw the video. She said the Transport Aide did tell her on 08/09/24 that she had seen the video. She said she quit working at the facility because she felt things were not being addressed. She said there were a few other reasons. She said she understood the facility did not want a tag, but they had to do the right thing. She said she knew the DON was made aware of the video on 7/31/24 and HR K told her again on 8/12/24. During an interview on 10/23/24 at 9:14 a.m., HR K said she found out about the video on 8/2/24. She said ADON H told her about the video. She said RN A was going around showing everyone videos of Resident #1 walking around in his room butt naked. She said she immediately texted Administrator G. She said he said he texted her back and Oh no that is really bad. The family could sue us. Could you please tell the nurse's that is not funny, and they should not be doing that? She said nothing happened after that. She said there was no investigation. She said she reported it to the DON on 8/12/24 and voiced her concerns about nothing happening. She said, and still nothing was done. She said she never saw the video. She said she was told by multiple people it did exist and what it consisted of. During an interview on 10/23/24 at 9:31 a.m., the DON said she first became aware of the video approximately 2 days before she reported the incident to the state. She said HR K told her but did not tell her any details about the video. She said prior to 8/21/24 she had not even heard of the video. She said she was on vacation 7/30/24 - 8/5/24. She said the video was not reported to her during that time. She said on 8/22/24 she became of aware of the content of the video. She said she was told by the Staffing Coordinator. She said the Staffing Coordinator told her there was a video of Resident #1 with his genitals exposed and that RN A had taken the video. She said she suspended RN A immediately. She said she discussed the video with the Administrator G. She said he told her he had no idea about the video. She said she went back to HR K and asked her if she had reported the incident to Administrator G. She said HR K showed her a text message showing that she had reported the video to Administrator G. She said the text was dated 8/2/24. She said to her knowledge there was no investigation started by Administrator G. She said she began the investigation herself on 8/23/24. She said her investigation concluded that RN A had taken the video of Resident #1 and had shown multiple co-workers. She said RN A was terminated on 08/26/24. She said she h[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment are reported immediately or not later than 2 hours for 1 of 11 residents reviewed for abuse and neglect. (Resident #1) The facility staff (RN B, LVN C, CNA D, LVN E, the Staffing Coordinator, the Transport Aide, PTA L) failed to report abuse immediately to the Abuse Coordinator after they had viewed or became aware of video taken by RN A of Resident #1 naked from the waist down. Facility Administrator G failed to investigate and to report an allegation of abuse to the state agency after he became aware of the video on 07/31/24. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 07/26/24 and ended on 08/30/24. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for ongoing abuse and neglect. Findings included: Record review of a face sheet dated 10/22/24 revealed Resident #1 was an [AGE] year-old male and admitted on [DATE] with diagnoses including dementia, depression, and anxiety. Record review of a quarterly MDS dated [DATE] revealed Resident #1 was understood and usually understood others. The MDS revealed a BIMS score of 7, indicating severe cognitive impairment. The MDS indicated Resident #1 required supervision with most ADLs. Record review of Resident #1's physician's orders indicated on dated 08/23/24 indicated a verbal order was obtained to monitor for emotional distress every shift for 3 days. Record review of a care plan last revised on 10/12/24 revealed Resident #1 was at risk for impaired thought processes related to a history of dementia. Resident #1 needed assistance with all decision making. Resident #1 had an ADL self-care performance deficit related to decreased mobility and intermittent confusion. The care plan indicated Resident #1 had potential for a behavior problem as evidenced by inappropriate sexual behaviors. There was an intervention to provide privacy and encourage resident to remain clothed per family request. Record review of text messages dated 08/02/24 at 6:14 p.m., indicated texts between HR K and Administrator G. The texts indicated HR K wrote, .And ANOTHER note, I don't know who, how or where it originated from but there has been a video taken of (Resident #1) with no pants on and making its way around the building. Administrator G responded, Oh no! If you're still there, will you mention to one or two of the staff at the nurse's station that any videos taken of residents against their will can give family members a foot hold to sue whoever has the video. HR K responded, I left unfortunately but I was told over the phone, not in person at the facility or I would have said just that and how it's not funny. Administrator G responded, Mmm, ok. I'll mention it to (the Treatment Nurse). Record review of a text message dated 08/02/24 at 6:38 p.m., to the Treatment Nurse from Administrator G indicated, Hey, I just got word that there's an inappropriate video of (Resident #1) going around the facility. Will you mention to the staff that any videos taken of residents against their will can give family members a foot hold to sue whoever has the video. It has happened to our sister facility . Record review of a Grievance Resolution Form dated 08/23/24 indicated Resident #1 was involved in a video without his knowledge. The report indicated the compliance department was involved and notified administration. Record review of a Progress Note dated 08/23/24 indicated, SW (Social Worker) visited with resident (Resident #1) this afternoon .SW noticed no change in his mood or behavior after he was notified of the incident. He continues to show confusion, per his usual state. He states I am OK. I am not going to let this effect my life. He is agreeable to speaking with (psych services). SW has sent in a referral for evaluation and spoke with .counselor, re: the incident. SW will continue to monitor resident and will assist further as needed. The note was signed by the Social Worker. Record review of Nurse's notes for Resident #1 dated 08/23/24 - 08/28/24 indicated Resident #1 was monitored for mood and distress. The notes did not indicate Resident #1 had a change in mood or emotional distress. Record review of an Investigation Summary and Timeline report dated 08/30/24 indicated the DON was notified of the allegation of abuse on 08/22/24 at approximately 5:00 p.m. related to the conduct of RN A. The allegation suggested that the nurse had taken an unauthorized video of a resident. RN A was immediately suspended at the time it was reported, pending investigation. During the interview process, it was confirmed that RN A had taken a video of a resident while in his room The resident was not wearing pants and his genitals were visible. The Investigation Summary and Timeline indicated that Resident #1 had been interviewed by Administrator G and had knowledge of the video at the time of the interview. The Investigation Summary and Timeline report indicated RN A was terminated in person on 08/26/24. The report indicated the police were notified and the RP requested to press charges against RN A. Record review of a Provider Investigation Report dated 08/23/24 indicated that on an unknown date RN A took an unauthorized video of Resident #1. The investigation findings were confirmed. Record review of an interview of RN A dated 08/23/24 at 9:30 a.m. indicated she had taken a video of Resident #1. She stated Resident #1 had been in his room with his roommate. She said it had been reported to her by someone in therapy that they smelled smoke in the residents' room. She said she went to the room and Resident #1 was leaning over his roommate and his genitals were rubbing on the roommate. She stated the video showed Resident #1's backside, naked from the waist down. She said she showed the video to LVN C. She said the purpose of filming the video was to show LVN C the residents behavior. She stated, .I shouldn't have done that. I should have verbally told the nurse or done a progress notes. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by RN A. On 10/22/24 at 11:30 a.m., an attempt was made to reach RN A by telephone. There was no answer. A detailed message requesting a return call was left on voicemail. Record review of an interview of LVN C dated 08/23/24 at 10:10 a.m. indicated that she knew about and had seen the video. She said she had seen the video. She said it was of Resident #1 walking over to his roommate. She said Resident #1 only had a shirt on. She said she just saw the back of Resident #1. She said she saw his buttocks. She said he was bending over to do something, and she could see his genitals hanging down. She said RN A had shown her from her phone. She stated RN A said, Oh my God, look what (Resident #1) did. She said RN A thought it was funny. She said she did not report the video. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by LVN C. Record review of an interview of the Transport Aide dated 08/23/24 at 10:20 a.m. indicated the Transport Aide was aware of and had seen the video. She said the video was shown to her by RN A. She said the video was of Resident #1 walking with a shirt on. She said she could see Resident #1's genitals. The interview indicated that the Transport Aide asked RN A why she had the video and RN A said something to her about when he was younger, he probably had big balls. The Transport Aide said she had seen the video weeks ago. The interview indicated the Transport Aide did not report the video to anyone and when asked why she said, I know I should have. I don't know why I didn't. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by the Transport Aide. During an interview on 10/22/24 at 3:34 p.m., the Transport Aide said she walked in one morning. She said RN A said to come see the video and said, it's really funny. She said she did not understand why RN A would have even filmed the video. She said she watched the video on RN A's phone, and it was never sent to her. She said she thought the video was shown to her in July 2024. She said the video was inappropriate. She said on the video she saw Resident #1 over by the air conditioner. She said RN A said, Look at his balls going back in forth, I bet when he was younger, he was bigger. Record review of an interview of CNA D dated 08/23/24 at 10:20 a.m. indicated CNA D was aware of the video and that she had seen the video. She said it was both shown to her and sent to her via text by RN A. She stated that on the video Resident #1 was standing by his roommate with no pants or underwear on, just a shirt. Resident #1 leaned over to help his roommate and she saw his buttocks, penis, and scrotum. She said it had been less than a month since she had seen the video. She said she did not report the video to anyone. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by CNA D. Record review of an interview of LVN E dated 08/23/24 at 10:20 a.m. indicated LVN E had heard about the video but had not seen the video. He stated it had been about a month since he had heard about the video. He said he heard there was a video of Resident #1's genitalia. He said RN A had told him about the video. He said he thought he should have reported the video but did not report the video. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by LVN E. Record review of an interview of the Staffing Coordinator dated 08/23/24 at 11:05 a.m. indicated the Staffing Coordinator became aware of the video on 08/22/24. The Staffing Coordinator stated RN A came to the office and stated that compliance had called her about a video she had taken of one of the residents and she was scared and didn't know what to do. The Staffing Coordinator indicated she had not seen the video and had only heard gossip about the video. She said the staff that were gossiping did explain what was in the video. She said she did not report what was in the video because it was just gossip. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by the Staffing Coordinator. During an interview on 10/22/24 at 11:42 a.m., the Staffing Coordinator said she was in the hallway on a day in August 2024. She did not remember the date. She said RN A pulled her into the office and said compliance had reached out to her and she did not know what to do. The Staffing Coordinator said RN A was scared. The Staffing Coordinator said RN A said, I think they are calling me about the video. The Staffing Coordinator said she had heard rumors about the video but was not sure if those rumors were true. She said she has never seen the video. She said she heard there was a video out of a resident that they had at the time. She said she did not know any details. She said RN A did not tell her what was on the video or show it to her. She said she reported the incident to the DON after RN A had come into her office. Record review of a telephone interview of the Treatment Nurse dated 08/23/24 at 11:15 a.m. indicated the Treatment Nurse was aware of and had seen the video. She said it was shown to her right before she went on maternity leave. She said in the video she could see Resident #1's behind and his scrotum between his legs. She said RN A had shown her the video. She said it was on RN A's phone. The Treatment Nurse said she had mentioned the video to Administrator G and ADON H. She said she may have reported it the next day but could not remember. She stated that RN A thought the video was funny and was showing staff. She said she told RN A that the video was inappropriate, and she should not be videoing the residents. The interview was conducted and signed by the DON and the Clinical Resource Nurse. During an interview on 10/22/2024 at 1:06 p.m., the Treatment Nurse said she went on leave in August 2024 . She said it would have been the middle of August 2024. She said RN A did show her the video. She said RN A did not send her the video. She said RN A stopped her in the hall and said, Hey look at this. She said you could see Resident #1 and his roommate messing with the air conditioner. She said Resident #1 only had a shirt on. She said you could see his scrotum. She said the video was from behind and she was not sure if you could see the resident's penis. She said it did not appear Resident #1 was aware he was being videoed. She said RN A was laughing about the video. She said she told RN A it was inappropriate, and RN A said, I just thought it was funny. She said she did report it immediately to the previous ADON H that and told Administrator G the same day. She said she told Administrator G on 07/30/24 or 07/31/24. She said Administrator G told her he would address it at the next all staff meeting. Record review of a police Incident Report, dated 08/23/24 indicated Administrator G was the reportee. The report indicated the offense was solicitation to commit - invasive visual recording in bathroom/changing room. The report indicated RN A was the offender. The report indicated the officer spoke with Administrator G and the DON. The report indicated the DON explained that RN A recorded a patient in secret. The report indicated Resident #1 liked to walk around in the nude and RN A had secretly recorded Resident #1 and sent the video through text to RN B and made jokes about Resident #1. RN A showed her co-workers the video while making fun of Resident #1. The officer asked RN B if she still had the video and was told that she had deleted it. The report indicated on 08/27/24 It was concluded by (the facility) that (RN A) had acted inappropriately by recording (Resident #1) and was subsequently terminated for that reason. According to the interviews, (RN A) was distributing the video to other employees and making comments like, When he was younger, he probably had big balls and Look what you're missing out on. RN A herself was interviewed and stated that her reasoning for recording (Resident #1) was to provide his nurse with information on his behavior. During an interview on 10/22/24 at 9:28 a.m. a family member of Resident #1 said the incident of RN A videoing Resident #1 had been reported to the police. He said the investigating officer was Officer J. He said RN A took a video of Resident #1 and shared the video with her co-workers. The family member said they had not personally seen the video. They said Officer J had seen the video. He said Officer J had interviewed some of the facility staff at the police department and had taken several phones. The family member said one of the phones had produced the video. The family member said they did not know which one had. The family member said the facility was aware of the incident in July 2024. The family member said they were not notified of the video until the end of August 2024. The family member said Resident #1 had no memory of the incident. The family member said Resident #1 cannot even remember what he had for breakfast. During an interview and observation on 10/22/24 at 1:30 p.m., Officer J said nursing home staff did not report the video to the police department until a month after it was recorded. He said then the following week, Resident #1's family had reported the video to the police department. He said the first report was made on 8/23/2024. He said review of the video indicated a