**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews the facility failed to implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 3 residents (Resident #1) reviewed in that: CNA A failed to follow the plan of care which required a 2 person assist to transfer Resident #1 with the Hoyer Lift (a mechanical lift that uses a sling attached to a hoist to transfer a person from a bed to a wheelchair) on 03/23/24. This failure resulted in the identification of Immediate Jeopardy (IJ) on 3/23/24 at 6:53 p.m. While the immediacy was removed on 3/28/24 at 3:42 p.m., the facility remained out of compliance at scope of isolated and a severity with actual harm due to the facility's need to monitor the implementation of the plan of removal. This failure placed residents at the facility who required the mechanical lift for transfers at risk for pain or injuries. Findings included: Record review of Resident #1's undated face sheet revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included diabetes (sustained high blood sugar levels and can increase risk of damage to eyes, nerves, heart and cause delayed wound healing), morbid obesity (severe form of excess body weight), contracture of the left knee (gradual shortening of muscles, tendons, and skin that causes the joints to shorten and prevent normal movement), hemiplegia (paralysis of one side of the body) and high blood pressure. Record review of Resident #1's electronic physician's orders revealed an order for ADL - transfer by 2 staff with mechanical lift, with a start date of 09/09/23. Record review of Resident #1's MDS, a Quarterly assessment dated [DATE], revealed a BIMS score of 11 out of 15 which indicated his cognitive skills for daily decision making were moderately impaired; he had functional limitation in range of motion on 1 side of his upper and lower extremities (legs and arms), used a wheelchair, and was dependent on staff assistance of 2 or more helpers with transfer from chair/bed-to-chair. Record review of Resident #1's Care Plan for the problem of Alteration in ADL self-performance and mobility related to weakness, left sided hemiparesis, contractures to left upper extremity, revealed under Approaches with a start date of 11/09/22 was Requires assist x 2 staff with Hoyer [mechanical lift] with transfer tasks. Record review of Resident #1's Nurse's Note, dated 3/23/24 at 4:00 PM by LVN B revealed Called to resident room - upon entry resident sitting up in wheelchair alert awake and active forgetful and anxious - CNA A reports resident had light on and asked to put him up for dining-he asked to move to the chair for dinner - she informed him she would go find someone to help - was unable to find assistance - was then transferring resident to wheelchair using Hoyer [mechanical] lift and while put him in wheelchair the back of the wheelchair . reclined quickly and then CNA C came into the room at about 3:30 PM and saw he was in chair. Resident says he fell on the floor while being transferred to wheelchair - resident says he was put in sling and CNA A went to get some help - came back and was trying to put him in wheelchair when he fell to floor - denies pain or loc [loss of consciousness] at this time. Record review of a handwritten, signed statement from CNA A, dated 3/23/24, revealed Resident #1 hes [sic] call light was on. He asked to put him up for dining he asked to move to the chair for dinner. I told him I was going to go find someone. I couldn't find anyone. I went to move him to the chair, his chair reclined back. He did fall. He was placed in the chair. CNA C walked in about 3:35 PM and saw he was in his chair. Record review of a handwritten, signed statement from CNA C, dated 3/24/24, revealed March 23, 2024 about 3-4 PM I heard CNA A's voice. I went to room check if she needed any help only to find she was attempting to transfer Resident #1 to his chair alone, she already had him over his chair but the back of the chair was reclined to [sic] far. I guided him so he was placed in the chair . In an interview on 03/25/24 at 10:33 AM, Resident #1 stated on 3/23/24, around 4 PM, CNA A came into his room to transfer him from his bed to his wheelchair per the resident's request. Resident #1 said CNA A placed the mechanical lift sling underneath him, then she told Resident #1 that he might have to help her because the other CNAs were working. Resident #1 stated he asked CNA A if she could wait until the other aides finished their work to assist her. Resident #1 said CNA A left the room and came back about five minutes later, said she could not find anyone and moved the mechanical lift over to the bed, attached the lift sling that was under him, grabbed the lift remote control and asked Resident #1 if he was ready. Resident #1 stated he responded, Yes, I'm ready, just don't drop me on the floor. Resident #1 stated when CNA A moved him from his bed to the wheelchair with the mechanical lift by herself, she could not bring him to the chair, and he fell. Resident #1 stated another CNA (CNA C) came into the room, and assisted CNA A. In an interview on 03/25/24 at 2:53 PM, CNA C stated on 3/23/24 when she entered Resident #1's room, the back part of his chair had reclined back all the way, and he was a bit crooked in the chair, holding onto the right arm rest with his right arm and Resident #1 stated he fell. CNA C said she asked CNA A why she was doing it by herself, and CNA A said she could not find anyone to help her. CNA C said she assisted CNA A with positioning Resident #1 in his chair correctly, the sling that was under him was crooked, so they fixed the sling, sat him upright, unhooked the straps of the lift sling from the mechanical lift. In a telephone interview on 03/25/24 at 4:38 PM to 4:54 PM, CNA A stated when the mechanical lift was used to move a resident there must be 2 employees present to operate the lift and there could be a lot of damage to the resident if one person transferred a resident by themselves with the lift. CNA A stated she was the shower aide but on 3/23/24 she was working as a CNA and there were 3 other CNAs for a total of 4 CNAs. CNA A stated on 3/23/24 was the first time she cared for Resident #1, but she was aware the aides would use a mechanical lift with the assistance of two staff to move Resident #1. CNA A stated on 3/23/24 Resident #1 insisted on getting out of bed into his chair. CNA A said she told Resident #1 to wait while she went to find assistance. CNA A stated she could not find anyone and came back into Resident #1's room and Resident #1 insisted that he be moved from the bed to his chair. CNA A stated she moved Resident #1 into his wheelchair with the mechanical lift by herself and as she placed him into his wheelchair, the back of the chair reclined, and he got scared. CNA A said Resident #1 stated that he fell but she told him he did not fall, his chair just reclined back. CNA A said then another CNA (CNA C) came into the room, saw Resident #1 in the chair, together they repositioned the resident in his wheelchair. CNA A stated the reason why she did the transfer by herself was because she could not find anyone else to assist her. In an interview on 03/27/24 at 10:50 AM, LVN B stated on 03/23/24 around 4 PM CNA C told her to go see Resident #1. LVN B said when she entered Resident #1's room, he was in his wheelchair and told her he fell when CNA A dropped him to the floor. LVN B stated CNA A then entered the room and said she was getting him ready to take him to the dining room, Resident #1 was in his bed, and she (CNA A) transferred him to his wheelchair with the mechanical lift. CNA A told LVN B the back of Resident #1's wheelchair reclined abruptly, and Resident #1 said his foot hurt; then CNA C walked into the room and assisted CNA A with repositioning Resident #1 into his wheelchair. LVN B said CNA A denied Resident #1 fell to the floor. LVN B stated she expects CNAs to always have 2 people transferring a resident with a mechanical lift and if they cannot find another person, the CNA should wait until they can get assistance. LVN B said a resident could fall, get injured or die because of being transferred with a mechanical lift that was done by only one person. LVN B stated it was important to follow a resident's plan of care because the care plan specifically addressed the resident's needs. In an interview on 03/27/24 at 2:00 PM, RN D stated the DON was on leave, she was the DON Designee in her absence and had worked in the facility for less than one month. RN D stated staff were expected to have 2 CNAs or nurses in the room when they transfer a resident with the mechanical lift, and they should not do the transfer until 2 people are present. RN D stated the harm of transferring a resident with only 1 person operating a mechanical lift instead of 2 people could cause falls, serious injuries, head injuries, broken bones or cause psychological harm. In an interview on 03/25/24 at 6:43 PM, the Assistant Administrator stated the risk of 1 person transferring a resident with a mechanical lift instead of 2 people could result in the resident falling, slipping out of the sling, or a plethora of things could happen. The Assistant Administrator stated CNA A told him she was not able to find anyone right away to assist her, the resident was getting impatient, and she did it right away by herself instead of waiting for assistance. In an interview on 3/25/24 at 3:40 PM, RN D stated an in-service had been completed on use of a mechanical lift in January 2023 and she could not find any other in-service trainings on use of a mechanical lift. Record review of an Employee In-Service Attendance Record, dated 01/15/24, revealed CNA A was in-serviced on mechanical lift transfers. Record review of the facility's policy Safe Lifting and Movement of Residents, revised July 2017, revealed In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents .1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents .5. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. Record review of the facility's policy Care Planning - Interdisciplinary Team, revised September 2013, revealed Our facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident .2. The care plan is based on the resident's comprehensive assessment and is developed by a care planning/interdisciplinary team . This was determined to be an Immediate Jeopardy (IJ) on 03/25/24 at 6:53 PM. The facility Assistant Administrator was notified. The Assistant Administrator was provided with the IJ template on 03/25/24 at 6:53 PM. On 03/26/24 the facility provided a plan of removal titled: Plan of Removal. The plan of removal was accepted on 03/26/2024 at 7:49 PM. It is documented as follows: Plan of Removal Problem: Failure to prevent accidents allegation Interventions: -CNA A was suspended, and terminated as of 03/26/24 -In the course of investigation, it was reported that CNA A stated Resident #1's foot hit the floor hard. A written statement from CNA A contradicted this, and there was no mention of resident hitting his foot on the floor. -CNA A also admitted that she transferred Resident #1 with no assistance, which is against company policies and procedures -In-service nursing staff on Mechanical Lift Transfer with two staff members at all times, starting on 3/24/24. New in-servicing regarding proper sling placement, and the wear and tear of a sling, as well as the steps to be taken if no other staff members are available at the time of transfer, will begin on 3/26/24. Staff not present on 03/25/24 will be in-serviced prior to attempting to transfer a resident with a mechanical lift. -Abuse and neglect in-service for all staff started on 03/24/24 -Inspection of all lift slings, with removal from service any sling that is frayed or torn, will be conducted on 03/26/24. -Maintenance supervisor to visually inspect both mechanical lifts to ensure that they are in proper working order, and that there is no damage that would prevent the safety of patient transfers Monitoring -The DON and/or Designee will monitor at least 5 lift transfers per week, observing for proper technique and staff assistance, and maintain a running log of said transfers. -The DON/Designee will observe and log that all slings are in good working order at least once a week -The QAPI committee will review findings monthly for no less than 90 days and makes changes as needed The facility's POR Verification was as follows: In an interview on 03/27/24 at 2:30 PM, the Assistant Administrator stated CNA A was terminated from employment on 3/26/24. In an interview on 03/27/24 at 2:00 PM, the DON Designee, RN D, said she had a list of two employees who had not received the education and would not schedule them to work until they received the in-service training. In an interview on 03/27/24 at 3:00 PM, the Assistant Administrator stated the DON Designee had identified employees who had not received education at that time and the employees were not scheduled to work until they have received the education. The Assistant Administrator stated the facility had a QAPI meeting on 03/27/24 and discussed the findings of the deficient practice and the plan of removal. The Administrator said the findings of the audits would be brought to the monthly QAPI meetings and reviewed. He stated the information would be used to determine if the interventions in place were effective or if they need to make changes to their systems. In an interview on 3/27/24 at 3:05 PM, the Maintenance Director stated he inspected both mechanical lifts on 3/26/24 and the lifts were functioning properly. He stated the mechanical lifts were inspected weekly and kept an inspection log in a binder and if there was a concern with a mechanical lift, it would be removed from service and be repaired and notify the DON and the Assistant Administrator. In a group interview on 03/28/24 at 11:15 AM with the Assistant Administrator and the DON Designee, RN D stated an audit log was created to document observations of mechanical lift transfers. RN D stated she or the DON would observe 5 mechanical lift transfers weekly; and two observations were completed on 3/27/24 at 4:45 PM and on 3/28/24 at 8:30 AM. RN D stated there were no concerns with the mechanical lift, technique used by staff or the sling that was used for the transfer. RN D stated she observed the mechanical lift slings used during the transfer and the slings were in good condition. The Administrator stated the log would be reviewed and facility would track the findings and use the information to determine if further education was needed or if staff performed the transfers correctly. The Assistant Administrator stated the audit information would be brought to QAPI meeting monthly and the information would be reviewed to determine effectiveness and if changes needed to be made to the system, policy, or procedure. The Assistant Administrator stated the Housekeeping Supervisor completed a sling audit on 03/27/24 at 4 PM that revealed 9 slings in use were in good working condition. He stated the slings will be observed weekly by the Housekeeping Supervisor and would be recorded on the audit log. He stated any slings with holes, tears or frays would be removed from service. He stated the audit information will be reviewed and used to track the condition of the sling supply and determine when new slings should be purchased. In an interview on 03/28/24 at 1:35 PM, the housekeeping Supervisor stated she completed the sling audit on 03/27/24, there were 9 slings in use, and they were in good condition. She stated if a sling was found with worn, torn, or frayed material she would remove it from service, log the information on the audit log and place an order to replace the sling. Interviews with 23 of 29 direct care staff from different shifts was completed on 03/27/24 and 03/28/24 which consisted of 13 direct care staff from day shift (6 AM-6 PM) and 10 direct care staff from night shift (6 PM-6 AM). All 23 staff