Based on interview and record review it was confirmed that the facility failed to have policies and procedures in place to assure the prevention and appropriate response to any incident. Findings include but not limited to:

During an unannounced site visit on 6/23/22, Staff #3 (S3) indicated that Resident #3 (R3) was left on the toilet for 30 minutes which caused her pain on 8/29/2021.

Compliance Specialist (CS) requested and reviewed all incident reports dated 7/21/2021 through 6/12/2022 related to R3 and an incident report for the above incident was not included.

The facility was unable to produce an incident report for this event and could not confirm that an investigation of this event had been completed and was not self-reported to Adult Protective Services (APS).

These findings were reviewed with and acknowledged by Staff #1-#3 (S1-S3)

Facility Plan of Correction: Review of Abuse reporting guide by Executive Director and Resident Care Coordinators. Facility will report any incidences involving medication errors, injuries of unknown origin to Adult Protective Services for them to rule out abuse/neglect in addition to conducting their own investigations in both RCF and endorsed memory care unit.