create date of 7/26/24. He said the police department still had custody of CNA D's and RN B's cell phones. He said they each gave consent for their phones to be searched. He said the video was eventually found on RN B's cellphone. He said on some of the phones there were text messages from the staff members and RN A discussing what Resident #1 might have looked like when he was younger. The video was observed in Officer J's office. The video showed Resident #1 from behind. Resident #1's roommate was sitting in a chair. Each resident had their backs to the camera. Resident #1 had on a polo type shirt. He was naked from the waist down. His buttocks and testicles were visible. At one point in the video, Resident #1 walked over to his roommate and bent over as if to help him with something. When the resident bent over it further exposed his testicles. In the background, there was heard a female voice laughing off and on throughout the video. At one point the female voice said, What is he doing? followed by more laughter. During an observation on 10/22/24 at 2:00 p.m., a video of RN B being interviewed by Officer J revealed RN B stated RN A had sent the video to a few people. RN B said the video was, inappropriate to say the least. RN B said RN A sent the video to her between 07/21/24 to 07/28/24. RN B said she had deleted the video from her phone after she found out that compliance had called RN A. RN B said she had deleted text messages from her phone also. During an interview on 10/23/24 at 8:25 a.m., RN B said she went on vacation for a whole week. She said she then tested positive for Covid and was off another week. She said texted RN A to ask what she had missed at work. She said RN A said, Hey I'm about to send you a video. She said she watched most of the video but not all of it. She said this was normal behavior for Resident #1 and she had seen this behavior daily. She said she felt the video was inappropriate. She said she thought the video was meant to be humorous. She said she thought she typed back, LOL. She said after that she did not think anything else about the video. She said she was sick, and she really did not give it much thought. She said RN A texted her and told her she had sent the video to several other people. She said she did not know the date the video was sent to her, but it was towards the end of July 2024 because she was home sick. She said Resident #1 had a shirt on and nothing below. She said he was walking away from the camera. She said that was as far as she watched. She said she could see his buttocks. She said she did not have her glasses on and did not see his testicles. She said around 8/28/24 she did have a meeting with Compliance. She said she had already deleted the video from her phone. She said now the police had her phone. She said it was sent to forensics and they found the video on the phone. During an observation on 10/22/24 at 2:10 p.m., a video of CNA D was being interviewed by Officer J. CNA D said she was shown the video in the hallway right after RN A had come out of Resident #1's room. CNA D said that at the nurse's station RN A was showing the video to LVN C, LVN E, and herself. During an interview on 10/22/24 at 4:20 p.m., CNA D said RN A sent the video to her the day she recorded the video. She said this date was 7/27/24 on her birthday. She said the resident's roommate was in his wheelchair over by the air conditioner. She said Resident #1 was standing over him with a polo type shirt on and was naked from the waist down. She said she could see his buttocks, testicles, and his penis. She said RN A did not tell her why she took the video. She said she could not remember the context of her conversation with RN A. She said she could not remember if she saw all of the video, but she did feel it was inappropriate. She said she did not report the video to anyone. She said she was not aware of anyone else seeing the video. She said RN A never showed the video to LVN C, LVN E, and herself at the nurse's station. During an interview on 10/22/24 at 2:38 p.m., LVN C said RN A just showed her the video to show her what he was doing. She said the video was just the back of Resident #1 walking over to his roommate with just a shirt on. She said you could not see his face. She said you could see his testicles from behind. She said the video was never sent to her. She said she was at her medication cart when RN A showed her the video. She said LVN E and CNA D were at the facility but were not present when she watched the video. She said the resident's behavior was not a shock to her because he did stuff like that all the time. She said the video was inappropriate and was not necessary. She said RN A was laughing and said, I can't believe this, look at him. She said she did not report the incident. She said at the time she did not think RN A was going to do anything with it. She said at the time she did not think about it reporting it. She said she was not sure of the date the video was taken. She said she felt RN A showed it to her immediately after it was recorded. She said Resident #1 had dementia and would not remember the incident. She said one time he had even walked down the hall with only a shirt on. During an interview on 10/22/24 at 3:24 p.m., PTA L said she was aware RN A took a video of Resident #1. She said RN A showed her the video on her phone. She said she saw Resident #1 in his room naked from the waist down. She said he had only a shirt on. She said he was walking around the room. She said as soon as she saw it, she quit watching the video. She said she did not know if it was the day, RN A took the video. She said she worked at different facilities and was not sure of the day. She said residents across the hall had complained about Resident #1 walking around naked. She said she told RN #1 about the complaint and that was when she showed her the video. She said after viewing the video she did not report it to anyone. She said she did not know why. She said the video made her uncomfortable. She said, I just didn't. I don't know why. I just didn't want that in my brain. She said when RN A showed her the video she was laughing. She thought it was funny. She said Resident #1 was not aware the incident happened. During an interview on 10/22/24 at 3:56 p.m., Administrator G said what occurred was HR K informed him that a video was going around. He said that was either 7/31/2024 or 8/2/2024. He said he thought it was in August 2024. He said he could not remember if she gave him details of the video. He said the allegation did not hit his abuse and neglect radar. He said about two weeks later the DON was informed of the video and communicated the details the video to him and it was reported. He said RN A was suspended immediately and never brought back from suspension. He said he did send a text to the Treatment Nurse on 08/02/24. He said he did say the video was inappropriate. He said he just did not realize how bad the video was or the response would have been completely different. He said he had never seen the video. He said he left the facility sometime in August 2024. He said he was given the option to resign. During an interview 10/22/24 at 4:12 p.m., the Social Worker said she was not even aware of the video until compliance got involved. She said she usually did a checkup with residents after any incident. She said she did safe surveys and there were no concerns. She said she did talk to Resident #1. She said Administrator G had just come out of his room, so the incident was fresh on Resident #1's mind. She said he did not seem upset. She said he did say, I just don't know why someone would do something like that. I'm not going to let it affect me. She said she did get an order for psychology services to check on him. During an interview on 10/23/24 at 8:50 a.m., ADON H said she quit working at the facility on approximately 8/12/24. She said she became aware of the video in July 2024 on a Wednesday. She said the Treatment Nurse had told her. She said she told the Treatment Nurse that she needed to report the video to the DON and Administrator G. ADON H said she reported the video to Compliance on 8/3/24 at 2:00 a.m. She said therefore she was told about the video on 7/31/24. ADON H said she never saw the video. She said the Transport Aide did tell her on 08/09/24 that she had seen the video. She said she quit working at the facility because she felt things were not being addressed. She said there were a few other reasons. She said she understood the facility did not want a tag, but they had to do the right thing. She said she knew the DON was made aware of the video on 7/31/24 and HR K told her again on 8/12/24. During an interview on 10/23/24 at 9:14 a.m., HR K said she found out about the video on 8/2/24. She said ADON H told her about the video. She said RN A was going around showing everyone videos of Resident #1 walking around in his room butt naked. She said she immediately texted Administrator G. She said he said he texted her back and Oh no that is really bad. The family could sue us. Could you please tell the nurse's that is not funny, and they should not be doing that? She said nothing happened after that. She said there was no investigation. She said she reported it to the DON on 8/12/24 and voiced her concerns about nothing happening. She said, and still nothing was done. She said she never saw the video. She said she was told by multiple people it did exist and what it consisted of. During an interview on 10/23/24 at 9:31 a.m., the DON said she first became aware of the video approximately 2 days before she reported the incident to the state. She said HR K told her but did not tell her any details about the video. She said prior to 8/21/24 she had not even heard of the video. She said she was on vacation 7/30/24 - 8/5/24. She said the video was not reported to her during that time. She said on 8/22/24 she became of aware of the content of the video. She said she was told by the Staffing Coordinator. She said the Staffing Coordinator told her there was a video of Resident #1 with his genitals exposed and that RN A had taken the video. She said she suspended RN A immediately. She said she discussed the video with the Administrator G. She said he told her he had no idea about the video. She said she went back to HR K and asked her if she had reported the incident to Administrator G. She said HR K showed her a text message showing that she had reported the video to Administrator G. She said the text was dated 8/2/24. She said to her knowledge there was no investigation started by Administrator G. She said she began the investigation herself on 8/23/24. She said her investigation concluded that RN A had taken the video of Resident #1 and had shown multiple co-workers. She said RN A was terminated on 08/26/24. She said she had not seen the video. She said all staff that had knowledge of or saw the video was given final written warnings for failure to report. She said once she heard the content of the video, she felt it was abuse. She said she felt it should have been reported and investigated right from the very beginning. She said she did talk to Resident #1 about the video. She said he did not remember the incident unless it was brought up by staff. She said she did feel like this was a dignity issue. She said he had been the mayor at one time. She said he was a photographer. She said he could not help his behavior. During an interview on 10/23/24 at 1:30 p.m. RN B said if this happened to herself or a family member, she would feel awful. She said, I would be so mad. During an interview on 10/23/24 at 2:21 p.m., a family member of Resident #1 said in the condition of dementia or Alzheimer's they would not know if this had happened to them. The family member said if they did know, they would feel it was demeaning or demoralizing and against all privacy. They said they thought the whole thing horrible. They said Resident #1 had been a very private but public person. The family member said Resident #1 was the mayor at one time. The family member said Resident #1 never discussed the birds and bees with them because he was a private person. The family member said Resident #1 would not have liked this at all. During an interview on 10/23/24 at 2:43 p.m., the Social Worker said if this happened to her or a family member she would be upset. She said she would probably feel embarrassed. During an interview on 10/23/24 at 3:00 p.m., the Treatment Nurse said this had happened to her dad she would be hell mad. She said the video was a dignity issue and abusive to the resident. During an interview on 10/23/24 at 3:18 p.m., CNA D if someone took a video of her or a family member naked, she would be livid. She said if it were her, she would feel humiliated. During an interview on 10/23/24 at 3:23 p.m., the Activity Director said if someone videoed her naked and shared it with others, she would be ashamed, mad, embarrassed and just pissed off. During an interview on 10/23/24 at 3:26 p.m., ADON F said she was a floor nurse when the video was taken. She said she never even heard about the video until there were in-services. She said if this happened to her or her family it would be upsetting. She said it was a modesty and dignity issue. She said it was a lack of respect. During an interview on 10/23/24 at 3:31 p.m., PTA L said if it happened to her, she would not like it at all. She said she would be extremely embarrassed and angry. She said she did take seriously that these are people's lives and they had feelings. During an interview on 10/23/24 at 3:46 p.m., LVN C said if someone took a video of her naked and shared it with other people, she would feel embarrassed and violated. During an interview on 10/23/24 at 4:02 p.m., LVN E said if this happened to family it would made him highly upset. He said he would be furious if it happened to him. He said it would be a total invasion of privacy. During an interview on 10/23/24 at 4:12 p.m., the Staffing Coordinator said if someone took a video of her naked and shared it with other people, she would feel embarrassed. During an interview on 10/23/24 at 4:21 p.m., the Clinical Resource Nurse said she learned of the video during one of her weekly visits. She said it was probably on 08/22/24 or 08/23/24. She said she was told there was a nurse that had taken an inappropriate video of a resident not fully dressed and that it was sent to a staff member that was not on duty that day. She said she interviewed RN A. She said RN A was off that day and she was told she had to come to the facility to be interviewed. She said RN A admitted to taking the video. She said during interview RN A said, there was no reason for taking the video. She RN A said during that interview she had shown the video to no one. The Clinical Resource Nurse said she never saw the video. She said RN A told her the video was no longer on her phone, and she had deleted the video. She said every staff member was in-serviced. She said there were some one-on-one in-services. She said these were with the people that were disciplined. She said RN A was suspended that day. She said RN A's license were referred to the state. She said if this happened to her, she would be humiliated. She said it would be humiliating regardless of her age. She said she was angry and very emotional about what happened. She said it was just disgusting. She said she had assisted with safe surveys and with Resident #1 and he had no concerns. She said she did know Administrator G had interviewed the resident. She said Administrator G told her the resident did not recall the incident. She said Administrator G was asked to resign or he would be terminated. During an interview on 10/23/24 at 4:45 p.m., the DON said if someone took a video of her naked and shared it with other people, she would feel absolutely disgusted, violated, and awful. During an interview on 10/22/24 at 4:46 p.m., Administrator M said he was not the administrator when the incident happened or when it was first reported. He said his first day was