members reported there were educated and trained on the use of mechanical lifts. Interviews on 03/27/24 and 03/28/24 with 50 of 66 facility staff from different shifts revealed staff have received education on abuse and neglect. Observations on 03/27/24 and 03/28/24 of resident and staff interactions revealed no signs of abuse or neglect. Observations on 03/26/24 of 5 resident slings and on 03/27/24 of 4 resident slings revealed no holes, tears, or frays on the slings. Record Review of CNA A's termination paperwork dated 3/26/24 revealed she was terminated on 03/26/24 for operating a mechanical lift without 2 people; the document was signed by the Assistant Administrator, and he noted CNA A refused to sign the document. Record review of education sign in sheet, dated 03/24/24, revealed 48 staff received education on proper techniques of a mechanical lift transfer which always included the use of 2 persons for mechanical lift transfers. Record review of education sign in sheet, dated 03/26/24, revealed 66 staff received education on using 2 people to perform a safe mechanical lift transfer. Record review of education sign in sheet, dated 03/26/24, revealed 66 staff received education on reporting incidents of abuse and neglect immediately to the Assistant Administrator, DON, and Charge Nurse. Record Review of the facility sling audit tool dated 03/27/24 revealed documentation 9 slings were in use and in good condition. Record Review of an inspection check off list completed on 3/26/24 for two facility mechanical lifts showed no concerns with the mechanical lifts. Record review of an audit form reflecting a mechanical lift observation was done on 03/27/2024 at 4:45 PM by CNA G and CNA H, who performed a mechanical lift of a resident revealed no concerns were noted. Record Review of the QAPI meeting Sign-in Sheet revealed a QAPI meeting was held on 03/26/24 at 8:30 AM and in attendance was the Administrator, Medical Director, RN Designee-RN D, Director of Marketing, Director of Rehab and 9 other department managers. On 03/28/24 at 3:42 PM, the Assistant Administrator was notified the immediacy was lifted on 03/28/24 at 3:42 PM but the facility remained out of compliance at scope of isolated and a severity with actual harm due to the facility's need to monitor the implementation and effectiveness of its POR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents, hazards, and supervision in that: CNA A failed to follow Resident #1's physician order and plan of care which required a 2-person assist to transfer Resident #1 with a Mechanical Lift (a mechanical lift with a sling attached to a hoist to transfer a person from a bed to a wheelchair) on 03/23/24, which resulted in the back of Resident #1's wheelchair to recline as he was placed in it and caused an injury to his right foot when his foot hit the floor. Resident #1 was transferred to a local hospital and was diagnosed with a fracture of the right 5th metatarsal bone (break in the little toe). This failure resulted in the identification of Immediate Jeopardy (IJ) on 3/23/24 at 6:53 p.m. While the immediacy was removed on 3/28/24 at 3:42 p.m., the facility remained out of compliance at scope of isolated and a severity with actual harm due to the facility's need to monitor the implementation of the plan of removal. The failure placed residents at the facility who required the mechanical lift for transfers at risk for pain or serious injuries. Findings included: Record review of Resident #1's undated face sheet revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included diabetes (sustained high blood sugar levels and can increase risk of damage to eyes, nerves, heart and cause delayed wound healing), morbid obesity (severe form of excess body weight), contracture of the left knee (gradual shortening of muscles, tendons, and skin that causes the joints to shorten and prevent normal movement), hemiplegia (paralysis of one side of the body) and high blood pressure. Record review of Resident #1's electronic physician's orders revealed an order for ADL - transfer by 2 staff with mechanical lift, with a start date of 09/09/23. Record review of Resident #1's MDS, a Quarterly assessment dated [DATE], revealed a BIMS score of 11 out of 15 which indicated his cognitive skills for daily decision making were moderately impaired; he had functional limitation in range of motion on 1 side of his upper and lower extremities (legs and arms), used a wheelchair, and was dependent on staff assistance of 2 or more helpers with transfer from chair/bed-to-chair. Record review of Resident #1's Care Plan for the problem of Alteration in ADL self-performance and mobility related to weakness, left sided hemiparesis, contractures to left upper extremity, revealed under Approaches with a start date of 11/09/22 was Requires assist x 2 staff with Hoyer (mechanical lift] with transfer tasks. Record review of Resident #1's Nurse's Note, dated 3/23/24 at 4:00 PM by LVN B revealed Called to resident room - upon entry resident sitting up in wheelchair alert awake and active forgetful and anxious - CNA A reports resident had light on and asked to put him up for dining-he asked to move to the chair for dinner - she informed him she would go find someone to help - was unable to find assistance - was then transferring resident to wheelchair using Hoyer [mechanical] lift and while put him in wheelchair the back of the wheelchair . reclined quickly and then CNA C came into the room at about 3:30 PM and saw he was in chair. Resident says he fell on the floor while being transferred to wheelchair - resident says he was put in sling and CNA A went to get some help - came back and was trying to put him in wheelchair when he fell to floor - denies pain or loc [loss of consciousness] at this time. Record review of Resident #1's Nurse's Note, dated 3/23/24 at 4:10 PM by LVN B revealed Resident now begins to c/o [complain of] pain to outer right foot - small bump to area palpated with c/o pain - no discoloration noted - foot is warm/dry - capillary refill [assessment done to determine blood flow to the toes/fingers] less than three seconds pedal [foot] pulse present - this writer asked if his body hurt in any way and he now begins to c/o some back pain. Record review of Resident #1's Nurse's Note, dated 3/23/24 at 4:16 PM by LVN B revealed contact made with RN D - informed her of occurrence she and I [LVN B] connect via phone with Assistant Administrator and notified him of the occurrence. Record review of Resident #1's Nurse's Note, dated 3/23/24 at 4:25 PM by LVN B revealed Resident #1's family member contacted informed her - verbalizes understanding. Record review of Resident #1's Nurse's Note, dated 3/23/24 at 4:29 PM by LVN B revealed physician made aware, order to send to ER to eval and treat. Record review of Resident #1's Nurse's Note, dated 3/23/24 at 4:40 PM by LVN B revealed report called to nurse at Hospital E's Emergency Room, 911 called pending arrival. Record review of Resident #1's Nurse's Note, dated 3/23/24 at 4:42 PM by LVN B revealed neuro checks [special assessment done to determine if there is injury to the brain or nervous system] initiated - Resident #1 remains alert awake and active continues to c/o slight pain to back and to outer right foot - denies loc - no change in neuro status noted pending EMS to arrive. Record review of Resident #1's Nurse's Note, dated 3/23/24 at 5:00 PM by LVN B revealed no change in neuro status is alert awake and active forgetful and confused at times .continues to c/o slight pain to right outer foot and to back will continue to monitor. EMS here - patient report and patient care turned over. Record review of Resident #1's Nurse's Note, dated 3/23/24 at 9:15 PM by LVN F revealed received report from nurse at Hospital E's Emergency Room, Resident #1 ready to be discharged back to facility .diagnoses: right foot sprain, contusion [bruising] to lower back, fracture of 5th metatarsal [little toe] bone .Assistant Administrator notified, RN D/Weekend Supervisor notified of above. Record review of Resident #1's Nurse's Note, dated 3/23/24 at 9:30 PM by LVN F revealed resident returned to facility via EMS accompanied by 2 EMTs, x3 assist to transfer resident back to bed, and made comfortable - Resident #1 c/o back pain administered, pain medication was administered at ER prior to leaving, discoloration noted to right lower extremity [lower leg], resident wearing post-op shoe, no physical sign of distress noted . Record review of Resident #1's Hospital E's emergency room Patient Visit Information sheet, dated 3/23/24, revealed he was seen for contusion of lower back, right foot sprain, and fracture of right fifth metatarsal bone and discharge instructions were sent for the foot fracture. Record review of Resident #1's Hospital E's emergency room Discharge Instructions for Foot Fracture, dated 3/23/24, revealed A foot fracture is a break in any of the 26 bones in the foot. It may take 3 to 10 weeks to heal . Record review of Resident #1's Event [Incident] Report dated 3/23/24 revealed the resident had a fall in his room, complained of pain to his back and outer right foot, resident was sent to the ER for evaluation and treatment, the physician was notified on 3/23/24 at 4:29 PM and gave order to send to ER to evaluate and treat, Resident #1's family member was notified and would meet Resident #1 at the ER. Record review of a handwritten, signed statement from CNA A, dated 3/23/24, revealed Resident #1 hes [sic] call light was on. He asked to put him up for dining he asked to move to the chair for dinner. I told him I was going to go find someone. I couldn't find anyone. I went to move him to the chair, his chair reclined back. He did fall. He was placed in the chair. CNA C walked in about 3:35 PM and saw he was in his chair. Record review of a handwritten, signed statement from CNA C, dated 3/24/24, revealed March 23, 2024 about 3-4 PM I heard CNA A's voice. I went to room check if she needed any help only to find she was attempting to transfer Resident #1 to his chair alone, she already had him over his chair but the back of the chair was reclined to [sic] far. I guided him so he was placed in the chair but he was not correct. As we adjusted him, he stated to me that 'he fell'. I asked him what he meant, and he stated that he fell to the floor. CNA A said 'no' that as she placed him to the chair, that the back dropped as she lowered him, he got scared but he never fell to the floor. He then stated that his right foot hurt I asked what part? He said the outside his toe's. I asked why? He said he hit something when she was transferring him. I told him not to worry we will figure it out. They both told the story until CNA A left the room. Then I asked again if anything hurt he said just his foot. I asked did you drop to the floor. He said 'yes', he was on the floor. I told him to give me a minute that I had to talk to LVN B about what to do next. In an interview on 03/25/24 at 10:33 AM, Resident #1 stated on 3/23/24, around 4 PM, CNA A came into his room to transfer him from his bed to his wheelchair per the resident's request. Resident #1 said CNA A placed the mechanical lift sling underneath him, then she told Resident #1 that he might have to help her because the other CNAs were working. Resident #1 stated he asked CNA A if she could wait until the other aides finished their work to assist her. Resident #1 said CNA A left the room and came back about five minutes later, said she could not find anyone and moved the mechanical lift over to the bed, attached the lift sling that was under him, grabbed the lift remote control and asked Resident #1 if he was ready. Resident #1 stated he responded, Yes, I'm ready, just don't drop me on the floor. Resident #1 stated when CNA A moved him from his bed to the wheelchair with the mechanical lift by herself, she could not bring him to the chair, and he fell. Resident #1 stated another CNA (CNA C) came into the room, asked him if anything hurt and he told her his back and his right foot hurt. Resident #1 stated LVN B came into the room and asked him if he was alright, and he told her his back and his right foot hurt. Resident #1 stated LVN B came back into the room, told him she called his family member to let her know he fell, and his family member was going to meet him at the hospital. Resident #1 stated then the ambulance came and took him to the hospital, and he did not return from the hospital until after 10 PM because the hospital needed the x-ray results. Resident #1 stated he did get out of bed yesterday (3/24/24) and today (3/25/24) he was still a little bit sore, his right foot still hurt, and he received Tylenol for his foot pain which helped. In an interview on 03/25/24 at 2:53 PM, CNA C stated on 3/23/24 when she entered Resident #1's room, the back part of his chair had reclined back all the way, and he was a bit crooked in the chair, holding onto the right arm rest with his right arm and Resident #1 stated he fell. CNA C said she asked CNA A why she was doing it by herself, and CNA A said she could not find anyone to help her. CNA C said she assisted CNA A with positioning Resident #1 in his chair correctly, the sling that was under him was crooked, so they fixed the sling, sat him upright, unhooked the straps of the lift sling from the mechanical lift. CNA C stated when the sling was removed from the lift, Resident #1 stated to her again that he fell. CNA C said she asked Resident #1 what he meant, and the resident said he fell. CNA A told CNA C that Resident #1 did not fall but the back of the chair reclined back and stated again that Resident #1 did not fall. CNA C said Resident #1 told her his foot hurt, so she reassured him, and left the room to notify LVN B of the situation. CNA C stated as LVN B assessed Resident #1 told LVN B the same story of what happened. In a telephone interview on 03/25/24 at 4:38 PM to 4:54 PM, CNA A stated when the mechanical lift was used to move a resident there must be 2 employees present to operate the lift and there could be a lot of damage to the resident if one person transferred a resident by themselves with the lift. CNA A stated she was the shower aide but on 3/23/24 she was working as a CNA and there were 3 other CNAs for a total of 4 CNAs. CNA A stated on 3/23/24 was the first time she cared for Resident #1, but she was aware the aides would use a mechanical lift with the assistance of two staff to move Resident #1. CNA A stated on 3/23/24 Resident #1 insisted on getting out of bed into his chair. CNA A said she told Resident #1 to wait while she went to find assistance. CNA A stated she could not find anyone and came back into Resident #1's room and Resident #1 insisted that he be moved from the bed to his chair. CNA A stated she moved Resident #1 into his wheelchair with the mechanical lift by herself and as she placed him into his wheelchair, the back of the chair reclined, and he got scared. CNA A said Resident #1 stated that he fell but she told him he did not fall, his chair just reclined back. CNA A said then another CNA (CNA C) came into the room, saw Resident #1 in the chair, together they repositioned the resident in his wheelchair and Resident #1 complained that his foot hurt so the nurse was informed who assessed the resident. CNA A stated when the wheelchair back reclined back, Resident #1's foot hit the floor hard. She stated the reason why she did the transfer by herself was because she could not find anyone else to assist her. CNA A stated she received verbal training on how to use the mechanical lift about a month ago and was not in-serviced on 3/23/24 or on 3/24/24 on use of the mechanical lift. In an interview on 03/27/24 at 10:50 AM, LVN B stated on 03/23/24 around 4 PM CNA C told her to go see Resident #1. LVN B said when she entered Resident #1's room, he was in his wheelchair and told her he fell when CNA A dropped him to the floor. LVN B stated CNA A