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure an allegation of abuse was thoroughly investigated for 1 of 11 residents reviewed for abuse. (Resident #1) The facility Administrator, Administrator G, failed to investigate an incident where RN A videoed Resident #1 in his room naked from the waist down. RN A shared the video with other staff. The facility failed to protect Resident #1 from potential further abuse after the allegation. RN A was allowed to work from the date of the incident until she was suspended on 08/22/24. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 07/26/24 and ended on 08/30/24. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for further abuse, physical or psychological harm or injury. Findings included: Record review of a face sheet dated 10/22/24 revealed Resident #1 was an [AGE] year-old male and admitted on [DATE] with diagnoses including dementia, depression, and anxiety. Record review of a quarterly MDS dated [DATE] revealed Resident #1 was understood and usually understood others. The MDS revealed a BIMS score of 7, indicating severe cognitive impairment. The MDS indicated Resident #1 required supervision with most ADLs. Record review of Resident #1's physician's orders indicated on dated 08/23/24 indicated a verbal order was obtained to monitor for emotional distress every shift for 3 days. Record review of a care plan last revised on 10/12/24 revealed Resident #1 was at risk for impaired thought processes related to a history of dementia. Resident #1 needed assistance with all decision making. Resident #1 had an ADL self-care performance deficit related to decreased mobility and intermittent confusion. The care plan indicated Resident #1 had potential for a behavior problem as evidenced by inappropriate sexual behaviors. There was an intervention to provide privacy and encourage resident to remain clothed per family request. Record review of text messages dated 08/02/24 at 6:14 p.m., indicated texts between HR K and Administrator G. The texts indicated HR K wrote, .And ANOTHER note, I don't know who, how or where it originated from but there has been a video taken of (Resident #1) with no pants on and making its way around the building. Administrator G responded, Oh no! If you're still there, will you mention to one or two of the staff at the nurse's station that any videos taken of residents against their will can give family members a foot hold to sue whoever has the video. HR K responded, I left unfortunately but I was told over the phone, not in person at the facility or I would have said just that and how it's not funny. Administrator G responded, Mmm, ok. I'll mention it to (the Treatment Nurse). Record review of a text message dated 08/02/24 at 6:38 p.m., to the Treatment Nurse from Administrator G indicated, Hey, I just got word that there's an inappropriate video of (Resident #1) going around the facility. Will you mention to the staff that any videos taken of residents against their will can give family members a foot hold to sue whoever has the video. It has happened to our sister facility . Record review of a Grievance Resolution Form dated 08/23/24 indicated Resident #1 was involved in a video without his knowledge. The report indicated the compliance department was involved and notified administration. Record review of a Progress Note dated 08/23/24 indicated, SW (Social Worker) visited with resident (Resident #1) this afternoon .SW noticed no change in his mood or behavior after he was notified of the incident. He continues to show confusion, per his usual state. He states I am OK. I am not going to let this effect my life. He is agreeable to speaking with (psych services). SW has sent in a referral for evaluation and spoke with .counselor, re: the incident. SW will continue to monitor resident and will assist further as needed. The note was signed by the Social Worker. Record review of Nurse's notes for Resident #1 dated 08/23/24 - 08/28/24 indicated Resident #1 was monitored for mood and distress. The notes did not indicate Resident #1 had a change in mood or emotional distress. Record review of an Investigation Summary and Timeline report dated 08/30/24 indicated the DON was notified of the allegation of abuse on 08/22/24 at approximately 5:00 p.m. related to the conduct of RN A. The allegation suggested that the nurse had taken an unauthorized video of a resident. RN A was immediately suspended at the time it was reported, pending investigation. During the interview process, it was confirmed that RN A had taken a video of a resident while in his room The resident was not wearing pants and his genitals were visible. The Investigation Summary and Timeline indicated that Resident #1 had been interviewed by Administrator G and had knowledge of the video at the time of the interview. The Investigation Summary and Timeline report indicated RN A was terminated in person on 08/26/24. The report indicated the police were notified and the RP requested to press charges against RN A. Record review of a Provider Investigation Report dated 08/23/24 indicated that on an unknown date RN A took an unauthorized video of Resident #1. The investigation findings were confirmed. Record review of an interview of RN A dated 08/23/24 at 9:30 a.m. indicated she had taken a video of Resident #1. She stated Resident #1 had been in his room with his roommate. She said it had been reported to her by someone in therapy that they smelled smoke in the residents' room. She said she went to the room and Resident #1 was leaning over his roommate and his genitals were rubbing on the roommate. She stated the video showed Resident #1's backside, naked from the waist down. She said she showed the video to LVN C. She said the purpose of filming the video was to show LVN C the residents behavior. She stated, .I shouldn't have done that. I should have verbally told the nurse or done a progress notes. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by RN A. On 10/22/24 at 11:30 a.m., an attempt was made to reach RN A by telephone. There was no answer. A detailed message requesting a return call was left on voicemail. Record review of an interview of LVN C dated 08/23/24 at 10:10 a.m. indicated that she knew about and had seen the video. She said she had seen the video. She said it was of Resident #1 walking over to his roommate. She said Resident #1 only had a shirt on. She said she just saw the back of Resident #1. She said she saw his buttocks. She said he was bending over to do something, and she could see his genitals hanging down. She said RN A had shown her from her phone. She stated RN A said, Oh my God, look what (Resident #1) did. She said RN A thought it was funny. She said she did not report the video. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by LVN C. Record review of an interview of the Transport Aide dated 08/23/24 at 10:20 a.m. indicated the Transport Aide was aware of and had seen the video. She said the video was shown to her by RN A. She said the video was of Resident #1 walking with a shirt on. She said she could see Resident #1's genitals. The interview indicated that the Transport Aide asked RN A why she had the video and RN A said something to her about when he was younger, he probably had big balls. The Transport Aide said she had seen the video weeks ago. The interview indicated the Transport Aide did not report the video to anyone and when asked why she said, I know I should have. I don't know why I didn't. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by the Transport Aide. During an interview on 10/22/24 at 3:34 p.m., the Transport Aide said she walked in one morning. She said RN A said to come see the video and said, it's really funny. She said she did not understand why RN A would have even filmed the video. She said she watched the video on RN A's phone, and it was never sent to her. She said she thought the video was shown to her in July 2024. She said the video was inappropriate. She said on the video she saw Resident #1 over by the air conditioner. She said RN A said, Look at his balls going back in forth, I bet when he was younger, he was bigger. Record review of an interview of CNA D dated 08/23/24 at 10:20 a.m. indicated CNA D was aware of the video and that she had seen the video. She said it was both shown to her and sent to her via text by RN A. She stated that on the video Resident #1 was standing by his roommate with no pants or underwear on, just a shirt. Resident #1 leaned over to help his roommate and she saw his buttocks, penis, and scrotum. She said it had been less than a month since she had seen the video. She said she did not report the video to anyone. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by CNA D. Record review of an interview of LVN E dated 08/23/24 at 10:20 a.m. indicated LVN E had heard about the video but had not seen the video. He stated it had been about a month since he had heard about the video. He said he heard there was a video of Resident #1's genitalia. He said RN A had told him about the video. He said he thought he should have reported the video but did not report the video. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by LVN E. Record review of an interview of the Staffing Coordinator dated 08/23/24 at 11:05 a.m. indicated the Staffing Coordinator became aware of the video on 08/22/24. The Staffing Coordinator stated RN A came to the office and stated that compliance had called her about a video she had taken of one of the residents and she was scared and didn't know what to do. The Staffing Coordinator indicated she had not seen the video and had only heard gossip about the video. She said the staff that were gossiping did explain what was in the video. She said she did not report what was in the video because it was just gossip. The interview was conducted by the DON and the Clinical Resource Nurse. The interview was signed by the Staffing Coordinator. During an interview on 10/22/24 at 11:42 a.m., the Staffing Coordinator said she was in the hallway on a day in August 2024. She did not remember the date. She said RN A pulled her into the office and said compliance had reached out to her and she did not know what to do. The Staffing Coordinator said RN A was scared. The Staffing Coordinator said RN A said, I think they are calling me about the video. The Staffing Coordinator said she had heard rumors about the video but was not sure if those rumors were true. She said she has never seen the video. She said she heard there was a video out of a resident that they had at the time. She said she did not know any details. She said RN A did not tell her what was on the video or show it to her. She said she reported the incident to the DON after RN A had come into her office. Record review of a telephone interview of the Treatment Nurse dated 08/23/24 at 11:15 a.m. indicated the Treatment Nurse was aware of and had seen the video. She said it was shown to her right before she went on maternity leave. She said in the video she could see Resident #1's behind and his scrotum between his legs. She said RN A had shown her the video. She said it was on RN A's phone. The Treatment Nurse said she had mentioned the video to Administrator G and ADON H. She said she may have reported it the next day but could not remember. She stated that RN A thought the video was funny and was showing staff. She said she told RN A that the video was inappropriate, and she should not be videoing the residents. The interview was conducted and signed by the DON and the Clinical Resource Nurse. During an interview on 10/22/2024 at 1:06 p.m., the Treatment Nurse said she went on leave in August 2024 . She said it would have been the middle of August 2024. She said RN A did show her the video. She said RN A did not send her the video. She said RN A stopped her in the hall and said, Hey look at this. She said you could see Resident #1 and his roommate messing with the air conditioner. She said Resident #1 only had a shirt on. She said you could see his scrotum. She said the video was from behind and she was not sure if you could see the resident's penis. She said it did not appear Resident #1 was aware he was being videoed. She said RN A was laughing about the video. She said she told RN A it was inappropriate, and RN A said, I just thought it was funny. She said she did report it immediately to the previous ADON H that and told Administrator G the same day. She said she told Administrator G on 07/30/24 or 07/31/24. She said Administrator G told her he would address it at the next all staff meeting. Record review of a police Incident Report, dated 08/23/24 indicated Administrator G was the reportee. The report indicated the offense was solicitation to commit - invasive visual recording in bathroom/changing room. The report indicated RN A was the offender. The report indicated the officer spoke with Administrator G and the DON. The report indicated the DON explained that RN A recorded a patient in secret. The report indicated Resident #1 liked to walk around in the nude and RN A had secretly recorded Resident #1 and sent the video through text to RN B and made jokes about Resident #1. RN A showed her co-workers the video while making fun of Resident #1. The officer asked RN B if she still had the video and was told that she had deleted it. The report indicated on 08/27/24 It was concluded by (the facility) that (RN A) had acted inappropriately by recording (Resident #1) and was subsequently terminated for that reason. According to the interviews, (RN A) was distributing the video to other employees and making comments like, When he was younger, he probably had big balls and Look what you're missing out on. RN A herself was interviewed and stated that her reasoning for recording (Resident #1) was to provide his nurse with information on his behavior. During an interview on 10/22/24 at 9:28 a.m. a family member of Resident #1 said the incident of RN A videoing Resident #1 had been reported to the police. He said the investigating officer was Officer J. He said RN A took a video of Resident #1 and shared the video with her co-workers. The family member said they had not personally seen the video. They said Officer J had seen the video. He said Officer J had interviewed some of the facility staff at the police department and had taken several phones. The family member said one of the phones had produced the video. The family member said they did not know which one had. The family member said the facility was aware of the incident in July 2024. The family member said they were not notified of the video until the end of August 2024. The family member said Resident #1 had no memory of the incident. The family member said Resident #1 cannot even remember what he had for breakfast. During an interview and observation on 10/22/24 at 1:30 p.m., Officer J said nursing home staff did not report the video to the police department until a month after it was recorded. He said then the following week, Resident #1's family had reported the video to the police department. He said the first report was made on 8/23/2024. He said review of the video indicated a create date of 7/26/24. He said the police department still had custody of CNA D's and RN B's cell phones. He said they each gave consent for their phones to be searched. He said the video was eventually found on RN B's cellphone. He said on some of the phones there were text messages from the staff members and RN A discussing what Resident #1 might have looked like when he was younger. The video was observed in Officer J's office. The video showed Resident #1 from behind. Resident #1's roommate was sitting in a chair. Each resident had their backs to the camera. Resident #1 had on a polo type shirt. He was naked from the waist down. His buttocks and testicles were visible. At one point in the video, Resident #1 walked over to his roommate and bent over as if to help him with something. When the resident bent over it further exposed his testicles. In the background, there was heard a female voice laughing off and on throughout the video. At one point the female voice said, What is he doing? followed by more laughter. During an observation on 10/22/24 at 2:00 p.m., a video of RN B being interviewed by Officer J revealed RN B stated RN A had sent the video to a few people. RN B said the video was, inappropriate to say the least. RN B said RN A sent the video to her between 07/21/24 to 07/28/24. RN B said she had deleted the video from her phone after she found out that compliance had called RN A. RN B said she had deleted text messages from her phone also. During an interview on 10/23/24 at 8:25 a.m., RN B said she went on vacation for a whole week. She said she then tested positive for Covid and was off another week. She said texted RN A to ask what she had missed at work. She said RN A said, Hey I'm about to send you a video. She said she watched most of the video but not all of it. She said this was normal behavior for Resident #1 and she had seen this behavior daily. She said she felt the video was inappropriate. She said she thought the video was meant to be humorous. She said she thought she typed back, LOL. She said after that she did not think anything else about the video. She said she was sick, and she really did not give it much thought. She said RN A texted her and told her she had sent the video to several other people. She said she did not know the date the video was sent to her, but it was towards the end of July 2024 because she was home sick. She said Resident #1 had a shirt on and nothing below. She said he was walking away from the camera. She said that was as far as she watched. She said she could see his buttocks. She said she did not have her glasses on and did not see his testicles. She said around 8/28/24 she did have a meeting with Compliance. She said she had already deleted the video from her phone. She said now the police had her phone. She said it was sent to forensics and they found the video on the phone. During an observation on 10/22/24 at 2:10 p.m., a video of CNA D was being interviewed by Officer J. CNA D said she was shown the video in the hallway right after RN A had come out of Resident #1's room. CNA D said that at the nurse's station RN A was showing the video to LVN C, LVN E, and herself. During an interview on 10/22/24 at 4:20 p.m., CNA D said RN A sent the video to her the day she recorded the video. She said this date was 7/27/24 on her birthday. She said the resident's roommate was in his wheelchair over by the air conditioner. She said Resident #1 was standing over him with a polo type shirt on and was naked from the waist down. She said she could see his buttocks, testicles, and his penis. She said RN A did not tell her why she took the video. She said she could not remember the context of her conversation with RN A. She said she could not remember if she saw all of the video, but she did feel it was inappropriate. She said she did not report the video to anyone. She said she was not aware of anyone else seeing the video. She said RN A never showed the video to LVN C, LVN E, and herself at the nurse's station. During an interview on 10/22/24 at 2:38 p.m., LVN C said RN A just showed her the video to show her what he was doing. She said the video was just the back of Resident #1 walking over to his roommate with just a shirt on. She said you could not see his face. She said you could see his testicles from behind. She said the video was never sent to her. She said she was at her medication cart when RN A showed her the video. She said LVN E and CNA D were at the facility but were not present when she watched the video. She said the resident's behavior was not a shock to her because he did stuff like that all the time. She said the video was inappropriate and was not necessary. She said RN A was laughing and said, I can't believe this, look at him. She said she did not report the incident. She said at the time she did not think RN A was going to do anything with it. She said at the time she did not think about it reporting it. She said she was not sure of the date the video was taken. She said she felt RN A showed it to her immediately after it was recorded. She said Resident #1 had dementia and would not remember the incident. She said one time he had even walked down the hall with only a shirt on. During an interview on 10/22/24 at 3:24 p.m., PTA L said she was aware RN A took a video of Resident #1. She said RN A showed her the video on her phone. She said she saw Resident #1 in his room naked from the waist down. She said he had only a shirt on. She said he was walking around the room. She said as soon as she saw it, she quit watching the video. She said she did not know if it was the day, RN A took the video. She said she worked at different facilities and was not sure of the day. She said residents across the hall had complained about Resident #1 walking around naked. She said she told RN #1 about the complaint and that was when she showed her the video. She said after viewing the video she did not report it to anyone. She said she did not know why. She said the video made her uncomfortable. She said, I just didn't. I don't know why. I just didn't want that in my brain. She said when RN A showed her the video she was laughing. She thought it was funny. She said Resident #1 was not aware the incident happened. During an interview on 10/22/24 at 3:56 p.m., Administrator G said what occurred was HR K informed him that a video was going around. He said that was either 7/31/2024 or 8/2/2024. He said he thought it was in August 2024. He said he could not remember if she gave him details of the video. He said the allegation did not hit his abuse and neglect radar. He said about two weeks later the DON was informed of the video and communicated the details the video to him and it was reported. He said RN A was suspended immediately and never brought back from suspension. He said he did send a text to the Treatment Nurse on 08/02/24. He said he did say the video was inappropriate. He said he just did not realize how bad the video was or the response would have been completely different. He said he had never seen the video. He said he left the facility sometime in August 2024. He said he was given the option to resign. During an interview 10/22/24 at 4:12 p.m., the Social Worker said she was not even aware of the video until compliance got involved. She said she usually did a checkup with residents after any incident. She said she did safe surveys and there were no concerns. She said she did talk to Resident #1. She said Administrator G had just come out of his room, so the incident was fresh on Resident #1's mind. She said he did not seem upset. She said he did say, I just don't know why someone would do something like that. I'm not going to let it affect me. She said she did get an order for psychology services to check on him. During an interview on 10/23/24 at 8:50 a.m., ADON H said she quit working at the facility on approximately 8/12/24. She said she became aware of the video in July 2024 on a Wednesday. She said the Treatment Nurse had told her. She said she told the Treatment Nurse that she needed to report the video to the DON and Administrator G. ADON H said she reported the video to Compliance on 8/3/24 at 2:00 a.m. She said therefore she was told about the video on 7/31/24. ADON H said she never saw the video. She said the Transport Aide did tell her on 08/09/24 that she had seen the video. She said she quit working at the facility because she felt things were not being addressed. She said there were a few other reasons. She said she understood the facility did not want a tag, but they had to do the right thing. She said she knew the DON was made aware of the video on 7/31/24 and HR K told her again on 8/12/24. During an interview on 10/23/24 at 9:14 a.m., HR K said she found out about the video on 8/2/24. She said ADON H told her about the video. She said RN A was going around showing everyone videos of Resident #1 walking around in his room butt naked. She said she immediately texted Administrator G. She said he said he texted her back and Oh no that is really bad. The family could sue us. Could you please tell the nurse's that is not funny, and they should not be doing that? She said nothing happened after that. She said there was no investigation. She said she reported it to the DON on 8/12/24 and voiced her concerns about nothing happening. She said, and still nothing was done. She said she never saw the video. She said she was told by multiple people it did exist and what it consisted of. During an interview on 10/23/24 at 9:31 a.m., the DON said she first became aware of the video approximately 2 days before she reported the incident to the state. She said HR K told her but did not tell her any details about the video. She said prior to 8/21/24 she had not even heard of the video. She said she was on vacation 7/30/24 - 8/5/24. She said the video was not reported to her during that time. She said on 8/22/24 she became of aware of the content of the video. She said she was told by the Staffing Coordinator. She said the Staffing Coordinator told her there was a video of Resident #1 with his genitals exposed and that RN A had taken the video. She said she suspended RN A immediately. She said she discussed the video with the Administrator G. She said he told her he had no idea about the video. She said she went back to HR K and asked her if she had reported the incident to Administrator G. She said HR K showed her a text message showing that she had reported the video to Administrator G. She said the text was dated 8/2/24. She said to her knowledge there was no investigation started by Administrator G. She said she began the investigation herself on 8/23/24. She said her investigation concluded that RN A had taken the video of Resident #1 and had shown multiple co-workers. She said RN A was terminated on 08/26/24. She said she had not seen the video. She said all staff that had knowledge of or saw the video was given final written warnings for failure to report. She said once she heard the content of the video, she felt it was abuse. She said she felt it should have been reported and investigated right from the very beginning. She said she did talk to Resident #1 about the video. She said he did not remember the incident unless it was brought up by staff. She said she did feel like this was a dignity issue. She said he had been the mayor at one time. She said he was a photographer. She said he could not help his behavior. During an interview on 10/23/24 at 1:30 p.m. RN B said if this happened to herself or a family member, she would feel awful. She said, I would be so mad. During an interview on 10/23/24 at 2:21 p.m., a family member of Resident #1 said in the condition of dementia or Alzheimer's they would not know if this had happened to them. The family member said if they did know, they would feel it was demeaning or demoralizing and against all privacy. They said they thought the whole thing horrible. They said Resident #1 had been a very private but public person. The family member said Resident #1 was the mayor at one time. The family member said Resident #1 never discussed the birds and bees with them because he was a private person. The family member said Resident #1 would not have liked this at all. During an interview on 10/23/24 at 2:43 p.m., the Social Worker said if this happened to her or a family member she would be upset. She said she would probably feel embarrassed. During an interview on 10/23/24 at 3:00 p.m., the Treatment Nurse said this had happened to her dad she would be hell mad. She said the video was a dignity issue and abusive to the resident. During an interview on 10/23/24 at 3:18 p.m., CNA D if someone took a video of her or a family member naked, she would be livid. She said if it were her, she would feel humiliated. During an interview on 10/23/24 at 3:23 p.m., the Activity Director said if someone videoed her naked and shared it with others, she would be ashamed, mad, embarrassed and just pissed off. During an interview on 10/23/24 at 3:26 p.m., ADON F said she was a floor nurse when the video was taken. She said she never even heard about the video until there were in-services. She said if this happened to her or her family it would be upsetting. She said it was a modesty and dignity issue. She said it was a lack of respect. During an interview on 10/23/24 at 3:31 p.m., PTA L said if it happened to her, she would not like it at all. She said she would be extremely embarrassed and angry. She said she did take seriously that these are people's lives and they had feelings. During an interview on 10/23/24 at 3:46 p.m., LVN C said if someone took a video of her naked and shared it with other people, she would feel embarrassed and violated. During an interview on 10/23/24 at 4:02 p.m., LVN E said if this happened to family it would made him highly upset. He said he would be furious if it happened to him. He said it would be a total invasion of privacy. During an interview on 10/23/24 at 4:12 p.m., the Staffing Coordinator said if someone took a video of her naked and shared it with other people, she would feel embarrassed. During an interview on 10/23/24 at 4:21 p.m., the Clinical Resource Nurse said she learned of the video during one of her weekly visits. She said it was probably on 08/22/24 or 08/23/24. She said she was told there was a nurse that had taken an inappropriate video of a resident not fully dressed and that it was sent to a staff member that was not on duty that day. She said she interviewed RN A. She said RN A was off that day and she was told she had to come to the facility to be interviewed. She said RN A admitted to taking the video. She said during interview RN A said, there was no reason for taking the video. She RN A said during that interview she had shown the video to no one. The Clinical Resource Nurse said she never saw the video. She said RN A told her the video was no longer on her phone, and she had deleted the video. She said every staff member was in-serviced. She said there were some one-on-one in-services. She said these were with the people that were disciplined. She said RN A was suspended that day. She said RN A's license were referred to the state. She said if this happened to her, she would be humiliated. She said it would be humiliating regardless of her age. She said she was angry and very emotional about what happened. She said it was just disgusting. She said she had assisted with safe surveys and with Resident #1 and he had no concerns. She said she did know Administrator G had interviewed the resident. She said Administrator G told her the resident did not recall the incident. She said Administrator G was asked to resign or he would be terminated. During an interview on 10/23/24 at 4:45 p.m., the DON said if someone took a video of her naked and shared it with other people, she would feel absolutely disgusted, violated, and awful. During an interview on 10/22/24 at 4:46 p.m., Administrator M said he was not the administrator when the incident happened or when it was first reported. He said his first day was on 10/2/24. He said he would consider the video abuse. He said abuse sums it up. He said if[TRUNCATED]

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible, and each resident received adequate supervision to prevent accidents for two of two residents (Resident #1 and #2) reviewed for accidents and hazards in that: 1. The facility failed to update Resident #1's elopement evaluation after he exhibited exit seeking behavior, and Resident #1 was able to elope from the facility without staff's knowledge due to an exit door failing to activate and Resident #1 was found on the roadway by police 2. The facility failed to ensure coffee was served at a safe temperature for Resident #2. Resident #2 received second degree burns to the left arm and abdomen after hot coffee was spilled on her. Resident #2 was not thoroughly assessed for burns after the coffee was spilled and treatment was not provided to the abdominal burn until 2 days after the incident occurred 3. The facility failed to have a policy to ensure coffee temperatures were at the appropriate temperature prior to serving These failures resulted in the identification of an Immediate Jeopardy (IJ) on 09/12/23 at 02:06 PM. While the IJ was removed on 09/13/23 at 1:45PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place the residents at risk for further elopement, burns, serious harm, serious injury, or death. Findings included: 1. Record review of Resident #1's face sheet, dated 09/11/23, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included generalized muscle weakness (decreased strength and compromised ability to perform active movements), type 2 diabetes mellitus (a long-term medical condition in which your body doesn't use insulin properly, resulting in unusual blood sugar levels), and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Record review of Resident #1's admission MDS assessment, dated 02/20/23, indicated he did not have a BIMS conducted because he was rarely/never understood. He had problems with both short-term and long-term memory, and his cognitive skills for daily decision making were severely impaired. He required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. He required supervision assistance with eating. Resident #1's locomotion on and off unit were not coded in the assessment because he had only performed those activities once or twice during the assessment. He used a wheelchair as a mobility device. Resident #1 received antidepressant medications 7 of 7 days of the assessment. Record review of Resident #1's care plan, created and initiated on 03/27/23, indicated a focus of elopement risk/wanderer related to disoriented to place, history of attempts to leave facility unattended, impaired safety awareness, resident wanders aimlessly. Interventions included: *Assess for fall risk *Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book *Document wandering behavior and attempted diversional interventions *Establish behavior patterns in the resident: look for patterns in the places the resident wanders repeatedly, what time of day they tend to wander most, and if the resident was engaging in a particular activity prior to wandering. *Monitor fatigue and weight loss *Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes *Redirect them once you have distracted them: once you have gained their attention, redirect them in an assuring manner Further record review of Resident #1's care plan, created and initiated on 02/20/23, indicated a focus of at risk for falls related to decreased mobility and poor safety awareness. Interventions included: *Avoid rearranging furniture *Be sure the call light is within reach and encourage to use it to call for assistance as needed *Bed in lowest position *Educate resident/family/caregivers about safety reminders and what to do if a fall occurs *Ensure resident is wearing appropriate footwear when ambulating or wheeling in wheelchair *Needs a safe environment: floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; side rails as ordered, handrails on walls, personal items within reach Record review of Resident #1's progress note, dated 03/21/23 at 09:49AM, stated: resident going into other rooms, per resident that is [alert and oriented] went into her room last night, attempted to go into kitchen this am but staff present and redirected, shower given this am. Record review of Resident #1's progress note, dated 03/21/23 at 01:03 PM, written by RN H, stated: Resident propelled self using wheel chair to hall one exit door. Resident pushed the door attempting to exit setting off the alarm. This nurse turned off the alarm and redirected the resident back to the nurses station. Record review of Resident #1's progress note, dated 03/23/23 at 02:21 PM, stated: noted resident going into others room, per other staff members taking belonging from other rooms, belongings returned Record review of Resident #1's progress note, dated 03/24/23 at 05:45 PM, written by LVN G, stated: [Resident] attempted to go out back door on hall 400. Staff quickly redirected [Resident]. Alarm reset. [Resident] wanders, propels self in wheelchair. Record review of Resident #1's progress note, dated 03/25/23 at 03:47PM, written by LVN G, stated: [Resident] has attempted to go out door on hall 100 & hall 300 today. Sat at front door attempting to open door unsuccessfully. Record review of Resident #1's progress note, dated 03/27/23 at 09:46AM, stated: Up in [wheelchair] and propels self .continues to attempt to go into others room Record review of Resident #1's progress note, dated 03/28/23 at 05:02 AM, stated: Received call from [facility's city police department] that a [name of facility] patient was on [local farm-to-market road] in a [wheelchair]/ This nurse and 2 CNAs went out to road to find patient in [wheelchair] on the side of the