then entered the room and said she was getting him ready to take him to the dining room, Resident #1 was in his bed, and she (CNA A) transferred him to his wheelchair with the mechanical lift. CNA A told LVN B the back of Resident #1's wheelchair reclined abruptly, and the Resident #1 said his foot hurt; then CNA C walked into the room and assisted CNA A with repositioning Resident #1 into his wheelchair. LVN B said CNA A denied Resident #1 fell to the floor. LVN B stated she assessed Resident #1, felt his foot, and felt a bump on his foot which the resident stated he had a lot of pain, and when she assessed his back Resident #1 stated it hurt. LVN B said she notified the RN on duty (RN D), the Assistant Administrator and Resident #1's physician who gave orders to send the resident to the hospital. LVN B stated she expects CNAs to always have 2 people transferring a resident with a mechanical lift and if they cannot find another person, the CNA should wait until they can get assistance. LVN B said a resident could fall, get injured or die because of being transferred with a mechanical lift that was done by only one person. In an interview on 03/27/24 at 2:00 PM, RN D stated the DON was on leave, she was the DON Designee in her absence and had worked in the facility for less than one month. RN D stated staff were expected to have 2 CNAs or nurses in the room when they transfer a resident with the mechanical lift, and they should not do the transfer until 2 people are present. RN D stated the harm of transferring a resident with only 1 person operating a mechanical lift instead of 2 people could cause falls, serious injuries, head injuries, broken bones or cause psychological harm. In an interview on 03/25/24 at 6:43 PM, the Assistant Administrator stated the risk of 1 person transferring a resident with a mechanical lift instead of 2 people could result in the resident falling, slipping out of the sling, or a plethora of things could happen. The Assistant Administrator stated CNA A told him she was not able to find anyone right away to assist her, the resident was getting impatient, and she did it right away by herself instead of waiting for assistance. In an interview on 3/25/24 at 3:40 PM, RN D stated an in-service had been completed on use of a mechanical lift in January 2024 and she could not find any other in-service trainings on use of a mechanical lift. Record review of an Employee In-Service Attendance Record, dated 01/15/24, revealed CNA A was in-serviced on mechanical lift transfers. Record review of the facility's policy on Safe Lifting and Movement of Residents, revised July 2017, revealed In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents .1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents .5. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. This was determined to be an Immediate Jeopardy (IJ) on 03/25/24 at 6:53 PM. The facility Assistant Administrator was notified. The Assistant Administrator was provided with the IJ template on 03/25/24 at 6:53 PM. On 03/26/24 the facility provided a plan of removal titled: Plan of Removal. The plan of removal was accepted on 03/26/2024 at 7:49 PM. It is documented as follows: Plan of Removal Problem: F689 Failure to prevent accidents allegation Interventions: -CNA A was suspended, and terminated as of 03/26/24 -In the course of investigation, it was reported that CNA A stated Resident #1's foot hit the floor hard. A written statement from CNA A contradicted this, and there was no mention of resident hitting his foot on the floor. -CNA A also admitted that she transferred Resident #1 with no assistance, which is against company policies and procedures -In-service nursing staff on Mechanical Lift Transfer with two staff members at all times, starting on 3/24/24. New in-servicing regarding proper sling placement, and the wear and tear of a sling, as well as the steps to be taken if no other staff members are available at the time of transfer, will begin on 3/26/24. Staff not present on 03/25/24 will be in-serviced prior to attempting to transfer a resident with a mechanical lift. -Abuse and neglect in-service for all staff started on 03/24/24 -Inspection of all lift slings, with removal from service any sling that is frayed or torn, will be conducted on 03/26/24. -Maintenance supervisor to visually inspect both mechanical lifts to ensure that they are in proper working order, and that there is no damage that would prevent the safety of patient transfers Monitoring -The DON and/or Designee will monitor at least 5 lift transfers per week, observing for proper technique and staff assistance, and maintain a running log of said transfers. -The DON/Designee will observe and log that all slings are in good working order at least once a week -The QAPI committee will review findings monthly for no less than 90 days and makes changes as needed The facility's POR Verification was as follows: In an interview on 03/27/24 at 2:30 PM, the Assistant Administrator stated CNA A was terminated from employment on 3/26/24. In an interview on 03/27/24 at 2:00 PM, the DON Designee, RN D, said she had a list of two employees who had not received the education and would not schedule them to work until they received the in-service training. In an interview on 03/27/24 at 3:00 PM, the Assistant Administrator stated the DON Designee had identified employees who had not received education at that time and the employees were not scheduled to work until they have received the education. The Assistant Administrator stated the facility had a QAPI meeting on 03/27/24 and discussed the findings of the deficient practice and the plan of removal. The Administrator said the findings of the audits would be brought to the monthly QAPI meetings and reviewed. He stated the information would be used to determine if the interventions in place were effective or if they need to make changes to their systems. In an interview on 3/27/24 at 3:05 PM, the Maintenance Director stated he inspected both mechanical lifts on 3/26/24 and the lifts were functioning properly. He stated the mechanical lifts were inspected weekly and kept an inspection log in a binder and if there was a concern with a mechanical lift, it would be removed from service and be repaired and notify the DON and the Assistant Administrator. In a group interview on 03/28/24 at 11:15 AM with the Assistant Administrator and the DON Designee, RN D stated an audit log was created to document observations of mechanical lift transfers. RN D stated she or the DON would observe 5 mechanical lift transfers weekly; and two observations were completed on 3/27/24 at 4:45 PM and on 3/28/24 at 8:30 AM. RN D stated there were no concerns with the mechanical lift, technique used by staff or the sling that was used for the transfer. RN D stated she observed the mechanical lift slings used during the transfer and the slings were in good condition. The Administrator stated the log would be reviewed and facility would track the findings and use the information to determine if further education was needed or if staff performed the transfers correctly. The Assistant Administrator stated the audit information would be brought to QAPI meeting monthly and the information would be reviewed to determine effectiveness and if changes needed to be made to the system, policy, or procedure. The Assistant Administrator stated the Housekeeping Supervisor completed a sling audit on 03/27/24 at 4 PM that revealed 9 slings in use were in good working condition. He stated the slings will be observed weekly by the Housekeeping Supervisor and would be recorded on the audit log. He stated any slings with holes, tears or frays would be removed from service. He stated the audit information will be reviewed and used to track the condition of the sling supply and determine when new slings should be purchased. In an interview on 03/28/24 at 1:35 PM, the housekeeping Supervisor stated she completed the sling audit on 03/27/24, there were 9 slings in use, and they were in good condition. She stated if a sling was found with worn, torn, or frayed material she would remove it from service, log the information on the audit log and place an order to replace the sling. Interviews with 23 of 29 direct care staff from different shifts was completed on 03/27/24 and 03/28/24 which consisted of 13 direct care staff from day shift (6 AM-6 PM) and 10 direct care staff from night shift (6 PM-6 AM). All 23 staff members reported there were educated and trained on the use of mechanical lifts. Interviews on 03/27/24 and 03/28/24 with 50 of 66 facility staff from different shifts revealed staff have received education on abuse and neglect. Observations on 03/27/24 and 03/28/24 of resident and staff interactions revealed no signs of abuse or neglect. Observations on 03/26/24 of 5 resident slings and on 03/27/24 of 4 resident slings revealed no holes, tears, or frays on the slings. Record Review of CNA A's termination paperwork dated 3/26/24 revealed she was terminated on 03/26/24 for operating a mechanical lift without 2 people; the document was signed by the Assistant Administrator, and he noted CNA A refused to sign the document. Record review of education sign in sheet, dated 03/24/24, revealed 48 staff received education on proper techniques of a mechanical lift transfer which always included the use of 2 persons for mechanical lift transfers. Record review of education sign in sheet, dated 03/26/24, revealed 66 staff received education on using 2 people to perform a safe mechanical lift transfer. Record review of education sign in sheet, dated 03/26/24, revealed 66 staff received education on reporting incidents of abuse and neglect immediately to the Assistant Administrator, DON, and Charge Nurse. Record Review of the facility sling audit tool dated 03/27/24 revealed documentation 9 slings were in use and in good condition. Record Review of an inspection check off list completed on 3/26/24 for two facility mechanical lifts showed no concerns with the mechanical lifts. Record review of an audit form reflecting a mechanical lift observation was done on 03/27/2024 at 4:45 PM by CNA G and CNA H, who performed a mechanical lift of a resident revealed no concerns were noted. Record Review of the QAPI meeting Sign-in Sheet revealed a QAPI meeting was held on 03/26/24 at 8:30 AM and in attendance was the Administrator, Medical Director, RN Designee-RN D, Director of Marketing, Director of Rehab and 9 other department managers. On 03/28/24 at 3:42 PM, the Assistant Administrator was notified the immediacy was lifted on 03/28/24 at 3:42 PM but the facility remained out of compliance at scope of isolated and a severity with actual harm due to the facility's need to monitor the implementation and effectiveness of its POR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews the facility failed to ensure residents had the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers, for 1 of 16 residents (Resident #14) reviewed for advance education for medication benefits versus risks. The facility administered medroxyprogesterone, a type of hormone (progestin), from June 2023 to March 2024 to Resident #14 without Resident #14 and/or Resident #14's representative receiving education on the rationale for the prescription, the benefits vs. the risks of medroxyprogesterone and offered options for treatment. An Immediate Jeopardy (IJ) was identified on 03/15/2024. The IJ was provided to the facility on [DATE] at 08:05 PM. While the IJ was removed on 03/18/2024, the facility remained out of compliance at a scope of isolated with a severity level of potential harm because of the facility's need to evaluate the effectiveness of their corrective actions. This failure denied the resident their right to participate in their care and treatment and placed other residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party or being aware of the benefits and risks of the medications prescribed. The findings included : A review of Resident #14's admission record dated 03/14/2024, revealed an admission date of 05/10/2023 with diagnoses which included dementia, psychotic disturbance, mood disturbance, anxiety, and alcohol use. The admission record revealed Resident #14 had two representatives. A record review of Resident #14' quarterly MDS assessment revealed Resident #14 was a [AGE] year-old male admitted for long term care assessed with a BIMS score of 5 which indicated severe cognitive impairment . A record review of Resident #14's physicians orders, dated 03/14/2024, revealed the physician prescribed medroxyprogesterone (a hormone which help other hormones start and stop the menstrual cycle) 10 mg once a day at bedtime. A review of Resident #14's medication Administration Records for June, July, August, September, October, November, December 2023, and January, February, March 2024 revealed Resident #14 was receiving medroxyprogesterone daily. Record review of Resident #14's medical record revealed no evidence Resident #14 and or his representatives received any education on the rationale for the prescription, benefits vs risks, or potential adverse reactions of the prescribed medroxyprogesterone. A record review of the National Library of Medicine's website, https://www.ncbi.nlm.nih.gov/books/NBK559192/ , Medroxyprogesterone .Last Update: June 30, 2022 revealed, Continuing Education Activity: This article highlights medroxyprogesterone .This activity discusses the mechanism of action, adverse effects, monitoring, and contraindications for medroxyprogesterone. Also, it highlights the important role that providers play in administering medroxyprogesterone and regularly monitoring patients for side effects . Off-Label Indications: Paraphilia/hypersexuality . Both genders reported experiencing changes in breast and sexual function . Patients currently using medroxyprogesterone for paraphilia/hypersexuality, LFTs (liver function tests), CBC (complete blood count), serum testosterone (male hormone), LH, FSH (a lab for decreased functional activity of the gonads (ovaries or testes)), and glucose require regular monitoring. Also, if serum testosterone shows a marked decrease, consider an annual bone scan. A record review of Resident #14's medical records revealed no evidence Resident #14 received monitoring and or lab studies for the potential adverse effects of the female hormone medroxyprogesterone he was prescribed and administered for 9.5 months. During an interview on 03/13/24 at 02:29 PM LVN K stated she had been the charge nurse for Resident #14. LVN K stated Resident #14 had a history of aggressive sexual harassment behaviors towards staff and Resident s. LVN K stated Resident #14 had been prescribed medroxyprogesterone. LVN K stated the medication aide had administered Resident #14's medroxyprogesterone. LVN K stated there had been no monitoring measures for testosterone levels or breast tenderness . During an interview on 03/14/2024 at 03:00 PM Dr. Y stated he was the primary care physician for Resident #14. Dr. Y stated he had received reports from nursing staff, in June of 2023, that Resident #14 was developing unwanted sexual behaviors towards staff, and he prescribed medroxyprogesterone, a hormone prescribed to reduce Resident #14's unwanted sexual harassment behaviors. Dr. Y stated he had trust and faith the nursing staff would have advised Resident #14 and his representatives of the new medication to include rationale for the prescription, risks versus benefits, and potential adverse reactions. Dr. Y stated since June 2023 he had not received any reports from the nursing staff for any signs and or symptoms of adverse effects from the medroxyprogesterone . During an interview on 03/15/2024 at 02:44 PM Resident #14's 2 representatives stated Resident #14 occasionally had behaviors where he would become upset and would be calmed by the facility when offered non-alcoholic beer, he doesn't know the difference, and the representatives would call and further calm Resident #14. Resident #14's representatives stated Resident #14 was not able to receive education on the rationale, benefits vs risks of any prescribed medications. Resident #14's representatives stated they were unaware of Resident #14's inappropriate sexual behaviors towards female residents. Resident #14's representatives stated they were not informed Resident #14 was prescribed and administered a hormone to reduce his sexual inappropriate behaviors. Resident #14's representatives stated they had not received any education on the rationale, benefits vs risks of the prescribed medroxyprogesterone, and stated We have no idea what the drug is and what it does. The facility called us today to schedule a meeting next week, but they did not report to us any information on any drugs and or past sexual behaviors. During an interview on 03/18/24 at 02:20 PM LVN N stated she was the charge nurse who reported in June 2023 Resident #14's sexual harassment behaviors and received from Dr. Y the order for medroxyprogesterone. LVN N stated she had not clarified Resident #14's medroxyprogesterone order for monitoring for adverse effects of the medroxyprogesterone, breast tenderness and or laboratory test for monitoring Resident #14's testosterone blood levels, because it did not occur to her. LVN N stated she had not consulted with Resident #14 and or his representatives to provided informed consent to include the rationale for the medroxyprogesterone, the benefits versus the risk, and the potential adverse effects of the medroxyprogesterone prior to the administration of the medroxyprogesterone. LVN N stated not having provided Resident #14 the opportunity to receive education for benefits vs risks of medroxyprogesterone would deny him his right to participate in his plan of care and to consent or refuse the care. During an interview on 03/18/24 at 03:50 PM the MDS Nurse stated a review of Resident #14's medical record revealed no evidence for laboratory studies for testosterone, no monitoring for adverse effects medroxyprogesterone, no evidence for education for benefits vs risks of medroxyprogesterone, no care plan summaries to reveal Resident #14 and or the representatives received education for benefits vs risks of medroxyprogesterone. The MDS Nurse stated not having provided Resident #14 the opportunity to receive education for benefits vs risks of medroxyprogesterone would deny him his right to participate in his plan of care and to consent or refuse the care. During an interview on 03/18/2024 at 05:20 PM the Administrator stated the policy and expectation was for residents to receive informed consent prior to the initial dose of any medication and or treatment. The Administrator stated going forward he would ensure residents received from the physician and or nursing staff the rational for the new prescription and or treatment, the risks versus benefits, and potential adverse reactions. The Administrator stated not having provided Resident #14, or any resident, the opportunity to receive education for benefits vs risks of a medication and or treatment would deny their rights to participate in their plan of care and to consent or refuse the care. During an interview on 03/18/2024 at 05:31 PM the ADON stated a review of Resident #14's medical record revealed no evidence for laboratory studies for testosterone, no monitoring for adverse effects medroxyprogesterone, no evidence for education for benefits vs risks of medroxyprogesterone, no care plan summaries to reveal Resident #14 and or representatives received education for benefits vs risks of medroxyprogesterone. The ADON stated not having provided Resident #14 the opportunity to receive education for benefits vs risks of medroxyprogesterone would deny him his right to participate in his plan of care and to consent or refuse the care. A record review of the facility's Resident Participation - Assessment/Care Plans policy dated February 2021, revealed, the Resident/representatives right to participate in the development and implementation of his or her plan of care includes the right to: participate in the planning process; identify individuals to be included in the planning process; request meetings; request revisions to the plan of care; participate in the establishing his or her goals and expected outcomes of care; participate in the type, amount, frequency, and duration of care; receive the services and or items included in the care plan; be informed, in advance, of changes to the plan of care; refuse, request changes to and or discontinued care or treatment offered or proposed; be informed, in advance by the physician more professionals, of the risks and benefits of the care or treatment proposed . The following Plan of Removal submitted by the facility was accepted on 03/17/2024 at 07:08 AM. POR Verification Problem: F552 Failure to ensure resident had the right to be informed of, and participate in, his or her treatment Interventions: o Resident #14's Responsible Party was notified, according to progress notes, again of orders for Resident #14 to be prescribed medroxyprogesterone. Record review of progress note, dated 03/17/2024 at 1:12 PM, reflected that the MDS Coordinator, spoke with Resident #14's responsible parties to include educating on risk vs benefits of medroxyprogesterone. The progress notes further revealed that the responsible party voiced their understanding of the medication and its side effects and agreed that it was beneficial for the resident to remain on the medication. Interview on 3/18/2024 at 1:06 PM, the Administrator stated that Resident #14's responsible party was notified of the orders for medroxyprogesterone on 3/17/2024. o Resident #14's care plan was updated to reflect responsible party's notification of the medication being prescribed. Record review of the care plan, dated 3/15/2024, reflected Problem: Resident #14 is taking hormone medroxyprogesterone with Approach: Education provided to family as to risk vs benefit of medication. o Any new medication or treatment that Resident #14 (or any other resident) is prescribed will be assessed by nurse staff for a minimum of 72 hours. Record review of Resident #14 progress notes reflected an assessment of adverse reactions by nursing staff on medications. Interview on 3/18/2024 at 1:09 PM, the Administrator stated the assessments of adverse reactions of the new medication or treatments for Resident #14 were in the progress notes. A record review of the facility's employee roster dated, 03/16/2024 revealed of the 71 employees, 10 were nurses. A sample of 8 nurses, 5 on day shift and 3 on night shift , were interviewed to confirm receiving in-services and training on recognizing the side effects of the medication Medroxyprogesterone. o The need for education regarding adverse effects, risks vs. benefits, etc. of treatment before treatment begins, was identified, and in-servicing has begun by administrator; in-servicing will be completed by the end of business on 3/17/2024. This in-service is to include all nurses, and any nurse not in-serviced will not be allowed to perform duties until they are in-serviced. Interview on 3/17/2024 at 3:15 PM, the MDS Coordinator revealed that nursing staff who had not been in-serviced would be allowed to perform duties until they had been in-serviced. Record review of document titled In-Service Training, dated 3/15/2024, with the topic The Importance of Reporting Events to Physicians and Emergency Contacts revealed 7 of 11 nursing staff as having completed the in-service. o The following in-services were initiated on 3/14-16/2024: All available nursing staff will begin being in-serviced on 3/15/2024. Any nursing staff member not present or in-serviced, will not be allowed to assume their duties until in-serviced. Administrator/Designee to ensure that in service training has been done for all nurse staff. o AII Nurse Staff) nurses, CNA, MA) o Abuse/Neglect o The importance of reporting events to physicians and responsible parties A record review of the facility's employee roster dated, 03/16/2024 revealed 71 employees. 57% of employees, 44 of the 74, were interviewed to confirm receiving in-services for IJ F552 The Right to Participate in Their Care. A record review of the facility's employee roster dated, 03/16/2024 revealed of the 71 employees, 10 were nurses. A sample of 8 nurses, 5 on day shift and 3 on night shift, were interviewed to confirm receiving in-services for IJ F552 The Right to Participate in Their Care. A record review of the facility's employee roster dated, 03/16/2024 revealed of the 71 employees 17 were CNAs. A sample of 8 CNAs, 5 on day shift and 3 on night shift, were interviewed to confirm receiving in-services for IJ F552 The Right to Participate in Their Care. Record review of document titled Staff in-service, dated 3/15/2024, with the topic Abuse/Neglect Inservice revealed 46 of 71 staff signed off as having completed the in-service. Interview on 3/17/2024 at 3:15 PM, the MDS Coordinator revealed that not all staff reported to physicians or emergency contacts, and that only 11 nurses would be responsible with reporting any events to physicians and emergency contacts. Record review of a document titled In-Service Training, dated 3/15/2024, with the topic The Importance of Reporting Events to Physicians and Emergency Contacts revealed 7 of 11 nursing staff signed off as having completed the in-service. Record review of document titled Staff in-service, dated 3/15/2024, with the topic Any staff who is turning off the lights and shutting the doors to any room shall check the room for any other persons prior to turning off the lights and shutting the door. Further review of this in-service revealed 49 of 71 staff signed off as having completed the in-service. Interview on 3/17/2024 at 12:30 PM, LVN N revealed that the in-service consisted of abuse and neglect prevention, complaints, when and where to file grievances and who to report grievances to. Interview on 3/17/2024 at 12:33 PM, CNA J stated that the in-service consisted of ensuring no residents are locked in shower rooms and monitoring showers and reporting to nursing staff. Interview on 3/17/2024 at 12:34 PM, CNA I stated that the in-service she received detailed ensuring that grievances are recognized and reported. Interview on 3/17/2024 at 1:35 PM, CNA P stated the in-service detailed abuse, neglect, exploitation, and discussing any of these concerns with the administrator. Interview on 3/17/2024 at 2:04 PM, LVN K stated her most recent in-service consisted of abuse and neglect training, to include specifics about what is abuse and neglect, changes in conditions, and when to notify family and physicians. Interview on 3/17/2024 at 3:00 PM, LVN R stated the in-service she had most recently consisted of ensuring residents' complaints were recognized and grievances were filed. Interview on 3/17/2024 at 4:13 PM, CNA O stated the in-service they completed on 3/15/2024 consisted of reporting grievances and who to give them to. Interview on 3/17/2024 at 4:23 PM, LVN T stated the most recent in-service was about abuse and neglect and reporting any abuse or neglect to supervisors, as well as reporting to physicians. Monitoring: o DON/Designee will perform a weekly audit of EMR to ensure that resident and/or responsible parties are being notified and educated with regard to any treatment changes, including but not limited to, any possible adverse effects, risks and benefits, or any alternative treatments that might be available BEFORE any changes are made Record review reflected a facility activity report, detailing each residents EMR, signed as Reviewed by the Administrator and DON on 3/16/2024. Interview on 3/18/2024 at 10:36 AM, the Administrator stated that the DON would be performing a weekly audit of the EMR. o This weekly audit will be monitored on an ongoing weekly basis, to be integrated into the normal work routine of the nurse management team. Initial audit to be performed on 3/16/2024 by DON/Designee. Interview on 3/18/2024 at 10:36 AM, the Administrator stated that the DON will be performing a weekly audit of the EMR. Record review reflected a facility activity report, detailing each residents EMR, signed as Reviewed by the Administrator and DON on 3/16/2024. o The QAPI committee will review findings monthly for no less than 90 days and makes changes as needed Interview on 3/18/2024 at 10:36 AM, the Administrator stated that during QAPI they will follow a template relating to the deficiencies and discuss any changes or suggestions relating to any changes in care for residents with all members of the QAPI committee. An Immediate Jeopardy (IJ) was identified on 03/15/2024. The IJ was provided to the facility on [DATE] at 08:05 PM. While the IJ was removed on 03/18/2024, the facility remained out of compliance at a scope of isolated with a severity level of potential harm because of the facility's need to evaluate the effectiveness of their corrective actions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for 2 of 18 residents (Residents #14 and #23) reviewed for physician notification of changes. 1 . The facility failed to inform Resident #14's physician when Resident #14 made sexual lewd comments towards female residents and entered Resident #23's shower room while she was showering on 02/06/2024 and again on 03/12/2024 and unsuccessfully attempted to enter Resident #23's shower room on 02/15/2024. 2. The facility failed to inform Resident #23's physician when Resident #14 entered Resident #23's shower room while she was showering on 02/06/2024, again on 03/12/2024, and unsuccessfully attempted to enter Resident #23's shower room on 02/15/2024. An Immediate Jeopardy (IJ) was identified on 03/15/2024. The IJ was provided to the facility on [DATE] at 08:05 PM. While the IJ was removed on 03/18/2024, the facility remained out of compliance at a scope of isolated with a severity level of potential harm because of the facility's need to evaluate the effectiveness of their corrective actions. This failure denied residents and their physicians accurate and timely assessments so the physician could intervene with care. The findings included : 1. A record review of Resident #14's admission record dated 03/14/2024, revealed an admission date of 05/10/2023 with diagnoses which included dementia, psychotic disturbance, mood disturbance, anxiety, and alcohol use. Resident #14's admission record revealed Resident #14 had two representatives. A record review of Resident #14' quarterly MDS assessment revealed Resident #14 was a [AGE] year-old male admitted for long term care assessed with a BIMS score of 5 which indicated severe cognitive impairment . A record review of Resident #14's care plan dated 03/14/2024 revealed, Resident has episodes of inappropriate behaviors AEB (As Evidenced By) disrobes in public areas, sexual innuendos/gestures .Problem Start Date: 06/26/2023 . Behavioral episodes will be reduced to less than daily over the next 90 days . Monitor and chart behaviors and report to MD . A record review of Resident #14's nursing progress notes revealed LVN A documented on 06/07/2023, Resident urinated in shower room. Redirected resident to room and told resident that was not appropriate. Resident resting in bed . we'll continue to monitor. A record review of Resident #14's nursing progress notes revealed the DON documented on 08/18/2023, Resident sitting in dining room having non-alcoholic beverage. Activity director states that he was having a behavior issue earlier. He kept signaling to female resident to go to shower with him to shower . asked him to stop, he replied she wants to. Resident was redirected and asked to stop behavior . A record review of Resident #14's nursing progress note dated 08/28/2023 revealed LVN A documented, . resident had sexual behaviors this evening was blowing kisses and saying I love you to this writer when