road by the driveway turn in. Spoke with police, thanked him and brought patient via [wheelchair] back into building. No alarms went off. No employees let him out. Patient placed in bed. 15 min check in place. DON notified. Will continue to monitor. Record review of Resident #1's elopement / wandering evaluation, signed on 02/13/23, indicated Resident #1 was a low risk. Record review of Resident #1's elopement / wandering evaluation, signed on 03/28/23, indicated he was a high risk. Record review of Resident #1's incident report, dated 03/28/23, indicated the city police had called the facility and informed them that a patient was on the road in front of the facility in a wheelchair. A nurse and two CNAs went out and brought the resident back into the facility. There were no injuries observed. He had a predisposing situation factor of being an active exit seeker and a wanderer. Record review of the facility's provider investigation report for Resident #1's elopement stated in the second investigation summary section: .Evaluation of facility doors revealed the door alarm closest to the resident's room was not activated at the time of his elopement . During an interview and observation on 09/11/23 at 1:58 PM, the Maintenance Director said he was working in the facility when the resident eloped in March 2023. He said the resident got out because the doors did not lock at the time of the incident. He said he was unsure if the alarm went off or not at the time of the incident. He tested all of the door alarms weekly, sometime during the week. He said he did not check on a specific day. He said he kept the checks on a log. He said the front and the back door were secured and alarmed. He said before the elopement, only the front and back door were secured. He said the other doors were only alarmed but not locked. They could still be pushed opened to allow egress. He said the nurses and the Maintenance Director had a key to the alarm. He said after the elopement all exterior doors were upgraded so they could be secured in the same way as the front and back door with a magnet lock. They were all alarmed. He took this surveyor around the facility and checked each exterior door and they were all secured and alarmed. During an interview on 09/11/23 at 2:58 PM, CNA M said she remembered seeing Resident #1 around 3:00 AM. She said she missed out on everything because the others ran outside. She said the nurses had a key to the alarms. She said she had never seen anyone turn off the alarm. She said she thought they were always on. She said she never heard an alarm sound that morning when the resident eloped. During an interview on 09/11/23 at 3:04 PM, CNA L said Resident #1 had behaviors before of exit seeking and trying to exit. She was not sure how he got out of the facility at the time of the elopement. She said he got out and they noticed he was missing and ran out to look for him and they found him at the end of the parking lot next to the road. She said he did not exhibit any distress. They got him back inside and the nurse looked him over. She said she was not sure if she heard an alarm that morning. She said the nurses had a key to the alarms. During an interview on 09/11/23 at 3:14 PM, CNA K said she dressed Resident #1 that morning. She said she brought him to the front of the building near the nurses station and gave him some snacks to keep him occupied. She said he then wandered around the facility either to the dining room or another hall. When she came back to check on him, he was not in the same spot when she left him. She said she could not find him in his usual places. The PD called and he was out of the facility down beside the street. They found him out of the parking lot by the side of the street. She said he did not have any injuries. She said they brought him back into the facility. She said later that day after her shift the DON or the ADON called her and they said the 400 hall door was found unlocked. She said she never heard an alarm that morning. She said she last saw him around 5-10 minutes before they found him outside. She said the nurses and the ADON have a key to the alarms. She said he just mumbled when asked how he got out. During an interview on 09/11/23 at 3:25 PM, LVN B said she said took care of Resident #1 the next shift after his elopement. She said he did not have any negative effects and did not have any injuries related to the elopement. During an interview on 09/11/23 at 3:29 PM, the ADON said Resident #1 got out of the building. She said the nurse assessed him. She said Resident #1 had no negative effects. She said he was outside around 10-20 minutes. She said they put him on 1:1 observation until he left to another facility later that day on 03/28/23. During an interview on 09/11/23 at 3:32 PM, the DON said she headed the facility's investigation. She said one of the nurses found that the alarm was turned off after Resident #1's elopement. She said when she arrived to the facility on [DATE], she checked the doors and the alarms were activated. She said one of the nurses that were working at the time of the elopement told her that the alarm to the 400 hall was turned off. She said the 400 hall door was the only one that was found not activated. She said the nurses had a key at the time of the elopement. She said after the incident, they changed the door locks to magnets that auto lock. She said Resident #1 was put on 15-minute checks until he was transferred out to another facility. She said they reevaluated all elopement risk residents. She said they did in-services related to the alarms. She said her investigation found that the resident was out of the building about 20-25 minutes. She said the current administrator had only been there about 1 month. During an interview on 09/11/23 at 4:00 PM, the DON said they did not have a policy that addressed how often the door alarms should be checked. During an observation on 09/11/23 at 4:16 PM, this surveyor found a speed limit sign for the road that the facility driveways end on. The speed limit was 55 miles per hour. During an interview on 09/11/23 at 4:43 PM, RN H said he did not remember taking care of Resident #1. He said he wrote a progress note on 03/21/23 likely because he noticed the resident was exit seeking. He said he could not recall the event but he said he would have notified the nurse and the DON about the new exit seeking behaviors. He said he was unsure if a new elopement assessment was completed on Resident #1 related to his exit seeking. During an interview on 09/11/23 at 4:49 PM, LVN G said Resident #1 was frequently exit seeking. She said she kept a closer eye on him since he started exit seeking. She said the hall doors had alarms and would sound when someone opened the door. She said she was unable to remember if a new elopement assessment was completed or if the DON was notified about Resident #1's exit seeking behaviors. She said for a resident that was a low risk to elope and then started to be exit seeking, she said she would notify the DON and complete a new elopement risk assessment. She said she did not create a new elopement/wandering risk assessment for Resident #1 when she noticed his exit seeking behaviors. During an interview on 09/12/23 at 9:09 AM, the DON said she last conducted an elopement in-service in March 2023 after Resident #1 eloped. She said newly hired employees were taught about elopement during their orientation training. She said she expected to be notified about Resident #1's new exit-seeking behaviors prior to his elopement. She said she expected the nurses to complete a new elopement assessment when they noticed new exit-seeking behaviors. During an interview on 09/12/23 at 9:14 AM, the Administrator said he did an in-service on elopement with the nurses on 09/11/23 after this surveyor left the facility. 2. Record review of Resident #2's face sheet, dated 09/12/23, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included generalized muscle weakness (decreased strength and compromised ability to perform active movements), and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Record review of Resident #2's quarterly MDS assessment, dated 07/03/23, indicated she did not have a brief interview for mental status conducted because she was rarely/never understood. Her staff assessment for mental status indicated she had a problem with both short and long-term memory, and that her cognitive skills for daily decision making were severely impaired. She did not exhibit behaviors of rejection of care or wandering. She required extensive assistance with bed mobility, transfers, locomotion on and off unit, dressing, eating, toileting, and personal hygiene. Her primary medical condition that best described her primary reason for admission was non-traumatic brain dysfunction (a brain injury not caused by external physical force or trauma exerted on the head). Record review of Resident #2's physician's orders, dated 09/12/23, indicated he had these orders: *Cleanse left arm wound with normal saline/wound cleanser, apple silver sulfadiazine cream (used with other treatments to help prevent and treat wound infections in patients with serious burns) to left arm BID and cover with kerlix (a brand of gauze that is used to cover wounds) every shift for wound healing. The start date was 07/07/23. *Cleanse lower left abdomen wound with normal saline/wound cleanser, apply silver sulfadiazine cream to left arm BID and cover with kerlix every shift for wound. The start date was 07/09/23. Record review of Resident #2's care plan, created on 07/10/23, indicated a focus of Resident #1 has actual impairment to skin integrity related to burn to left arm from spilt coffee. The focus also indicated 07/09/23 burn areas noted on abdomen - resident refusing treatment frequently due to impaired cognition. Interventions included: *Notified wound MD, orders implemented *Educate resident/family/caregivers of causative factors and measures to prevent skin injury. *Follow facility protocols for treatment of injury *Identify/document potential causative factors and eliminate/resolve where possible *Monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, signs or symptoms of infection, maceration to MD. Further record review of Resident #2's care plan, created on 07/25/2019, indicated a focus of Resident #2 is at risk for impaired cognitive function/dementia or impaired thought processes. Interventions included: *Identify yourself at each interaction. Face when speaking and make eye contact. Reduce any distractions. Use simple, directive sentences. Provide with necessary cues - stop and return if agitated. *Engage in simple, structured activities that avoid overly demanding tasks Further record review of Resident #2's care plan, created on 07/10/23, indicated a focus of Resident #2 is resistive to care as evidenced by refusing wound care treatments related to dementia. Interventions included: *Encourage as much participation/interaction by the resident as possible during care activities *If resident resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again *Praise when behavior is appropriate Record review of Resident #2's incident report, dated 07/07/23, indicated she was given a cup of coffee on 07/07/23 in the morning in the dining room. She spilled coffee on her left arm and abdomen causing a burn. The incident indicated Resident #2's arm was assessed, cleaned, and silver sulfadiazine cream was applied. A note at the bottom of the incident report indicated Resident #2 spilled coffee on her arm during breakfast causing a burn, and education was provided to the kitchen regarding coffee temperatures. Record review of Resident #2's progress note, dated 07/07/23 at 01:32 PM, written by LVN B, stated: resident was given a cup of coffee this morning in the dining room, resident spilled the coffee on her left arm causing a burn. Treatment nurse, [LVN C], notified and treatment of SSD cream implemented . Record review of Resident #2's progress note, dated 07/09/23 at 05:26 PM, written by LVN B, stated: during rounds this shift it was observed that resident has two burns to left side of abdomen. Area was cleaned with NS and SSD cream applied and covered with dry dressing. Wound care nurse notified and orders put in . Record review of Resident #2's progress note, dated 07/11/23 at 07:18 PM, written by LVN C, stated: Resident evaluated this AM by [Wound care doctor E]. Following wound evaluated: -[left] arm and [left upper quadrant abdomen]: burn to area, 11x10x0.1 cm, 110.00 cm^2, light serous drainage, 80% granulation tissue/20% skin. [treatment] of silver sulfadiazine and rolled gauze daily . Record review of Resident #2's skin evaluation, dated 07/07/23 at 09:05 AM, indicated Resident #2 had a burn to her left upper arm, forearm, antecubital area (the region of the arm in front of the elbow), and forearm. Record review of Resident #2's initial wound evaluation and management summary, dated 07/11/23, indicated she had a burn wound to her left arm that was a full thickness burn (third-degree burn). The wound size was 11 x 10 x 0.1 cm, and the surface area was 110.00 cm^2. The summary further stated: During today's visit, 35 minutes were spent in providing patient care related to reviewing of history, relevant investigations, performing examination, and/or coordination of care and counseling specific to Burn wound of the Left Arm . The summary did not address the burn of Resident #2's abdomen. The exam portion of the summary indicated Resident #2's abdomen was normal, and that there was a wound present to Resident #2's left upper extremity. Record review of Resident #2's wound evaluation and management summary, dated 07/18/23, indicated she had a burn wound to her left arm. The wound size was 10 x 5 x 0.1cm, and the surface area was 50.00 cm^2. The exam portion of the summary indicated Resident #2's abdomen was normal, and that there was a wound present to Resident #2's left upper extremity. The summary did not address the burn of Resident #2's abdomen. Record review of Resident #2's wound care progress note, with a date of service of 07/18/23, and signed by Wound Care Doctor E on 07/20/23 at 3:17PM stated: The patient has partial second degree burns on the abdomen as well. However, the wounds are not open. We will apply Silvadene to wounds with dry dressing daily and prn. Record review of Resident #2's skin ulcer non-pressure assessment, dated 07/11/23 and completed by LVN C, indicated Resident #2 had a burn to her left arm and left lateral (of or relating to the side) abdomen. The onset date was 07/07/23. The size was 11x10 cm. The burn was described as a full thickness wound. The wound was noted to have a small amount of serous exudate (a clear fluid that leaks out of wounds). Record Review of Resident #2's wound care progress note, dated 7/11/23, and signed by Wound Care Doctor E on 09/13/23 at 10:05 AM, indicated that the wound care note dated for 07/18/23 concerning Resident #2's abdominal wound progress note was supposed to be dated for the 7/11/23 visit. This record was provided by the Administrator via email to this surveyor on 09/13/23 at 12:49 PM. Wound Care Doctor E signed this note on 09/13/23 at 10:05 AM, after surveyor interview with the Wound Care Doctor E, and after this surveyor notified the Administrator and DON of IJ on 09/12/23. During an interview on 09/12/23 at 9:40 AM, LVN B said she looked at the burn on Resident #2's left arm and grabbed the wound care nurse, LVN C. She said they immediately rinsed it with water and the wound nurse treated and bandaged the burn. She said she spoke with the kitchen about not giving out hot coffee. She said the resident had not had coffee before and she was unsure if it was given because she asked or if the kitchen had mistakenly given it to her. She said she notified the MD, DON, and family. During an interview on 09/12/23 at 9:55AM, LVN B said she did not notice the burn to Resident #2's abdomen on 07/07/23. During an interview on 09/12/23 at 10:05AM, LVN C said Resident #2 had sustained a coffee burn. He said he did not notice the burn to her abdomen on 07/07/23. He said the abdominal burn was found sometime between 07/07/23 and 07/11/23 because he remembered telling Wound Care Doctor E to look at both wounds on 07/11/23. During an interview on 09/12/23 at 10:19AM, LVN B said she found Resident #2's abdominal burn on 7/9/23. She said she was not told in report about the burns and treated them as new. She thought they were delayed from the coffee burn on her arm on 7/7/23. She said she immediately cleaned and treated the wound, and notified the DON, MD, Family, and treatment nurse. During an interview on 09/12/23 at 10:30AM, the Dietary Manager said they did not log the coffee temperature before the burn incident on the morning of 07/07/23. She said before the incident she expected the aides to read the temperature reading on the coffee maker and not to serve if the coffee temperature was greater than 180 degrees F. She said the dietician gave her some guidance at the time of the event that indicated there was no minimum or maximum that the coffee should be served. She said in the mornings the dietary aides assisted the nursing staff to give out coffee before breakfast. She after the burn incident they changed to use a thermometer to check the temps of the coffee and keep a log. She said the residents also now have coffee cups with lids to reduce the risk of spillage. She said the coffee maker was set to 200 degrees F and the coffee was usually around 180 degrees F when it finished brewing. During an interview on 09/12/23 at 10:40AM, the DON said they do not have a policy that addresses the coffee