providing care - when resident started rubbing his private area through shorts, he was told that was inappropriate and this writer lowered the bed, close the curtain, and stepped out of room. call light within reach. A record review of Resident #14's nursing progress note dated 09/19/2023 revealed LVN AA documented, resident is showing sexual behaviors with aides, continues to tell aides to touch him down there, stating that he likes it, and throws kisses, blinking his eye. A record review of Resident #14's nursing progress note dated 02/06/2024 revealed LVN A documented, this writer was paged to station 1 where this resident was standing in the middle of the shower room while there was already a female resident using it (Resident #23). This resident refused to leave the Shower room after being told several times there was a female showering. The resident did not leave until an aide agreed to shower him in a different room once she was done with her round. A record review of Resident #14's nursing progress note dated 02/15/2024 revealed LVN A documented, resident came to station one and started calling this writer a 'pendeja' ([NAME] -a derogatory name in Spanish ) and demanding that this writer take him into the shower (in Spanish) writer told resident to go back to his room and would let his nurse know. Difficult to redirect. resident kept shaking shower door handle on station 1 after being told several times there was a female resident using the shower. this is not the first-time resident becomes aggressive. resident does not belong to station one but will still come to this station to yell and demand to be showered. A record review of Resident #14's nursing progress note dated 03/12/2024 revealed LVN A documented, ad 0015 (15 minutes past midnight) Resident (#14) walked into station one shower while a female Resident (Resident #23) was using it and refused to leave. Resident (#14) became angry when asked to leave and walked to 700 hall and started opening several rooms - Resident (#14) kept stating he wanted to leave the facility (Spanish speaking). Resident (#14) was cussing and doing sexual gestures to staff. Resident (#14) was repeatedly told that was inappropriate and to stop. Resident (#14) replied I don't give a F*** I'm leaving (Spanish speaking). Resident (#14) walked to front hallway and started shaking door handles and running shoulder into door to force it open. Resident (#14) went to front door and pushed it open - this writer and CNA we're trying to hold it closed as resident repeatedly pushed on it. This writer called [Resident #14] representative and she was able to talk resident down. Resident stated to representative he wanted to be showered - [Resident #14's] representative was told tomorrow is Resident's shower day. [Resident #14's] representative was still on the phone while Resident (#14) was making sexual gestures to staff and was made aware. [Resident #14's] representative told Resident (#14) she would come to facility tomorrow to speak with him . attempted to call the DON and the ADON no answer. called the administrator made aware. A record review of Resident #14's medical record, on 03/14/2024, revealed no evidence for providing the physician with reports where Resident #14 had increased sexual harassment behaviors towards residents since June 2023. During an interview on 03/13/24 at 04:15 PM the BOM stated Resident #23 had complained in early February about Resident #14 trying to get into her shower room. The BOM stated the previous DON reported Resident #14 attempted to enter the room and was unsuccessful and redirected, I did not know [Resident #14] entered [Resident #23's] shower room. During an interview on 3/14/24 at 03:00 PM, Dr. Y stated he was the primary care physician for Resident #14 and, over the span of several months, had received multiple reports Resident #14 was sexually inappropriate with staff . Dr. Y stated he continued with resident #14's drug regiment to allow time for the therapies to progress. Dr. Y stated he had not received any reports Resident #14 was sexually inappropriate toward any resident. Dr. Y stated, I would have recalled a report of him getting in a female resident's shower. Dr. Y stated, if he had received such a report, he would have ordered for a 1 to 1 staff level of supervision for Resident #14 and ordered a psychiatric evaluation. The medical director stated he had received reports of Resident #14's inappropriate sexual behaviors however the reports were limited to staff harassment and not resident harassment. The reports were incomplete and lacking the scope of Resident #14's behaviors towards female residents. Dr. Y stated he was concerned for the behavior towards residents and would have considered further interventions for Resident #14's safety and the safety of residents. During an interview on 03/15/2024 at 09:30 AM Resident #14 stated he was wanting beer, a dance party, and a sexual partner. He stated, I have not been drunk, had sex in a long time .there are no dances here and they only have church! Resident #14 stated he enjoyed female CNAs assisting him with showers and they didn't shower him when he demanded. Resident #14 denied he was in any females shower room. 2. A record review of Resident #23's admission record, dated 03/14/2024, revealed an admission date of 09/09/2016 with diagnoses of dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), mood disturbance and anxiety. A record review of Resident #23's quarterly MDS assessment, dated 02/12/2024, revealed Resident #23 was an [AGE] year-old female admitted for long term care assessed with a BIMS score of 10 which indicated moderate cognitive impairment. A record review of Resident #23's care plan, dated 03/14/2024, revealed Resident #23 had a history of rejecting care and or limited permission for assessments and therapies. Further review revealed interventions avoidance of over-stimulation and avoidance of aggressive peer residents. During an interview on 03/13/2024 at 02:30 PM Resident #23 stated she felt unsafe due to Resident #14's sexual harassment behaviors (attempts to get in the shower with her) and now wished to avoid showers and stay in her room. During an interview on 03/13/24 at 04:30 PM Resident #23 stated on several occasions a man got into the shower with her, to which she would yell and scream at him until staff intervened and re-directed him away. Resident #23 stated she had increased anxiety and insomnia due to the fear of resident #14 entering her room and or shower. A record review of Resident #23's medical record, on 03/14/2024, revealed no evidence for providing the physician with reports where Resident #14 had increased sexual harassment behaviors towards Resident #23 since February 2024. During an interview on 03/14/24 at 08:28 AM the Medical Director stated he was unsure if he received a report from the nursing staff that Resident #23 was involuntary secluded in the shower. The medical Director stated if he had he could have assessed resident for psychiatric evaluation. During an interview on 03/15/2024 at 02:00 PM the Medical Director stated he was Resident #23's physician, and he was unaware Resident #14 had on 2 occasions entered Resident #23's shower room. The Medical Director stated had he known he may have assessed Resident #23 for anxiety and may have intervened with a psychiatric evaluation. The physician stated at a minimum he would have expected a report from nursing for Resident #14's sexual harassment behaviors and Resident #23's potential anxiety and fear. During an interview on 03/18/24 at 03:50 PM the MDS Nurse stated a review of Resident #14's medical record revealed no evidence for reports to the physician that Resident #14 was having sexual harassment behaviors towards residents . During an interview on 03/18/2024 at 05:20 PM the Administrator stated the policy and expectation was for nursing staff to timely report to Resident's physicians any changes in residents' health status to include increased and or decreased behaviors and or responses to therapies. The Administrator stated nursing staff should have reported to the physician and himself Resident #14's sexual harassment episodes towards residents. The Administrator stated nursing staff had not reported Resident #14 had made sexual harassment behaviors towards residents. During an interview on 03/18/2024 at 05:31 PM the ADON stated a review of Resident #14's and Resident #23's medical record revealed no evidence for reports to the residents' physicians for any of Resident #14's sexual harassment episodes towards residents and or Resident #23. A record review of the facility's Accidents and Incidents - Investigating and Reporting, dated July 2017, revealed, all accidents or incidents involving residents, employees, visitors, vendors, etcetera, occurring on our premises shall be investigated and reported to the Administrator .the following data, as applicable, shall be included on the report of incident accident form; the date and time the accident or incident took place; the nature of the injury illness; where the accident or incident took place; the names of witnesses and their accounts of the accident or incident; the injured person's account of the accident or incident; the time the injured person's attending physician was notified, as well as the time the position responded and his or her instruction . An Immediate Jeopardy (IJ) was identified on 03/15/2024 at 08:05 PM and presented to the Administrator, a plan of removal was requested. The following Plan of Removal submitted by the facility was accepted on 03/17/2024 at 07:08 AM. Plan of Removal Verification Problem: F580 Notification of physicians and responsible parties Interventions: o Responsible parties of both Resident #14 and Resident #23 notified of incident as of 3/16/2024. Record review of Resident #23's progress note dated 3/15/2024 at 11:43 AM, made by the Worker reflected, SW spoke with resident today, via a Spanish translator, and asked if she had any lingering emotional distress or anxiety related to the 2/6/24 incident and if so does she want to be seen by psych. services/counseling. Resident stated she is o.k. and did not want any type of counseling/psych. services. SW also had a conversation with her MPOA regarding the incident on 2/6/24 and asked if she wanted resident to have counseling/psych. services and she stated no she doesn't want that for resident at this time as resident seems fine. SW let her know that counseling/psych. services is available if she ever changes her mind and that she may always speak to SW as needed. Record review of a progress note dated 3/15/2024 at 6:21 PM reflected the Social Worker, and Administrator spoke with Resident #14's RP of the resident's incidents. Interview on 3/18/2024 at 1:10 PM, the Administrator stated that each incident was discussed with Resident #14's responsible parties. The Administrator then confirmed Resident #23's responsible party had been notified of the incidents. The Administrator also confirmed the medication and its adverse effects were discussed with Resident #14's responsible parties. Record review of Resident #14's Progress Note, dated 3/17/2024 at 1:12 PM and written by the MDS Coordinator reflected that education was provided to the RP of risks vs benefits of taking the medication medroxyprogesterone and went on to list risks and benefits. o Evidence of deficiencies in notification of physicians and responsible parties was found to exist in the facility. Interview on 3/18/2024 at 10:55 AM, the Administrator stated that the evidence of deficiencies in notification were found during the survey process and no other evidence of deficiencies in notification were found during the facilities audit after notification of the initial deficiencies. o The following in-services were initiated on 3/14-16/2024: All available staff will begin being in serviced on 3/15/2024, to be completed on or before 3/16/2024. Any staff member not present or in-serviced by this time will not be allowed to assume their duties until they have been in serviced. Administrator/Designee to ensure that in-service training has been done for all staff. O All Staff o Abuse/Neglect o Incident reporting, to include behaviors, to Admin/Physicians o The importance of reporting events to physicians and responsible parties A record review of the facility's all discipline employee roster dated, 03/16/2024 revealed 71 employees. 57% of employees, 44 of the 71, were interviewed to confirm receiving in-services for IJ F580 Reporting Change of Condition to Physician. A record review of the facility's employee roster dated, 03/16/2024 revealed of the 71 employees, 10 were nurses. A sample of 8 nurses, 5 on day shift and 3 on night shift, were interviewed to confirm receiving in-services for IJ F580 Reporting Change of Condition to Physician. A record review of the facility's employee roster dated, 03/16/2024 revealed of the 71 employees 17 were CNAs. A sample of 8 CNAs, 5 on day shift and 3 on night shift, were interviewed to confirm receiving in-services for IJ F580 Reporting Change of Condition to Physician. Record review of document titled Staff in-service, dated 3/15/2024, with the topic Abuse/Neglect Inservice revealed all disciplines, 46 of 71 staff signed off as having completed the in-service. Interview on 3/17/2024 at 3:15 PM, the MDS Coordinator stated that not all staff report to physicians or emergency contacts, and that only 11 nurses would be responsible with reporting any events to physicians and emergency contacts. Record review of document titled In-Service Training, dated 3/15/2024, with the topic The Importance of Reporting Events to Physicians and Emergency Contacts revealed 7 of 11 nursing staff signed off as having completed the in-service. Record review of document titled Staff in-service, dated 3/15/2024, with the topic Any staff who is turning off the lights and shutting the doors to any room shall check the room for any other persons prior to turning off the lights and shutting the door. Further review of this in-service revealed 49 of 71 staff signed off as having completed the in-service. Interview on 3/17/2024 at 12:30 PM, LVN N revealed that the in-service consisted of abuse and neglect prevention, complaints, when and where to file grievances and who to report grievances to. Interview on 3/17/2024 at 12:33 PM, CNA J stated that the in-service consisted of ensuring no residents are locked in shower rooms and monitoring showers and reporting to nursing staff. Interview on 3/17/2024 at 12:34 PM, CNA I stated that the in-service she received detailed ensuring that grievances are recognized and reported. Interview on 3/17/2024 at 1:35 PM, CNA P stated the in-service detailed abuse, neglect, exploitation, and discussing any of these concerns with the administrator. Interview on 3/17/2024 at 2:04 PM, LVN K stated her most recent in-service consisted of abuse and neglect training, to include specifics about what is abuse and neglect, changes in conditions, and when to notify family and physicians. Interview on 3/17/2024 at 3:00 PM, LVN R stated the in-service she had most recently consisted of ensuring residents' complaints were recognized and grievances were filed. Interview on 3/17/2024 at 4:13 PM, CNA O stated the in-service they completed on 3/15/2024 consisted of reporting grievances and who to give them to. Interview on 3/17/2024 at 4:23 PM, LVN T stated the most recent in-service was about abuse and neglect and reporting any abuse or neglect to supervisors, as well as reporting to physicians. Monitoring o DON/Designee will perform a weekly audit of EMR (electronic medical record) to ensure that physicians and responsible parties are being notified with regard to any scenarios outlined in, but not limited to, CMS F580, to include medication changes, changes in condition, and critical labs. Record review reflected a facility activity report, detailing each residents' EMR, signed as Reviewed by the Administrator and DON on 3/16/2024. Interview on 3/18/2024 at 10:36 AM, the Administrator stated that the DON will be performing a weekly audit of the EMR. o Facility will be monitoring this by weekly EMR audits. Nurses will chart items in progress notes, and flagged on 24 hour report which will be discussed Monday - Friday by IDT. Interview on 3/18/2024 at 10:36 AM, the Administrator stated that they will be discussing the 24-hour report during the morning meeting to see if there need to be any changes made to any care for the residents based on what is on the 24 hour report. o The QAPI committee will review findings monthly for no less than 90 days and makes changes as needed Interview on 3/18/2024 at 10:36 AM, the Administrator stated that during QAPI they followed a template relating to the deficiencies and discussed any changes or suggestions related to any changes in care for residents with all members of the QAPI committee. An Immediate Jeopardy (IJ) was identified on 03/15/2024. The IJ was provided to the facility on [DATE] at 08:05 PM. While the IJ was removed on 03/18/2024, the facility remained out of compliance at a scope of isolated with a severity level of potential harm because of the facility's need to evaluate the effectiveness of their corrective actions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure Residents had the right to be free from abuse, neglect, and involuntary seclusion for 3 (Resident #23, #43, and #1) of 16 residents reviewed for abuse and neglect. 1. The facility failed to ensure Resident #23 was not neglected when she was left in a dark, locked, shower room alone. 2. The facility failed to protect Resident #23 from abuse by allowing a male resident access to her while in the shower. 3. The facility failed to protect Resident #1 when she wandered into Resident #43's room and Resident #43 hit her (Resident #1) on the head. An Immediate Jeopardy (IJ) was identified on 03/14/2024 at 08:05 PM. While the IJ was removed on 03/18/2024 at 07:26 PM, the facility remained out of compliance at a scope of isolated with potential harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions. This failure denied residents their rights for freedom from abuse, neglect, and involuntary seclusion. The findings included: A record review of Resident #23's admission record, dated 03/14/2024, revealed an admission date of 09/09/2016 with diagnoses of dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), mood disturbance, anxiety, and Onchocerciasis with glaucoma (a disease where a parasite destroyed parts of the eye). A record review of Resident #23's quarterly MDS assessment, dated 02/12/2024, revealed Resident #23 was an [AGE] year-old female admitted for long term care assessed with a BIMS score of 10 which indicated moderate cognitive impairment. Section G of the MDS assessment revealed resident #23 used a wc independently and was Setup or clean-up assistance - for transfers and showers. A record review of Resident #23's care plan, dated 03/14/2024, revealed Resident #23 had a history of rejecting care and or limited permission for assessments and therapies. Further review revealed interventions for avoidance of over-stimulation and avoidance of aggressive peer residents and, Problem Start Date: 07/17/2020 .ADLs (activities of daily life) . Presents with alteration in ADL self-performance & mobility R/T hx (related to history) of Rhabdomyolysis (damaged muscle tissue releases its proteins and electrolytes into the blood. These substances can damage the heart and kidneys and cause permanent disability or even death) & failure to thrive, Dementia, stiff left shoulder, muscle weakness, lack of coordination, muscle wasting and atrophy AEB (as evidenced by) requires staff assistance with all ADL's . Approach Start Date: 01/21/202 1; Resident requires supervision and set up by staff with showers. A record review of Resident #23's nursing notes revealed LVN K documented on 02/06/2024 at 01:12 AM, an incident where Resident #23 was in the shower room bathing alone. LVN K documented she heard screams and shouts and discovered Resident #23 in the darkened shower room and on the floor. LVN K also documented Resident #23 was locked in the shower by another LVN (LVN A) who was re-directing Resident #14 from entering the shower room, while unknowing Resident #14 was in the shower, resident (#23) propel self in wheelchair to shower room. Another Resident (#14) wanting to take a shower and kept wanting to go in shower. Staff (LVN A) unknowing that resident was in shower turned light off and locked door so that other resident would not go into the shower by himself. Resident (#23) calling for help from the shower room and was sitting on the floor. asst. x2 to wheelchair. moving all extremities, refused writer to take vitals and/or check head. resident wanted to be left alone so that she could take her shower. Resident (#23) upset because she could hear other Resident (#14) wanting to go into shower. took other Resident to 200 hall shower room and showered. A record review of the facility's incident reports from June 2023 to March 2024 revealed no evidence for the incident on 02/06/2024 where Resident #23 was showering and Resident #14 attempting to enter the shower room while Resident #23 was bathing. During an interview on 03/13/2024 at 02:30 PM Resident #23 stated she felt unsafe due to Resident #14's sexual harassment behaviors (attempts to get in the shower with her). During an interview on 03/13/24 at 04:30 PM Resident #23 stated on several occasions a man got into the shower with her, to which she would, pull the shower curtain closed, yell and scream at him until staff intervened and re-directed him away. During an interview on 03/13/24 at 02:29 PM LVN K stated she and LVN A were the charge nurses on 02/06/2024 from 06:00 PM to 06:00 AM. LVN K stated Resident #23 had a preference to bathe herself in the shower room early in the mornings around midnight to 01:00 AM. LVN K stated Resident #23's routine was she would gather her clothes and bathing supplies and self-ambulate in her wheelchair to the shower room. LVN K stated on 02/06/2024 around 01:00 AM screams and shouting were heard coming from the shower room. LVN K stated she ran to the shower room and discovered Resident #23 in the dark on the floor. Resident #23 was upset and claimed she was locked in the shower with the lights off. LVN K stated Resident #23 stated she fell in the dark attempting to get out of her wheelchair trying to get to the light switch or door. LVN K stated she spoke with LVN A and learned Resident #14 was attempting to get into the shower room with Resident #23 when LVN A redirected Resident #14 away and LVN A did not recognize Resident #23 was in the shower room. LVN A turned off the light and locked the shower room door to prevent Resident #14 from entering. LVN K stated she had not initiated an incident report for any of Resident #14's sexual harassment incidents towards peer Residents, did not document on the 24 hour reports the sexual harassment behaviors towards peer residents. During an interview on 03/15/24 at 10:59 AM LVN A stated on the early morning of 02/06/2024 around midnight Resident #14 entered the shower room while Resident #23 was showering; although LVN A did not know Resident #23 was in the shower room. LVN A stated she heard Resident #23 in the shower room and entered and redirected him out and away from the shower room and turned off the shower room light and locked the door. LVN A stated she did not check for other residents in the shower room and did not see Resident #23 possibly due to the shower curtain was pulled shut. LVN A stated she had not initiated an incident report for any of Resident #14's sexual harassment incidents towards peer Residents, did not document on the 24 hour reports the sexual harassment behaviors towards peer residents. A record review of Resident #14's admission record dated 03/14/2024, revealed an admission date of 05/10/2023 with diagnoses which included dementia, psychotic disturbance, mood disturbance, anxiety, and alcohol use. A record review of Resident #14's quarterly MDS assessment revealed Resident #14 was a [AGE] year-old male admitted for long term care assessed with a BIMS score of 5 which indicated severe cognitive impairment. During an interview on 03/18/2024 at 05:20 PM the Administrator stated the policy and expectation was for facility staff to ensure residents were supported in their rights to be free from abuse and or neglect, including Resident #23's rights for safety. The Administrator stated he expected a report for all incidents involving resident #23 being secluded and harassed by resident #14 in her shower room. The Administrator stated not having provided any Resident, supports for ensuring their rights could have placed residents at risk for abuse, neglect, exploitation, and or mistreatment. 3. A record review of Resident #43's admission record dated 03/15/2024 revealed an admission date of 04/26/2023 with diagnoses which included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities.). A record review of Resident #43's quarterly MDS assessment, dated 02/21/2024, revealed Resident #43 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 05 out of a possible 15 which indicated severe cognitive impairment . A record review of Resident #43's care plan dated 03/15/2024 revealed Resident #43 had a history of physical aggression towards staff and peer residents in areas of increased stimulation. Resident #43's care plan revealed interventions for monitoring for early signs of aggression and encouragement to attend social activities. A record review of Resident #1's admission record revealed an admission date of 12/14/2014 with diagnoses which included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities.). A record review of Resident #1's quarterly MDS assessment, dated 02/06/2024, revealed Resident #1 was an [AGE] year-old female admitted for long term care and assessed with a BIMS score of 99 which indicated Resident #1 could not participate in the assessment and may be severely cognitively impaired . A record review of Resident #1's care plan dated 03/15/2024 revealed Resident #1 had a history of unsafely wandering in her wheelchair. Further review revealed interventions which included, .Avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents) . Remove resident from other resident's rooms and unsafe situations . A record review of Resident #43's nursing progress notes revealed LVN N documented on 01/01/2024 at 10:35 AM, Resident (#43) in his room watching television (Resident #1) wandered into his room via wheelchair was asked to leave she did not - then he hit her in head just above left ear - resident is forgetful at times - and does not like people going into his room re-educated on importance of not hitting people and keeping his hands to himself - verbalized understanding stated she shouldn't be in my room. A record review of Resident #1's nursing progress notes revealed LVN N documented on 01/01/2024 at 10:32 AM, Resident (#1) propelling self in and out of other residents room went into room (Resident #43's room) was in room and she would not leave and (Resident #42) hit in head just above left ear - no apparent injuries noted resident moved from area and placed in main dining room to participate in activities. A record review of the Texas Unified Licensure Information Portal on 03/18/2024 revealed no evidence for reporting the alleged incident of abuse on 01/01/2024 between Residents #43 and #1. A record review of the facility's incidents and accidents log for the review dates of June 2023 through March 2024 revealed no reporting for the 01/01/2024 alleged peer to peer physical abuse between Resident #1 and Resident #43. During an interview on 03/12/2024 at 10:10 AM LVN N stated on 01/01/2024 at around 10:00 am Resident #1, who was pleasant and confused wandered into Resident #43's room when he began yelling at Resident #1 to get out of his room. LVN N stated she received a report from the CNA who saw Resident #43 hit Resident #1 on the side of the head. LVN N stated she assessed both residents for injuries and or pain and none were evidenced. Resident #43 was counseled and redirected to not hit anyone and Resident #1 was redirected to the living room to participate in activities. LVN N stated she had not generated an incident report, nor documented the incident on the 24-hour report but had documented the incident on the residents nursing progress notes. LVN N stated she had not reported the incident to the physician since there was no injuries . During an interview on 03/15/24 at 10:10 AM the DON stated the facility policy and her expectations were for all allegations of abuse, neglect, exploitation and or mistreatment were to be reported to the abuse, neglect, and exploitation prevention coordinator, the Administrator, herself (the DON), and document on the facility's incident report, and the 24-hour report. The DON stated record reviews of the incident reports and 24-hour reports failed to evidence the allegation of abuse on 01/01/204 for Resident #43's aggressive behavior towards Resident #1 therefore the facility leadership was unaware of the incident and failed to report and investigate the incident . During an interview on 03/15/24 at 11:00 AM the Administrator stated the facility policy, and his expectations were for all allegations of abuse, neglect, exploitation and or mistreatment were to be reported to the abuse, neglect, and exploitation prevention coordinator, (himself), and documented on the facility's incident report, and the 24-hour report. The Administrator stated record reviews of the incident reports and 24-hour reports failed to evidence the allegation of abuse on 01/01/204 for Resident #43 aggressive behavior towards Resident #1 therefore the facility leadership was unaware of the incident and failed to report and investigate the incident . A record review of the facility's Abuse / Neglect policy dated 01/08/2003, revealed, The Resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents should not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff, of other agencies serving the Resident, family members or legal guardians, friends, or other Residents .the facility will provide and ensure the promotion and protection of Resident rights. It is each individuals' responsibility to recognize, report, and promptly follow-up abuse or neglect allegations, suspicion of abuse or neglect, and situations that may constitute abuse or neglect to any Resident in the facility . An Immediate Jeopardy (IJ) was identified on 03/15/2024 at 08:05 PM and presented to the Administrator, a plan of removal was requested. The following Plan of Removal submitted by the facility was accepted on 03/17/2024 at 07:08 AM. Plan of Removal Verification Problem: F600 Sexual Inappropriateness allegation Interventions: Resident #14 placed in 1:1 observation and continues currently Record review of Resident #14's Orders reflected, One on one care d/t behaviors. with a start date of 3/14/2024. Observation and interview on 03/16/2024 at 11:25 AM revealed CNA M was assigned to monitor Resident #14 and has monitored him most of the day. She stated she must document on a sheet of paper every 15 minutes. During an observation on 03/16/2024 at 04:00 PM revealed Resident #14 was asleep in his bedroom while CNA M monitored Resident #14 for safety. Observation on 03/16/2024 at 5:10 PM revealed resident #14 in the dining room being observed by staff while eating a meal. Record review of Resident #14's 1 to 1 documentation sheet, dated 03/16/2024, revealed Resident #14 was continuously monitored for safety and documented every 15 minutes. Interview on 3/18/2024 at 12:49 PM, the Administrator stated that Resident #14 is on 1:1 observation and will continue to be pending further evaluation by physician for effectiveness and