temperature or the temperature that would be safe to serve to residents. She said after the incident the dietician provided some guidance that they now follow. During an interview on 09/12/23 at 10:51AM, LVN D said she was called into the shower room and noticed the burn on Resident #2's L Arm. She did not observe an abdomen burn on 07/07/23. She treated and covered the wound as ordered by the wound care doctor. She notified the MD, nurse, and DON. She was not sure if Resident #2 normally drank coffee. During an interview on 09/12/23 at 11:28AM, LVN B said he was unsure if Wound Care Doctor E saw the burn to Resident #2's abdomen on the 11th. He said he was not sure if Wound Care Doctor E was going to look at the abdominal wound or not. He said sometimes Wound Care Doctor E does not look at wounds the facility can treat. During an interview on 09/12/23 at 11:35AM, the DON said she expected Wound Care Doctor E to assess and treat the abdominal wound on 7/11/23. During an interview on 09/12/23 at 11:37AM, Wound Care Doctor E said Resident #2 had a big burn wound on her left arm and it never appeared to be infected. He said he was unsure if he saw the abdominal part of the wound on 7/11/23. He said he knew he saw it on the 7/18/23 visit. During an interview on 09/12/23 at 12:50PM, the DON said her investigation showed that Resident #2 spilled coffee on herself during breakfast. The CNA first noticed the burn to Resident #2's left arm when undressing her for a shower after breakfast. She said the CNA noticed the burn approximately at 9 to 9:30 AM. She said the resident did not express pain or any facial grimace. During an interview on 09/12/23 at 12:56PM, the Dietary Manager said they started the coffee temperature log the day after the burn incident. She said it was possible she put the coffee temps for the 8th on the 7th line. She said she did not have a record of the coffee temperature for the morning of the 7th. She said coffee was normally served between 6:30-7AM and breakfast was normally served at 7:15AM. During an interview on 09/12/23 at 3:46PM, CNA F said she took care of Resident #2 on 07/07/23. She said the resident had breakfast in the dining room and then participated in an activity. She said after the activity she took her out of the dining room to bathe her at approximately 10:00 AM. She said she noticed Resident #2's jacket was wet and undressed her. She then noticed a reddened area to Resident #2's left arm. She said she did not remember if Resident #2 had any reddened areas on her abdomen. She said she notified the nurse about the reddened area. During an interview on 09/13/23 at 3:50PM, the ADON said she expected the 400-hall alarm to be turned on at all times. The risk to Resident #1 was that he could have gotten hurt or injured. She expected the nurses to follow the elopement policy. During an interview on 09/13/23 at 3:59 PM, the DON said the risk to her Resident #2 as a result of the abdominal burn not being identified for two days was that she could have had skin breakdown or an infection. She said she expected the nurses to complete a new elopement evaluation when they noticed Resident #1 had new exit-seeking behaviors. She said she expected the 400-hall alarm to be turned on at all times. She said the risk to Resident #1 eloping could have been serious injury. Record review of the facility's policy titled elopement / unsafe wandering, last revised on January 2022, stated: .It is the policy of this facility to provide a safe environment for all residents through appropriate assessment and interventions to prevent accidents related to unsafe wandering or elopement . .Procedure 1. Resident with capabilities of ambulation and/or mobility in wheelchair will have an elopement/wandering evaluation completed to determine risks for elopement and unsafe wandering on admission and with observed behaviors of wandering or attempting to elope. 2. Residents with high risk factors will be identified as at risk and will have an individualized care plan developed that included measurable objectives and timeframes. a. Care plan interventions will consider the elements of the evaluation or behavior observations that identified the resident at risk. b. interventions will address the individualized level of supervision needed to prevent elopement/unsafe wandering. 3. Staff shall promptly report any resident who is trying to leave the premises or is suspected of being missing to the Charge Nurse or Supervisor to evaluate the need for further interventions Record review of an undated coffee safety Inservice sheet, provided by the DM on 09/12/23 at 10:39AM stated: .*Coffee should be brewed around 180 degrees F per the manufacturer's recommendation for flavor. *There is no temperature minimum or maximum for point of service. *Temperature designation at point of service is not recommended. *Coffee service below 150 degrees F will likely result in complaints of cold coffee and will not eliminate the risk of burns. *To help mitigate the risk of burns, ensure adequate monitoring and assistance is available to residents Record review of the facility policy for accident intervention, last revised May 2007, stated: .It is the policy of this facility that the resident environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent accidents . .Procedures: 1. Assess resident fully. 2. Provide needed emergency care . .3. Notify physician immediately and responsible party by telephone. 4. Minor injuries may be reported to physician and responsible party at the earliest appropriate hour. 5. Document - notification of physician and orders received notification of family incident report - complete nurses notes 6. Follow up - assess resident during each shift - at least once. Document findings for seventy-two (72) hours 7. Report- 24 hours report. Pass information on in shift report The Administrator was notified of an IJ on 09/12/23 at 2:06PM and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 09/13/23 at 11:00AM and included the following: [Facility Name] F689 Plan of Removal 09/12/23 Per the information provided in the IJ Template given on 09/12/23 at 1409, the facility failed to temp the coffee prior to giving it to the residents and failed to assess resident abdomen immediately. The facility failed to have a policy to ensure coffee temps were at the appropriate temperature. The facility failed to follow the elopement policy and the facility failed to ensure the alarm on the exit door on hall 400 was turned on. 1. The Medical Director was notified of IJ on 09/12/23 1425. 2. Skin sweep of total census initiated 09/12/23 and will be completed 09/12/23 by Clinical Resources, Clinical Le[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 5 residents reviewed for pressure ulcers. (Resident #52) *The facility failed to prevent the sacral wound from deterioration from a Stage 2 to a Stage 4 (over a 7-day period) of time. *The facility failed to notify the physician of the wound decline between the visits on 10/04/22 and 10/11/22. *The facility failed to obtain #52's recommended lab orders (WBC, ESR, and CRP) from the wound care consultant on 11/01/22. *The facility failed to ensure Resident #52's low air loss mattress was functioning for 5 hours and 47 minutes on 11/06/22 from 9:15 a.m. to 3:02 p.m. *The facility failed to provide treatment for Resident #52's sacral wound for 4 days after admission starting on 08/30/22. *The facility failed to provide #52's wound care consultant evaluation for the sacral wound, indicated on 08/26/22 admission assessment until 9/27/22. An Immediate Jeopardy (IJ) situation was identified on 11/07/22 at 4:40 p.m. While the IJ was removed on 11/08/22, the facility remained out of compliance at the severity of actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents with skin breakdown at risk of pain, worsening of wounds, wound infection, emotional distress, harm, or even death. Findings included: Record review of Resident #52's face sheet with a printed date of 11/07/22, indicated she was a [AGE] year-old-female, admitted on [DATE] and readmitted on [DATE] with the diagnoses of diabetes, difficulty swallowing, protein-calorie malnutrition, and anxiety. Resident #52's hospital assessment indicated she admitted to the local hospital on 9/11/22. Record review of an Initial admission Record dated 08/26/22 indicated Resident #52 was admitted with a weight of 225.4 pounds and was 65 inches tall. The assessment indicated Resident #52's skin was normal, pale, not flushed or blueish colored, warm and not cold. The admission assessment indicated Resident #52 had a ½ inch stage 2 ulcer on her left buttock. The additional documentation indicated Resident #52 had non-blanchable open area to the sacrum that was to be evaluated by the wound consultant. The admission record indicated Resident #52 was not provided an alternating air mattress, or a pressure re-distributing overlay mattress. Record review of an admission MDS dated [DATE] indicated Resident #52 was admitted from an acute hospital, was rarely understood, and rarely understands. The MDS indicated Resident #52's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident #52 did not reject care. The MDS indicated Resident #52 required extensive assistance with two staff for bed mobility, dressing and toilet use. She required limited assistance of two staff with transfers. Resident #52 required extensive assistance with eating and personal hygiene and total assistance of two staff for bathing. The MDS indicated Resident #52 was always incontinent of bowel and bladder. The MDS indicate Resident #52 was 65 inches tall and her weight was 225 pounds. The MDS indicated she had no weight loss of the last month. Section M of the MDS indicated Resident #52 had a pressure ulcer, a formal assessment tool, and a clinical assessment. The MDS indicated Resident #52 was at risk for pressure ulcers. The MDS indicated she had one or more unhealed pressure ulcers. The MDS indicated Resident #52 had a Stage 2 pressure ulcer (some of the outer surface of the skin or the deeper layer was damaged). The MDS indicated Resident #52 did not have any other pressure injuries. Record review of a medication administration record dated September 2022 indicated an order for the application of collagen powder to a pressure wound on sacrum and cover with a dry dressing daily starting on 08/30/22 ending on 09/06/2022. Record review of the September 2022 medication administration record indicated Resident #52 had an order for the application of barrier cream to bilateral buttocks daily and as needed for MASD (moisture associated skin damage) starting 09/14/22. The medication administration record indicated the first application occurred on 09/14/22 Record review of a Braden Scale for Predicting Pressure Sore Risk dated 08/30/22 indicated Resident #52's score was a 7 indicating very high risk to develop a pressure sore. Record review of a Braden Scale for Predicting Pressure Sore Risk dated 09/06/22 indicated Resident #52's score was a 9 indicating she was at a very high risk to develop a pressure sore. Record review of a hospital History and Physical dated 09/11/22 indicated Resident #52 was admitted and assessed by the physician on 09/11/22 and noted to have a sacral pressure ulcer, and excoriations (removal of skin) in the perineum ( area between anus and vulva) and thigh suggestive of incontinence associated dermatitis (diaper rash like). The History and Physical indicated a wound consult recommendation. Record review of an Initial admission assessment dated [DATE] indicated Resident #52 was readmitted after a hospital stay for cystitis (bladder infection). Resident #52 was 65 inches tall, and her weight was 220.8 pounds. The admission assessment indicated Resident #52 did not have a pressure re-distributing mattress but had an alternating air mattress. The general skin condition of Resident #52 was indicated to be normal and warm. The skin integrity indicated she had moisture associated skin damage on her buttocks but no pressure ulcers. Record review of the EMR (electronic medical record) dated October 2022 indicated Resident #52 was ordered a low air loss mattress initiated on 09/26/22. Record review of a skin evaluation dated 09/27/22 indicated Resident #52 had MASD (moisture associated skin damage) to her buttocks completed by the treatment nurse . The note did not reflect a pressure injury. Record review of an Initial Wound Evaluation and Management Summary (documented by the wound care consulting physician) dated 9/27/22 indicated Resident #52 had a Stage 2 pressure ulcer to the sacrum for at least 1 day duration. The note indicated there was moderate serous exudate (thin watery drainage). The note indicated the wound to Resident #52's sacral region measured 7 cm x 8 cm x 0.1 cm with moderate exudate. The treatment plan included to apply calcium alginate once daily for 30 days and collagen powder once daily for 30 days and cover with a gauze sponge once daily. The note indicated a recommendation for a Prealbumin (protein monitoring) and a hemoglobin AIC (blood sugar monitoring). Record review of a facility wound care report dated October 2022 indicated Resident #52 had a pressure ulcer to her sacrum (a shield shaped bony structure located at the base of the lumbar vertebrae and that was connected to the pelvis). The facility wound report indicated Resident #52's pressure wound was obtained in-house on 9/27/22. The wound stage was classified as unstageable due to slough and eschar. Resident #52 was high risk due to the results of the last Braden score completed on 09/12/22. The wound care report indicated in the month of October 2022 Resident #52's sacral wound reflected the following: Week #1 measured 6 cm x7.0 cm 0.1 cm; Week #2 measuring 6 cm x 5 cm x 1 cm; Week #3 measuring 6 cm x 9 cm x 1.4 cm; Week #4 measuring 10 cm x 12 cm x 2 cm; and week #5 measuring 10 cm x 12 cm x 5 cm. Record review of a Wound Evaluation and Management Summary dated 10/04/22 indicated Resident #52 had a stage 2 pressure ulcer to her sacrum for at least 7 days. The note indicated the wound had moderate serous exudate. The wound measurements were 6 cm x 7 cm x 0.1 cm with moderate exudate and 10% skin. The treatment plan included collagen powder application once daily, calcium alginate application once daily cover with gauze sponge once daily. Record review of a Wound Evaluation and Management Summary dated 10/11/22 indicated Resident #52 now had an unstageable wound due to necrosis (dead) tissue to her sacrum. The note indicated there was moderate serous exudate and was now a full thickness wound (tissue loss of the epidermis and dermis). The note indicated Resident #52's wound measured 6 cm x 9.5 cm x 1 cm. The note indicated the wound had 40% slough, 50% granulation tissue, and 10% skin with the deteriorated wound status. The wound was surgically debrided (removal of dead tissue with a blade) devitalized tissue including slough, biofilm, and non-viable tissue at a depth of 1 cm. The treatment for Resident #52's wound was calcium alginate twice daily with a gauze sponge twice daily. Record review of the progress notes from 10/04/22 through 10/11/22 did not reflect a decline in Resident #52's sacral wound from a Stage 2 to a Stage 4 during this time nor any documentation of the notification of her physician or responsible party. Record review of laboratory results dated [DATE] indicated WBC (white blood cells measuring infection) resulted at 15.7 with the normal range of 4.0-9.6, ESR Erythrocyte sedimentation rate of 90 indicated a high level of inflammation. The normal ESR range was 0-20. Record review of a wound culture dated 10/13/22 and resulted on 10/15/22 indicated Resident #52's sacral wound had a moderate gram-positive coccus. The wound had many groups A streptococcus isolated (infections range from minor to illness to very serious and deadly diseases) and moderate proteus mirabilis (can cause serious infections in humans). Record review of a physician's order dated 10/18/22 indicated Resident #52 was ordered Amoxicillin 500 milligrams by mouth three times daily for 10 days. (Although Resident #52's wound culture was resulted on 10/15/22 the order for the antibiotic therapy was not provided or initiated until 10/18/22 when Resident #52 received two doses). Record review of a Wound Evaluation and Management Summary dated 10/18/22 indicated Resident #52 continued to have an unstageable sacral wound with moderate serous exudate. The note indicated the wound measured 6 cm x 9 cm x ¼ cm with 30% being slough, 60 % granulation tissue, and 10% skin. The treatment plan was calcium alginate twice daily and a gauze sponge twice daily. The wound was again debrided using a surgical blade. The physician surgically excised devitalized tissue including slough, biofilm, and non-viable subcutaneous level tissues at a depth of ¼ cm. Record review of a Wound Evaluation and Management Summary dated 10/25/22 indicated Resident #52 had a Stage 4 pressure wound (wound extending to the ligaments, muscle, and bone) with moderate serous exudate. The wound measurements were 10 cm x 12 cm x 2 cm with undermining at 4 cm. The treatment plan was sodium hypochlorite solution and calcium alginate with a second dressing. Record review of a nurse practitioner no te dated 10/31/22 at 9:00 a.m., indicated Resident #52 was currently being treated for a sacral pressure ulcer stage 4 (the most severe form of a bedsore, a deep wound reaching the muscles, ligaments, or bones. Often cause extreme pain infection, invasive surgeries, or even death). The note indicated she was non-distressed in appearance. The note indicated the NP was increasing her pain medication to Tramadol 100 milligrams by mouth every 6 hours routinely. Record review of a Wound Evaluation and Management Summary dated 11/01/22 indicated Resident #52 had a Stage 4 pressure ulcer to the sacrum. The wound had moderate serous exudate. The wound measurement was 10 cm x 12 cm x 5 cm with undermining of 4 cm at 3 o'clock. The wound had 20% slough and 60% granulation tissue and 20% muscle tissue with the wound deteriorated since last visit. Again, the wound was debrided using a surgical blade. The excision of 24.0 cm² squared of devitalized tissue including slough, biofilm and non-viable muscle level tissues were removed at a depth of 5 cm. The physician recommended a CRP (measuring protein in the blood), WBC (lab for white blood cells indicating infection), ESR (lab level of measuring inflammation) and a culture of the sacral wound. Record review of the Resident #52's laboratory results did not indicate laboratory results for the CRP, WBC, and ESR recommended by the wound care physician on 11/01/22. During an interview on 11/07/22 at 12:38 p.m., the DON indicated Resident #52's labs ordered on 11/01/22 was not completed because they were only suggested. The DON indicated she was unsure why the wound culture was obtained and not the laboratory levels. During an interview on 11/07/22 at 1:20 p.m., the wound care consulting physician indicated Resident #52's wound care started with a Stage 2 sacral wound on 9/27/22 which had declined now to a large Stage 4 sacral wound. The physician indicated he had made the recommendation for labs to determine if Resident #52 had osteomyelitis (bone infection). The physician indicated he had not seen bone in the wound and therefore required the labs to help determine if Resident #52 required intravenous antibiotic therapy instead of antibiotics through the gastrostomy tube. During an observation on 11/06/22 at 9:15 a.m., Resident #52's low air loss mattress cord was not plugged in to the electrical outlet. The mattress cord was lying on the floor underneath her bed. The lights on the monitoring box were not on. During an observation on 11/06/2022 at 3:02 p.m., Resident #52's low air loss mattress cord was not plugged in to the electrical outlet. The mattress cord was lying on the floor underneath her bed. The lights on the monitoring box were not on. During an observation on 11/07/22 at 7:50 a.m., Resident #52's low air loss mattress was now plugged into the electrical outlet and the lights were on the monitor box. Resident #52 was facing the right side toward the wall. Resident #52 had a scabbed area to her left [NAME] (ear). Record review of a comprehensive care plan indicated Resident #52 had a pressure ulcer to sacral area initiated on 10/14/22 with a revision on 11/07/2022 there was no goal for the pressure wound. The interventions included pressure relieving devices per orders, wound consultant visits, and weekly had to toe skin at risk assessments. A potential for pressure ulcer development care plan indicated the goal was to have intact skin, free of redness, blisters, or discoloration with the interventions of administer treatments as ordered and monitor the effectiveness, notify the nurse immediately of any new areas of skin breakdown such as redness, blisters, bruises, discoloration noted during bathing or daily care, obtain and monitor lab and diagnostic work reporting results to the medical director, and weekly head to toe skin at risk assessments. Record review of a wound culture dated 11/04/22 and resulted on 11/06/22 indicated Resident #52 continued to have a sacral wound infection with proteus mirabilis and moderate group A streptococcus. The physician ordered to complete the oral antibiotic Augmentin. Record Review of a November 2022 medication administration record indicated Resident #52 was ordered Augmentin 600-125 milligrams one tablet every 12 hours for 7 days starting on 11/5/22 until 11/11/22. Record review of Resident #52's clinical record indicated the CRP, WBC, ESR, was not obtained until after surveyor intervention on 11/07/22. The WBC, CRP, ESR, and a wound culture were recommended on the 11/01/22 wound consultant report. The records indicated the wound care consultant physician obtained Resident #52's wound culture was obtained during the wound care. The WBC count was 10.3 with the normal level of 4.0 - 9.6. The CRP result was high at 25.9 indicating inflammation the normal range was 0.1 - 0.8. The ESR result was high indicating inflammation at a result of 109 with the normal range of 0-20. Record review of a medication administration record dated November 2022 indicated Resident #52 was administered Piperacillin Sod-Tazobactam solution 3-0.375 grams intravenously three times daily for wound infection for three weeks. Resident #52 received her first dose on 11/08/22 at 4:00 a.m. Record review of Resident #52's consolidated physician's orders dated 11/07/22 indicated Resident #52 had an ordered to cleanse the sacrum wound with wound cleanser, dry with gauze, pack with Dakin's-soaked gauze, cover with calcium alginate and dry dressing twice daily and as needed for a pressure wound initiated on 10/13/2022. Augmentin tablet 500-125mg administer 1 tablet via the gastrostomy every 12 hours for wound infection initiated on 11/05/22 with an end date of 11/12/22 for a wound infection. Dakin's (1/4 strength) Solution 0.125% (Sodium hypochlorite) apply to sacrum topically every shift for pressure wound. Record review of a care plan dated 11/07/22 indicated Resident #52 was on intravenous antibiotics for osteomyelitis and the goal was not to have any complications. The interventions included to monitor and document any symptoms of infection such as drainage, inflammation, swelling, redness, or warmth. Provide PICC line care every 7 days and flush the PICC line prior to the medication administration was the other interventions for Resident #52. During an observation and interview on 11/07/22 at 9:16 a.m. to 9:49 a.m., the treatment nurse performed wound care for Resident #52's Stage 4 sacral wound. The treatment nurse removed the top dressing and revealed a large and deep sacral wound with necrotic (dead) tissue at the noon to 3'oclock portion of the wound. The dressing was saturated in a copious amount of serosanguineous (blood-tinged drainage), and the wound was odorous. The treatment nurse indicated he was assisted by the staffing coordinator because she had a stronger stomach and could handle the odor. During the wound care Resident #52 began grimacing, groaning, and moving her face to the right imbedding her face in her pillow. Resident #52 was encouraged by the staffing coordinator to squeeze her hand. The staffing coordinator indicated Resident #52 was displaying pain. The staffing coordinator indicated Resident #52 displayed this behavior each time during the actual wound care procedure. The treatment nurse indicated Resident #52 was medicated earlier this morning. The treatment nurse indicated he had even mentioned to the family about hospice care to have more effective pain management. During the wound care neither the treatment nurse nor the staffing coordinator stopped the wound care process to ensure adequate pain relief was achieved prior to finishing the treatment. Resident #52 made a grimacing face as the treatment nurse initiated the cleaning of the wound. The staffing coordinator indicated the cleaning must hurt by the face Resident #52 was making. The treatment nurse stated he was unsure if the moaning was pain or how Resident #52 was positioned. During the repositioning of Resident #52 the surveyor noticed two skin concerns. The treatment nurse indicated he was unaware of these two areas. Resident #52 had a 2.5 cm x 0.5 cm x 0.1 cm stage 2 pressure injury, and a 0.5 cm x 0.5 cm fluid filled blister to the right heel. The treatment nurse indicated Resident #52 should have had some heel protection boots on. During an interview after the wound care the treatment nurse indicated Resident #52's grunting, moaning, and grimacing was demonstration of pain. The treatment nurse indicated he should have stopped the procedure and obtained pain medication. The treatment nurse indicated he did not stop the wound care, assess Resident #52 because he was in a hurry to finish. The treatment nurse indicated even though Resident #52's wound looked bad it was actually better in his opinion. The treatment nurse indicated the antibiotic therapy and the Daiken's wound solution was helping the odor. During a telephone interview on 11/07/22 at 6:32 p.m., the MD indicated he was aware Resident #52 had a Stage 4 pressure injury but had not seen the wound himself. The MD indicated he was not made aware the wound declined in a 7-day period from a Stage 2 to a Stage 4. The MD indicated he had not been made aware Resident #52 had two new wounds today nor had he been informed Resident #52 had increased pain with her wound care. The MD indicated he expected the wound care nurse to stop the wound care when any resident demonstrated pain. The MD indicated a low air mattress being unplugged was not ideal for wound healing. The MD indicated he allowed the wound care physician to make recommendations for the wound needs. During an interview on 11/07/22 at 1:51 p.m., CNA F indicated she was the CNA providing care to Resident #52. CNA F indicated she had not noticed Resident #53's two new wounds on her right heel. During an interview on 11/07/22 at 4:16 p.m., the DON indicated Resident #52 was admitted on a Friday evening. The DON indicated the treatment nurse did not work the weekend and was not made aware of the wound care referral therefore Resident #52 was not seen by the wound care physician, and the DON indicated Resident #52's wound was not open on 08/26/22 therefore the wound care consulting physician wound not have seen Resident #52's wound. The DON indicated Resident #52's wound declined from a Stage 2 to a Stage 4 only after the wound care consultant physician debrided the wound. During a phone interview on 11/08/22 at 6:06 p.m., the wound consultant physician was questioned about the debridement of a stage 2 pressure wound. The wound consultant physician stated he would never debride a Stage 2 wound to any resident. He stated he would debride a Stage 3, Stage 4, or an unstageable pressure ulcer. The wound care physician indicated he had never debrided a Stage 2 wound on Resident #52. Record Review of a Wound Evaluation and Management Summary dated 11/08/22 indicated Resident #52 had a stage 4 pressure wound to the sacrum. There was a light serous drainage. The wound measured 11 cm x 14 cm x 5 cm with undermining at 3 o'clock measuring 4 cm. The wound was 20 % slough, 60% granulation tissue, and 20% muscle with the wound deteriorated. The note included additional wound details of now the wound has osteomyelitis (inflammation of the bone caused by an infection). The physician recommended to start Zosyn (antibiotic) for 4 weeks for a maximum of 8 weeks if indicated. The wound dressing continues to be sodium hypochlorite solution apply twice daily and with a gauze sponge dressing twice daily. The note indicated Resident #52's wound was debrided using a surgical blade excising 30.8 cm² squared of devitalized tissue including slough, biofilm, and non-viable muscle tissue was removed at a depth of 5 cm. Record review of a chest x-ray dated 11/08/22 for a PICC (peripherally inserted central catheter) line placement verification. Resident #52 received a PICC Line for the administration of intravenous antibiotic therapy. Record review of a Skin and Wound Monitoring and Management policy and procedure dated 03/2015 and revised date of 01/2022 indicated It was the policy of this facility that 1. A resident who enters the facility without a pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable; and 2. A resident having pressure injury (s) receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing. The purpose of this policy was that the facility provides care and services to 1. Promote interventions that prevent pressure injury development; 2. Promote the healing of pressure injuries that are present (including prevention of infection to the extent possible); and 3. Prevent the development of additional, avoidable pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are no visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage. Stage 4 pressure injury: full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an unstageable pressure injury. 7. Communication of Changes a. any changes in the condition of the resident's skin as identified daily, weekly, monthly or otherwise, must be communicated to the resident/responsible party, resident physician, and others as necessary to facilitate healing. The Administrator and DON were notified 11/07/22 at 5:02 p.m. that an Immediate Jeopardy (IJ) was identified due to the above failures. The IJ template was provided on 11/07/22 at 5:05 p.m. The following Plan of Removal submitted by the facility was accepted on 11/08/22 at 8:34 p.m. and included the following: Immediate action: The Medical Director was notified of IJ on 11/7/22 at 5:45pm. Review of all pressure ulcer treatments orders was initiated and will be completed 11/08/22 by the DON. Review/Identification/Interventions will be completed to assure all residents at high risk for pressures ulcers (as determined via Braden scale) will be completed by DON/ADON by 11/07/22. Review of all residents with current pressure ulcers to assure appropriate treatment in place. Education initiated with Nurses and CNAs that included change in condition procedures for wounds, change in behaviors, refusal of care, notification of changes in condition, wound identification, and documentation. This education will be included in the new hire orientation and to including agency staff. Identification of Others Affected Currently there are 67 residents residing in the facility. The facility initiated a skin sweep on 11/07/22 of all residents and will complete 11/08/22. Systemic Change to Prevent Re-occurrence DON started in-service on 11/07/22 with facility charge nurses and CNAs on documentation and monitoring skin integrity system along with skin assessments. The training includes use of shower sheets by the CNAs as well as the Stop and Watch Program, reporting new areas to nurses, nurse documentation / treatment / notification of new areas, new admission assessments to occur once a week for four weeks, quarterly, and with any change of condition. In-services included: documenting skin assessments, timely follow up and notification to RP, DON and MD, wound treatments and reporting until all applicable personnel complete education. In-services will be completed prior to accepting assignments for all charge nurses, nursing assistants, including agency, new hires, and PRN staff. This education will be included in the new hire orientation to include agency - will be completed by 11/08/22. Nurses will complete education for skin assessment prior to the start of their next shift. CNAs will also receive education on shower sheets and Stop and Watch program prior to the start of their shift will be completed by 11/08/22. Shower sheets to be completed by CNA and any new areas to be communicated to Charge Nurse. Skin assessments to be completed by Treatment Nurse, document and communicate any new skin changes to physician, responsible party, and place on 24 hr. report for DON notification. Monitoring: Interviews on 11/08/22 from 12:58 p.m. until 3:18 p.m. the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Interviews with 8 CNAs indicated they had received a written in-service regarding monitoring low air loss mattresses for functioning properly, reporting of all new alterations in skin integrity to the licensed nurse immediately upon discover. Utilization of the shower sheets to document and identify all skin alterations found on a resident while providing care. Interviews with 6 LVNs indicated to monitor a low air loss mattress every shift to determine whether functioning properly. Reporting of skin alterations to the physician, DON, and responsible party. A treatment for alteration must be received and documented when reporting to the physician. The use of shower sheets for monitoring new skin issues. Interviews with 5 RNs indicated to monitor a low air loss mattress every shift to determine whether functioning properly. Reporting of skin alterations to the physician, DON, and responsible party. A treatment for alteration must be received and documented when reporting to the physician. The use of shower sheets for monitoring new skin issues. During an interview on 11/08/22 at 12:58 p.m., the DON indicated she reviewed all pressure ulcer treatments and did not change any treatments. She said a full skin sweep was completed and all identified skin alteration had a treatment in place even if it was a healing scratch. She in-serviced all staff on change of condition on wounds, change in behaviors, refusal of care, notification of changes, wound identification, and documentation. The DON indicated she in-serviced night shift last night and day shift today and including PRN (as needed) nurses. The DON indicated she in-serviced regarding skin integrity, shower sheets with every shower for CNA's, stop and watch for CNA's (doc anything new or new to that CNA), new admission assessment weekly for 4 weeks, doc skin assessment, timely follow up, notifying the responsible party, MD, and the DON. The in-services included reporting all new treatments to the DON, ADON, and treatment nurse. The DON indicated all staff not having the in-services would be in-serviced prior to accepting assignments. Record review of a written in-service dated 11/07/22 indicated the policy of the facility was if a resident has a low air loss mattress it must be assessed every shift to determine if it is function properly. When in a resident's room and notice a mattress unplugged, first plug it back in and you must report to the nurse. Record review of a written in-service dated 11/07/22 indicated unlicensed staff were required to report all new alterations in skin integrity which includes bruises, skin tears, abrasions, scratches, discolored areas, etc. to licensed nurse immediately upon discovery. Licensed staff were required to report alterations of skin integrity to the physician, DON, and the resident's responsible party. A treatment for the alteration must be received and documented at the time of the reporting to the physician. The treatment ordered must be reported to the responsible party and notification must be documented. Record review of a written in-service dated 11/07/22 indicated the unlicensed staff would utilize shower sheets to document and identify all skin alterations found on a resident at any point while providing care. The shower sheet must be turned into the treatment nurse at the end of the shift, with signatures of the nurse indicating understanding of alterations and copy of new order received from the physician. The Administrator and DON were informed the Immediate Jeopardy was re[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure pain management is provided to residents who require such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 20 residents reviewed for pain management. (Resident #52) The facility failed to ensure Resident #52 had effective pain management by evaluating Resident #52's by prior to wound care, during wound care, and post wound care. The facility failed to acknowledge or provide any pain relief medications for Resident #52's pain when she was grimacing and groaning during wound care. The facility failed to notify the physician of Resident #52's pain with wound care. These failures could place residents who received wound care, who had chronic pain conditions, who received as needed pain medication, or who received routine pain medications at risk for not having had their pain addressed causing undo suffering. An Immediate Jeopardy (IJ) situation was identified on 11/07/22 at 4:40 p.m. While the IJ was removed on 11/08/22, the facility remained out of compliance at the severity of actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. Findings included: Record review of Resident #52's face sheet with a printed date of 11/07/22, indicated she was a [AGE] year-old-female, admitted on [DATE] and readmitted on [DATE] with the diagnoses of diabetes, difficulty swallowing, protein-calorie malnutrition, and anxiety. Record review of an Initial admission Record dated 08/26/22 indicated Resident #52 was admitted with a weight of 225.4 pounds and was 65 inches tall. The admission record indicated Resident #52 was not provided an alternating air mattress, or a pressure re-distributing overlay mattress. The assessment indicated Resident #52's skin was normal, pale, not flushed or blueish colored, warm and not cold. The admission assessment indicated Resident #52 had a ½ inch stage 2 ulcer on her left buttock. The additional documentation indicated Resident #52 had non-blanchable open area to the sacrum that was to be evaluated by the wound consultant. The assessment indicated Resident #52 smiles occasionally and was very quiet, indicating Resident #52's baseline. Record review of an admission MDS dated [DATE] indicated Resident #52 was admitted from an acute hospital, was rarely understood, and rarely understands. The MDS indicated Resident #52's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident #52 did not reject care. The MDS indicated Resident #52 required extensive assistance with two staff for bed mobility, dressing and toilet use. She required limited assistance of two staff with transfers. Resident #52 required extensive assistance with eating and personal hygiene and total assistance of two staff for bathing. The MDS indicated Resident #52 was always incontinent of bowel and bladder. The MDS indicated in the section J0100 Pain Management Resident #52 received no scheduled pain medications, received no as needed pain medication, nor any non-medication pain interventions. The MDS indicate Resident #52 was 65 inches tall and her weight was 225 pounds. Section M of the MDS indicated Resident #52 had a pressure ulcer, a formal assessment tool, and a clinical assessment. The MDS indicated Resident #52 was at risk for pressure ulcers. Section M0210 indicated had one or more unhealed pressure ulcers. The MDS indicated in Section M0300 Resident #52 had a Stage 2 pressure ulcer (some of the outer surface of the skin or the deeper layer was damaged). The MDS indicated Resident #52 did not have any other pressure injuries. The MDS did not reflect a pain assessment. The comprehensive care plan dated 8/26/22 with a revision on 11/07/22 indicated Resident #52 had a potential for pain with a goal of Resident #52 would voice a level of comfort or will not have an interruption in normal activities due to pain. The interventions included to administer analgesia medication as per orders; give ½ hour before treatments or care, anticipate need for pain relief and respond immediately to any complaint of pain, monitor, and document any side effects, monitor and report any symptoms of non-verbal pain, changes in breathing, grunting, moaning, and even silence. Also report grimacing, clenched teeth, tense body, and face appearing worried. Pain assessment each shift and observe and report any changes in normal routine. Record review of the October 2022 Medication Administration Record revealed Resident #52 had ordered 10/11/22 Tramadol 50 mg administer one tablet every 8 hours as needed for pain. The medication record indicated Resident #52 received only 8 doses in the month of October. Record review of the October 2022 Medication Administration Record revealed Resident #52 was assessed for pain using the PAINAID tool and the assessments indicated she had no pain the entire month of October. Record review of the November 2022 consolidated physician orders printed on 11/07/22 indicated on 10/31/22 Resident #52 was ordered Tramadol 100 mg per the gastrostomy tube 4 times a day routinely. This medication was on scheduled for administration at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m. Resident #52 was ordered Acetaminophen 325 mg 2 tablets every 4 hours as needed for pain/temperature. Record review of the October 2022 electronic medication administration record indicated Resident #52 had no pain documented in the entire month. The record indicated Resident #52 had acetaminophen 325 mg give 2 tablet every 4 hours as need for pain ordered on 9/12/22. The record indicated Resident #52 received acetaminophen administration a total of 4 times in the entire month of October. Record review of the November 2022 electronic medication administration record indicated Resident #52 had pain on the day shift on November 5th, 6th, and 7th and the 4th and 6th on the night shift. The record indicated Resident #52 received acetaminophen 325 mg 2 tablets every 4 hours on 11/05/22. The electronic medication administration record did not reflect any as needed medications were administered for 11/04/22, 11/96/22, and 11/07/22. Record review of the November 2022 electronic medication administration record indicated Resident #52 had pain on these days: 11/04 /22 rated at a 2; 11/05/22 rated at a 6, 11/06/22 rated at a 2 on the day shift and a 3 on the night shift, and 11/07/22 pain at a 3 on the day shift. The November EMAR indicated Resident #52 received Tramadol 100 mg by gastrostomy tube four times daily 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m. The EMAR indicated Resident #52 had acetaminophen 325 mg two tablets administered on 11/5/22 for a pain level of a 6. The EMAR indicated the medication was effective. During an observation and interview on 11/7/22 at 9:16 a.m. to 9:49 a.m., the treatment nurse performed wound care on Resident #52's Stage 4 sacral wound. The treatment nurse removed the top dressing and revealed a large and deep sacral wound with necrotic (dead) tissue at the noon to 3'oclock portion of the wound. The dressing was saturated in a copious amount of serosanguineous (blood-tinged drainage), and the wound was odorous. The treatment nurse indicated he was assisted by the staffing coordinator because she had a stronger stomach and could handle the odor. During the wound care Resident #52 began grimacing, groaning, and moving her face to the right imbedding her face in her pillow. Resident #52 was encouraged by the staffing coordinator to squeeze her hand. The staffing coordinator indicated Resident #52 was displaying pain. The staffing coordinator indicated Resident #52 displayed this behavior each time during the actual wound care procedure. The treatment nurse indicated Resident #52 was medicated earlier this morning. The treatment nurse indicated he had even mentioned to the family about hospice care to have more effective pain management. During the wound care neither the treatment nurse nor the staffing coordinator stopped the wound care process to ensure adequate pain relief was achieved prior to finishing the treatment. Resident #52 was noted to be making a grimacing face as the treatment nurse initiated the cleaning of the wound. The staffing coordinator indicated the cleaning must hurt by the face Resident #52 was making. The treatment nurse stated he was unsure if the moaning was pain or how Resident #52 was positioned. During the repositioning of Resident #52 the surveyor noticed two skin concerns. The treatment nurse indicated he was unaware of these two areas. Resident #52 had a 2.5 cm x 0.5 cm x 0.1 cm stage 2 pressure injury, and a 0.5 cm x 0.5 cm fluid filled blister to the right heel. The treatment nurse indicated Resident #52 should have had some heel protection boots on. During an interview after the wound care the treatment nurse indicated Resident #52's grunting, moaning, and grimacing was demonstration of pain. The treatment nurse indicated he should have stopped the procedure and obtained pain medication. The treatment nurse indicated he did not stop the wound care, assess Resident #52 because he was in a hurry to finish. During an interview on 11/07/22 at 12:17 p.m., the nurse practitioner indicated she had not actually visualized the Stage 4 pressure ulcer to Resident #52's sacrum. She indicated she ordered the tramadol in anticipation the wound would cause discomfort and she indicated she had not been advised the pain medication was not effective. The nurse practitioner also indicated she expected the nursing staff to monitor and notify her of ineffective pain management. The Nurse Practitioner indicated she expected the pain medication to be administered 1-2 hours prior to wound care. During an interview on 11/07/22 at 12:46 p.m., LVN E indicated she had been completing the wound care for Resident #52 and had noticed the facial grimacing and some moaning . LVN E indicated she had notified the nurse practitioner of the pain and the tramadol order was provided. During an interview on 11/07/22 at 1:20 p.m., the wound care consulting physician indicated Resident #52 had a rather large Stage 4 sacral wound. The physician indicated he had made the recommendation for labs to determine if Resident #52 had osteomyelitis (bone infection). The physician indicated he had not seen bone in the wound and therefore required the labs to help determine if Resident #52 required intravenous antibiotic therapy instead of antibiotics through the gastrostomy tube. The wound care consultant indicated Resident #52 had not displayed pain during his wound care, but he had used a topical anesthesia with wound debridement. During a telephone interview on 11/07/22 at 6:32 p.m., the MD indicated he was aware Resident #52 had a Stage 4 pressure injury but had not seen the wound himself. The MD indicated he had not been made aware Resident #52 had two new wounds today nor had he been informed Resident #53 had increased pain with her wound care. The MD indicated he expected the wound care nurse to stop the wound care when any resident demonstrated pain. During an interview on 11/08/22 at 1:15 p.m., the treatment nurse indicated he should have premedicated Resident #52 prior to the wound care on 11/07/22. The treatment nurse indicated he should have then waited for the medication to be effective prior to starting the wound care for Resident #52. The treatment nurse indicated the PAINAID tool was used to indicated pain for non-verbal residents. During an interview on 11/08/22 at 5:25 p.m., the DON indicated Resident #52 had been medicated two hours prior to her treatment and this was in the time frame of an effective pain management criteria. Record review of a pain policy dated 05/2007 with a revision on 01/2022 indicated the policy of this facility to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Purpose Identify circumstances when pain can be anticipated. Procedure 3. For the resident who was unable to communicate verbally or understand abstract concepts, the PAINAD scale for the cognitively impaired will be used and documented in the residents HER. . The Administrator and DON were notified on 11/07/22 at 5:02 p.m. an Immediate Jeopardy (IJ) was identified due to the above failures. The IJ template was provided on 11/07/22 at 5:05 p.m. The following Plan of Removal submitted by the facility was accepted on 11/08/22 at 8:34 p.m. and included the following: Immediate action: Immediate Action The Medical Director was notified of IJ on 11/7/22 at 5:45pm. Review of all residents with pressure ulcers to assure current orders are in place for pain management to be completed by DON by 11/07/22 Education provided to all licensed nurses to assure pain assessment is completed prior to all wound care. New pain medication orders received for affected resident from physician for Methadone 5mg/5ml - give 5 ml via gastrostomy tube daily for pain. Tramadol 100mg via gastrostomy tube Q 6 as needed for pain and Tylenol 500mg 2 tabs via gastrostomy tube every 8 hours as need for pain. Identification of Others Affected Currently there are 67 residents residing in the facility. The facility will assure pain assessments for all residents with pressure ulcers are completed prior to treatment. Systemic Change to Prevent Re-occurrence DON started in-service on 11/07/22 with facility charge nurses on documentation and pain assessments prior to wound care treatments. The training includes use of pain assessment prior to any wound care and post pain assessment after treatment is completed will be completed by 11/08/22. Nurses will complete education for pain assessment prior to the start of their next shift - date of completion 11/08/22. Education provided to charge nurses to notify physician if pain management plan is ineffective based on assessment of the resident. Monitoring: Interviews on 11/08/22 from 12:58 p.m. until 3:18 p.m. the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Interviews with 8 CNAs indicated they had received a written in-service regarding monitoring reporting pain to the nurses. Referencing pain is whatever the person says it is, existing whenever the experiencing person say it does. Also referencing, Pain is an unpleasant sensory and emotional experience, associated with, or potential tissue damage. Pain is an unpleasant sensory and emotional experience, associated with actual or potential tissue damage. Interviews with 6 LVNs indicated the in-services included: *Pain assessment was a broad concept involving clinical judgement based on observation of the type, significance, and context of an individual's pain experience. *Provide analgesia 30 to 60 minutes before dressing change. Assess the patient for pain before, during, and after dressing changes. *If no order available for analgesia please notify physician prior to performing the treatment. *Pain assessment to be documented in the resident's medical record, before, during, and after the dressing changes. Interviews with 5 RNs indicated the in-services included: *Pain assessment was a broad concept involving clinical judgement based on observation of the type, significance, and context of an individual's pain experience. *Provide analgesia 30 to 60 minutes before dressing change. Assess the patient for pain before, during, and after dressing changes. *If no order available for analgesia please notify physician prior to performing the treatment. *Pain assessment to be documented in the resident's medical record, before, during, and after the dressing changes. During an interview on 11/08/22 at 12:58 p.m., the DON indicated the nursing staff would be in-serviced prior to accepting their assignments regarding pain. The DON indicated the nurse would assess pain prior, during, and after wound care or ADL care. The DON indicated the nurses will notify the physician if there were no analgesics to administer for pain needs. During an interview on 11/08/22 at 4:41 p.m., the Administrator indicated he was under the understanding the facility had done all the appropriate interventions regarding Resident #52's Stage 4 pressure ulcer. The administrator indicated he expected the residents to have their pain managed. The Administrator indicated education had been provided to the staff and the skin and pain issues will be taken to on-going scheduled QAPI meetings. The Administrator and DON were informed the Immediate Jeopardy was removed on 11/08/22 at 8:34 a.m. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.