necessity. Immediate psychiatric services via telehealth initiated on 3/14/2024 Record review of psychiatric evaluation dated 3/14/2024 at 06:06 PM. Record review of consolidated orders dated March 2023 revealed to be evaluated and treated by Psychiatric Services as needed, dated 3/14/2024. Record review of revealed Resident #14 RP verbally consented over the phone on 3/14/2024 to resident receiving psychiatric services. Interview on 3/18/2024 at 10:59 AM, the Administrator stated that Resident #14 had been seen by psychiatric services. Record review of Progress Note, dated 3/14/2024, reflected that Resident #14 was seen by a psychiatric NP with plan based on residents' diagnosis. STAT CBC, CMP, BMP, TSH, Ammonia level, and UA ordered by Primary Care Provider on 3/14/2024 Record review of Resident #14's orders reflected STAT CBC, CMP, UA ordered by the resident's physician on 3/14/2024. Record review of Resident #14's orders reflected Draw blood for TSH and Ammonia level ordered by the resident's physician on 3/15/2024. Record review of Resident #14's lab drawn on 3/14/2024 reflected CBC UA CMP, TSH and Ammonia with no recommendations signed Administrator/DON on 3/17/2024. New order for Sertraline, ordered by psychiatric services NP on 3/14/2024 Record review of telephone order dated 3/14/2024, start date for 3/22/2024 Sertraline 50 mg, 1 tablet once a day, oral for insomnia, ordered by the resident's PCP. Record review of telephone order dated 3/14/2024, start date 3/14/2024, end date 3/21/2024 for Sertraline 25 mg 1 tablet once a day by mouth with diagnosis of insomnia, ordered by the resident's PCP. Record review of telephone order dated 3/16/2024, start date 3/16/2024, with no end date for Risperidone 1 mg 1 tablet twice a day by mouth with diagnosis of anxiety disorder. Record review of telephone order dated 3/16/2024, start date 3/16/2024, with no end date for Melatonin 5 mg 2 tablets once daily at bedtime with diagnosis of insomnia. Psychiatric services to be offered to Resident #23 in order to provide for any mental or emotional anguish created by any interactions with Resident #14 Record review of progress note dated 3/16/2024 at 4:29 PM, LVN K spoke with Resident #23's RP regarding the incident on 2/6/2024 as well as the incident on 3/12/2024. Record review of progress note dated 3/15/2024 at 11:43 AM revealed the Social Worker, spoke with Resident #23 who declined psychiatric services. Further review of the progress note revealed the Social Worker spoke with the MPOA regarding the incident on 2/6/2024 and the MPOA stated she did not want the resident to receive psychiatric services at this time. Abuse and Neglect prevention in-service for all facility staff initiated and completed by Admin/DON/Compliance Nurse on 3/14/2024 A record review of the facility's employee roster dated, 03/16/2024 revealed 74 employees. 57% of employees, 44 of the 74, were interviewed to confirm receiving in-services for IJ F600. A record review of the facility's employee roster dated, 03/16/2024 revealed of the 74 employees, 10 were nurses. A sample of 8 nurses, 5 on day shift and 3 on night shift, were interviewed to confirm receiving in-services for IJ F600. A record review of the facility's employee roster dated, 03/16/2024 revealed of the 74 employees 17 were CNAs. A sample of 8 CNAs, 5 on day shift and 3 on night shift, were interviewed to confirm receiving in-services for IJ F600. Interview on 3/17/2024 at 12:30 PM, LVN N revealed that the in-service consisted of abuse and neglect prevention, complaints, when and where to file grievances and who to report grievances to. Interview on 3/18/2024 at 12:54 PM, the Administrator stated most staff have been in-serviced and those who have not will be in-serviced before resuming duties. The following in-services were initiated on 3/14/2024: All available staff will be in-serviced by close of 3/15/2024 mandatory staff meeting, to be held at 1400 . Any staff member not present or in-serviced at close of mandatory meeting, will not be allowed to assume their duties until in-serviced. Administrator/Designee to ensure that in-service training has been done for all staff. oAll Staff Abuse/Neglect Abuse/Neglect Reporting Who to Report Abuse/Neglect to Incident reporting, to include behaviors, to Admin/Physicians. A record review of the facility's employee roster dated, 03/16/2024 revealed 71 employees. 57% of employees, 44 of the 74, were interviewed to confirm receiving in-services for IJ F600, Prevention and Reporting of Abuse, Neglect, and Exploitation. A record review of the facility's employee roster dated, 03/16/2024 revealed of the 71 employees, 10 were nurses. A sample of 8 nurses, 5 on day shift and 3 on night shift, were interviewed to confirm receiving in-services for IJ F600, Prevention and Reporting of Abuse, Neglect, and Exploitation. A record review of the facility's employee roster dated, 03/16/2024 revealed of the 71 employees 17 were CNAs. A sample of 8 CNAs, 5 on day shift and 3 on night shift, were interviewed to confirm receiving in-services for IJ F600, Prevention and Reporting of Abuse, Neglect, and Exploitation. Record review of document titled Staff in-service, dated 3/15/2024, with the topic Abuse/Neglect Inservice revealed 46 of 71 staff signed off as having completed the in-service. Interview on 3/17/2024 at 3:15 PM, the MDS Coordinator revealed that not all staff report to physicians or emergency contacts, and that only 11 nurses would be responsible with reporting any events to physicians and emergency contacts. Record review of document titled In-Service Training, dated 3/15/2024, with the topic The Importance of Reporting Events to Physicians and Emergency Contacts revealed 7 of 11 nursing staff signed off as having completed the in-service. Record review of document titled Staff in-service, dated 3/15/2024, with the topic Any staff who is turning off the lights and shutting the doors to any room shall check the room for any other persons prior to turning off the lights and shutting the door. Further review of this in-service revealed 49 of 71 staff signed off as having completed the in-service. Interview on 3/17/2024 at 12:30 PM, LVN N revealed that the in-service consisted of abuse and neglect prevention, complaints, when and where to file grievances and who to report grievances to. Interview on 3/17/2024 at 12:33 PM, CNA J stated that the in-service consisted of ensuring no residents are locked in shower rooms and monitoring showers. Interview on 3/17/2024 at 12:34 PM, CNA I stated that the in-service she received detailed ensuring that grievances are recognized and reported. Interview on 3/17/2024 at 1:35 PM, CNA P stated the in-service detailed abuse, neglect, exploitation, and discussing any of these concerns with the administrator. Interview on 3/17/2024 at 2:04 PM, LVN K stated her most recent in-service consisted of abuse and neglect training, to include specifics about what is abuse and neglect. Interview on 3/17/2024 at 3:00 PM, LVN R stated the in-service she had most recently consisted of ensuring residents complaints were recognized and grievances were filed. Interview on 3/17/2024 at 4:13 PM, CNA O stated the in-service they completed on 3/15/2024 consisted of reporting grievances and who to give them to. Interview on 3/17/2024 at 4:23 PM, LVN T stated the most recent in-service was about abuse and neglect and reporting any abuse or neglect to supervisors. Interview on 3/18/2024 at 12:54 PM, the Administrator stated most staff have been in-serviced and those who have not will be in-serviced before resuming duties. Monitoring Administrator/DON to review findings of psychiatric NP and ensure implementation of treatment plan if found to be necessary. DON to ensure care plans have been updated for resident #14 as well as resident #23. Record review of Progress Note, dated 3/14/2024, reflected that Resident #14 was seen by a psychiatric NP. Further review reveals the DON and Administrator signed the document as Reviewed on 3/14/2024. Interview on 3/18/2024 at 10:59 AM, the Administrator stated that Resident #14 had seen the psychiatric NP and that he and the DON had reviewed the findings. He further stated that he, along with the DON, reviewed the psychiatric services progress note and will continue to do so after any psychiatric services appointment. Administrator will work with social services to develop a plan of action to find suitable placement for resident #14 in order to provide a better, more appropriate level of care, to provide a safer environment for resident #14 as well as all others residing in the facility Interview on 3/18/2024 at 12:58 PM, the Administrator stated that the social worker has put in referrals for 3 places and continues to search for placement. The residents RP's have declined some placements for the resident. Record review of Resident #14's care plan revealed, Problem: Administrator issued 30 Day Discharge Notice has been issued effective from 3/15/24. with interventions of Social services to send referrals to facilities that will meet Resident #14's needs. Thirty-Day Notice of discharge to be issued to resident #14, resident #14's representative, and representative of long-term care ombudsman program on 3/15/2024 Record review of document titled 30 Day Discharge Notice reflected a 30 day discharge notification provided to the residents representative on 3/15/2024. Record review of email to Ombudsman reflected notification of 30-day discharge notice on 3/15/2024. Record review of Resident #14's care plan revealed, Problem: Administrator issued 30 Day Discharge Notice has been issued effective from 3/15/24. with interventions of Social services to send referrals to facilities that will meet Resident #14 's needs. Interview on 3/18/2024 at 1:04 PM, the Administrator stated the family was provided with a 30-day notice to Resident #14, and the ombudsman was provided with the 30-day notice as well. The QAPI committee will review findings monthly for no less than 90 days and makes changes as needed Interview on 3/18/2024 at 10:36 AM, the Administrator stated that during QAPI they will follow a template relating to the deficiencies and discuss any changes or suggestions relating to any changes in care for residents with all members of the QAPI committee. An Immediate Jeopardy (IJ) was identified on 03/14/2024 at 08:05 PM. While the IJ was removed on 03/18/2024 at 07:26 PM, the facility remained out of compliance at a scope of isolated with potential harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure that Residents environments remained as free from accident and hazards as possible, and each resident received adequate supervision and assistive devices to prevent accidents for 2 of 16 residents (Residents #14 and #23) reviewed for environments free from accident and hazards. 1. The facility failed to check a shower room prior to turning off the shower room lights and locking the door; Resident #23 was in the shower room and left alone in a dark with the door locked and fell. 2. The facility failed to ensure storage rooms containing equipment to draw blood for lab work, such as needles and syringes, were secured. This failure could place residents at risk for involuntary seclusion and injuries as well as injuries from syringe needles. An Immediate Jeopardy (IJ) was identified on 03/14/2024 at 08:05 PM. While the IJ was removed on 03/18/2024 at 07:26 PM, the facility remained out of compliance at a scope of isolated with potential harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions. The findings included: 1. A record review of Resident #23's admission record, dated 03/14/2024, revealed an admission date of 09/09/2016 with diagnoses of dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), mood disturbance, anxiety, and Onchocerciasis with glaucoma (a disease where a parasite destroyed parts of the eye). A record review of Resident #23's quarterly MDS assessment, dated 02/12/2024, revealed Resident #23 was an [AGE] year-old female admitted for long term care assessed with a BIMS score of 10 which indicated moderate cognitive impairment. A record review of Resident #23's care plan, dated 03/14/2024, revealed Resident #23 had a history of rejecting care and or limited permission for assessments and therapies. Further review revealed interventions for avoidance of over-stimulation and avoidance of aggressive peer residents and, Problem Start Date: 07/17/2020 .ADLs (activities of daily life) . Presents with alteration in ADL self-performance & mobility R/T hx (related to history) of Rhabdomyolysis (damaged muscle tissue releases its proteins and electrolytes into the blood. These substances can damage the heart and kidneys and cause permanent disability or even death) & failure to thrive, Dementia, stiff left shoulder, muscle weakness, lack of coordination, muscle wasting and atrophy AEB (as evidenced by) requires staff assistance with all ADL's . Approach Start Date: 01/21/202 1; Resident requires supervision and set up by staff with showers. A record review of Resident #14's admission record dated 03/14/2024, revealed an admission date of 05/10/2023 with diagnoses which included dementia, psychotic disturbance, mood disturbance, anxiety, and alcohol use. A record review of Resident #14's quarterly MDS assessment revealed Resident #14 was a [AGE] year-old male admitted for long term care assessed with a BIMS score of 5 which indicated severe cognitive impairment. A record review of Resident #23's nursing notes revealed LVN K documented on 02/06/2024 at 01:12 AM, an incident where Resident #23 was in the shower room bathing alone. LVN K documented she heard screams and shouts and discovered Resident #23 in the darkened shower room and on the floor. LVN K also documented Resident #23 was locked in the shower by another LVN (LVN A) who was re-directing Resident #14 from entering the shower room, while unknowing Resident #14 was in the shower, resident (#23) propel self in wheelchair to shower room. Another Resident (#14) wanting to take a shower and kept wanting to go in shower. Staff (LVN A) unknowing that resident was in shower turned light off and locked door so that other resident would not go into the shower by himself. Resident (#23) calling for help from the shower room and was sitting on the floor. asst. x2 to wheelchair. moving all extremities, refused writer to take vitals and/or check head. resident wanted to be left alone so that she could take her shower. Resident (#23) upset because she could hear other Resident (#14) wanting to go into shower. took other Resident to 200 hall shower room and showered. A record review of the facility's incident reports from June 2023 to March 2024 revealed no evidence for the incident on 02/06/2024 where Resident #23 was showering and Resident #14 trespassed and intruded in her privacy and safety while bathing. During an interview on 03/13/2024 at 02:30 PM Resident #23 stated she felt unsafe due to Resident #14's sexual harassment behaviors (attempts to get in the shower with her). During an interview on 03/13/24 at 04:30 PM Resident #23 stated on several occasions a man got into the shower with her, to which she would, pull the shower curtain closed, yell and scream at him until staff intervened and re-directed him away. During an interview on 03/13/24 at 02:29 PM LVN K stated she and LVN A were the charge nurses on 02/06/2024 from 06:00 PM to 06:00 AM. LVN K stated Resident #23 had a preference to bathe herself in the shower room early in the mornings around midnight to 01:00 AM. LVN K stated Resident #23's routine was she would gather her clothes and bathing supplies and self-ambulate in her wheelchair to the shower room. LVN K stated on 02/06/2024 around 01:00 AM screams and shouting were heard coming from the shower room. LVN K stated she ran to the shower room and discovered Resident #23 in the dark on the floor. Resident #23 was upset and claimed she was locked in the shower with the lights off. LVN K stated Resident #23 stated she fell in the dark attempting to get out of her wheelchair trying to get to the light switch or door. LVN K stated she spoke with LVN A and learned Resident #14 was attempting to get into the shower room with Resident #23. LVN A redirected Resident #14 away and LVN A did not recognize Resident #23 was in the shower room. LVN A turned off the light and locked the shower room door to prevent Resident #14 from entering. LVN K stated she had not initiated an incident report for any of Resident #14's sexual harassment incidents towards peer Residents, did not document on the 24 hour reports the sexual harassment behaviors towards peer residents. During an interview on 03/15/24 at 10:59 AM LVN A stated on the early morning of 02/06/2024 around midnight Resident #14 entered the shower room while Resident #23 was showering; although LVN A did not know Resident #23 was in the shower room. LVN A stated she heard Resident #23 in the shower room and entered and redirected him out and away from the shower room and turned off the shower room light and locked the door. LVN A stated she and LVN B spoke and concluded the chain of events. LVN A stated she did not check for other residents in the shower room and did not see Resident #23 possibly due to the shower curtain was pulled shut. LVN A stated she had not initiated an incident report for any of Resident #14's sexual harassment incidents towards peer Residents, did not document on the 24 hour reports the sexual harassment behaviors towards peer residents. 2. Observation and interview on 3/11/2024 at 10:55 AM revealed the storage room behind Nurses Station 1 was unlocked and the door was open. Further observation revealed phlebotomy products in the storage room to include needles, syringes, and empty vials for collecting blood. The Administrator approached at this time, and stated to surveyor that the door should be closed and was unsure if the door should be locked. LVN K then approached and stated she was not sure whether the door should be closed or locked. During an observation and interview on 3/13/2024 at 02:45 PM revealed the storage room behind Nurses Station 2 was unlocked and the door was open. Further observation revealed phlebotomy products in the storage room to include needles, syringes, and empty vials for collecting blood. LVN N stated that she was not sure if the door should be locked, and that she had been told that day to ensure the door was closed. LVN N also stated that the needles and other phlebotomy equipment have always been in the storage room with the door opened and unlocked. During an observation on 03/14/2024 at 12:30 PM, the medical equipment storage room behind Nurses Station 1 was observed to have the door open with phlebotomy equipment visible from the hallway. There were no staff present for approximately 15 minutes while the surveyor observed. During an interview on 03/15/2024 at 05:15 PM, the DON stated the storage room doors behind each nursing station should be closed and was unsure if they should be locked. The DON stated the risk could include residents getting into storage rooms and hurting themselves. Record review of facility policy titled Storage of Medications stated, Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. A record review of the facility's Accidents and Incidents - Investigating and Reporting, dated July 2017, revealed, All accidents or incidents involving residents, employees, visitors, vendors, etcetera, occurring on our premises shall be investigated and reported to the Administrator .the following data, as applicable, shall be included on the report of incident accident form; the date and time the accident or incident took place; the nature of the injury illness; where the accident or incident took place; the names of witnesses and their accounts of the accident or incident; the injured person's account of the accident or incident; the time the injured person's attending physician was notified, as well as the time the position responded and his or her instruction . An Immediate Jeopardy (IJ) was identified on 03/15/2024 at 08:05 PM and presented to the Administrator, a plan of removal was requested. The following Plan of Removal submitted by the facility was accepted on 03/17/2024 at 07:08 AM. Plan of Removal Problem: F689 Inadequate supervision to prevent accidents allegation Interventions: Resident #23 insists on having her privacy during shower times; staff is to assist in setting up resident for self-showering to include, but not limited to, assisting with transfers to and from wheelchair to shower chairs. Record review of care plan dated 3/16/2024 for Resident #23 revealed Problem: [Resident #23] desires privacy/modesty during showers. With interventions including Staff monitoring showers will be stationed outside the shower room door in order to provide for residents desire for modesty and privacy., and Staff monitoring shower will provide security from any intrusion by other staff or residents seeking entrance to shower room. Further review of the care plan revealed, staff is to assist in setting up resident for self-showering to include but not limited to transferring to and from wheelchair to shower chair. Interview on 3/17/2024 at 5:03 PM, CNA L stated she works overnight shifts and was informed that during Resident #23's shower, she would need to assist the resident with anything she may need in setting up her showers. Interview on 3/18/2024 at 12:55 PM, the Administrator stated that they put in place measures to ensure resident #23's privacy during her showers to include a nursing staff member ensuring no one enters the room, assists the resident as necessary, and monitor. Resident #23's shower time will be monitored by a dedicated nursing staff member at all times while she is showering. Interview on 3/17/2024 at 5:03 PM, CNA L stated she works overnight shifts and was informed that during Resident #23's shower, she or another nursing staff member would be required to monitor during Resident #23's shower. Interview on 3/18/2024 at 12:55 PM, the Administrator stated that they put in place measures to ensure resident #23's privacy during her showers to include a nursing staff member monitoring during all times in which the resident is showering. Staff monitoring showers will be stationed outside the shower room door in order to provide for resident #23's desire for modesty and privacy. Interview on 3/17/2024 at 5:03 PM, CNA L stated she worked overnight shifts and was informed that during Resident #23's shower, she or another nursing staff member would be required to monitor by standing outside the shower room door while the resident was showering to provide privacy to the resident. Interview on 3/18/2024 at 12:55 PM, the Administrator stated that they put in place measures to ensure resident #23's privacy during her showers to include a nursing staff member stationed outside the shower room door. Staff monitoring Resident #23's showers will provide security from any intrusion by other staff or residents seeking entrance to shower room. Interview on 3/17/2024 at 5:03 PM, CNA L stated she worked overnight shifts and was informed that during Resident #23's shower, she or another nursing staff member would be required stand outside the shower room door while the resident was showering to provide privacy to the resident and ensure no other residents enter the shower room. Interview on 3/18/2024 at 12:55 PM, the Administrator stated that they put in place measures to ensure resident #23's privacy during her showers to include a nursing staff member stationed outside the shower room door. We have changed out the doorknobs to the showers, and they are now classroom style locks, which automatically lock from the outside, and cannot be locked from the inside. Residents do not have access to the keys to these locks. Resident #23 will not be able to enter the shower area without a staff member opening the door for her. Observation of Shower room near Nurses Station 1 (of 2) on 3/16/2024 at 5:02 PM revealed doorknobs to the shower room automatically lock from the outside. Further observation revealed the door cannot be locked from the inside. Observation on 3/16/2024 at 5:15 PM revealed Shower Room in 200 hall had doorknobs to the shower room that automatically lock from the outside. Further observation revealed that the doors cannot be locked from the inside. Observation on 3/16/2024 at 5:25 PM revealed all shower room doors at the facility no longer have keys that unlock the shower room door visible or available to residents. These tasks will be added to staff's ADL Flow Chart/POC, which will in turn be monitored by DON/ Designee Record review of Order, start date 3/17/2024 with no end date reflected Ensure Privacy during shower time as follows: 1. Dedicated nursing staff member to monitor and be stationed outside shower room door in order to provide modesty/privacy. 2. Ensure security from any intrusion by other staff or residents seeking entrance to shower room on Monday, Wednesday, and Friday between 6:00 PM and 6:00 AM. Record review of Medication Administration Record, dated 3/18/2024, reflected the above order, once daily on Monday, Wednesday, and Friday between 6:00 PM and 6:00 AM with a start date of 3/17/2024. All shower rooms to have LED night lights installed on 3/15/2024. Observation on 3/16/2024 at 5:07 PM of Shower Room near Nurses Station 1 (of 2) revealed night light mounted near shower that activates when absence of light is detected through a sensor in the light. Observation on 3/16/2024 at 5:16 PM of Shower Room in 200 hall revealed night lights mounted in the shower room that activate when the absence of light is detected through a sensor in the light. Interview on 3/16/2024 at 5:29 PM, the Maintenance Director revealed the LED night lights installed in both shower rooms contain an internal battery, so if the power to them fails or is disrupted, they will remain on so long as the battery is charged. The following in-services were initiated on 3/14-16/2024: All available staff will be in-serviced by close of 3/15/2024 mandatory staff meeting, to be held at 1400 . Any staff member not present or in-serviced at close of mandatory meeting, will not be allowed to assume their duties until in-serviced. Administrator will ensure that trainings have been completed by keeping an in-service log that spells out the names of the staff members who have had trainings and have signed off on their attendance of said trainings. oAll Staff Abuse/Neglect Abuse/Neglect Reporting Who to Report Abuse/Neglect to Incident reporting to Admin/Physicians Importance of staff checking shower rooms for residents before turning off lights and locking doors A record review of the facility's employee roster dated, 03/16/2024 revealed 71 employees. 57% of employees, 44 of the 74, were interviewed to confirm receiving in-services for IJ F689. A record review of the facility's employee roster dated, 03/16/2024 revealed of the 71 employees, 10 were nurses. A sample of 8 nurses, 5 on day shift and 3 on night shift, were interviewed to confirm receiving in-services for IJ F689. A record review of the facility's employee roster dated, 03/16/2024 revealed of the 71 employees 17 were CNAs. A sample of 8 CNAs, 5 on day shift and 3 on night shift, were interviewed to confirm receiving in-services for IJ F689. Record review of document titled Staff in-service, dated 3/15/2024, with the topic Abuse/Neglect Inservice revealed 46 of 71 staff signed off as having completed the in-service. Interview on 3/17/2024 at 3:15 PM, the MDS Coordinator revealed that not all staff report to physicians or emergency contacts, and that only 11 nurses would be responsible with reporting any events to physicians and emergency contacts. Record review of document titled In-Service Training, dated 3/15/2024, with the topic The Importance of Reporting Events to Physicians and Emergency Contacts revealed 7 of 11 nursing staff signed off as having completed the in-service. Record review of document titled Staff in-service, dated 3/15/2024, with the topic Any staff who is turning off the lights and shutting the doors to any room shall check the room for any other persons prior to turning off the lights and shutting the door. Further review of this in-service revealed 49 of 71 staff signed off as having completed the in-service. Interview on 3/17/2024 at 12:30 PM, LVN N revealed that the in-service consisted of abuse and neglect prevention, complaints, when and where to file grievances and who to report grievances to. Interview on 3/17/2024 at 12:33 PM, CNA J stated that the in-service consisted of ensuring no residents are locked in shower rooms and monitoring showers and reporting to nursing staff . Interview on 3/17/2024 at 12:34 PM, CNA I stated that the in-service she received detailed ensuring that grievances are recognized and reported and checking shower rooms for residents. Interview on 3/17/2024 at 1:35 PM, CNA P stated the in-service detailed abuse, neglect, exploitation, and discussing any of these concerns with the administrator. Interview on 3/17/2024 at 2:04 PM, LVN K stated her most recent in-service consisted of abuse and neglect training, to include specifics about what is abuse and neglect, changes in conditions, and when to notify family and physicians. Interview on 3/17/2024 at 3:00 PM, LVN R stated the in-service she had most recently consisted of ensuring residents' complaints were recognized and grievances were filed. Interview on 3/17/2024 at 4:13 PM, CNA O stated the in-service they completed on 3/15/2024 consisted of reporting grievances and who to give them to. Interview on 3/17/2024 at 4:23 PM, LVN T stated the most recent in-service was about abuse and neglect and reporting any abuse or neglect to supervisors, as well as reporting to physicians. Monitoring Psychiatric services to be offered to Resident #23 in order to provide for any mental or emotional anguish created by being left in shower room with lights off. Record review of progress note dated 3/16/2024 at 4:29 PM, LVN K spoke with Resident #23's RP regarding the incident on 2/6/2024 as well as the incident on 3/12/2024. Record review of progress note dated 3/15/2024 at 11:43 AM revealed the Social Worker, spoke with Resident #23 who declined psychiatric services. Further review of the progress note revealed the Social Worker spoke with the MPOA regarding the incident on 2/6/2024 and the MPOA stated she did not want the resident to receive psychiatric services at this time. The QAPI committee will review findings monthly for no less than 90 days and makes changes as needed. Interview on 3/18/2024 at 10:36 AM, the Administrator stated that during QAPI they will follow a template relating to the deficiencies and discuss any changes or suggestions relating to any changes in care for residents with all members of the QAPI committee. DON to ensure care plans have been updated for resident #23 to reflect that she will have staff monitoring her during shower times. Record review of care plan dated 3/16/2024 for Resident #23 revealed Problem: [Resident #23] desires privacy/modesty during showers. With interventions including Staff monitoring showers will be stationed outside the shower room door in order to provide for residents desire for modesty and privacy., and Staff monitoring shower will provide security from any intrusion by other staff or residents seeking entrance to shower room. Further review of the care plan revealed, staff is to assist in setting up resident for self-showering to include but not limited to transferring to and from wheelchair to shower chair. An Immediate Jeopardy (IJ) was identified on 03/14/2024 at 08:05 PM. While the IJ was removed on 03/18/2024 at 07:26 PM, the facility remained out of compliance at a scope of isolated with risk for potential harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions.