Every finding on record at Avir at Town Creek

Based on observation, interview, and record review, the facility failed to ensure that alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse for 2 of 7 residents (Residents #1 and #2) reviewed for abuse. The facility failed to report abuse on 2/4/26 at approximately 3:38 p.m. when Resident #2 allegedly struck Resident #1 in the face with a closed fist. This failure could place residents at risk of abuse, emotional distress, and loss of dignity.Findings included: 1.Record review of an admission Record, dated 2/18/26, for Resident #1 indicated a [AGE] year-old male, readmitted [DATE], with diagnoses of autistic disorder (impacts how person perceives and socializes with others), muscle wasting and atrophy (weakness from disuse), and diabetes mellitus. Record review of a quarterly MDS, dated [DATE], indicated Resident #1 was rarely or never understood and a BIMS was not conducted. Record review indicated he required partial assistance with toileting hygiene, upper body dressing, lower body dressing, and personal hygiene. Further record review indicated Resident #1 required substantial assistance with eating, oral hygiene, and putting on/taking off footwear. Record review of a comprehensive care plan, dated 2/4/26, indicated Resident #1 had behavioral symptoms related to severe intellectual disability which included biting himself and yelling out when agitated. Further record review indicated interventions included maintaining a calm environment, using calming techniques, and calming words with resident and removing the resident from the area if the behavior interfered with others. 2. Record review of an admission Record, dated 2/18/26, for Resident #2 indicated an [AGE] year-old male, admitted [DATE] with diagnoses of unspecified dementia (altered cognition) and psychotic disorder with delusions due to known physiological condition. Record review of an admission MDS, dated [DATE], indicated Resident #2 had severely impaired cognition with a BIMS of 4. The MDS indicated Resident #2 required supervision with eating, partial assistance with oral hygiene, upper body dressing, lower body dressing, and personal hygiene. Further review of the MDS indicated he required substantial assistance with toileting hygiene, shower/bathing, and putting on/taking off footwear with no noted physical or behavioral symptoms directed toward others. Record review of a comprehensive care plan, dated 2/4/26, indicated Resident #2 was at risk for impaired social interactions related to mood disorder and psychotic disorder. Record review indicated care planned interventions included administer medications as ordered and monitor for side effects and effectiveness. Review of an incident report for physical aggression, dated 2/4/26 at 3:38 p.m., indicated LVN A was assisting a resident in their room when she heard someone call out for the nurse. LVN A exited the room and saw Resident #2 make contact with another resident (Resident #1) on the cheek. LVN A separated the two residents from each other and notified the DON, NP, and RP. No distress or injuries were noted during the assessment. During an interview on 2/18/26 at 10:55 a.m., LVN A said she witnessed the resident-to-resident altercation between Residents #1 and #2. LVN A said she was coming out of a room, after assisting another resident, and saw Resident #2 appeared to hit Resident #1 in the face with a closed fist. LVN A said she separated the residents and notified the DON, NP, and RP. LVN A said she conducted a skin assessment on Resident #1 and noted no injuries. LVN A said Resident #1 was moved off the secured unit away from Resident #2. LVN A said Resident #1 was nonverbal and did not appear to be emotionally distressed following the incident. LVN A said she had training in the form of in-services which covered reporting abuse. LVN A said she reported the incident immediately to the DON but was unsure if the ADM was informed. Record review of a skin assessment, dated 2/4/29 at 3:29 p.m. completed by LVN A, indicated Resident #1 had no alterations in skin integrity. During an interview on 2/18/26 at 11:30 a.m., the DON said she was familiar with the resident-to-resident altercation involving Residents #1 and #2. The DON said she and the ADM discussed the incident and determined it was not reportable due to the residents involved limited cognition he could not willfully act. The DON said the facility did investigate the incident and took measures to ensure resident safety including increased supervision and psychiatric services. The DON said it was determined that Resident #1 exhibited behaviors (loud noises) which appeared to be triggering to Resident #2. During an interview and observation on 2/18/26 at 1:58 p.m., Resident #2 was observed in his room, lying in bed. Resident #2 presented clean and well-groomed with no noted offensive odor. Resident had no noted marks, bruises, or skin tears. Resident #2 opened his eyes and looked toward the surveyor but did not answer interview questions. During an interview and observation on 2/18/26 at 2:15 p.m., Resident #1 was observed in his room, sitting in a wheelchair. Resident #1 presented clean and well groomed with no offensive odors. Resident had no suspicious marks, skin tears, or bruising noted. Resident #1 did not respond to interview questions. During an interview on 2/18/26 at 2:30 p.m., the ADM said she was notified of the resident-to-resident altercation involving Residents #1 and #2 the day of the incident. The ADM said she did not believe the incident required reporting to the state due to Resident #2's cognition making him unable to willfully act. The ADM said she planned on in-servicing all staff again on abuse and reporting requirements. During interviews conducted on 2/18/26 between 10:00 a.m. and 1:00 p.m. all staff interviewed said they had training covering abuse and reporting requirements. All staff interviewed said they would report witnessed or suspected abuse to the ADM immediately. Staff interviewed included (CNA B, LVN C, CNA D, Housekeeping Supervisor). Record review of facility in-service titled, Abuse, Neglect, and Misappropriation, dated 1/7/2026, indicated 21 nursing staff members attended the training, including the DON. Record review of a facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 2021, indicated .Residents have the right to be free from abuse, neglect, misappropriation of property and exploitation. Record review of a facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated 2022, indicated, .If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law and HHSC reporting guidelines.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 Kitchen reviewed for food safety requirements and kitchen sanitation.The facility failed to ensure all food items stored in the refrigerator and freezer were dated and labeled.These failures could place residents at risk of foodborne illness and food contamination.Findings included:During an observation on 08/12/2025 at 8:28am-9:10am, the following undated and unlabeled items was identified by the dietary manager in the refrigerator and freezer:Freezer*1-bag of 12 premade waffles with no date or label.*3-gallon bags of precooked chicken with no date or label.*1-gallon bag of uncooked chicken no date or label.*1-gallon bag of breaded squash with no date or labelRefrigerator**9-pre-made fruit cups with no date or label.*2-5lb rolls of ground beef with no date or label.*1-6lb ham with no date or label.During an interview on 08/13/2025 at 9:55 AM with the DM he said food should be dated and labeled when it's opened and placed in a different container. He said when food comes into the facility it should be immediately dated and labeled and stored in the refrigerator, freezer or pantry. He said no dates and labels could cause the staff to cook something that is contaminated, out of date and cause illness to residents. During an interview on 08/13/2025 at 10:06 AM with Cook/Aide E she said dating and labeling should happen when storing leftovers and when food comes into to the kitchen it should be dated and labeled immediately. She said if food was not dated and labeled staff would not know the expiration date and may not be able to identity the food item. She said not dating and labeling food items could cause the staff to serve the wrong food and may cause sickness to the residents. During an interview on 08/13/2025 at 10:12 AM with Cook/Aide F, she said food should be dated and labeled upon deliver and prior to storing the food item. She said if staff opens food they should date and label the item with an open date and expiration date. She said if there was no date or label on all food products in the kitchen the staff could use expired foods and cause residents to get sick.During an interview on 08/13/2025 at 10:17 AM with the Dietitian she said food should be dated and labeled when it is received into the kitchen. She said staff should date and label food items when staff opens or removes food from its original container and when storing leftovers. She said when food was not dated and labeled correctly staff would not know the date it was delivered, the date it expires or the date it was opened. She said with no date or label to identify the item or expiration date the food could be bad and should not be served to the residents. She said if food was expired or spoiled it could cause food borne illness. During an interview on 08/13/2025 at 10:45 AM with the Administrator she said staff should be dating and labeling all foods when it was delivered in the kitchen. She said if there was left over food or if food was removed from its original container kitchen staff should apply a new label and date with the name of the item and the expiration date. She said if food was not dated and labeled the staff could serve expired foods or the wrong foods and could cause a severe allergic reaction to a resident or make residents ill. Record review of a facility policy titled Food Storage dated 10/01/2018, revised 06/01/2019 indicated, .It is the policy of this facility to ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. 2.c. Refrigerator, food should be dated, labeled and sealed. 3.c. Freezers, Items should be labeled and dated. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. d. Dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food .Record review of the Food and Drug Code dated 2022 indicated.3-602 Labeling3-602.11 Food Labels.(A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified inLAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, markingdevices, and containers.(B) Label information shall include:(1) The common name of the FOOD, or absent a common name, anadequately descriptive identity statement; 3-201.11 Compliance with Food Law.(C) PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18

Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Resident's #2 and #3) and 2 of 5 staff (CNA B and LVN G) reviewed for infection control. 1.The facility failed to ensure CNA B changed gloves and washed or sanitized her hands when providing care to Resident #2 on 8/12/2025.2. The facility failed to ensure LVN G changed gloves and washed or sanitized her hands during wound care to Resident #3 on 08/12/2025.These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings included: 1. Record review of a Resident Face Sheet for Resident #2 dated 8/12/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of schizoaffective disorder (a mental illness that can cause hallucinations and delusions), atherosclerotic heart disease (plaque buildup that causes narrowing and limited blood flow in the blood vessels), and polyosteoarthritis (joint stiffness and pain in multiple areas).Record review of Resident #2's Quarterly MDS assessment dated [DATE] indicated she had moderate impairment in thinking with a BIMS score of 11. She required substantial/maximal assistance with personal hygiene and was always incontinent of bowel/bladder.Record review of a care plan for Resident #2 dated 12/31/2024 indicated she had a self-care deficit related to schizoaffective disorder with intervention for two staff to assist with bed mobility.During an observation on 8/12/2025 at 10:18 AM, CNA B was in the room of Resident #2 to provide incontinent care. She sanitized her hands and donned (put on) gloves. She pulled the bed linens down to the foot of the bed and opened Resident #2's brief and pulled it in between her thighs. CNA B had supplies in a plastic bag that were on an overbed table. She removed wipes from the plastic bag and wiped Resident #2's abdomen and down both inner thighs with a wipe and placed it inside the brief. She removed another wipe and wiped down the middle from front to back and placed the wipe inside the dirty brief. Resident #2 was rolled onto her left side, and CNA B removed a wipe and wiped the resident's rectal area from front to back. She rolled the dirty brief under the resident's back and placed a clean brief under the resident's buttocks. She rolled the resident to her right side and removed the brief and placed it in the trash. She removed another wipe and wiped the rectal area again and placed the wipe in the trash. She applied barrier cream to the perineal area and secured the clean brief. Resident was covered back up with the linens. CNA B removed the glove from her right hand and placed it in her left hand and grabbed the bed control and repositioned the bed in a low position. She removed the glove from her left hand and placed both gloves in the trash. She exited the room and took the trash to the dirty linen closet and sanitized her hands.During an interview on 8/12/2025 at 10:20 AM, CNA B said she had been employed at the facility since April 2025. She said during the care provided to Resident #2 she should have changed her gloves when she changed tasks from dirty to clean. She said she was nervous and forgot to change her gloves. She said she had been trained to change gloves when changing from dirty to clean and to sanitize or wash hands between glove changes. She said there was a risk for contamination if staff did not change gloves or sanitize their hands between gloves changes. Record review of a CNA Proficiency Audit for CNA B dated 5/7/2025 indicated she was satisfactory with female perineal care and infection control awareness.2. Record review of a face sheet for Resident #3 dated 2/20/2025 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Cerebral Infraction (stroke), Muscle Weakness, Non-pressure chronic ulcer of other part of left lower leg (wound), Hemiplegia and hemiparesis (paralyzed on one side of the body).Record review of a Quarterly MDS Assessment for Resident #3 dated 6/13/2025 indicated he had severe cognitive impairment with a BIMS score of 5. He was dependent on staff for personal hygiene. He had an indwelling catheter and was always incontinent of bladder/bowel. Record review of a care plan for Resident #3 dated 1/13/2025 indicated he had an impaired cognitive deficit with interventions for skin care: Nursing staff will monitor skin and keep clean and dry as possible.Record review of physician's orders for Resident #3 dated 7/10/2025 indicated an order for wound care to his left posterior (back) knee to clean with normal saline/wound cleanser, apply collagen powder (a substance that is used to promote skin growth) and cover with a primary dressing daily.During an observation on 8/12/2025 at 2:38 PM in the room of Resident #3 LVN G and CNA C were present. There was a PPE container on the outside of the door that consisted of gowns and gloves. Prior to entering Resident #3's room LVN G and CNA C sanitized their hands and put on PPE. CNA C placed a clean protective covering (wax paper) over Resident # 3's bedside table. LVN G assembled her supplies for wound care consisting of extra gloves, hand sanitizer, bandage, normal saline and collagen power on the bedside table. CNA C rolled Resident #3 on his right side and LVN G performed wound care. LVN G removed the bandage from Resident #3's left knee and placed it in a disposable bag. LVN G then took a pen out of her pocket and wrote (date and time) on the new bandage. LVN G cleaned Resident #3's wound with normal saline, applied collagen power, opened the new bandage, and placed it on Resident #3's wound. LVN G did not change her gloves or sanitize her hands after removing the dirty bandage and before applying the clean bandage to Resident #3's wound. LVN G and CNA C removed PPE and disposed the PPE in the trash inside Resident #3' room. LVN G and CNA C sanitized their hands prior to leaving Resident # 3's room. During an interview on 8/12/2025 at 3:00 PM, LVN G she said she forgot to wash her hands and change her gloves between taking off the dirty bandage and placing the clean bandage on Resident #3's wound. She said going from dirty to clean she should have sanitized her hands and changed her gloves. She said poor hand hygiene could cause cross contamination, spread of bacteria and infection control issues. During an interview on 8/13/2025 at 10:34 AM, the ADON said she was the IP for the facility and was responsible for training staff on hire and quarterly on hand hygiene with infection control. She said staff should change their gloves when going from dirty to clean and sanitize or wash their hands. She said hand hygiene should be performed before and after care. She said there was a risk for infections to residents if staff did not change gloves or perform hand hygiene.During an interview on 8/13/2025 at 12:24 PM, the DON said she, along with the ADON, conducted training with the staff on hand hygiene and infection control. She said gloves should be changed during care when changing from dirty to clean. She said staff were to wash or sanitize their hands with glove changes. She said staff should never cross contaminate with clean to dirty. She said she expected the staff to follow infection control practices and change gloves during care provided. She said there was a risk for infections if staff did not change gloves during care.During an interview on 8/13/2025 at 2:53 PM, the Administrator said nursing management were responsible for staff training on infection control. She said when there was direct contact with a resident staff should sanitize their hands thoroughly before moving on to the next task. She said during wound care the nurse should change their gloves and sanitize their hands when going from a dirty task to a clean task and after care was complete prior to leaving the resident's room. She said staff must change gloves and sanitize their hands to minimize the spread of infection, germs, and bacteria. She said not using good hand hygiene put all residents at an increased risk for illness.Record review of a facility policy titled Hand Hygiene dated 6/2025 indicated, .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Hand hygiene table: before and after handling clean or soiled dressings, linens, etc .

Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 12 (Resident #6) residents observed for care. The ADON failed to provide Resident #6 with full privacy while providing gastric tube care on 08/12/25. This failure could place residents at risk of not being treated with dignity and respect. Findings:Record review of a facility face sheet dated 08/12/25indicated Resident #6 was a [AGE] year-old male that was admitted to the facility on [DATE]. He was re-admitted on [DATE] with diagnosis of tracheostomy (airway surgically created in the trachea), gastrostomy (tube placed surgically into the stomach for feeding), cerebral ischemia (decreased circulation in the brain), muscle wasting and dysphagia (inability to swallow). Record review of a comprehensive care plan revised 7/20/25 indicated Resident #6 required a gastrostomy tube (a tube placed in the stomach) for feeding and medication administration.Record review of a Quarterly MDS assessment dated [DATE] indicated Resident #6 had a BIMS score of 14 which indicated intact cognition and was dependent on staff for gastrostomy tube care and positioning. During an observation on 08/12/25 at 09:00 AM Resident #6 was provided gastrostomy care by the ADON. The ADON did not pull the privacy curtain between the room and door or close the door to the hallway. Resident #6 was visible from the hallway while visitors, staff and other residents passed by the open doorway. At 09:15 AM CNA B knocked on Resident #6's door and walked in room while resident was receiving care and drew the privacy curtain around resident #6 and closed the door. During an interview on 08/12/25 at 09:30 AM the ADON said she had been trained on resident privacy and dignity. She said the privacy curtain should have been pulled to keep Resident #6 from being exposed to the hallway. She said the resident could be upset being exposed and privacy not maintained. During an interview on 08/12/25 at 09:45 AM CNA B said she had been trained on resident privacy and dignity. She said the privacy curtain should have been pulled to keep Resident #6 from being exposed to the hallway. She said the resident could be exposed and embarrassed being exposed and privacy not maintained. During an interview on 08/12/25 at 10:59 AM Resident #6 nodded his head yes, when asked if it bothered him when the staff don't pull his privacy curtain, and he felt exposed and embarrassed. During an interview on 08/13/25 at 10:53 AM the DON said she was responsible for oversight of all nursing staff and education on resident rights. She said all staff should pull the privacy curtain during care. She said by not doing so it could make a resident feel exposed, embarrassed, or rushed. She said she expected all staff to maintain resident rights and dignity.During an interview on 08/13/25 at 11:00 AM the Administrator said all employees were responsible for following resident rights and ensuring resident privacy and dignity were maintained. The Administrator said she expected all staff to always respect resident privacy and dignity. Record review of a facility policy dated 2/2021 titled Dignity indicated, .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .

Based on observations, interviews and record reviews, the facility failed to provide a safe, clean, comfortable and homelike environment 1 of 4 halls (room [ROOM NUMBER]) reviewed for environment.The facility failed to repair the window in Resident #2's room [ROOM NUMBER] that had a broken frame that had detached from the wall on 8/12/2025.This failure could place the residents at risk of living in an unsafe, unsanitary, and uncomfortable environment. Findings included:Record review of a Resident Face Sheet for Resident #2 dated 8/12/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of schizoaffective disorder (a mental illness that can cause hallucinations and delusions), atherosclerotic heart disease (plaque buildup that causes narrowing and limited blood flow in the blood vessels), and polyosteoarthritis (joint stiffness and pain in multiple areas).Record review of a Quarterly MDS assessment dated [DATE] indicated she had moderate impairment in thinking with a BIMS score of 11. She required substantial/maximal assistance with personal hygiene.Record review of a care plan for Resident #2 dated 12/31/2024 indicated she had a self-care deficit related to schizoaffective disorder with intervention for two staff to assist with bed mobility.Record review of maintenance records dated 8/12/2025 indicated there was not a request for the repair of the window in room [ROOM NUMBER].During an observation on 8/12/2025 at 10:18 AM, CNA B was in the room to provide care to Resident #2. Resident #2's bed was positioned by the window. The window frame at the bottom of the window was detached from the wall, with one screw and one nail exposed with the top of them showing that were about one-half inch out of the wall.During an observation and interview on 8/12/2025 at 10:22 AM, CNA B was in room [ROOM NUMBER]. CNA B said she did not notice the window in the room when she provided care to Resident #2 because her bed was right against the wall. She said the window frame was detached from the wall. She said if they noticed any issues they were supposed to report it to the Maintenance Supervisor by scanning a QR code that was at the nurses'desk. She said residents could be at risk for injury if the window was not repaired.During an observation and interview on 8/12/2025 at 3:03 PM, CNA C observed the window frame in Resident #2's room and said she was not aware that anything was wrong with her window. She said the window frame was detached and said she would report it to Maintenance. Resident #2 was in bed awake and said it had been repaired a while ago but was not sure how long this time it had been broken. CNA C said there was a risk for injury, or it could allow bugs into the facility if the window frame was broken.During an observation and interview on 8/12/2025 at 3:25 PM, the Maintenance Supervisor was in room [ROOM NUMBER] working on repairing the window frame. He said he had been employed at the facility for 6 weeks. He said staff usually put in work orders for him that he would check every hour daily. He said he was not aware of the window in that room until that day. He said residents could be at risk for getting cuts, scrapes, or bruises if the window frame was not repairedDuring an interview on 8/13/2025 at 2:38 PM, the SW said the department heads conducted angel rounds in the facility daily where the staff were assigned rooms to check for environment issues and any other deficiencies. He said he was assigned the hall where Resident #2 resided. He said he checked her room daily but did not check the window because the blinds were always closed and did not think there were any issues with the window. He said if staff noticed anything in the rooms that needed repair, they were to report it to the Administrator during the morning meetings. He said staff could also scan the QR codes around the facility that would notify the Maintenance Supervisor of issues that needed repair. He said there was a risk of safety concerns if repairs were not reported.During an interview on 8/13/2025 at 2:53 PM, the Administrator said the department heads in the facility were assigned rooms that they were to check daily. She said they were to check and report any environment issues. She said throughout the facility, any staff could scan QR codes to report issues that needed to be repaired directly to the Maintenance Supervisor. She said she was not made aware of Resident #2's window until yesterday 8/12/2025. She said she would in-service the staff in the facility on reporting issues to maintenance and expected the staff to communicate more. She said environment issues that were found during the angel rounds were discussed in the morning meetings daily and the window in room [ROOM NUMBER] was not discussed. Record review of a facility policy titled Homelike Environment revised February 2021 indicated, .Residents are provided with a safe, clean, comfortable and homelike environment. 2. The facility staff and management maximized, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. The characteristics include: a. clean, sanitary, and orderly environment .

Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications for 1 of 1 resident reviewed for tube feeding management (Resident #6).The facility failed to follow their policy for maintaining Resident #6's positioning while administering medications via gastrostomy tube on 8/12/2025.The facility failed to follow their policy for labeling gastrostomy tube feeding for Resident #6 on 08/12/2025.These failures placed the resident at risk for aspiration of water/feedings and reduced therapeutic effects of gastrostomy feedings by not following current clinical standards of care.Findings included: Record review of a facility face sheet dated 08/12/25indicated Resident #6 was a [AGE] year-old male that was admitted to the facility on [DATE]. He was re-admitted on [DATE] with diagnoses of tracheostomy (airway surgically created in the trachea), gastrostomy (tube placed surgically into the stomach for feeding), cerebral ischemia (decreased circulation in the brain), muscle wasting and dysphagia (inability to swallow). Record review of a Quarterly MDS assessment dated [DATE] indicated Resident #6 had a BIMS score of 14 which indicated intact cognition and was dependent on staff for gastrostomy tube care and positioning. Record review of a comprehensive care plan revised 7/20/25 indicated Resident #6 required a gastrostomy tube (a tube placed in the stomach) for feeding and medication administration.Record review of a comprehensive care plan revised 06/20/2025 indicated: Resident requires feeding tube related to pharyngeal dysphagia. Peg- tube placed on 10/4/24. He is at risk for aspiration r/t noncompliance with positioning in bed. He will purposely scoot down in bed to a lying position. Resident will not exhibit signs of complications from feeding tube or enteral feeding solution through next 90 days.Record review of consolidated physician orders dated 08/12/2025 indicated: Enteral Administration Set & Bag - Change every 24 hours.Special Instructions: Residents name, Date, Time, and initials of nurse on feeding, Flush bag and tubing Once A Day-Enteral Feeding (Aspiration Precaution) Elevate HOB 30-45 degrees Every Shift.During an observation and interview on 08/12/2025 at 08:45 AM Resident #6 was lying supine (on back with face up) in bed with head of bed at 10 - 15 degrees elevation. Resident #6's gastrostomy tube (tube in stomach for feeding) feeding was infusing per pump with the label blank with no date, time or initials when hung. The ADON said the feeding should be labeled with date, time and initial when hung. She said there was a risk of the feeding not being changed as needed or the infusion of the feeding not administered as ordered.During an observation on 08/12/2025 at 09:00 AM Resident #6 was lying supine in bed with head of bed at 10- 15 degrees elevation. The ADON administered g-tube flushes before administration of meds and after each medication as ordered per medical doctor. Resident #6 continued to be lying supine in bed with head of bed at 10- 15 degrees elevation. Resident #6 began coughing and the ADON raised the head of bed to over 45 degrees per standard of care.During an observation and interview on 08/12/2025 at 09:10 Resident #6 nodded he was alright, smiled and coughing subsided.During an observation on 8/12/2025 at 12:00 PM Resident #6 was in the dining room participating in music activities, he was laughing and communicating with staff. Resident #6 had no negative effects observed from flushes.During an interview on 8/12/2025 at 09:30 AM the ADON said she should have raised the head of bed before beginning the flushes and medication administration. She said by not maintaining the resident in position as ordered he was at risk for aspiration of his water flushes and feedings. The ADON said that the feedings should always be labeled as required by facility policy.During an interview on 8/13/2025 at 08:30 AM the DON said she was responsible for ensuring the nursing staff followed standards of care and policies regarding g-tube feedings and positioning of residents during flushes to ensure the risk of aspiration was decreased. She said the ADON should have raised the head of bed before beginning the flushes and medication administration. She said by not maintaining the resident in fowlers position (head of head up at least 30-45 degrees) as ordered, placed the resident at risk for aspiration of his water flushes and feedings. The DON said she had already started an in-service to staff to ensure compliance with facility policies and standards of care concerning positioning of residents during gastrostomy tube feedings/flushes and labeling of gastrostomy tube feedings.During an interview on 08/13/2025 at 11:30 AM the Administrator said the DON was responsible for ensuring compliance to standards of care for feeding tubes. She said not labeling the feedings or keeping the head of bed raised could put the resident at risk for aspiration of water/feedings and reduced therapeutic effects by not following current clinical standards of care.Record review of a facility policy dated 07/01/2025 titled Flushing a Feeding Tube .Policy: It is the policy of this facility to ensure that staff providing care and services to the resident via a feeding tube are aware of, competent in and utilize facility protocols regarding feeding nutrition and care. Feeding tube care and services will be provided in accordance with resident needs and professional standards of practice .5. Elevate the bed to a comfortable working height and place the patient in Fowler's position (45-60-degree elevation of the head of bed) .14. Prevent aspiration risk by keeping the head of bed elevated at a minimum of 30 degrees.Record review of a facility policy dated 07/2025 titled Care and Treatment of Feeding Tubes .Policy: It is the policy of this facility to utilize feeding tubes in accordance with clinical standards of practice, with interventions to preventcomplications to the extent possible .13. The resident's plan of care will direct staff regarding proper positioning of the resident consistent with the resident's individual needs .

Based on observations, interviews, and record reviews, the facility failed to ensure it formulated, adopted, and enforced policies regarding smoking, smoking areas, and smoking safety that also consider non-smoking residents for 1 of 2 smoking areas (secured unit smoking area) reviewed for smoking safety.The facility failed to ensure paper and plastic trash were not discarded into the fire safety can on 8/12/2025.This failure could place residents at risk of injury, burns, and an unsafe smoking environment.Findings included:During an observation and interview on 8/12/2025 at 9:00 am the red fire can in the smoking area located on the secured unit was observed with a plastic liner, cigarette butts and plastic and paper trash. CNA A was outside with a resident and said everyone was responsible for the smoking area and was unsure who would have put a liner in the can, but the trash was probably placed by other staff and residents. She said the red fire can should only have cigarette butts because of fires. During an interview on 8/12/2025 at 9: 20 am the Maintenance Director said he was new and was not sure who was responsible for the fire cans in the smoking area but would find out. He said he was not sure if a liner and trash should be in the fire can but could see that it could be a fire hazard. During an interview on 8/12/2025 at 4:00 pm the Administrator said that the designated smoking areas were to be maintained by the Maintenance Director but all staff that assisted the residents to smoke should be mindful of the ashtrays and fire cans and ensure there was no trash or plastic liner in the red fire can. She said the Maintenance Director was new in his position and would see that he was trained on the smoking policy and maintenance of the smoking areas. She said that by not maintaining the smoking area fires could happen.Record review of an undated facility policy titled Resident Smoking Policy indicated, .It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents. 3. Safety measures for the designated smoking area will include, but are not limited to: c. Accessible metal containers with self-closing covers into which ashtrays can be emptied .

46273 46436 Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene were provided for 3 of 12 residents (Residents #18, #3, and #22) reviewed for ADL care. 1. The facility failed to ensure Resident #18 had clean and trimmed nails on 3/24/25 and 3/25/25. 2. The facility failed to ensure Resident #3 had clean and trimmed nails on 3/34/2025 and 3/25/2025. 3. The facility failed to shave Resident #22 and she had facial hair on her chin and lip on 3/24/2025. These failures could place residents at risk of not receiving care/services, decreased quality of life, and loss of dignity. Findings included: 1.Record review of a facility face sheet dated 3/24/25 for Resident #18 indicated that he was a [AGE] year-old male originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnosis of dementia. Record review of a quarterly MDS dated [DATE] for Resident #18 indicated that he had a BIMS score of 5 which indicated severely impaired cognition. He did not exhibit rejection of care. He required supervision for personal hygiene. Record review of a comprehensive care plan dated 1/29/25 for Resident #18 indicated that he required assistance of 1 staff member for hygiene and grooming and nail care was to be performed on shower days. The care plan indicated shower days were Monday, Wednesday, and Friday. Record review of Point Of Care History for bathing/showering dated 3/1/25 to 3/25/25 for Resident #18 indicated he received a shower on 3/24/25. During an observation and interview on 3/24/25 at 10:10 am revealed Resident #18 was observed lying in bed and had long fingernails with a dark brown substance observed underneath them. He said it had been a while since anyone had cleaned or trimmed his nails. He said he would like for them to be cleaned and shorter, and that it would make him feel better. During an observation on 3/25/25 at 8:51 am revealed Resident #18 was observed lying in bed with head of bed elevated, eating breakfast. His fingernails were observed to still be long and dirty. During an observation and interview on 3/25/25 at 11:14 am CNA C said CNAs were responsible for nail care unless the resident was diabetic. She observed Resident #18's fingernails and said they needed to be cleaned and trimmed. She said she would be giving him a shower today and would clean his nails. She asked him if he would like a shower and nail care and he said yes. She said there could be a risk of bacteria and infection if nails were not kept clean and trimmed. She said she would not like to have long, dirty nails. 2. Record review of a Face Sheet for Resident #3 dated 3/25/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of schizoaffective disorder (a mix of symptoms that include seeing and hearing things and mood disorders such as depression), atherosclerotic heart disease (caused by plaque buildup that restricts blood flow to organs and parts of the body), and polyosteoarthritis (multiple areas of arthritis). Record review of a Quarterly MDS Assessment for Resident #3 dated 1/29/2025 indicated she did not have any impairment in thinking with a BIMS of 15. She required partial/moderate assistance with personal hygiene. Record review of a care plan for Resident #3 dated 1/29/2025 indicated she had an ADL functional status/rehabilitation potential with interventions to clean and trim finger and toenails on bath/shower days. Record review of a point of care history for Resident #3 dated 3/1/2025-3/25/2025 indicated her shower days were on Tuesday, Thursday, and Saturday. Tasks to clean and trim fingernails and toenails on bath/shower days were documented as being done from 3/1/2025-3/25/2025. During an observation and interview on 3/24/2025 at 9:53 AM, revealed Resident #3 was in her room sitting up in a wheelchair. She was alert to person, place, time, and situation. Her nails were about 1/2 inch to 1 inch in length and had a brown substance underneath them. She said they trimmed them sometimes and would get the goo out of them. She said she received her showers on Tuesday, Thursday, and Saturday. She said she would like her nails trimmed and cleaned. During an observation on 3/25/2025 at 9:49 AM, revealed Resident #3 was in bed awake, and her fingernails were still long with a brown substance underneath them. During a joint interview on 3/25/2025 at 10:20 AM, CNA A and CNA C were both present in the room of Resident #3. Both said the resident would refuse care at times and said her shower days were on Tuesday, Thursday, and Saturday and that was when the resident's nails were trimmed and cleaned but only if the resident was not diabetic and she was not. Both observed her nails and said they were long and dirty and should have been cleaned. Both said they would feel upset and gross if they did not have their nails cleaned and she used her hands to eat at times. During an interview on 3/25/2025 at 1:35 PM, LVN D said if a resident was diabetic, then the nurse was responsible for cleaning and trimming nails, but if they were not diabetic, then the nurse aides were responsible for trimming, filing, cleaning, and soaking nails and it should be done daily. She said she was aware that nail care was not done daily and had talked to the nurse aides about it. She said if a resident refused, they could not make them. She said Resident #3 had refused in the past but was not aware of any refusals recently. She said if her nails were long and dirty it would make her feel cruddy (dirty). During an interview on 03/25/25 at 01:47 PM, the DON said the nurse aides were responsible for doing nail care and documenting it. She said there would be a risk for infection and cross-contamination if nails were not cleaned and trimmed. She said she would not feel good if her nails were long and dirty. She said going forward she would check behind the CNAs and ensure nail care was properly done. During an interview on 03/25/25 at 02:08 PM, the Administrator said he and the DON/ADON were responsible for ensuring ADL care was being done on the residents. He said the licensed nurses and certified nurse aides should be providing the ADL care to the residents. He said he would do in-services to ensure staff knew they were responsible for ADL care. He also said he would have the DON/ADON go behind staff to ensure compliance. He said CNAs and nurses were responsible for nail care and it should be done as needed and also on shower days. He said nail care would be added to Angel Rounds for observation that nail care was being done. He said if proper nail care was not done residents could be at risk for germs and bacteria, and it could be a dignity issue. Record review of a facility policy titled Fingernails/Toenails, Care of revised February 2018 indicated, .The purposes of this procedure are to clean the nail bed, to keep nails trimmed and to prevent infections. General Guidelines: 1. Nail care included daily cleaning and regular trimming . 3. Record review of a facility face sheet dated 3/24/25 revealed Resident #22 was an [AGE] year-old female that admitted to the facility on [DATE] with diagnosis of senile degenerative brain disorder (brain deterioration from age and disease). Record review of a quarterly MDS assessment dated [DATE] revealed Resident #22's BIMS was not completed. Further review revealed a staff assessment for mental status (SAMS) was completed and indicated severely impaired cognitive skills for daily decision-making and required maximal assist with personal hygiene. Record review of a comprehensive care plan dated 12/11/2024 revealed Resident #22 had an ADL self-care deficit and required dressing and grooming every shift. During an observation on 03/24/25 at 11:46 am revealed Resident # 22 was observed with facial hair to her chin and upper lip that was approximately 1 inch long. During an interview on 03/24/25 at 11:50 am CNA A said that Resident # 22 was seen Monday through Friday for personal care by the hospice aide. She said care that was not done by the hospice aide should be done by the facility aide. She said she had not noticed the facial hair and had not shaved Resident #22. She said by leaving hair on her face could cause her embarrassment. During an interview on 03/24/25 at 11:54 am LVN B said that Resident #22 would sometimes refuse care, but she had allowed staff to shave her in the past. She said she had not noticed the aides were not shaving her. She said she oversaw the ADL care and helped as needed and Resident #22 should be shaved as needed to prevent embarrassment. During an observation on 03/25/25 at 7:21 AM revealed Resident # 22 up in the dining room and the facial hair had been removed. During an interview on 03/25/25 at 7:26 am the Hospice Aide said she had provided personal hygiene and care to Resident #22 on 3/24/25. She said that Resident #22 had on her hospice aide care plan to shave weekly, but she had not been shaving her because she would resist care. She said she told the nurse at the facility but that was several months ago. She said a female having facial hair could be embarrassing. Record review of a hospice aide care plan report dated 3/24/2025 revealed Resident #22 was to be shaved once per week. During an interview on 03/25/25 at 7:33 am LVN B said the staff shaved Resident #22 yesterday evening and she did well. She said Resident #22 would at times resist care, but the staff should give her time to calm down and reapproach her again. She said she would continue to monitor that ADL care was completed. During an interview on 03/25/25 at 11:34 am the DON said that the charge nurses, ADON and herself were responsible for oversight of resident care. She said if a resident could not perform ADL's themself the staff were to provide that care to them. She said the facility staff were responsible regardless of hospice care and the facility staff should have been ensuring care was being completed. She said not providing grooming and a female resident being left with facial hair could affect their dignity and self-esteem. She said she would monitor ADL care more closely on a weekly basis. During an interview on 03/25/25 at 2:10 pm the Administrator said that himself, the DON and ADON were responsible for ADL oversight and ADL's should be provided by the nurses and aides. He said the facility staff should be checking behind outside care aides to ensure care was provided. He said not providing ADL care could affect dignity. He said he expected all care be provided and would retrain all staff on ADL care. Record review of a facility policy titled Activities of Daily Living (ADLs), Supporting dated March 2018 revealed, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene, 2. appropriate care and services will be provided for residents who are unable to carry out ADLs independently including hygiene, 4. if residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem, approach the resident in a different way or different time .

Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items, per facility policy, for 1 of 8 resident's (Resident #5) personal refrigerators reviewed for food and nutrition services. The facility failed to ensure a personal refrigerator on [DATE] and [DATE] for Resident #5 did not have a plastic bag of sliced cheese dated [DATE]. These failures could place residents at risk for food borne illnesses. Findings include: Record review of a face sheet for Resident #5 dated [DATE] indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of cerebral palsy (a birth defect that caused damage to the brain), mild intellectual disabilities (a condition that limits intelligence and disrupts abilities necessary for living independently), and GERD (reflux disease). Record review of an Annual MDS Assessment for Resident #5 dated [DATE] indicated he did not have any impairment in thinking with a BIMS score of 14. He required supervision or touching assistance with eating. Record review of a MAR for Resident #5 dated [DATE]-[DATE] indicated an order for the resident's refrigerator daily at bedtime: check for cleanliness and expiration of foods. Everything should be labeled and disposed of within 5 days . Record review of a care plan for Resident #5 dated [DATE] indicated he had ADL functional status/rehabilitation potential with interventions that included the resident required x 1 assistance with eating. During an observation on [DATE] at 9:45 AM, revealed Resident #5 was not in his room, and he had a personal refrigerator present that had a plastic bag with sliced cheese dated [DATE]. The cheese was not in the original package. During an observation and interview on [DATE] at 9:20 AM, revealed Resident #5 was in the dining room and said he ate foods from his personal refrigerator and his best friend would get things out for him. He said the sliced cheese was purchased one day last week and his best friend made him a sandwich using the cheese yesterday, [DATE]. During an observation and interview on [DATE] at 9:25 AM, the Best Friend of Resident #5 said she did not prepare a sandwich for Resident #5 yesterday, [DATE] and he ate a sandwich that was prepared in the kitchen. She looked in the refrigerator and said the cheese had been in the refrigerator for a long time. She said she was not sure who was supposed to check his refrigerator for expired foods. During an observation and interview on [DATE] at 10:08 AM, HSK E said she started at the facility in [DATE] and the housekeeping staff were responsible for checking the personal refrigerators for cleanliness, temperatures, and defrosted them as needed. She said they checked the refrigerators about every 2 weeks or so. She said she never checked the foods in the refrigerators because they belonged to the residents. She said she was not sure who was supposed to check the foods. During an interview on [DATE] at 10:52 AM, the HSK Supervisor said the nurses were supposed to check the personal refrigerators for expired foods. She said the housekeeping staff were to only clean and check the temperatures. She said if she saw something that was expired, she would tell the resident and then throw it away. She said if a resident ate something that was expired, it could make them sick. During an observation and interview on [DATE] at 1:35 PM, LVN D said housekeeping were responsible for checking the refrigerators in the residents' rooms for expired foods. She said Resident #5 had been known to refuse to allow staff to remove foods from his refrigerators in the past but was not aware of any recent refusals. She observed his personal refrigerator and a plastic bag of sliced cheese dated [DATE] was removed by her and said she would throw it away. She said residents could get sick if they ate foods that were expired. During an interview on [DATE] at 1:55 PM, the DON said she had been employed as the DON for 4 weeks. She said housekeeping was responsible for checking the personal refrigerators to make sure they were clean; temperatures were good and did not have any expired or outdated foods. She said they were to check them weekly and was not aware that Resident #5 had any foods that were expired in his refrigerator. She said if a resident ate foods that were expired it could make them sick. During an interview on [DATE] at 2:04 PM, the Administrator said he was ultimately responsible, but the nursing staff were supposed to check the personal refrigerators daily. He said he was not aware that Resident #5 had any foods that were expired in his refrigerator. He said he planned to make sure everyone was aware who was responsible for checking the personal refrigerators and they could be checked during morning rounds. He said there could be a risk for residents to get food borne illnesses if they ate foods that were beyond the expired date. Record review of a facility policy titled Personal Resident Refrigerators revised [DATE] indicated, .This facility does not provide a refrigerator in a resident's room. However, it is the policy of this facility to ensure safe and sanitary use of any resident-owned refrigerators. 3. Housekeeping and/or nursing staff as assigned shall clean the refrigerator weekly and discard any foods that are out of compliance .

Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 4 residents reviewed for quality of care in that: The facility did not prevent the development and worsening of two facility acquired wounds for Resident #1. The facility failed to ensure a bed of appropriate size to prevent the developement and worsening of wounds was provided for Resident #1. The facility failed to document weekly skin assessments for Resident #1. The noncompliance was identified as PNC. The past noncompliance began on 12/02/24 and ended on 01/27/25. The facility had corrected the noncompliance before the survey began. These failures could place residents with limited mobility at risk of developing facility acquired pressure injuries. Findings included: Record review of Resident #1's undated face sheet indicated Resident #1 was a [AGE] year-old male admitted on [DATE] with diagnoses of type 2 diabetes, end stage renal (kidney) disease, and chronic ulcers of left and right feet. Record review of an MDS dated [DATE] indicated Resident #1 had a BIMS score of 15 which indicated intact cognition and he required assistance for ADL s. He required total assistance for toileting, hygiene, and bathing; maximal assistance for upper and lower body dressing, putting on/taking off footwear, and personal hygiene; partial assistance with sit to stand and chair/bed-to-chair transfers; touch assist with rolling from left to right, lying to sitting up, and lying to sitting on the side of the bed. Record review of an admission observation completed by RN A of Resident #1 on 12/03/2024 at 4:23PM included a skin assessment which indicated Resident #1 was admitted to the facility with no alterations in skin integrity and no pressure injuries to sacrum, heels, hips, ankles, elbows, ears, or any other bony prominence. The same admission observation indicated Resident #1 was assessed for venous ulcers, arterial ulcers, and diabetic ulcers including assessment of lower extremities, upper and lower feet, and upper and lower toes, with no ulcers noted. Record review of a comprehensive care plan revision on 12/11/2024 indicated Resident #1 was at risk for pressure ulcers related to impaired mobility and incontinence. Interventions were put in place including weekly skin assessments with particular attention paid to the bone prominences (areas of the body where the underlying bone is particularly close to the surface of the skin), keeping resident clean and dry, and maintaining the head of the bed at lowest degree of elevation possible. Review of Weekly Skin assessments indicated only two skin assessments had been documented for Resident #1: *01/09/2025 by ADON - Resident with DTI (Deep Tissue Injury) on Right and Left plantar foot; *01/16/2025 by LVN A - DTI TO RT/LT PLANTAR (right and left sole of foot); Record review of Resident #1's comprehensive care plan revisions on 1/09/2025 indicated Resident #1 had developed a diabetic ulcer to his left first toe, and a diabetic ulcer to his right first toe. New interventions were added including avoiding friction and shearing forces during transfer and position change, keep bony prominences from direct contact with one another with pillows, foam wedges, etc., monitor for signs of osteomyelitis (bone infection), cellulitis (soft tissue infection), sepsis (an extreme bodily reaction to infection), and wound treatment orders to clean area with normal saline and apply skin prep daily. The same care plan also included initiation of a planned weight gain program on 1/09/2025 to assist Resident #1's wound healing. Record review of a wound care physicians Initial Wound Evaluation and Management Summary on 1/10/2025 indicated the focused wound exam revealed the presence of two Diabetic Wounds and the following new orders: - Site 1: Diabetic wound of the left, first toe, partial thickness. The wound measured 1cm x 1cm x Not Measurable (Length X width X Depth) due to scab covering wound. Treatment plan included applying skin prep daily for 30 days. - Site 2: Diabetic wound of the right, first toe, undetermined thickness. The wound measured 0.5cm x 1cm x Not Measurable due to scab covering wound. Treatment plan included applying skin prep daily for 30 days. - Follow-Up Evaluation by wound care provider weekly, or sooner as needed, with further intervention as indicated based on response to current treatment plan. Record review of Resident #1's comprehensive care plan revision on 1/26/25 indicated Resident #1 had developed a new diabetic wound to his right foot. New interventions were added including using a lift sheet to move resident in bed, resident continued with weekly wound care treatments from wound care provider. Record review of Resident #1's the most recent wound care physicians Wound Evaluation and Management Summary dated 1/31/25 indicated the following: - Site 1: Diabetic wound of left toe, partial thickness. The wound measured 1cm x 1cm x not measurable due to scab covering wound. Wound healing progress not at goal. Treatment plan included applying skin prep once daily for 16 days. - Site 2: Diabetic wound of the right, first toe, undetermined thickness. The wound measured 1.5cm x 2cm x Not Measurable due to scab covering wound. Healing progress at goal. Treatment plan includes applying skin prep once daily for 16 days. - Site 3: Diabetic wound of right, plantar foot full thickness. The wound measured 3.5cm x 3cm x 0.1cm. Healing progress improved as evidenced by decreased surface area. Treatment includes skin prep once daily for 30 days. No sharp debridement needed due to chronic stable wound with insignificant amount of necrotic tissue and no signs of infection. Monitor closely for now. During an interview on 2/03/25 at 10:10 AM, CNA B said she was familiar with Resident #1. She said his bed was not long enough for him and his feet pressed up against the footboard and hung over the edge of mattress after footboard was removed. During an interview on 2/03/25 at 10:25 AM, LVN A said Resident #1's bed was too small because he is 6ft 8in tall and his feet were pressing and rubbing against the footboard. She said she had reported the concerns to ADM, DON, ADON. She said ADM told her that was the biggest bed available for Resident #1. She said ADON removed the footboard from the bed after Resident #1 developed diabetic wounds on his feet. During an observation and interview on 2/03/25 at 10:30 AM, Resident #1 was observed lying in his bed in his room. His bed had no footboard, and feet were extended beyond the end of the mattress and were resting on a mattress extension attached to bedframe. Wounds to his right great toe, right sole, left great toe, and left sole were observed. The wound beds were covered over by scabbing and not visualized. Resident #1 said he was uncomfortable in the bed when he was admitted to the facility and had voiced this concern to staff, but he could not recall who he spoke to. He said he was comfortable now with the footboard being removed and mattress extension in place. He said he was uncomfortable lying flat in bed and preferred to have his head raised. During an interview on 2/03/25 at 1:00 PM, DON said the facility identified the need for and ordered an extension for Resident #1's bed when he was admitted but they misplaced it and had to order a new one. She said Resident #1 had other interventions in place including frequent rounding and pulling him up in the bed, so his feet don't press on the footboard. She said Resident #1 had weekly skin assessments ordered and all skin assessments should have been charted in his progress notes. She said no staff had ever voiced concerns about Resident #1's feet rubbing against the footboard causing skin breakdown. During an interview on 2/03/25 at 12:30 PM, ADM said he measured that mattress with a measuring tape, and it was 81in in length which was sufficient for Resident #1's height of 6ft 8in (80in) and additionally ordered a mattress extension. He said when Resident #1 was pulled up in his bed his feet weren't going to rub on the footboard. He said Resident #1 was mobile and slides down in the bed when he shifts positions. He said no one reported any concerns of skin break down related to resident's feet rubbing against the footboard. He said Resident #1 had a history of chronic diabetic ulcers which were one of his admitting diagnoses. He said following the first reported skin breakdown the facility put interventions in place including ordering a new mattress extension, provided an inservice to all clinical staff in which the topic of timely skin assessments was discussed, and got a referral for specialty wound clinic to assess and treat resident. He said the facility also planned to conduct further inservices and supply resident with a bariatric bed. Review of Facility Wound Summary Report dated 1/03/2025 to 2/03/2025 indicated Resident #1 had two facility acquired Diabetic Ulcers discovered on 1/09/2025. There were no other residents with pressure related injuries in the facility. Review of policy titled Pressure Injury/Skin Breakdown - Clinical Protocol last revised April 2024 indicated: .Within post-acute and long-term care, pressure injuries and other chronic wounds emerge as clinical concerns, heavily influenced by patient immobility, underlying health conditions and nutritional factors. These disruptions in skin integrity can gravely impact a resident's quality of life . And .The licensed nurse will complete a weekly skin assessment in the progress note section of the resident chart . It was determined these failures resulted in Resident #1 being harmed on 01/09/2025. Facility took the following actions to correct the non-compliance: - Record review of the facility's In-service binder revealed an in-service titled Mandatory meeting (all clinical staff) was conducted on 1/15/25 topics of in-service topics included Skin assessments need to be done in a timely Manner. They are now schedule by day shift 6-2 and evening shift 2-10 (evening shift are for night shift). - During interviews with 3 CNAs and 2 LVNs on the day shift, all employees indicated they would routinely check for skin concerns. The 3 CNA's said they look at resident's skin during incontinence care and when assisting with showers and would notify their charge nurse of any concerns. The 2 LVN's said they would assess residents as ordered and chart their findings in resident progress notes. - Review of an invoice indicated a mattress extension was purchased on 1/27/2025 and observations of Resident #1 at various times revealed the mattress extension to be in place. - Referral to wound care management with visit frequency of weekly or as needed.

Based on observation, interview, and record review, the facility failed to ensure that residents were provided with a separate bed of proper size and height for the safety and convenience of the resident for 1 of 4 residents (Resident #1) reviewed for appropriate functional furniture. The facility failed to ensure Resident #1 had a bed of proper size for his safety to prevent development and worsening of two facility acquired wounds. The noncompliance was identified as PNC. The past noncompliance began on 12/02/24 and ended on 01/27/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for discomfort, skin breakdown and a decreased quality of life. The findings included: Record review of Resident #1's undated face sheet indicated Resident #1 was a [AGE] year-old male admitted on [DATE] with diagnoses of end stage renal (kidney) disease and chronic ulcers of left and right feet, and muscle wasting (atrophy) of lower right and left legs, and chronic diabetic ulcers of both feet. Record review of an MDS dated [DATE] indicated Resident #1 had a BIMS score of 15 which indicated intact cognition and he required assistance for ADLs. He required total assistance for toileting, hygiene, and bathing; maximal assistance for upper and lower body dressing, putting on/taking off footwear, and personal hygiene; partial assistance with sit to stand and chair/bed-to-chair transfers; touch assist with rolling from left to right, lying to sitting up, and lying to sitting on the side of the bed. He was 80 inches tall. Record review of a comprehensive care plan revision on 12/11/2024 indicated Resident #1 had an ADL deficit related to End Stage Renal (kidney) Disease. The same care plan indicated he required the assistance of 2 people for ambulation, transfers, and bed mobility . During an interview on 2/03/25 at 10:10 AM, CNA B said Resident #1's bed was not long enough for him, and his feet were always hanging off the bed. During an observation and interview with Resident #1 on 02/03/25 at 10:30 AM revealed the footboard of his bed had been removed and he was lying on his back in bed with his legs and feet extended beyond the mattress, hanging over the edge. His feet were resting on a mattress extension that was attached to the end of the bed frame. His head was elevated to a semi-Fowler's position (upper body raised to a 30-45-degree angle). Resident #1 said when he was admitted to the facility, he notified staff members that his bed was too small, and it was uncomfortable. He said his feet pressed against the footboard. He said it was uncomfortable to lie flat in bed and he preferred to have his head elevated. During an interview on 2/03/25 at 10:25 AM, LVN A said Resident #1's bed is too small because he is 6ft 8in tall and his feet were pressing and rubbing against the footboard. She said she had reported the concerns to ADM, DON, ADON. She said ADM told her that was the biggest bed available for Resident #1. She said ADON removed the footboard from the bed after resident developed diabetic ulcers on both of his feet. During an interview on 2/03/25 at 1:00 PM, DON said the facility identified the need for and ordered a mattress extension for Resident #1's bed when he was admitted but they misplaced it and had to order a new one. She said Resident #1 had other interventions in place for comfort and safety including frequent rounding, maintaining the head of his bed in as low a position as possible to prevent sliding, and pulling him up in the bed so his feet don't press on the footboard. During an interview on 2/03/25 at 12:30 PM, ADM said he measured that mattress with a measuring tape, and it was 81in in length which was sufficient for Resident #1's height of 6ft 8in (80in) and additionally ordered a mattress extension but it was misplaced. He said when Resident #1 is pulled up in his bed his feet aren't going to rub on the footboard. He said resident is mobile and slides down in the bed when he shifts positions. He said Resident #1 had a history of chronic diabetic ulcers which were one of his admitting diagnoses. He said he already ordered a second mattress extension which was in place on resident's bed and the facility held a mandatory in-service for all clinical staff covering bed and chair positioning. He said the facility also planned to conduct further in-services and supply resident with a bariatric bed. Record review of facility policy titled Bed Safety indicated the following: .The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits . .As part of the resident's comprehensive assessment, the following components will be considered when determining the resident's needs . a. Medical diagnoses, conditions, symptoms, and/or behavioral symptoms b. Size and weight . It was determined these failures resulted in Resident #1 being harmed on 1/09/25. Facility took the following actions to correct the non-compliance: - Record review of the facility's In-service binder revealed an in-service titled Mandatory meeting (all clinical staff) was conducted on 1/15/25 topics of in-service topics included positioning residents correctly in chair or bed, positioning devices in beds or chairs, and increasing visual monitoring. - During interviews with 3 CNAs and 2 LVNs on the day shift, all employees indicated they would assess resident's comfort and needs when rounding. The 3 CNA's said they reposition residents according to their preference and medical needs and would notify their charge nurse of any concerns. The 2 LVN's said they would ask residents comfort and pain levels during assessments and communicate any concerns. - Review of an invoice indicated a mattress extension was purchased on 1/27/2025 and observations of Resident #1 at various times revealed the mattress extension to be in place.

Based on interviews and record review, the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, 7 days a week for 4 of 92 days reviewed. (April 2024, May 2024, and June 2024). The facility did not have RN coverage for 4 days in June 2024. This failure could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as emergency care and disasters. Findings: Record review of the Center for Medicare and Medicaid Services PBJ (Payroll Based Journal) report for the third quarter of 2024 (April 1 through June 31, 2024) indicated there were no RN hours for the following dates: 04/06 (SA); 04/07 (SU); 04/11 (TH); 04/12 (FR); 04/14 (SU); 04/20 (SA); 04/21 (SU); 04/27 (SA); 05/05 (SU); 06/08 (SA); 06/09 (SU); 06/15 (SA); 06/16 (SU); 06/17 (MO); 06/18 (TU); 06/19 (WE); 06/20 (TH); 06/21 (FR); 06/24 (MO); 06/25 (TU); 06/26 (WE); 06/27 (TH); 06/28 (FR); 06/29 (SA); 06/30 (SU). Record review of the monthly staffing schedules for April 2024, May 2024, and June 2024 revealed that there was a RN scheduled for most of the days in the report. Time sheets provided for proof of RN coverage on all dates except for 06/15, 06/16, 06/29, and 06/30. During an interview on 10/01/2024 at 2:09 p.m., the Administrator said that he had been employed here since August of 2023. The Administrator stated that during the time of reporting staffing, there was not RN coverage on 6/15/24, 6/16/24, 6/29/24, and 6/30/24. He stated during that time period, the Director of Nurses at that time left the position and he did not have any other RN's on staff. The Administrator said the corporate travel nurses were not available at that time. He said that they were utilizing agency registered nursing staff to provide the required 8 hours daily coverage but on those occasions the nurse had called in prior to the shift. He said that the staffing agency did not try to find replacements for the dates that the nurses called in. He stated the DON was the only RN on staff at that time and she had left. The Administrator said that he has hired a weekend RN since then. He said that he expected a licensed registered nurse to be on the schedule for 8 hours a day. He said that the DON was to provide RN coverage if there was not an RN on the schedule . He stated that failure to have an RN in the building could result in not having staff available to assess and recognize changes in resident condition. During an interview with the corporate compliance officer on 10/1/2024 at 2:15 PM, she said that on the dates that there was not an RN in the building, there was not an RN employed by the facility, and the corporate RN's were not available. She said that with the onboarding of a new DON and hiring of a weekend RN has resolved the issue of no RN coverage . Record review of a facility policy titled Staffing dated 9/28/23 indicated .The facility utilizes the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week .

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 preparation kitchen. The facility did not ensure baking sheets did not have brown and/or black baked on build up on 9/30/2024. The facility did not ensure the chemical sanitizer for the dish machine was at the appropriate sanitization according to the manufacturer's guidelines for the machine from 9/1/2024-9/30/2024. The facility did not ensure scoops were not left in a bin that contained flour on 9/30/2024. These failures could place residents who eat from the kitchen at risk of foodborne illnesses. Findings included: During an observation and interview on 9/30/2024 during the initial tour of the kitchen at 9:05 AM indicated the dish machine was ran by the DM and after the final rinse she checked the chemical sanitizer with a test strip. She said it was 200 ppm. The State Surveyor questioned her if that was accurate, and she took the color code indicator strip out of the tube and looked at the test strip, and said it was 100 ppm. She said the dish machine had been between 100-200 ppm for the past couple of weeks. A manufacturer's label on the machine indicated the operating requirements indicated: 2. Chlorine residual 50 ppm minimum. Record review of the kitchen sanitation test log was reviewed and for the entire month of September 2024 in the AM, Noon, and PM shifts. Sanitation was recorded at 100-200 ppm. During an observation on 9/30/2024 at 9:13 AM, in the dry storage area a container of a white, powdery substance had a scoop inside of the bin lying on top of the powdery substance. During an observation and interview on 9/30/2024 at 9:14 AM, there were 6 large baking sheets with brown and/or black baked on build up that were stacked on top of each other. The DM said they had ordered more baking sheets and cleaned them the best that they could. During an interview on 9/30/2024 at 9:15 AM, the DM said the white, powder substance was flour, and it should not have a scoop inside of the container and said it should be stored in a plastic bag. She said everyone who worked in the kitchen was responsible for ensuring the scoop was not inside the container. She said she would contact someone about the dish machine. She said they had been running it at 200 ppm. During a follow-up observation and interview on 9/30/2024 at 2:30 PM of the kitchen, the DM was present and said a technician came out that morning 9/30/2024 and serviced the dish machine and told her that the sanitization should be between 50-70 ppm, not 100 ppm. She said she told him it had been running high at 200 ppm and he told her it was too high. She said she did not know of anything that could happen to the residents if the sanitization was too high. She ran the dish machine and tested the sanitization, and it was reading at 50 ppm. During a phone interview on 9/30/2024 at 2:55 PM, the Auto Chlor technician said the dish machine had a box timer that indicated when sanitization chemical needed to be added and it was adjusted so the correct amount would be included in the wash cycle. He said they usually liked to keep the sanitization at about 75 ppm. He said if the sanitization was reading 200 ppm, he did not think it would affect anything. He said sometimes the machines would read high if the cam broke, but it should be at a minimum of 50 ppm and not over 100 ppm with the water temp of 120 degrees. During an interview on 10/1/2024 at 8:11 AM, the DM said they noticed about 2 weeks ago that the dish machine's sanitization was in the range of 100 ppm-200 ppm. She said she contacted Auto Chlor and talked to someone who told her that someone would be out for service. She said she was not sure if someone had been out to the facility or not after she called for service as she could have been off work. During an interview on 10/1/2024 at 2:25 PM, the Administrator said the DM was responsible for oversight in the kitchen and he always thought the dish machine sanitization had to be a minimum 50 ppm and could not be more than 100 ppm with 200 ppm being the cut off. He said he thought the sanitization was fine with the dish machine. He said he planned to do an in-service training with the kitchen staff so they would follow the recommendations that the vendor had requested. He said scoops should not be left in the bins of dry goods as the kitchen had drawers for clean utensil storage. He said there was minimal risk to the residents if the sanitization chemical was high as the dishes were ran through the machine, allowed to air dry, and not served directly after being washed. He said he ordered new baking sheets for the kitchen as of 9/30/2024. Record review of a purchase order dated 9/30/2024 for the kitchen indicated the Administrator had ordered 8 aluminum sheet pans. Record review of a facility policy titled Food Storage undated indicated, .To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. 1. Dry Storage Rooms e. Provide scoops for items stored in bins, such as sugar, flour, rice, and other items. Store scoops covered in a protected area near the food containers . Record review of a facility policy dated 2018 indicated, .The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes for mechanical cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards. 7. If a machine that uses chemicals for sanitizing is in use, follow these guidelines: a. The temperature of the wash water must be at least 120 degrees. c. Chemicals added for sanitization purposes must be automatically dispensed. f. A test kit or other device that accurately measures the parts per million concentrations of the solution must be available and used . Record review of the Food and Drug Code dated 2022 indicated, .4-302.14 Sanitizing Solutions, Testing Devices. Testing devices to measure the concentration of sanitizing solutions are required for 2 reasons: 1. The use of chemical sanitizers requires minimum concentrations of the sanitizer during the final rinse step to ensure sanitization; and 2. Too much sanitizer in the final rinse water could be toxic .

Based on interviews and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS reviewed for administration (Fiscal year 2024 for the third quarter April 1, 2024 to June 31, 2024) The facility failed to submit accurate RN hours for: 04/06 (SA); 04/07 (SU); 04/11 (TH); 04/12 (FR); 04/14 (SU); 04/20 (SA); 04/21 (SU); 04/27 (SA); 05/05 (SU); 06/08 (SA); 06/09 (SU); 06/15 (SA); 06/16 (SU); 06/17 (MO); 06/18 (TU); 06/19 (WE); 06/20 (TH); 06/21 (FR); 06/24 (MO); 06/25 (TU); 06/26 (WE); 06/27 (TH); 06/28 (FR); 06/29 (SA); 06/30 (SU) These failures could place residents at risk for personal needs not being identified and met. The findings included: Record review of the CMS PBJ (Payroll Based Journal) report for the third quarter of 2024 (April 1, 2024 through June 31, 2024) indicated there was no RN hours for the following dates: 04/06 (SA); 04/07 (SU); 04/11 (TH); 04/12 (FR); 04/14 (SU); 04/20 (SA); 04/21 (SU); 04/27 (SA); 05/05 (SU); 06/08 (SA); 06/09 (SU); 06/15 (SA); 06/16 (SU); 06/17 (MO); 06/18 (TU); 06/19 (WE); 06/20 (TH); 06/21 (FR); 06/24 (MO); 06/25 (TU); 06/26 (WE); 06/27 (TH); 06/28 (FR); 06/29 (SA); 06/30 (SU). Record review of the monthly staffing schedules for April 2024, May 2024, and June 2024 revealed that there was a RN scheduled for most of the days in the report. Time sheets provided for proof of RN coverage on all dates except for 06/15, 06/16, 06/29, and 06/30. During an interview on 10/01/2024 at 2:09 p.m., the Administrator said that he had been employed here since August of 2023. The Administrator stated that during the time of reporting staffing, there was not RN coverage on 6/15/24, 6/16/24, 6/29/24, and 6/30/24. He stated during that time period, the Director of Nurses at that time left the position and he did not have any other RN's on staff. The Administrator said that during that reporting period, corporate was responsible for reporting the hours. He said that hours were assessed through the payroll system and that any registered nurse hours provided by the DON, traveling corporate nurses, and agency nurses would not be reflected in the payroll system. He stated that at that time the Administrators did not review the hours being reported to ensure that all hours were captured. The Administrator stated that since that time, the company has changed the process and that he reviews the hours prior to reporting so that the report can be accurate prior to the hours being submitted to CMS (Center for Medicare and Medicaid Services) . He stated that failure to have an RN in the building could result in not having staff available to assess and recognize changes in resident condition. In an interview with the corporate compliance officer on 10/01/2024 at 2:15 PM, she stated that on the dates that there was not an RN in the building, there was not an RN employed by the facility, and the corporate RN's were not available. She said that with the onboarding of a new DON and hiring of a weekend RN has resolved the issue of no RN coverage. The corporate compliance officer said that the tracking of RN hours has changed and that a new process has been put into place so that the facilities can make sure that information being reported is accurate. She said that the administrators were able to review hours so that any traveling nurses or corporate nurse hours are captured . During an interview with the corporate director of data analysis on 10/02/2024 at 10:45 AM she stated that she has been with the company for 9 months. She said that she was responsible for submitting the facilities hours to the PBJ system. She stated that during the reporting period in question she obtained the hours for reporting through the company payroll system. She said that any hours that were related to the DON, traveling nurses, or agency would not be available in the payroll system. She stated that she missed the hours for the registered nurses that were in the category of the DON, travel nurses, and agency during that reporting period. She stated that it was an oversite. The director stated that a new system was now in place, that the hours that were not in the payroll system flow through a different system and the hours were captured accurately now. She said that the administrators at each facility were also reviewing the hours prior to being reported to make sure that all hours were reported accurately. Record review of the Facility Assessment Tool dated 6/26/24 with a QAPI (Quality Assurance and Performance Improvement) committee review date of 8/19/24 indicated their plan for staff indicated one RN or LPN each 12-hour shift and a DON RN full-time Days. Record review of a facility policy titled Staffing dated 9/28/23 read .Direct care staffing information per day (including agency and contract staff) is submitted to the CMS payroll-based journal system on the schedule specified by CMS, but no less than once a quarter.

Based on interviews and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 1 of 9 residents (Resident #31) reviewed for psychotropic medications (medications that affect behavior, mood, thoughts, and perception). The facility failed to obtain a signed consent for psychotropic medications for Resident #31 that included: mirtazapine, risperidone, trazodone, Depakote, clonazepam, and Zyprexa that were administered to her. The failure could affect residents who received psychoactive medications without informed consents and place residents at risk of receiving unnecessary psychotropic medications. Findings included: Record review of a face sheet for Resident #31 dated 10/1/2024 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of manic episodes (racing thoughts, pressure speech, increased risk-taking and a decreased need for sleep), senile degeneration of brain (progressive loss of brain tissue and function), alcohol abuse with alcohol-induced psychotic disorder, anxiety, and dementia. Record review of a Sig Change MDS dated [DATE] for Resident #31 indicated she was rarely/never understood. During the 7 day look back period she took antipsychotic, antianxiety and antidepressant medications. She received antipsychotic medications since admission. Record review of active physician orders dated 10/1/2024 for Resident #31 indicated orders for: o Mirtazapine (an antidepressant used to treat major depressive disorder) 15 mg at bedtime started on 6/11/2024. o Risperdal (risperidone-an antipsychotic that works by changing the effects of chemicals in the brain) 1 mg at bedtime started on 6/11/2024. o trazodone (an antidepressant used to treat major depressive disorder) 150 mg at bedtime started on 6/29/2024. o Depakote (used to treat seizure disorders, certain psychiatric conditions and to prevent migraine headaches) 125 mg twice a day started on 7/1/2024. o clonazepam (used to prevent and control seizures) 0.5 mg three times a day started on 7/9/2024. o Zyprexa (used to treat severe agitation associated with certain mental/mood conditions) 5 mg daily started on 7/9/2024. Record review of the pharmacist's medication regimen review dated 6/1/2024 and 6/24/2024 indicated Resident #31 was reviewed and did not require any recommendations. Record review of a care plan for Resident #31 dated 6/17/2024 indicated she was at risk for adverse consequences related to receiving antipsychotic medication Risperdal and Zyprexa with diagnosis of alcohol abuse with alcohol-induced psychotic disorder. Interventions included to assess/record effectiveness of drug treatment. Monitor and report signs of sedation, anticholinergic and/or extrapyramidal symptoms. Record review of a care plan for Resident #31 dated 6/17/2024 indicated she was at risk for adverse consequences related to receiving antidepressant medication Mirtazapine. New order for trazodone on 6/17/2024 for diagnosis of insomnia. Interventions included to administer medications as ordered and assess/record effectiveness of drug treatment. Record review of a care plan for Resident #31 dated 6/17/2024 indicated she was at risk for adverse consequences related to receiving antianxiety medication for treatment of anxiety, new order for clonazepam. Interventions included to assess if the resident's behavioral/mood symptoms present a danger to the resident and/or others. Monitor for drug use effectiveness and adverse consequences. Record review of the Resident #31's medical record indicated there were not any consents for the psychotropic medications that were ordered. During a joint interview on 10/1/2024 at 2:07 PM, the Travel DON and the ADON both said that a previous Travel DON who was no longer employed at the facility was responsible for ensuring residents on antipsychotics had consents and appropriate documentation. The ADON said she was hired at the facility on July 23, 2024, and was responsible for antipsychotics as of last week. Both said they started an audit of the facility last week for residents on psychotropics medications and found that residents consents were scanned in different places but Resident #31 did not have any record of consents in her electronic health record. Both said on 9/26/2024 they spoke to Resident #31's RP and received verbal consent at that time and have since gotten signed consents for her medications as of 9/26/2024. Both said consents should be signed before medications were administered, complete an AIMS assessment, have target behaviors in an order along with behavior monitoring, side effects, and care planned for the medications. Both said there was a risk for adverse side effects and family not being aware if consents were not obtained before the medication was administered. Both said going forward they would monitor daily to make sure the consents were signed before psychotropic medications were given. Both said a PIP was put in place and started last week for psychotropic medications. During an interview on 10/1/2024 at 2:19 PM, the Administrator said the DON would be responsible for ensuring residents had consents for psychotropic medications. He said he was aware of Resident #31 not having signed consents as the facility conducted an audit about a week or so ago and found some issues. He said the facility put a PIP in place at that time. He said consents for psychotropic medications should be done before the medications were given to the residents. He said there was a risk for getting something the resident or POA did not want them to have. Record review of a Performance Improvement Plan: dated 9/23/2024 indicated they had identified concerns related to antipsychotic medications and making sure consents were obtained. Record review of a consent for use of psychotropic medication for Resident #31 dated 9/26/2024 indicated a consent for mirtazapine by the RP for the use of the prescribed medication. Record review of a consent for use of psychotropic medication for Resident #31 dated 10/1/2024 indicated a consent for Depakote by the RP for the use of the prescribed medications. Record review of a consent for use of psychotropic medication for Resident #31 dated 9/26/2024 indicated a consent for clonazepam by the RP for the use of the prescribed medications. Record review of a consent for use of psychotropic medication for Resident #31 dated 10/1/2024 indicated a consent for trazodone by the RP for the use of prescribed medications. Record review of a consent for use of psychotropic medication form 3713 for Resident #31 dated 9/25/2024 indicated a consent for Risperdal by the RP for the use of the prescribed medications. Record review of a consent for use of psychotropic medication form 3713 for Resident #31 dated 9/25/2024 indicated a consent for Zyprexa by the RP for the use of the prescribed medications. Record review of a facility policy titled Psychoactive Medication dated July 2024 indicated, .Residents are not given psychotropic medications unless the drug is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the residents, as demonstrated by monitoring and documentation of the residents' response to the medication. 9. Consent must be obtained from the resident or resident representative prior to administering a psychotropic medication (excluding an emergency). a. A consent form for antipsychotic/neuroleptic medication utilizing Texas form 3713 must be completed and signed by the residents or resident representative. Consent must be obtained in writing. b. A consent form for other psychotropic medications must be completed and signed by the resident or resident representative using the psychoactive consent form in Matrix .

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Resident #14 and #25) reviewed for infection control. The facility failed to ensure CNA B properly performed hand hygiene during incontinent care to Resident #14 on 9/30/2024. The facility failed to ensure LVN A properly cleaned reusable equipment when providing care to Resident #25 on 9/30/24. These failures could place residents at risk for cross contamination and infection. Findings included: 1. Record review of a facility face sheet dated 10/01/2024 indicated Resident # 14 was a [AGE] year-old male and admitted on [DATE] with diagnoses of Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right non-dominant side (unable to move is non-dominate side following a stroke). Record review of a Quarterly MDS assessment dated [DATE] indicated Resident #14 had a BIMS score of 09 indicating moderately impaired cognition and was incontinent of bladder and bowel. Record review of a comprehensive care plan dated 8/17/24 indicated Resident #14 was incontinent of bowel and bladder and provide incontinent care as needed. During an observation on 9/30/24 at 2:45 pm Resident #14 was provided incontinent by CNA B and CNA C. Both CNA's washed their hands and applied gloves. Resident #14 was rolled from side to side to remove the lift sling and clothes. Both CNA's removed their gloves, sanitized hands, and applied clean gloves. CNA B opened Resident #14's soiled brief and used wipes to clean the front perineal area of Resident #14. CNA C rolled Resident #14 to right side and CNA B cleaned Resident #14's back peri area. Without changing gloves or performing hand hygiene, CNA B placed a new brief under Resident #14 and applied barrier cream to his buttocks. CNA C assisted Resident #14 to his back and CNA B applied barrier cream to his front peri area and pulled the clean brief into place. CNA B removed her soiled gloves and applied clean gloves without hand hygiene. CNA B then repositioned Resident #14 in the bed and adjusted his bed and call light. Afterwards, both CNA's removed their gloves and washed their hands before leaving the room. During an interview on 9/30/24 at 3:07 pm CNA B said she had been a CNA since 1993 and employed at the facility for 3 months. She said she had been trained on incontinent care and hand hygiene and she should have changed her gloves and performed hand hygiene before applying Resident #14's clean brief and performed hand hygiene between glove changes. She said by not doing so could cause infections. 2. Record review of a facility face sheet dated 10/01/2024 indicated Resident # 25 was a [AGE] year-old male and admitted on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (unable to move is dominate side following a stroke). Record review of a Quarterly MDS assessment dated [DATE] indicated Resident #25 had a BIMS score of 08 indicating moderately impaired cognition and was incontinent of bladder and bowel. Record review of a comprehensive care plan dated 9/04/24 indicated Resident #25 had an ostomy and was provided ostomy care every shift. During an observation on 09/30/24 at 10:30 AM Resident #25 received ostomy care from LVN A. LVN A washed her hands and applied gloves. Supplies were set up on clean working area. LVN A dropped her scissors on the floor, picked them up, washed the scissors under cold water for 3 seconds and placed her scissors on the clean work area. LVN A removed her gloves, hands washed, and new gloves applied. LVN A removed soiled ostomy bag (bag outside the body that collects stool), removed gloves, sanitized her hands, and applied new gloves. LVN A used the soiled scissors to cut the opening in the ostomy wafer. LVN A then cleaned around the stoma and using wipes. LVN A then removed her gloves, sanitized her hands, and applied new gloves. LVN A then applied skin prep around the stoma site and applied paste to the ostomy wafer. LVN A applied new ostomy wafer and bag to Resident #25's skin and sealed. LVN A removed gloves and washed her hands. During an interview on 09/30/24 at 10:38 AM LVN A said she had worked at the facility since January 2024 and had been trained on infection control. She said when the scissors dropped on the floor, she should have cleaned them with an appropriate cleaner. LVN A said by not cleaning them appropriately it could cause infections. During an interview on 10/01/24 at 2:20 PM the ADON said she had worked at the facility since July 2024 and was the infection preventionist. She said she and the DON were responsible for the training of all staff on infection control measures. She said CNA B and LVN A had been trained on infection control and retrained on 9/30/2024. She said there had been lots of turn over with management nursing staff and she and the current DON were working on retraining all staff in all areas of care. She said that by not properly cleaning multi-use equipment and performing hand hygiene correctly it could lead to the spread of infections. During an interview on 10/01/24 at 2:25 pm the travel DON said she had worked at the facility for 3 weeks and she and the ADON have been working on retraining all staff on infection control as well as other areas. She said prior to her coming to the facility she was unsure on the training process, but she was working with management to put in place a new training program and would monitor weekly to ensure the program was working. She said if staff were not properly cleaning multi-use equipment and performing proper hand hygiene during incontinent care it could cause the spread of infections. She said she expected the staff to follow infection control measures. During an interview on 10/01/24 at 2:48 pm the Administrator said he had been at the facility 14 months and the DON and the ADON were responsible for the infection control program. He said infection control training was completed on hire and annually. He said there had been turnover of management and was in the process of getting all staff retrained. He said the risk of not following infection control measures were it could spread infections. He said he expected all staff were following policy and procedures for infection control measures. Record review of training report dated 01/13/2024 indicated LVN A had been trained on infection control. Record review of training report dated 7/23/2024 indicated CNA B had been trained on infection control. Record review of a facility policy titled Handwashing/Hand Hygiene dated 1/20/2023 indicated, .this facility considers hand hygiene the primary means to prevent the spread of infections. 5. Hand hygiene must be performed prior to donning and after doffing gloves . Record review of a facility policy titled Perineal Care dated 1/20/23 indicated, .Perineal Care is providing cleanliness and comfort to the resident, to prevent infections, skin irritation, and to observe the resident's skin condition. 12. Remove gloves and discard into designated container. 13. Perform Hand Hygiene . Record review of a facility policy titled Cleaning and Disinfecting Non-Critical Resident Care items dated April 2020 indicated, .reusable items are cleaned and disinfected or sterilized .

47339 49017 Based on observations, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 4 of 14 residents (Residents #15, Resident #24, Resident #25, and Resident #33 ) reviewed for care plans. On 4/1/24 the facility failed to implement care plan interventions for Resident #15 of providing physical help with meals and notifying MD of changes in abilities . On 4/2/24 the facility failed to implement care plan interventions for Resident #25 of their therapeutic diet of fortified foods during the lunch meal. On 4/3/24 the facility failed to implement care plan interventions for Resident #24 of required supervision and 1 person assistance with meals. The facility failed to implement care plan interventions for Resident #24 of weekly weights x4 weeks. Resident #24 was missing weekly weights on weeks of 1/22/24 and week of 2/5/24. The facility failed to implement care plan interventions for Resident #33 of weekly weights x4 weeks. Resident #33 was missing weekly weights on weeks of 2/12/24 and week of 2/26/24. These This failures could place residents in the facility at risk of not receiving the necessary care to meet their identified needs.nutritional needs. An Immediate Jeopardy (IJ) was identified on 04/04/2024 at 9:57 a.m. The IJ template was provided to the facility on [DATE] at 9:57 A.M. While the IJ was removed on 04/05/2024 at 05:20 p.m., the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy, because all staff had not been trained on weights, dietician recommendations, preferences versus orders, meal cards, the dietary process, pulling up resident profiles, and comprehensive care planning. Findings include: 1. Review of resident #15 face sheet reflect that he is an [AGE] year-old male admitted on [DATE]. His diagnosis include unspecified dementia with other behavioral disturbances (dementia is characterized by a decline in cognitive abilities that impacts a person's ability to perform everyday activities and behavioral disturbances can include verbal or physical aggression, incontinence, agitation, sleep disturbances or changes in appetite), dysphagia, oropharyngeal phase (a swallowing disorder that affects the mouth and throat characterized by difficulty initiating a swallow, coughing, choking or aspiration.) , cognitive communication deficit (difficulty with communication that is caused by a problem with thinking), and gastro-esophageal reflux disease (when stomach acid repeatedly flows back into the tube connecting your mouth and stomach). Record review of resident#15 Quarterly MDS dated [DATE], indicated that the resident had a BIMS score of 06, indicating severely impaired cognition. It indicated that resident requires substantial/maximal assistance with eating (helper does not than half the effort) and that he is dependent on staff for all activities of daily living. Record review of the care plans for resident #15 dated 4/1/2024 indicated that resident had the potential for weight loss related to dementia, feeding difficulties. Diet change was noted in care plan on 4/1/2024 for dysphagia puree with thickened liquids and on 4/2/2024 dysphagia puree with nectar thickened liquids. Nursing approaches included provide physical help assistance for meals dated 12/21/2023. Record review of resident #15 physician orders with a start date of 4/02/2024 diet of dysphagia puree with nectar thick liquids. 2. Record review of a facility face sheet dated 4/2/24 for Resident #25 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] with diagnosis of dementia. Record review of a Quarterly MDS assessment dated [DATE] for Resident #25 indicated that Brief Interview for Mental Status should not be conducted due to resident being rarely/never understood. Question C1000 indicated that resident had severely impaired cognition. Record review of physician orders for Resident #25 indicated that she had the following order: Diet: Regular diet, fortified foods; Texture: Mechanical soft; Fluid consistency: Thin dated 2/2/24. Record review of a comprehensive care plan for Resident #25 dated 3/31/24 indicated that she had experienced weight loss and was to receive fortified food with all meals. Record review of Resident #25's weights located in her electronic medical record indicated that on 10/05/2023, the resident weighed 138.5 lbs. On 04/03/2024, the resident weighed 110.8 pounds which is a -20.00 % loss in 180 days. 3. Record review of a face sheet for Resident #24 dated 4/03/2024 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: Hemiplegia following cerebral infarction affect left non-dominant side (paralysis or partial or total body function on left side of the body), partial loss of teeth, abnormal weight loss, and cognitive communication deficit (difficulty with thinking and how someone uses language). Record review of a Quarterly MDS assessment dated [DATE] for Resident #24 indicated that he had a BIMS score of 14, indicating his cognition was intact. Section GG of same MDS assessment indicated that he had received setup or clean-up assistance with eating. Record review of a care plan dated 4/04/2023 for Resident #24 indicated had a problem with nutritional status with interventions that included: Weigh me at least once a month and weekly if I show a significant weight loss. Resident #24 had a problem with ADL's Functional Status/Rehabilitation Potential with interventions that included: Resident requires supervised assist-limited x1 with eating. Record review of facility weight variance report dated 9/01/2023 to 3/10/2024 revealed Resident #24's weights were: 10/05/2023- 241.4 11/02/2023- 243.2 12/05/2023- 248.6 01/03/2024- 210.0 indicating a 15.5% loss in 29 days. 01/18/2024- 215.6 01/25/2024- 214.0 02/01/2024- 218.2 03/03/2024- 218.2 4.Record review of face sheet for resident #33 indicated that he was a [AGE] year old male admitted on [DATE] with diagnosis of unspecified dementia (symptoms that affect memory, thinking and social skills), dysphagia, oropharyngeal phase (a swallowing disorder that affects the mouth and throat characterized by difficulty initiating a swallow, coughing, choking or aspiration.), cognitive communication deficit (difficulty with communication that is caused by a problem with thinking), and gastro-esophageal reflux disease (when stomach acid repeatedly flows back into the tube connecting your mouth and stomach). Record review of resident #33 significant change MDS dated [DATE] indicated that resident has a BIMS score of 14 indicating that he is cognitively intact. It indicated that he was independent with eating and required supervision or set up assistance with activities of daily living. Record review of care plan for resident #33 dated 01/30/2024 resident was care planned for undesired weight loss with approach of weekly weights. Nutritional status care plan of mechanically altered diet with ground meat. Care plan dated 3/13/2024 for fortified foods. Care plan for set up assistance with meals reviewed. Record review of resident #33's physicians orders dated 3/13/2024 diet order for fortified foods, mechanical soft with ground meat. Review of order dated 11/28/2023 to discontinue double portions. Record review of facility weight variance report dated 12/12/2023 to 3/3/2024 revealed resident #33 weights were: 12/12/2023- 233.0 1/3/2024- 184.00- indicating a 21.2% loss in 22 days. 2/1/2024- 204.00 indicating a 11.0% gain in 29 days. 2/19/2024- 197.00 3/3/2024- 196.8 Record review of facility weight variance report revealed that resident was not weighed weekly as ordered on 1/30/2024 with weight not obtained during the week of 2/12/2024 and 2/26/2024. During dining room observation on 4/1/2024 at 12:00 PM, resident #15 was observed sitting at a table alone. Staff served resident his meal that was pureed and thickened liquids, the tray card indicated that resident diet was correct. Observed resident #15 feeding himself without staff assistance or verbal cueing. Resident remained at the dining room table alone. Staff assisted resident out of dining room when he finished eating. During dining room observation on 4/2/2024 at 8:30 AM and 12:00 PM, resident #15 was observed sitting at table alone, staff served his meal and resident ate both meals without assistance or verbal cueing. Resident was observed eating quickly, taking large bites of pureed food and occasionally coughing when he swallowed. During an observation and interview on 4/2/24 at 12:30 pm Resident #25 was observed sitting up in wheelchair in dining room being assisted with lunch meal by staff member. Her tray card was observed to say fortified food but there was no fortified food with resident's meal. Dietary manager said that Resident #25's fortified food must have gotten missed. She went to kitchen and returned to dining room with a cup of fortified soup for Resident #25. During an observation on 4/03/2024 at 08:50 AM Resident #24 observed eating breakfast in room with door closed and no supervision or assistance. During an observation of Resident #24's lunch meal on 4/03/2024 at 12:00 PM revealed Resident #24 was pushed via wheelchair to the main dining room by therapy. Resident #24 requested a hamburger for lunch. The Administrator verbally communicated residents request to the dietary staff. Resident was served a hamburger with potato chips, yogurt, and fortified mashed potatoes. Resident #24 picked up hamburger and put the entire hamburger in his mouth at one time, he then started placing potato chips in his mouth with the hamburger. Resident #24 took approximately 10-15 minutes to swallow the food in his mouth. Resident did not touch his fortified mashed potatoes. Resident #24 was not assisted by staff, no verbal cues were given by staff, and fortified food was never encouraged by staff. During an interview with the MDS coordinator on 4/3/2024 at 2:30 PM, she said she was an LVN. She said she was in the facility on 4/1/2024 during the time that resident #15 was eating his breakfast. She said that LVN A reported to her that the resident was choking and coughing during breakfast, and she instructed her to change his diet to pureed with thickened liquids until speech therapy could evaluate him. She said that nurses are allowed to downgrade resident diets if needed. She said that the doctor should have been notified and that the nurse should have documented notification in the nurse's progress notes. She said that the resident has a history of eating too fast and requires staff to remind him to slow down when eating. The MDS Coordinator said she reviewed and updated care plans with every MDS assessment. She said any nurse could update the resident care plans based on physician orders, and interactions or observations of the resident. A telephone interview with RP H (family member of Resident #25) was attempted on 4/4/24 at 3:11 pm. No answer was received, a voicemail requesting a return phone call was left. No return phone call was received before exiting the facility. During an interview 04/05/24 at 10:05 AM The DM said the proper procedure for plating resident meals is using the proper scoop sizes. She said when the cook plates residents' meals he determined the diet, preferences and if the resident wants extra food from the resident's tray card. She said once the food is plated it is put on the rack for dining room, 100 hall, and secure hall rack. She said then they pushed the carts to the nurse's station for the nurses to check and dietary staff returned to the kitchen before the check is completed. She said if there is a problem with the trays then the nurses take it back to the kitchen. The DM said for the dining room they waited till the nurse and aides were in the dining room to serve the meal. She said the dietary aide handed the trays to the nurse to be checked, then the nurse handed the tray to the CNAs to pass to the resident. She Said before 4/01/2024 the nurses did return 1 or 2 trays to the kitchen that did not have large or double portions. She said the tray cards where then reviewed for accuracy for those 1-2 residents. She said she did not know how many residents had large portions listed as preferences but knows it is a large number. She said her expectations is for her staff to follow the diets and preferences listed on the tray cards. She said she receives a communication form from the ADON for any diet changes. The DM said if she doesn't get a communication form for 2 weeks then she will ask the ADON/DON if there had been any diet changes. She said in the morning meetings they talked about what the meals would be for that day, any new orders, or anything pertaining to meals. She said other than the communication form on Resident #15 on 4/1/24 she had not received any dietary communication forms since 10/20/23 . During an interview on 04/05/24 at 04:29 PM with the Administrator, he said when a new order is received for a diet change, nursing is to fill out a dietary communication form. He said the ADON was responsible for overseeing the weights. He said as of 3/29/2024 CMA B was responsible for weighing all residents. He Ssaid his expectations were for care plans to be updated by the MDS Coordinator and are all changes of condition are added to the care plan during the morning QA meeting. He said the potential negative outcome for the resident if care plans were not accurate was the resident could possibly not receive the proper amount of care and nutrition. Record review of a facility policy titled Nutrition Supplementation dated 2018, read .Use of fortified foods at each meal could be used to provide additional calories for residents unable to meet estimated calorie and needs with current intake . Record review of a facility policy titled Nutrition Interventions dated October 1, 2018 read .Nutritional interventions will be implemented as recommended by the Nutrition and Foodservice Manager, dietitian and/or Nutrition and Dietetics Technician Registered (NDTR) to ensure the best possible nutritional status for residents of the facility . Record review of the facilities policy titled Comprehensive Care Plans dated 1/26/2024 revealed: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the resident's comprehensive assessment. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. This was determined to be an Immediate Jeopardy (IJ) on 04/04/2024 at 9:57 a.m. The Administrator was notified. The Administrator was provided with the IJ template on 04/04/2024 at 9:57 a.m. The following Plan of Removal submitted by the facility was accepted on 04/05/2024 at 11:51 a.m. and included: Action: The care plans for Resident #24, #25, and #33 have been reviewed and updated to reflect residents' comprehensive person centered care. Resident #24's care plan updated to reflect current needs of set up assistance and not 1 person assistance with meals??? to reflect resident's current needs. Resident #24 is on therapy services and the evaluation completed on 2/16/2024 states resident only requires set up or clean up assistance, care plan reflects this evaluation. Resident #24 is currently on Speech Therapist services and nursing will provide the assistance recommended by Speech. ? Person(s) Responsible: MDS Coordinator and Director of Reimbursement and Speech Therapy ? Date: 4/4/2024 by 3PM???? ?? Action: Reestablish all residents weights on 4/3/2024. Continue to weigh each resident x4 weeks. Designated employee will weigh residents, if employee is unavailable, Assistant Director of Nursing and/or Director of Nursing will complete. Educate employee(s) responsible for weighing residents (Designated CMA/CNA, Assistant Director of Nursing, and Director of Nursing). ?Charge Nurse has been educated on obtaining weight process. ?? Person(s) Responsible: Assistant Director of Nursing, Director of Nursing, and/or Designee ??? Date: 4/4/2024 completed by 5PM? ?? Action: Reviewed significant weight loss and weight gain for residents at 30 days (5% or greater), 90 days (7.5% or greater), and 180 days (10% or greater). Communicated weight variances to the dietitian, following any new orders received. Notification to dietitian, physician, and/or RP/resident. which residents were identified ??? Person(s) Responsible: Assistant Director of Nursing, Director of Nursing, and/or Designee ??? Date: 4/4/2024 by 5PM??? ?? Action: Care plans updated to reflect current residents with significant weight loss and weight gain for residents at 30 days (5% or greater), 90 days (7.5% or greater), and 180 days (10% or greater). ??? Person(s) Responsible: MDS Coordinator and/or Designee ??? Date: 4/4/2024 by 5PM??? ? Action: The Administrator, Director of Nursing, Assistant Director of Nursing, and the Dietary Manager have been educated over the process of dietitian recommendations and communication regarding orders and meal tray tickets, resident preferences vs. Dietitian/Speech Language Pathologist recommendations, following preferences and orders, dietary communication forms, checking trays- (texture, diet, preferences, portion size), and communication to the MDS nurse so care plans can be updated to reflect residents' current needs. ??? Person(s) Responsible: Director of Regulatory Compliance ??? Date: 4/4/2024 by 5PM? ? Action: Dietary Department educated on Dietary Process to include:??? Dietary Manager: Ensure orders in Matrix match tray cards in Menu Matrix and use of dietary communication forms. ??? Ensure all dietary staff understands the plated meal must match the tray card. ??? Proper scoops for portions. Verify portions on tray card vs. the plated tray. Fortified Foods. Following Recipes. Following Menu/substitution log. ??? All dietary employees will be educated prior to working their next shift. ??? Person(s) Responsible: Administrator??? Date: 4/5/2024 by 11AM??? Action: Resident #15's care plan updated to reflect resident's current needs for assistance. Audited care plan to ensure only 1 form of assistance is listed. Person(s) Responsible: MDS Coordinator?? Date: 4/5/2024 by 12PM Action: Care plans' problems and approaches audited to ensure approaches are not contradictory so staff can follow the residents' plan of care to avoid contradictory approaches. Care plans are also being reviewed for accuracy during this audit. Person(s) Responsible: MDS Coordinator?and/or Designee ? Date: 4/5/2024 1PM? ? Action: Charge Nurses, CNAs, and CMAs will be educated on how to pull the resident profile in which will indicate the supervision/assistance needs for the residents. ? All staff on-site will be educated. Staff, temporary and permanent will be educated prior to working their next shift. ? Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee ? Date: 4/5/2024 by 10AM ? ? Action: The Interdisciplinary Team, to include Director of Nursing, Assistant Director of Nursing, and MDS Coordinator educated over care planning to meet the needs according to the MDS assessment and resident observations and interactions. ? Person(s) Responsible: Director of Reimbursement ? Date: 4/5/2024 by 12PM?? ???? Action: Ad hoc QAPI performed with Medical Director regarding IJ template and the facility's plan to remove the immediacy. ??? Person(s) Responsible: Administrator ??? Date: 4/4/2024 by 11AM???? Monitoring of the plan of removal was completed on 04/05/2024 and revealed the following: 1. Record review of Resident #24's care plan revealed it was revised on 4/4/24, record review of Resident #25's care plan revealed it was revised on 4/5/24, record review of Resident #24's care plan revealed it was revised on 4/4/24. 2. Record review of Inservice titled weights dated 4/3/24 with DON, ADON, and CMA B signatures. Weight log dated 4/3/24 with 34 out of 34 residents reviewed for weight loss. Inservice dated 4/1/24-4/5/24 with all staff titled weights 24 employee's signatures. 3. Record review of Weight variance report 10/4/23 to 4/4/24 for 34 out of 34 residents reviewed for weight loss or gains. 4. Record review of Resident #15, Resident #24, Resident #25, and Resident #33 care plans updated to reflect current residents with significant weight loss and weight gains for residents at 30 days (5% or greater), 90 days (7.5% or greater), and 180 days (10% or greater). 5. Record review of Inservice dated 4/02/24 on dietician recommendations, orders, preferences versus orders, and meal cards with the signatures of the Administrator, DON, ADON, and DM. 6. Record review of Inservice dated 4/03/24 titled Dietary Process that included the DM, and cooks. 7. Record review of Resident #15's care plan that was updated on 4/05/24. 8. Record review of attestation dated 4/05/24 that 34 of 34 residents care plans updated signed by the MDS Coordinator. 9. Record review of Inservice dated 4/04/24 titled Pulling up a Resident Profile with 21 employee signatures. 10. Record review of Inservice dated 4/05/24 titled Comprehensive Care Planning signed by the MDS Coordinator, DON, ADON, SW, Administrator, DM, and DOR. 11. Record review of Ad Hoc QAPI dated 4/05/24 with signatures of the Administrator, DON, ADON, MDS Coordinator, DM, and Medical Director. 12. During interviews on 4/05/24 between 3:15 PM and 5:20 PM The DM, Cook, Cook M, and DA were able to verbalize understanding of the Dietary Process. 13. During interviews on 4/05/24 between 3:15 PM and 5:20 PM the DON, ADON, MDS Coordinator, LVN L, LVN D, LVN N, LVN P, and CMA B were able to verbalize understanding of the weight process. 14. During interviews on 4/05/24 between 3:15 PM and 5:20 PM the DON, ADON, MDS Coordinator, LVN L, LVN D, LVN N, LVN P, CMA B, CNA O, CNA K, CNA F, and CNA J were able to verbalize understanding of the Resident Profile. 15. During interviews on 4/05/24 between 3:15 PM and 5:20 PM the MDS Coordinator, DON, ADON, SW, Administrator, DM, and DOR were able to verbalize understanding of the Comprehensive Care Planning process. The Administrator was informed the Immediate Jeopardy was removed on 4/05/2024 at 5:20 p.m. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

46273 47339 49017 Based on observations, interviews, and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, and offered a therapeutic diet when there was a nutritional problem and the healthcare provider orders a therapeutic diet for 15 of 34 residents (#33, #24, #29, #9, #25, #34, #22, #17, #15, #18, #35, #6, #13, #31, and #1) reviewed for weight loss and nutrition. 1. The facility failed to communicate with dietary staff on dietary changes. 2. The facility failed to ensure systems were in place to monitor for weight changes. 3. The facility failed to ensure residents were weighed according to physician orders and dietary recommendations for Resident #33, #24, #29 and #9. 4. The facility failed to provide assistance and supervision with meals as indicated by resident care plans for Resident #24 on 4/3/2024. 5. The facility failed to provide residents with therapeutic meals as indicated by the physician orders, dietary recommendations, and dietary special preferences for Residents #34 on 4/1/2024; Residents #25, #9, #31, #17, #1, #24, #15, #18, #35, #6, #13, #33 on 4/2/2024; and Resident #22 on 4/3/2024. 6. The facility failed to obtain updated baseline weights after the facility scale was replaced on 3/12/2024 until state surveyor intervention. On 4/4/2024 at 8:15 AM an Immediate Jeopardy (IJ) situation was identified. While the IJ was removed on 4/5/2024 at 5:20 PM, the facility remained out of compliance at a potential for harm with a scope identified as a pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures placed all residents at risk of severe weight loss, delayed interventions, hospitalization , worsening health condition, and death. Findings included: 1.Record review of face sheet for Resident #33 indicated that he was a [AGE] year-old male admitted on [DATE] with diagnoses of unspecified dementia (symptoms that affect memory, thinking, and social skills), dysphagia, oropharyngeal phase (a swallowing disorder that affects the mouth and throat characterized by difficulty initiating a swallow, coughing, choking, or aspiration.), cognitive communication deficit (difficulty with communication that is caused by a problem with thinking), and gastro-esophageal reflux disease (when stomach acid repeatedly flows back into the tube connecting your mouth and stomach). Record review of Resident #33's significant change MDS dated [DATE] indicated that resident had a BIMS score of 14 indicating that he was cognitively intact. It indicated that he was independent with eating and required supervision or set up assistance with activities of daily living. Record review of care plan for Resident #33 dated 01/30/2024 revealed resident care planned for undesired weight loss with approach of weekly weights. Nutritional status care plan of mechanically altered diet with ground meat. Care plan dated 3/13/2024 for fortified foods. Care plan for set up assistance with meals reviewed. Record review of Resident #33's physicians orders dated 3/13/2024 revealed diet order for fortified foods, mechanical soft with ground meat. Review of order dated 11/28/2023 to discontinue double portions. Record review of facility weight variance report dated 12/12/2023 to 3/3/2024 revealed Resident #33's weights were: 12/12/2023- 233.0 1/3/2024- 184.00- indicating a 21.2% loss in 22 days 2/1/2024- 204.00 indicating a 11.0% gain in 29 days 2/19/2024- 197.00 3/3/2024- 196.8 Record review of facility weight variance report revealed that the resident was not weighed weekly as ordered on 1/30/2024 with weight not obtained during the week of 2/12/2024 and 2/26/2024 . During an observation on 4/01/2024 at 12:00 PM in the main dining room during lunch service, Resident # 33 received double portions at the lunch meal. 14 Residents with large portions on tray card received the same size portions as regular diets. During an observation on 4/3/2024 at 12:00 PM of the lunch meal service revealed Resident # 33 was served double portions due to tray card indicating double portions. 2. Record review of a facility face sheet dated 4/4/24 for Resident #13 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of dementia. Record review of a Comprehensive MDS assessment dated [DATE] for Resident #13 indicated that he had a BIMS score of 9, indicating that he had moderately impaired cognition. Record review of a comprehensive care plan dated 3/21/24 for Resident #13 indicated that large portions were not addressed . During an observation and interview on 4/1/2024 at 12:42 PM Resident # 13 was observed in the dining room on a secured unit feeding himself. He seemed to be having problems getting the food to his mouth on the spoon, said everything tasted great, but did not seem to be eating much. LVN D said he normally ate really slow and fed himself. He normally does not require assistance with meals. They just let him eat at his own pace. His tray card indicated that he was to have large portions, but his portions appeared to be the same size as all the residents received. During an observation on 4/2/24 at 12:00 pm of the lunch meal in the kitchen while meals were being plated and sent out of the kitchen revealed that Resident #13 did not receive large portions per instructions on the tray card. During an observation on 4/3/2024 at 12:00 PM of lunch meal service revealed Resident # 13's tray was returned to the kitchen due to no large portions served by the kitchen. 3. Record review of a face sheet for Resident #18 dated 4/4/2024 indicated he admitted to the facility on [DATE] and was an [AGE] year-old with diagnoses of dementia (loss of thinking, remembering, and reasoning), schizoaffective disorder, bipolar type (episodes of mood swings and sometimes depression), type 2 diabetes, and GERD (acid reflux disease). Record review of active physician orders dated 3/4/2024 to 4/4/2024 for Resident #18 indicated a diet order for a regular diet, thin consistency, and fortified foods with all meals that was discontinued on 4/2/2024. Record review of active orders for Resident #18 indicated a diet order for low concentrated sweets, regular, thin consistency, fortified foods with all meals with a start date of 4/2/2024. Record review of a Quarterly MDS dated [DATE] for Resident #18 indicated he had moderate impairment in thinking with a BIMS score of 12 and required set up/clean up assistance with eating. Record review of a care plan for Resident #18 dated 10/10/2022 indicated nutritional status with a regular diet, fortified food with all meals . During an observation on 4/01/2024 at 12:05 PM Resident #18 was observed in common area in the secured unit, eating lunch. Lunch consisted of a smothered pork chop, turnip greens, mashed potatoes, corn bread, and cake. Larger portions noted on tray which had larger portions on his plate than the other residents. During an observation on 4/2/2024 at 12:40 PM, the lunch trays in the secure unit revealed tray cards for some residents indicated fortified, some residents had a bowl of mashed potatoes added, and two residents had a cup of soup. Resident #18's tray card indicated large portions, but no large portions noted on his tray. He did have a bowl of mashed potatoes. His lunch consisted of Salisbury steak, new potatoes, broccoli and cauliflower, and a roll. 4. Record review of a facility face sheet dated 4/4/24 for Resident #6 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior). Record review of a Quarterly MDS assessment dated [DATE] for Resident #6 indicated that Brief Interview for Mental Status interview could not be conducted due to the resident being rarely/never understood. Question C1000 indicted that resident had severely impaired cognition. Record review of a comprehensive care plan dated 3/21/24 for Resident #6 indicated that it did not address receiving large portions . During an observation and attempted interview on 4/1/24 at 9:46 am Resident #6 was observed lying in bed. Resident would not speak to the state surveyor. During an observation on 4/2/24 at 12:00 pm of the lunch meal in the kitchen while meals were being plated and sent out revealed that Resident #6 did not receive large portions per instructions on the tray card. 5.Record review of face sheet for Resident #9 reflect that he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included cerebral palsy (a group of conditions that affect movement and posture), mild intellectual disabilities (a condition that limits intelligence and disrupts abilities necessary for living independently), dysphagia, oral phase (a swallowing disorder that affects the mouth and throat characterized by difficulty initiating a swallow, coughing, choking or aspiration.), bulimia nervosa (eating large amounts of food in one sitting), and gastro-esophageal reflux disease (when stomach acid repeatedly flows back into the tube connecting your mouth and stomach). Record review of Resident #9's quarterly MDS dated [DATE], indicated that the resident had a BIMS score of 15, indicating he was cognitively intact. It indicated that he required supervision for eating and was dependent or required substantial/ maximal assistance from staff for activities of daily living. Record review of care plans for Resident #9 dated 01/31/2024 indicated that the resident had experienced weight loss with an approach to monitor and record weight weekly for 4 weeks. And nutritional status care plan dated 2/21/2024 for regular diet with fortified foods with breakfast. Record review of Resident #9's physician orders with start date of 1/30/2024 for regular diet. New order dated 4/2/2024 for regular diet with fortified foods at breakfast. Record review of facility weight variance report dated 12/12/2023 to 3/3/2024 revealed resident #9's weights were: 12/12/2023- 184.0 1/3/2024- 171.2 indicating a 7.0% loss in 22 days 2/1/2024- 182.2 indicating a 6.8% gain in 29 days 2/12/2024- 196.6 indicating a 7.5% gain in 11 days 2/19/2024- 200.1 3/3/2024- 188.4 indicating a 5.8% loss in 13 days Record review of facility weight variance report revealed that the resident was not weighed weekly as ordered on 1/31/2024 with weight not obtained during the week of 2/26/2024 . 6.Record review of a facility face sheet dated 4/4/24 for Resident #31 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right side weakness/paralysis following a stroke). Record review of a Comprehensive MDS assessment dated [DATE] for Resident #31 indicated that he had a BIMS score of 7, which indicated severe cognitive impairment. Record review of a comprehensive care plan for Resident #31 dated 3/6/24 indicated that care plan did not address resident receiving large portions. During an interview on 4/1/24 at 10:03 am Resident #31 answered I don't know. to most questions and did not want to talk with the state surveyor. Resident #31 continued to watch television and ignored the state surveyor. During an observation on 4/2/2024 at 12:00 PM of the lunch meal in the kitchen while meals were being plated and sent out revealed Resident # 31 did not receive large portions per instructions on the tray card. 7. Record review of a face sheet for Resident #24 dated 4/03/2024 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: Hemiplegia following cerebral infarction affect left non-dominant side (paralysis or partial or total body function on left side of the body), partial loss of teeth, abnormal weight loss, and cognitive communication deficit (difficulty with thinking and how someone uses language). Record review of a Quarterly MDS assessment dated [DATE] for Resident #24 indicated that he had a BIMS score of 14, indicating his cognition was intact and he required setup or clean-up assistance with eating. Record review of a care plan dated 4/04/2023 for Resident #24 indicated he had a problem with nutritional status with interventions that included: Weigh me at least once a month and weekly if I show a significant weight loss. Resident #24 had a problem with ADL's Functional Status/Rehabilitation Potential with interventions that included: Resident requires supervised assist-limited x1 with eating. Record review of RD progress note dated 1/15/2024 the RD recommended reweighing Resident #24 for accuracy and weekly weights for 4 weeks. Record review of facility weight variance report dated 9/01/2023 to 3/10/2024 revealed Resident #24's weights were: 10/05/2023- 241.4 11/02/2023- 243.2 12/05/2023- 248.6 01/03/2024- 210.0 indicating a 15.5% loss in 29 days. 01/18/2024- 215.6 01/25/2024- 214.0 02/01/2024- 218.2 03/03/2024- 218.2 During an observation and interview on 4/03/2024 at 08:50 AM Resident #24 was observed eating breakfast in his room with the door closed and no supervision or assistance. Resident #24 was not able to answer questions due to cognitive communication deficit. During an observation on 4/03/2024 at 12:00 PM, Resident # 24 was pushed via wheelchair to the dining room by therapy. Resident #24 requested a hamburger for lunch. The Administrator verbally communicated resident's request to the dietary staff. Resident was served a hamburger with potato chips, yogurt, and fortified mashed potatoes. Resident #24 picked up the hamburger and put the entire hamburger in his mouth at one time, he then started placing potato chips in his mouth with the hamburger. Resident #24 took approximately 10-15 minutes to swallow the food in his mouth. Resident did not touch his fortified mashed potatoes. Resident #24 was not assisted by staff, no verbal cues were given by staff, and fortified food was never encouraged by staff. 8. Record review of a facility face sheet dated 4/2/24 for Resident #25 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of dementia. Record review of a Quarterly MDS assessment dated [DATE] for Resident #25 indicated that Brief Interview for Mental Status could not be conducted due to the resident being rarely/never understood. Question C1000 indicated that resident had severely impaired cognition. Record review of physician orders for Resident #25 indicated that she had the following order: Diet: Regular diet, fortified foods; Texture: Mechanical soft; Fluid consistency: Thin dated 2/2/24. Record review of a comprehensive care plan for Resident #25 dated 3/31/24 indicated that she had experienced weight loss and was to receive fortified food with all meals. Record review of Resident #25's weights located in her electronic medical record indicated that on 10/05/2023, the resident weighed 138.5 lbs. On 04/032024, the resident weighed 110.8 pounds which was a -20.00 % loss in 180 days. During an observation on 4/2/2024 at 12:30 pm, Resident #25 was observed up in a chair in the dining room being assisted with lunch meal by staff member. Tray card said, fortified food, but no fortified food was on the meal tray for resident. Dietary manager came to dining room and said that Resident # 25's fortified foods must have gotten missed. She returned to the dining room with a cup of fortified soup for Resident #25. A telephone interview with RP H of Resident #25 was attempted on 4/4/24 at 3:11 pm. No answer was received, a voicemail requesting a return phone call was left. No return phone call was received before exiting the facility on 4/5/2024. 9. Record review of a facility face sheet dated 4/3/24 for Resident #34 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of vascular dementia (a condition caused by the lack of blood that carries oxygen and nutrients to a part of the brain. It causes problems with reasoning, planning, judgment, and memory). Record review of a Comprehensive MDS assessment dated [DATE] for Resident #34 indicated that he had a BIMS score of 6, which indicated he had severe cognitive impairment. Record review of physician orders for Resident #34 indicated that he had the following order dated 11/28/23: Diet: Regular diet; Texture: Regular; Fluid Consistency: Thin; Fortified foods TID. During an observation and interview on 04/01/24 at 12:47 PM during lunch, Resident #34 was observed in his room eating lunch at 12:15 pm after CNA E who worked for hospice served him a tray. Resident #34 was served the wrong tray. Resident #34 was served Resident #25's tray, which was a mechanical soft (chopped meat). Resident #25 was observed in the dining room when staff realized her tray was not on the cart. Resident #34's tray was on the cart, but it was a regular tray, with a full pork chop. Staff went to the kitchen and got another tray made for Resident #25. Resident #25 received her tray at 12:30 pm in the dining room. Interview with CNA F said that CNA E had passed Resident #34 the wrong tray. She said that they should check the tray card before passing trays. She said that CNA E was working for hospice that day and not the facility, but she also worked for the facility. During an interview on 04/03/24 at 10:50 AM, CNA E said that she does not normally help pass trays when she comes in as a hospice aide, but she was trying to help on Monday 4/1/2024. She said that she had looked at the cart and Resident # 5 (another resident) had started talking to her and she got distracted and turned the cart around and accidentally gave Resident #34 the incorrect tray (Resident #25). She said that residents could be at risk of allergic reactions or choking if they received the wrong type of food. 10. Record review of a facility face sheet dated 4/3/24 for Resident #22 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of autistic disorder (a condition related to brain development that impacts how a person perceives and socializes with others, causing problems in social interaction and communication. The disorder also includes limited and repetitive patterns of behavior). Record review of a Quarterly MDS assessment dated [DATE] for Resident #22 indicated that Brief Interview for Mental Status interview could not be conducted due to the resident being rarely/never understood. Question C1000 indicated that the resident had severely impaired cognition. Record review of physician's orders for Resident #22 indicated that he had the following order dated 2/28/24: Diet: Regular, fortified foods; Texture: Mechanical soft; Fluid Consistency: Thin; Health Shakes TID with meals. Record review of a comprehensive care plan dated 4/3/24 for Resident #22 indicated that he was to receive fortified foods for nutritional status. During an observation on 4/3/2024 at 12:00 PM of the lunch meal service revealed Resident # 22's tray was returned to the kitchen due to the resident being lactose intolerant according to the tray card and he was served lasagna with cheese and yogurt. During an observation and interview on 4/3/24 at 12:39pm Resident #22 was observed to have a cut-up sandwich, a bag of Cheeto puffs, zucchini, and a banana for lunch. The ADON was asked what his fortified food was, and she said they had originally sent out the lasagna for him, but he was lactose intolerant, and the tray was sent back to the kitchen. She said his fortified food had been on his original tray and they must have just forgotten to bring it back. She then went to kitchen and brought back a cup of fortified soup for Resident #22. His tray card was observed to say fortified foods, large portions, and lactose intolerant. 11. Record review of a face sheet for Resident #35 dated 4/4/2024 indicated she admitted to the facility on [DATE] and was [AGE] year-old with diagnoses of bipolar disorder with psychotic features (having delusions or seeing things that are not there), schizoaffective disorder (mood symptoms), bipolar type (extreme mood swings), anxiety (nervousness) and schizophrenia (mental illness that affects how a person thinks, feels, and behaves). Record review of active physician orders for Resident #35 dated 3/4/2024 to 4/4/2024 indicated a diet order for regular texture with fluid consistency thin dated 5/27/2022. Record review of a care plan for Resident #35 dated 4/3/2024 indicated she had an undesirable weight gain due to excessive calorie intake. 15.5% weight gain in 180 days with interventions for diet as ordered and encourage oral intake of food and fluids. Record review of a Quarterly MDs for Resident #35 dated 1/25/2024 indicated she did not have any impairment in thinking with a BIMS score of 15 and required set up/clean up help with eating. During an observation on 4/1/24 at 12:15 pm, Resident #35 was observed in her room eating lunch after CNA E was observed serving her a tray. Observation indicated that the resident received a mechanical soft tray that was intended for Resident #25. During an observation on 4/2/2024 at 12:40 PM during lunch, Resident #35 did not receive her therapeutic diet of large portions. During an interview on 4/1/24 at 12:47 pm CNA F said that she had a new tray made for Resident #25 due to CNA E serving her tray to Resident #35. She said that CNA E was not working for the facility this day, she was in the facility seeing a hospice resident, but that she does also work prn for the facility. She said that if a resident that should get a mechanical soft or puree tray had accidentally received a regular tray, they could have been at risk for choking. She said that they should always check the tray cards on the trays before passing them to a resident. During an interview on 4/3/24 at 10:50 am, CNA E said that she does not normally help pass the trays when she was not working for the facility, but that she was just trying to help on Monday, April 1, 2024. She said that she had looked at the cart and another resident began talking to her and she got distracted and turned the cart around and accidentally gave Resident #35 the wrong tray. She said that residents could be at risk for allergic reactions or choking if they got the wrong type of food. 12. Record review of a face sheet for Resident #17 dated 4/04/2024 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: dementia (group of thinking and social symptoms that interferes with daily functioning), and cognitive communication deficit (difficulty with thinking and how someone uses language). Record review of a Quarterly MDS assessment dated [DATE] for Resident #17 indicated that he had a BIMS score of 14, indicating his cognition was intact. The functional abilities and goals section of same MDS assessment indicated that he was independent with eating . Record review of active physician orders undated revealed residents diet order of regular low concentrated sweets diet ordered on 4/04/2024. Record review of a care plan dated 4/03/2023 for Resident #17 indicated he had a problem with nutritional status with interventions that included: Monitor/Record weight as ordered by MD. Weekly weights x 4 weeks. Notify MD and family of significant weight changes. And Provide setup help assistance for meals. Record review of facility weight variance report dated 9/01/2023 to 3/10/2024 revealed Resident #17's weights were: 09/02/2023- 267.2 10/05/2023- 264.0 11/02/2023- 264.0 12/12/2023- 268.4 01/03/2024- 272.4 02/01/2024- 277.4 03/03/2024- 281.6 During an observation on 4/3/2024 at 12:00 PM of the lunch meal service revealed Resident # 17's tray was returned to the kitchen due to no large portions served by the kitchen. 13. Review of Resident #15's face sheet reflected that he was an [AGE] year-old male admitted on [DATE]. His diagnoses included unspecified dementia with other behavioral disturbances (dementia is characterized by a decline in cognitive abilities that impacts a person's ability to perform everyday activities and behavioral disturbances can include verbal or physical aggression, incontinence, agitation, sleep disturbances, or changes in appetite), dysphagia, oropharyngeal phase (a swallowing disorder that affects the mouth and throat characterized by difficulty initiating a swallow, coughing, choking or aspiration.), cognitive communication deficit (difficulty with communication that is caused by a problem with thinking), and gastro-esophageal reflux disease (when stomach acid repeatedly flows back into the tube connecting your mouth and stomach). Record review of Resident #15's Quarterly MDS dated [DATE], indicated that the resident had a BIMS score of 06, indicating severely impaired cognition. It indicated that the resident required substantial/maximal assistance with eating (helper does more t han half the effort) and that he is dependent on staff for all activities of daily living. Record review of the care plans for Resident #15 dated 4/1/2024 indicated that the resident had the potential for weight loss related to dementia and feeding difficulties. Diet change was noted in the care plan on 4/1/2024 for dysphagia puree with thickened liquids and on 4/2/2024 dysphagia puree with nectar thickened liquids. Nursing approaches included provide physical help assistance for meals dated 12/21/2023. Record review of Resident #15's physician orders with a start date of 4/02/2024 diet of dysphagia puree with nectar thick liquids. During dining room observation on 4/1/2024 at 12:00 PM, Resident #15 was observed sitting at a table alone. Staff served the resident his meal that was pureed and thickened liquids, the tray card indicated that resident diet was correct. Observed Resident #15 feeding himself without staff assistance or verbal cueing. Resident remained at the dining room table alone. Staff assisted resident out of dining room when he finished eating. During dining room observation on 4/2/2024 at 8:30 AM and 12:00 PM, Resident #15 was observed sitting at table alone, staff served his meal and resident ate both meals without assistance or verbal cueing. Resident was observed eating quickly, taking large bites of pureed food, and occasionally coughing when he swallowed. 14. Record review of a face sheet for Resident #1 dated 4/04/2024 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: schizoaffective disorder (delusions, hallucinations, depressed episodes, and manic periods of high energy), spastic diplegic cerebral palsy (muscle stiffness is mainly in the legs, with the arms less affected or not affected at all), abnormal weight loss, and dysphagia, oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat). Record review of a Quarterly MDS assessment dated [DATE] for Resident #1 indicated that she had a BIMS score of 15, indicating her cognition was intact. The functional abilities and goals section of same MDS assessment indicated that she had received partial/moderate assistance with eating. Record review of a care plan dated 4/02/2024 for Resident #1 indicated he had a problem with nutritional status with interventions that included: Weight as ordered. Resident #1 had a problem with ADL 's Functional Status/Rehabilitation Potential dated 6/14/2023 with interventions that included: Resident requires extensive x1 assist with eating . Record review of the facility Medical Nutrition Therapy Assessment for Skilled Nursing Facilities 11/2019 dated 10/27/2023 indicated Resident #1 had a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. The same assessment indicated Resident #1 was not on physician-prescribed weight-loss regimen. During an observation on 4/3/2024 at 12:00 PM of the lunch meal service revealed Resident # 1's tray was returned to the kitchen due to no large portions served by the kitchen . 15. Record review of a facility face sheet dated 4/4/24 for Resident #29 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Record review of a Quarterly MDS assessment dated [DATE] for Resident #29 indicated that Brief Interview for Mental Status could not be conducted due to resident being rarely/never understood. Question C1000 indicated that she had severely impaired cognition. Record review of a comprehensive care plan for Resident #29 dated 3/13/34 indicated that the resident had experienced weight loss and a new order was received on 12/23/23 to weigh weekly for 4 weeks. Record review of Resident #29's weights in her electronic medical record indicated that she was weighed on 1/4/24 and 1/15/24, indicating that she was not weighed the week of 12/24/23 through 12/30/23, nor the week of 1/7/24 through 1/13/24. During an interview on 04/02/24 at 10:45 AM, the DM said she was responsible for updating the tray cards to reflect the current diet. She said she updated the tray cards when she received a dietary communication form from nursing. During an interview on 4/2/2024 at 3:14 PM, the RD said she had been going to the facility monthly for the past two months. She said when she arrived at the facility, she checked in with the DON/ADON to ask if there was anyone that needed to be seen. She said each visit, she screened for weight loss in the past 180 days. She said she would see new admissions during the visits. She said residents that were on dialysis would be seen quarterly. If a resident had a weight loss would be seen monthly along with pressure injuries and tube feedings. She said she ran an audit report from the electronic health record system and looked for weight variances and it calculated the percentages of weight loss. She said her last visit at the facility was on 3/12/2024. She said during her visits, she conducted an audit of the recommendations from the previous month to ensure they were followed. She said if they were not, she would let the DON know that they were not done and would review the following month. She said during her monthly visits, she did not visit every resident in the facility, only the ones that were screened. During an interview on 4/2/2024 at 04:00 PM, the ADON said she had been in the ADON position since December 2023. She said that she was responsible for reviewing the residents' weights and entering the information into the electronic record. She said that she reviewed the weights and was responsible for re-weights and assuring that orders for weekly weights were done. She said that if a resident had a significant weight loss she notified the Registered Dietician, the PCP, and the resident's responsible party. She said that until March 2024, different staff were responsible for weighing residents monthly. She said that the issue of resident weight loss and weighing residents was part of a performance improvement plan and that the actions included had a designated employee to weigh the residents. She also said that a new scale was purchased. She said that residents on weekly weights were now being done by the designated employee and that a new tracking system was being developed. The ADON said that she was also responsible for reviewing the dietary recommendations and making sure that recommendations were communicated to the PCP. She said that she was responsible for writing any orders related to the registered dieticians' recommendations and communicating any changes to the dietary

Based on interview and record review, the facility failed to notify the resident's physician and responsible party when there was a significant change in the physical status for 1 of 14 residents (Resident #15) reviewed for notification of changes. The facility failed to ensure that the physician and the responsible party was notified of resident #15's change in condition when the resident experienced a choking incident on 4/1/2024. An IJ was identified on 04/04/2024. The IJ template was provided to the facility on [DATE] at . While the IJ was removed on 04/05/2024, the facility remained out of compliance at a scope of isolated and severity of no actual harm with the potential for more than minimal harm because of continued monitoring the effectiveness of the corrective systems. This deficient practice could place residents at risks for a delay in medical treatment, which could lead to worsening of their condition, hospitalization , or death. The findings include: Review of resident #15 face sheet reflect that he is an [AGE] year-old male admitted on [DATE]. His diagnosis include unspecified dementia with other behavioral disturbances (dementia is characterized by a decline in cognitive abilities that impacts a person's ability to perform everyday activities and behavioral disturbances can include verbal or physical aggression, incontinence, agitation, sleep disturbances or changes in appetite), dysphagia, oropharyngeal phase (a swallowing disorder that affects the mouth and throat characterized by difficulty initiating a swallow, coughing, choking or aspiration.) , cognitive communication deficit (difficulty with communication that is caused by a problem with thinking), and gastro-esophageal reflux disease (when stomach acid repeatedly flows back into the tube connecting your mouth and stomach). Record review of resident#15 Quarterly MDS dated [DATE], indicated that the resident had a BIMS score of 06, indicating severely impaired cognition. It indicated that resident requires substantial/maximal assistance with eating (helper does not than half the effort) and that he is dependent on staff for all activities of daily living. Record review of the care plans for resident #15 dated 4/1/2024 indicated that resident had the potential for weight loss related to dementia, feeding difficulties. Diet change was noted in care plan on 4/1/2024 for dysphagia puree with thickened liquids and on 4/2/2024 dysphagia puree with nectar thickened liquids. Nursing approaches included provide physical help assistance for meals dated 12/21/2023. Resident also has a care plan dated 3/27/2024 for risk for respiratory distress related to history of aspiration pneumonia (an infection of the lungs caused by inhaling saliva, food, liquid, or vomit). Record review of nurse's progress notes dated 4/1/2024 at 08:02 AM entered by LVN A, indicated that the resident had choked on every single bite of food .at breakfast the nurse charted that the MDS coordinator gave the OK to downgrade the residents diet to pureed with thickened liquids until speech can assess the resident. There was not any documentation that resident primary care provider was notified of incident and no documentation of responsible party notified. During dining room observation on 4/1/2024 at 12:00 PM, resident #15 was observed sitting at a table alone. Staff served resident his meal that was pureed and thickened liquids, the tray card indicated that resident diet was correct. Observed resident #15 feeding himself without staff assistance or verbal cueing. Resident remained at the dining room table alone. Staff assisted resident out of dining room when he finished eating. During dining room observation on 4/2/2024 at 8:30 AM and 12:00 PM, resident #15 was observed sitting at table alone, staff served his meal and resident ate both meals without assistance and verbal cueing. Resident was observed eating quickly, taking large bites of pureed food, and occasionally coughing when he swallowed. During an interview on 4/3/2024 at 2:30 PM, MDS coordinator said she was an LVN. She said she was in the facility on 4/1/2024 during the time that resident #15 was eating his breakfast. She said that LVN A reported to her that the resident was choking and coughing during breakfast, and she instructed her to change his diet to pureed with thickened liquids until speech therapy could evaluate him. She said that nurses are allowed to downgrade resident diets if needed. She said that the doctor should have been notified and that the nurse should have documented notification in the nurse's progress notes. She said that the resident has a history of eating too fast and requires staff to remind him to slow down when eating. During an interview on 4/4/24 at 2:47 PM, the DOR said she was a COTA. She said she was present on 4/1/2024 in the dining room when Resident #15 was eating. She said I feel like the nurses note is an over exaggeration. He was not choking. She said that the resident takes large bites and swallows his food without chewing. She said that the resident eats too fast. Prior to the pureed diet, the resident was on a mechanical soft diet with thin liquids. She said that the resident was put on the mechanical soft diet after a modified barium swallow (an analysis of swallowing) was done in November 2023. She said that the resident was scheduled for the speech therapist to evaluate on Friday (4/5/2024) or Monday (4/8/2024). She said that the speech therapist was in the facility daily but had not evaluated the resident yet because it would take treatment time from residents that are already scheduled. She said that she educated the nurse on Monday, 4/1/2024 during breakfast. She said that because the nurse was a traveler, she was not familiar with the resident. She said that the resident was not choking on every bite and that the resident was eating fast and cough one time after swallowing and would continue to eat and cough after each swallow. She said that she believed that she was able to recognize if the resident had aspirated (when food or liquid enters the lungs) due to her experience and familiarity with the residents. During an interview on 4/4/24 at 2:50 PM, LVN A said that she was an agency nurse and had only worked in the facility a few times. She said that she worked on Monday 4/1/2024 and Tuesday 4/2/2024. She said that on Monday, 4/1/2024 she was in in the dining room when Resident #15 was eating breakfast. She said that Resident #15 was eating scrambled eggs, hash browns, softened rice crispies cereal with milk. She said that the Resident #15 was choking on every bite that he consumed . She said that the resident was shoveling food into his mouth. She said that she made a nursing judgement and downgraded the resident's diet from mechanical soft to a pureed diet. She said that she spoke with the MDS Coordinator, and she had told her to downgrade his diet. She said that she thought that the MDS coordinator was going to notify the doctor and anyone else that needed to be notified. The nurse said that while the resident was coughing, he had a runny nose and watery eyes. During an interview on 04/04/24 at 4:42 PM , DON said that she would consider a medical emergency constituting immediate physician notification to include: a resident not breathing, bleeding profusely, having no pulse, unable to awaken, or anything that could constitute an immediate threat to life or anything that could cause a loss of life. During an interview on 4/4/24 at 4:52 PM, the NP said that the facility notified her earlier in the week and reported that Resident #15 was having difficulty swallowing. She said that she ordered a downgrade of diet at that time from a mechanical soft to a pureed diet and for speech to evaluate and treat as indicated . When asked if it was reported that Resident #15 was choking during his meal, she said No, if they would have reported choking while eating, I would have ordered a chest x-ray to rule out aspiration. The NP said that swallowing difficulties were the only thing reported. During an interview on 04/04/24 at 4:46 PM, LVN C said that she would consider a resident choking to be a medical emergency. During an interview on 4/5/2024 at 3:00 PM, the Regional Nurse said that the nurses in the facility were allowed to downgrade a resident's diet using nursing judgement. She said that the doctor and the speech therapy were involved in evaluating residents that have a change in condition like the ability to swallow. During an interview on 4/5/24 at 3:53 PM, the DON said that her expectations were that the charge nurse was to report any changes in the resident's baseline. She expected that significant changes as well as minor changes from baseline should be reported to the MD. She said that failure to notify the physician of any changes in condition could result in improper and or timely treatment for the resident. During an interview on 4/5/24 at 4:26 PM, the Administrator said that his expectations were that the physicians are notified, the event was charted, the responsible party to be notified of changes in condition and any new orders, that the changes and any orders be placed on the 24-hour report. He expected that any changes be reported and discussed in the morning meetings. He said that failures to notify the doctor of changes in condition can result in the resident not getting the appropriate care. Record review of the facility policy titled Change in a Resident's Condition or Status dated 4/20/2023, the policy statement is our facility promptly notifies the resident, his attending physician, health care provider and the resident representative of changes in the resident's medical condition and/or status. Policy interpretation and implementation included a significant change of condition is a major decline . that will not normally resolve itself without intervention by staff . and except in medical emergencies, notifications will be made within twenty-four hours of a change . Record review of facility document titled Emergency Procedure- Choking revised March 2011 indicated report results promptly to the supervisor and attending physician. This was determined to be an Immediate Jeopardy (IJ) on 4/4/2024 at 4:45PM. The facility's Administrator and Director of Regulatory Compliance were notified. The Administrator was provided with the IJ template on 4/4/2024 at 5:27 PM. The plan of removal was accepted 04/05/2024 at 5:20 PM. Plan of Removal: 580- Notification of Changes Date Initiated: 4/4/2024 Today's Date: 4/4/2024 The facility failed to immediately consult with the resident's physician when Resident #15 who is aspiration risk had a possible choking incident. All residents that can be at risk for aspiration can be affected by the alleged deficiency. Action: Speech Therapist assessed Resident #15 on 4/4/2024 and notes no concerns and is evaluating resident to return to mechanical soft diet. Resident is upgraded to Mechanical Soft. Will continue to have Resident #15 on caseload. Therapy to order a Modified Barium Swallow study on 4/5/2024. MD has been notified of the event that occurred on 4/1/2024 on 4/4/24 and 4/5/24, the downgrading of the resident's diet, the speech therapy evaluation that led to an upgrade back to mechanical soft, and the pending Modified Barium Swallow Study, MD is agreeable to the current plan of care. Called RP to notify about the Modified Barium Swallow Study, RP declined the Modified Barium Swallow Study, RP was educated regarding the negative repercussions of not having the Modified Barium Swallow Study, RP remains adamant that they will be declining the study. Person(s) Responsible: Speech Therapist and Director of Nursing Date: 4/5/2024 by 1PM Action: Charge Nurses and CNAs will be trained on what to do if residents are having coughing and choking issues, which will be notifying nursing administration, notifying the therapy department (nursing administration can be designated for the therapy communication, as well), notifying the MD or physician extender. All Charge Nurses and CNAs will be trained prior to working their next shift. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 4/5/2024 by 2:30PM Action: Educate Charge Nurses over Change in a Resident's Condition or Status policy with emphasis on the understanding of notifying the physician of significant changes immediately (or as soon as the resident is safe or stable) and all other within 24-hours per facility policy. Staff will be trained over examples of what a significant change in condition is. Significant Change can be defined as: Immediate Notification (Acute) Problems The following symptoms, signs and laboratory values (which are not all-inclusive) should prompt immediate notification of the physician, after an appropriate nursing evaluation. Immediate implies that the physician should be notified as soon as possible, either by phone, pager, text messaging, or other means. These situations include: 1. Witnessed cardiac or respiratory arrest for individuals who have full code status. 2. Rapid decline or continued instability (for example, markedly fluctuating vital signs), unless the individual is receiving palliative care and has declined workup or treatment. The following symptoms: a. Sudden in onset OR a marked change (for example, much more severe or frequent) compared to usual (baseline) status, AND are b. Unrelieved by measures which have already been prescribed and/or attempted. For example, consistent with criteria a) and b) above, abdominal pain with distension or fever; chest pain, pressure or tightness; new or worsening confusion; new or progressive gait or balance problem; persistent severe headache; persistent or recurrent nausea and vomiting; new onset of slurred or incoherent speech; suicidal thoughts with expressed plan; abrupt or rapidly progressive vision changes; new onset weakness of an arm or leg. 4. The following signs: The following list of physical signs is not meant to be all-inclusive. Depending on the situation, other physical findings may warrant physician notification. a. Change in vital signs. Follow these general guidelines: Temperature >101 Degrees rectally, or the parameters indicated by the physician Respiratory rate >28/min or a lower rate with respiratory distress or the parameters indicated by the physician? Pulse >110 or <55/min or the parameters indicated by the physician Blood Pressure >210 or <90 systolic; or >120 diastolic or the parameters indicated by the physician? b. Sudden loss of consciousness. c. Seizure activity. d. More than minimal bleeding, for example: o Persistent nosebleed o Gross hematemesis o Bright red blood in stool (not due to known hemorrhoids) o Profuse vaginal bleeding o Gross hematuria e. Fall with an identified or suspected injury (e.g., fracture or laceration). f. New and/or severe gastrointestinal signs, including: o Prolonged and/or progressive nausea and vomiting o Painful, persistent abdominal distention g. Sudden or rapid onset of new confusion, paranoia and delusions, and/or physical aggression, or progressive worsening of existing condition. h. New onset of, or progression of usual, tachypnea and dyspnea with a pulse oximetry below 90% or at least 3% below usual pulse oximetry range. Significant medication error a. If it involves a medication with significant side effects, risks, or adverse consequences. b. If the nature of the medication or severity of the reaction to the medication warrants discussion with the physician.5. Laboratory results a. Any lab result for which the physician requests immediate or STAT reporting. b. For guidance on reporting results, see Appendix B: Guidelines for Reporting Abnormal Test Results to Physicians and related to policy on Lab and Diagnostic Test Results: Physician Role and Follow-Up.? All Charge Nurses will be educated prior to working their next shift. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing Date: 4/5/2024 by 1:30PM Action: Progress notes will be reviewed for the last 30 days to audit for any significant changes that the physician and/or the physician extender may have not been notified of. Any findings will be immediately reported to the physician and/or the physician extender, RP (if applicable) Person(s) Responsible: Director of Regulatory Compliance Date: 4/5/2024 by 12PM Action: Ad hoc QAPI performed with Medical Director and Nurse Practitioner, and they have been made aware of the template and plan to remove the immediacy. Person(s) Responsible: Administrator Date: 4/4/2024 by 7PM Surveyors monitored Plan of Removal as follows: Record review of nurses note dated 4/5/2024 notifying resident #15 physician and obtaining order for barium swallow study and notifying responsible party of the barium swallow study. Reviewed speech therapy note dated 4/4/2024. Record review of an inservice dated 4/5/2024 titled coughing/choking issues with 15 of 29 employee signatures. Record review of inservice dated 4/4/2024 titled Change of condition with 15 of 29 employee signatures. Received attestation statement by director of regulatory compliance indicating that progress notes were reviewed for significant changes dated 4/5/2024. Record review of an Adhoc QAPI: dated 4/4/2024 indicated the Administrator, DON, ADON, MDS, DM and Medical Director were in attendance. Interviews on 4/5/2024 from 3:18 PM to 4:52 PM included: Staff: LVN's- 5 RN's- 2 CMA's- 1 CNA's- 4 Administrator - 1 Interview on 4/5/2024 at 3:18 pm CMA B said that if a resident is coughing or choking during meals that she would make sure that the resident is safe and notify a nurse immediately. She said if she could not leave the resident she would call for help. Interview on 4/5/2024 at 3:38 pm DON said that she expected the staff to make sure any resident coughing or choking while eating is stable. She said that the charge nurse is responsible for ensuring the resident is stable and notifying the physician. She said the charge nurse should also notify nursing administration and the responsible party of the resident. She said that if there is a change in condition, the charge nurse is to assess the resident and the notify the physician, DON and ADON must be notified and documentation of notification should be done in the chart. She said that a change in condition are changes in residents established baseline. Interview on 4/5/2024 at 3:58 pm CNA K was able to verbalize that if a resident is coughing or choking during meals that she would make sure that the resident is safe and notify a nurse immediately. She said if she could not leave the resident she would call for help. Interview on 4/5/2024 at 4:00 pm ADON said she expected the staff to make sure any resident coughing or choking while eating is stable. She said that the charge nurse is responsible for ensuring the resident is stable and notifying the physician. She said the charge nurse should also notify nursing administration and the responsible party of the resident. She said that if there is a change in condition, the charge nurse is to assess the resident and the physician and DON must be notified and documentation of notification should be done in the chart. She said that a change in condition are changes in residents established baseline. Interview on 4/5/2024 at 4:09 pm MDS verbalized that she expected the staff to make sure any resident coughing or choking while eating is stable. She said that the charge nurse is responsible for ensuring the resident is stable and notifying the physician. She said the charge nurse should also notify nursing administration and the responsible party of the resident. She said that if there is a change in condition, the charge nurse is to assess the resident and the physician, DON and ADON must be notified and documentation of notification should be done in the chart. She said that a change in condition are changes in residents established baseline. Interview on 4/5/2024 at 4:18 pm LVN L verbalized that if a resident is coughing or choking while eating or drinking she would make sure the resident is stable and breathing. She would tell the DON or ADON and call the physician or send the resident to the hospital depending on if the resident was having breathing difficulties. She said that she would document the event in the progress notes. She said that any changes in a residents condition is reported to the residents physician and the responsible party and that the DON and ADON are notified. She said that a change in condition is a change from the residents baseline. Interview on 4/5/2024 at 4:24 pm Administrator verbalized that he expects the charge nurse on duty to assess residents for any changes in conditions and that any changes be documented in the progress notes. He expects the charge nurse to notify the physician with any changes and the responsible party and document the contact and communication in the residents chart. He said that any changes in condition needed to be reported to the DON and ADON. Interview on 4/5/2024 at 3:17 pm LVN D said if a resident is coughing or choking while eating or drinking she would make sure the resident is stable and breathing. She would tell the DON or ADON and call the physician or send the resident to the hospital depending on if the resident was having breathing difficulties. She said that she would document the event in the progress notes. She said that any changes in a residents condition is reported to the residents physician and the responsible party and that the DON and ADON are notified. She said that a change in condition is a change from the residents baseline. Interview on 4/5/2024 at 3:19 pm CNA F said if a resident is coughing or choking while eating she would not give them any more to eat or drink and notify the charge nurse immediately. Interview on 4/5/2024 at 3:23 pm CNA J said if a resident is coughing or choking while eating she would not give them any more to eat or drink and notify the charge nurse immediately. Interview by telephone on 4/5/2024 at 5:04 pm LVN P verbalized that if a resident is coughing or choking while eating or drinking she would make sure the resident is stable and breathing. She would tell the DON or ADON and call the physician or send the resident to the hospital depending on if the resident was having breathing difficulties. She said that she would document the event in the progress notes. She said that any changes in a residents condition is reported to the residents physician and the responsible party and that the DON and ADON are notified. She said that a change in condition is a change from the residents baseline. Interview by telephone on 4/5/2024 at 5:00 pm LVN N said verbalized that if a resident is coughing or choking while eating or drinking she would make sure the resident is stable and breathing. She would tell the DON or ADON and call the physician or send the resident to the hospital depending on if the resident was having breathing difficulties. She said that she would document the event in the progress notes. She said that any changes in a residents condition is reported to the residents physician and the responsible party and that the DON and ADON are notified. She said that a change in condition is a change from the residents baseline. Interview by telephone on 4/5/2024 at 4:53 pm CNA O said if a resident is coughing or choking while they are eating or drinking she would notify the nurse immediately. Attempted a telephone interview on 4/5/2024 at 4:51 pm with LVN Q. Message received indicating number was no longer in service. Attempted a telephone interview on 4/5/2024 at 4:55 pm with LVN C left a voicemail for a return phone call. Attempted a telephone interview on 4/5/2024 at 4:52 pm with CNA R left a voicemail for a return phone call. All above staff were able to appropriately answer questions. An IJ was identified on 04/04/2024. The IJ template was provided to the facility on [DATE] at . While the IJ was removed on 04/05/2024, the facility remained out of compliance at a scope of isolated and severity of no actual harm with the potential for more than minimal harm because of continued monitoring the effectiveness of the corrective systems.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen (Main Kitchen). On [DATE] the facility failed to ensure food was discarded by the expiration date. This deficient practice could place residents who ate food from the kitchen at risk for foodborne illness. The findings included: During an observation, in the dry storage area inside of the kitchen, on [DATE] at 09:30 a.m., revealed white frosting 4.5 pounds in plastic bag with open date [DATE] with expiration date [DATE], in the same plastic bag bread pudding 18 ounces with no open date, yellow cake mix 5 pounds unopened expired on [DATE], large plastic bag of pasta 10 pounds opened with no date, 2 bags grits 5 pounds opened with no date and not bagged, large plastic bag of 33 thickened coffee 0.42 ounce individual packets with the expiration date [DATE], soy sauce 1 gallon bottle with plastic wrap covering top that was falling off due to no lid with no open date and a received date of [DATE], and 1 container labeled flour 12 liters with use by date [DATE]. During an observation of the refrigerator on [DATE] at 09:25 a.m., Flip Almond [NAME] Loco yogurt 4.5 ounce expired [DATE], prune Juice 46 ounces was opened on [DATE] and expired on [DATE], Strawberry Topping opened and stored in a 1-liter bowl with plastic wrap covering bowl dated [DATE], and an Energy Drink 12oz. belonging to employee dated [DATE]. During an observation and interview on [DATE] at 09:35 a.m. the DM confirmed, by observations, that the items in the dry storage area, and refrigerator were not discarded by the expiration dates. The DM said anything that was opened in the refrigerator should have an open date and expires on day 7 after opening. During an interview on [DATE] at 10:05 a.m., the DM said she had worked at the facility for about ,d+[DATE] months. She said it was all the dietary staff's responsibility to check the fridge, freezer, and dry storage for expired foods. She said the fridge and freezer were checked daily to make sure everything was labeled, and not expired. She said usually when she came in on Mondays she checked the fridge, freezer, and dry storage for expired foods, but she was short on staff last week. She said prior to [DATE] the last time the fridge, freezer, and dry goods had been checked would have been that prior Monday, [DATE]. She said consuming expired foods could put the residents at risk of food borne illnesses. She said the facility policy was all expired food was to be discarded by the expiration dates. During an interview on [DATE] at 04:29 p.m. the Administrator said he had worked at the facility for about 8 months. He said his expectations was for all expired food to be thrown away or sent back to the food company. He said it was the responsibility of the DM to make sure all expired food was removed from the kitchen. The Administrator said, the potential negative outcome for residents consuming expired foods could be food borne illnesses. Record review of facility policy titled Food Storage dated 2018, revealed To ensure that all food served by the facility is of good quality and safe for consumption, etc . 1. Dry storage rooms. D. To ensure freshness, store opened, and bulk items is tightly covered containers. All containers must be labeled and dated. 2. Refrigerators. D. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. E. Use all leftovers within 72 hours. Discard items that are over 72 hours old.

Based on interviews, observation and record reviews, the facility failed to implement written policies and procedures that prohibit abuse/neglect for 7 of 12 (Resident #'s 2, 3, 4, 5, 6, 7, and 8) residents reviewed for abuse, neglect, and misappropriation of property. 1.The facility did not implement their policies and procedures related to interventions for resident-to-resident altercations after Resident #1 hit Resident #2 twice on the arm. Resident #1 then hit and spit on Resident #3, 30 minutes later. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:37 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because (e.g.) all staff had not been trained on Abuse/Neglect, Resident-to-Resident Altercations, and 1:1 monitoring of the aggressors. 2.The facility did not implement their policies and procedures related to investigation and reporting allegations of misappropriation of property when Activity Director A: * took money via cash app from Resident #4 in the amount of $1,150.00 dollars; * took cash money from Resident #5 in the amount of $100.00 dollars. * attempted to take cash money from Resident #6 in the amount of $100.00 dollars. * took cash money from Resident #7 in the amount of $25.00 dollars. * took cash money from Resident #8 in the amount of $20.00 dollars. This failure could place residents at risk for abuse, neglect, misappropriation of property, and severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being. Findings included: Record review of the facility's policy dated [DATE] titled: Abuse Prevention Program 2. Out resident have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. 7. All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by center management. Findings of abuse investigations will also be reported. Policy interpretation and implementation: 3. Develop and implement policies and procedures to aid our center in preventing abuse, neglect, or mistreatment of our residents. 7. Protect residents during abuse investigations. Investigations: 6. The Administrator will ensure that any further potential abuse, neglect, exploitation, or mistreatment is prevented. Response: 1. C. Should the results indicate that abuse occurred, appropriate authorities will be notified. 1.Record review of Resident #1's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Dementia without behavioral disturbance (problem in the brain affecting memory), schizoaffective disorder (hallucinations and mood symptoms), and pseudobulbar affect (inappropriate laughing or crying). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 03, which indicated residents' cognition was moderately impaired. She required extensive assistance of 1 staff for ADL care. Record review of Resident #1's care plan dated [DATE] revealed she had behavioral symptoms as evidenced by cussing at someone not there and hears voices. Interventions were to keep distance between resident and others during delusional periods. Record review of Resident #2's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Dementia without behavioral disturbance (problem in the brain affecting memory), schizoaffective disorder (hallucinations and mood symptoms), and hypertension (high blood pressure). Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 12, which indicated residents' cognition was mildly impaired. he required limited assistance of 1 staff for ADL care. Record review of Resident #2's care plan dated [DATE] revealed he had cognitive loss/dementia as. Interventions were to approach in a calm manner. Record review of Resident #3's electronic face sheet revealed a [AGE] year-old male most recently admitted to the facility on [DATE]. His diagnoses included hepatic encephalopathy (loss of brain function when a damaged liver does not remove toxins from the blood), psychotic disorder (loss of contact with reality), and viral hepatitis (infection that causes liver inflammation). Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed a BIMS score of 00, which indicated residents' cognition was severely impaired. he required supervision to limited assistance of 1 staff for ADL care. Record review of Resident #3's care plan dated [DATE] revealed he had behavioral symptoms and has socially inappropriate/disruptive behavioral symptoms. Interventions were to assess whether the behavior endangers the resident and/or others, intervene if necessary. During an interview and observation on [DATE] beginning at 10:38 AM CNA D observed about to exit the secured unit. She said LVN N had told her she no longer had to do 1:1 monitoring with Resident #1. She said Resident #1 rolled into the dining room on Sunday [DATE] at 04:45 PM and hit Resident #2 twice on the right arm. She said Resident #1 and Resident #2 were immediately separated. She said a little while later Resident #1 rolled up to Resident #3 in the hallway of the secured unit and hit and spit on Resident #3. She said sometime after the second incident Resident #1 was put on 1:1 monitoring. She said she came in at 06:00 AM this morning on [DATE] and was told she no longer had to do 1:1 monitoring with Resident #1 so she was going to ask the ADON. During an interview on [DATE] at 10:50 AM CNA O said she works for an agency and had Been coming to this facility for about 3 weeks. She said she works All over the building and that was her 2nd day on the secured unit. She said there is always 2 CNAs on the unit. She said she had not received any in-services or training before working on the secured unit. She said yesterday [DATE] Resident #1 hit and spit on 2 residents. Said she was on the war path, and she went over and hit Resident #2 on the shoulder twice then went over to Resident #3 and hit him and spit on him. She said Resident #1 then sat at the table and cussed everyone out. She said on [DATE] her behavior was horrible, but that was her behavior sometimes. She said she reported to her charge nurse and wrote out witness statements. She said that is the only altercation she had witnessed. During an interview on [DATE] at 11:08 AM LVN N Said Resident #1 has sun downers in the evenings and said Resident #1 hit Resident #2 twice on the right arm and then went back and hit Resident #3 and spit on him in the hallway. She said Resident #1 gets very delusional in the evenings but has never hit anyone before [DATE]. She said the ADON asked her what Resident #1 was doing that morning, she said she was asleep. She said the ADON told her to take Resident #1 off 1:1 monitoring that morning since Resident #1 was not having any behaviors. Then the ADON told the CNA to keep Resident #1 on 1:1. She said the ADON came back and told her since state was in the building to go ahead and keep Resident #1 on 1:1 monitoring. She said she did not know if the situation has been reported to the administrator. She said she had received in-servicing over the last several weeks regarding resident-to-resident altercations. She said 2 CNAs were to be on the secured unit at all times. During an interview on [DATE] at 11:20 AM the DON said she was notified that Resident #1 had hit Resident #2 and spit on Resident #3. She said this behavior is out of the normal for Resident #1. She said she was called and told of the incident but was not in the building at the time. She said she assumed Resident #1 was put on 1:1 immediately. During an interview on [DATE] at 11:33 AM the ADON said she was called by the 6p-6a nurse and told of the incident and instructed the nurse to put Resident #1 on 1:1 monitoring on [DATE] at 06:16 PM. She said there was some confusion and she had told LVN N they would discuss taking resident off of 1:1 on the morning of [DATE]. During an interview on [DATE] at 02:52 PM LVN P said at 03:20 PM on [DATE] Resident #1 rolled up to the table and hit Resident #2 on the arm two times. She said staff separated and then 30 minutes later she rolled up to Resident #3 in the hallway hit him and spit on him. She said she called the family, MD, DON. She said the DON said she would call the Current Administrator and report it to her. She said the DON did not give her any instructions for any interventions at that time, she said she was only told to separate, assess, and notify. She said after she gave report to the oncoming nurse, that nurse called the ADON, and that nurse was instructed by the ADON to place resident on 1:1 supervision at 06:16 PM. Said she works 6am-6pm and the incident happened at 03:20 PM. LVN P said she left at 06:35 PM and Resident #1 was not on 1:1 monitoring. During an interview on [DATE] at 1:30 PM the Current Administrator She said she had been notified on Sunday [DATE] by the DON that Resident #1 had hit 2 residents on the secured unit. She said she did not feel like there was willful intent due to Resident #1's cognition, so she did not feel like she had to report it as abuse. Record review of event report dated [DATE] at 04:45 PM reveal per CNA, Resident #1 was in a wheelchair and rolled up to another resident working on a crossword puzzle in the dining room and proceeded to hit the resident in the right arm. Resident #1 also began cussing at Resident #2. The two residents were immediately separated. No injuries noted to either resident. Resident #1 was also involved in an incident following the previous incident in which she was rolling to her room and spit on another resident and attempted to hit the other resident. The two residents were immediately separated. The event report also revealed that physical and verbal behavioral symptoms were exhibited by Resident #1 occurred daily. Interventions documented were redirection and separation. Record review of event report dated [DATE] at 03:46 PM revealed per CNA Resident #2 was sitting at the dining room table reading a book when Resident #1 in a wheelchair rolled up next to him and proceeded to hit him in his right arm. Resident #2 held up his hands when he was being struck. Staff immediately separated the two residents. Resident #2 was assessed with no injuries noted. Resident #2 denied any pain or discomfort. Record review of event report dated [DATE] at 06:30 PM revealed Resident #3 was standing in the hallway and was approached by another resident who spit on him and attempted to hit him. Residents were separated immediately. No injuries noted to this resident. Record review of 15-minute checks dated [DATE] revealed 1:1 monitoring of Resident #1 began at 8:00 PM on [DATE]. Record review of facility policy dated [DATE] titled Resident-to-Resident Altercations. 2. If two residents are involved in an altercation, staff will: D. Review the events with the Nursing Supervisor and Director of Nursing, and possible measures to try to prevent additional incidents. F. Make any necessary changes in the care plan approaches to any or all of the involved individuals. G. Document in the resident's clinical record all interventions and their effectiveness. H. Consult psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for intervention and management as necessary or as may be recommended by the attending physician or interdisciplinary care planning team. K. Report incidents, findings, and corrective measures to appropriate agencies as outlined in our facility's abuse reporting policy. 3. Inquiries concerning resident-to-resident altercations should be referred to the Director of Nursing Services or to the Administrator. The facility Administrator was notified on [DATE] at 05:37 PM that an Immediate Jeopardy situation had been identified due to the above failures and the IJ template was given at that time. The facility's plan of removal was accepted on [DATE] at 12:14 PM and included: Action: Resident #1 has been placed on 1:1 (as of [DATE]). Resident #1 will remain on 1:1 until deemed no longer a danger to self or others by Physician/Physician Extender/Psych Services and discussed with the IDT- Administrator, Director of Nursing, Social Services Director and MDS Coordinator. Resident #1 and Resident #2 received head to toe assessment by the Director of Nursing and a safe survey performed by the Assistant Director of Nursing. Resident #3 is out of the facility on an unrelated matter at this time. No concerns with skin or psychosocial wellbeing noted during assessments/surveys. Responsible Person(s): Director of Nursing and Assistant Director of Nursing Date: [DATE] by 5PM Action: Activity Director was suspended pending investigation. Responsible Person(s): Administrator Date: [DATE] Action: Self reports submitted to CII on [DATE] for the resident-to-resident altercation and the misappropriation allegations. Facility investigations have been implemented. Responsible Person(s): Administrator Date: [DATE] Action: Police notified of allegations. Responsible Person(s): Administrator Date: [DATE] Action: Progress notes and event reports reviewed for all residents for the previous 30 days to identify any other resident-to-resident abuse that the facility failed to implement the abuse/neglect policy and/or resident-to-resident policy. No other concerns identified. Responsible Person(s): Clinical Company Leader and Survey Resource Date: [DATE] by 6PM Action: The Director of Nursing reviewed the incident and proper interventions have been implemented. Resident #1 has been placed on 1:1 and will remain on 1:1 until deemed safe to self and others. Responsible Person(s): Director of Nursing Date: [DATE] by 6PM Action: Resident safe surveys misappropriation performed on all residents. Resident safe surveys abuse/neglect performed on all residents. Any residents unable to answer for abuse/neglect survey had a skin assessment performed. Responsible Person(s): Administrator, Director of Nursing, and/or Designee Date: [DATE] by 12PM Action: Residents were educated on not giving money to any staff other than the designated employee for resident shopping. Activity Director #2 received education on when purchasing items for residents the receipt must be turned into the Business Office Manager and change counted and verified by the business office manager and returned to the residents. Responsible Person(s): Administrator, Activity Director #2, and BOM. Date: [DATE] by 12PM Action: Administrator and Director of Nursing educated regarding Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility (NF) Must Report to the Health and Human Services Commission (HHSC). Key Takeaway: Appropriate interventions following a resident-to-resident altercation to decrease the probability of another incident and what to self-report and when (any type of abuse- 2 hours). Responsible Person(s): Regional Resource Nurse Date: [DATE] by 5PM Action: Department Head education regarding: Abuse/Neglect, Resident-to-Resident, and 1:1 Monitoring of the aggressor. Key Takeaway: Department Heads will understand that taking a resident off 1:1 is an IDT decision (IDT: including but not limited to a Physician/Physician Extender/Psych Services, Administrator, Director of Nursing, Social Services Director, MDS Coordinator) and the resident has been deemed no longer a safety risk to themselves or others by the Physician/Physician Extender/Psych Services. Abuse and Neglect Policy with an emphasis on resident-to-resident abuse and misappropriation. Resident-to-Resident Altercation Policy Misappropriation of resident property Responsible Person(s): Survey Resource and Clinical Company Leader Date: [DATE] by 5PM Action: All staff educated regarding Abuse/Neglect, Resident-to-Resident Altercations, and 1:1 monitoring of the aggressors, misappropriation. Key Takeaway: Residents who are aggressors towards other residents will be immediately placed on 1:1 and the abuse coordinator will be immediately notified. If staff feel as if the abuse coordinator is not reacting appropriately to the allegation they will be educated to call the corporate compliance line. Misappropriation- not accepting electronic transfers from residents, not taking any money or items from residents. Tests to ensure competency will be completed for all staff. Facility staff and temporary staff will be trained/tested prior to working their next shift. Responsible Person(s): Administrator, Director of Nursing, and/or Designee Date: [DATE] by 12PM Action: Administrator, Business Office educated 1:1, and all staff have been educated on: If center personnel purchases items on behalf of residents, the center must obtain a signature from the resident upon return to the center, with items. The actual receipt must be signed. If the resident is unable to sign, signatures from two witnesses are required for the withdrawal or purchased items. The witnesses can be any person(s) except the person(s) responsible for accounting for the trust fund, that person's supervisor, or the person(s) that accepts the withdrawn funds, merchandise, or services. Anyone in the business office, administrator or the employee doing the shopping cannot sign as a witness Employees do not accept cash via any electronic funding app, such as CashApp, Venmo, [NAME], or any other funding app. Business Office Employees do not do any shopping on behalf of the resident Employees cannot accept gifts of any kind from a resident Employees cannot withdraw funds from an ATM for the resident using the residents' personal ATM Card. The resident or family member are responsible for ATM withdrawals. Responsible Person(s): Survey Resource and/or Designee Date: [DATE] by 12PM Action: Ad Hoc QAPI performed with Administrator, Director of Nursing, and Medical Director. ANE policy and procedure reviewed with no changes. Responsible Person(s): Administrator Date: [DATE] by 12PM On [DATE], the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: During an observation on [DATE] at 03:00 PM the Surveyor confirmed Resident #1 was on 1:1 monitoring. Record review of education provided to the DON and Current Administrator on Abuse, neglect, misappropriation. Record review of education provided to the Department heads on Abuse/neglect, Resident to resident altercations, misappropriation. Record review of education provided to all staff on Abuse/neglect, Resident to resident altercations, misappropriation, and Resident Funds. Record review of Survey Resource and Clinical Company Leader Progress Notes and event reports. Record review of 35 Safe Surveys completed by staff with no concerns noted. Record review of Ad hoc Qapi completed on [DATE] at 07:53 PM. Interviews on [DATE] from 12:00 PM through [DATE] 03:00PM with the Business Office Manager, SW, DON, ADON, LVN A, LVN B, LVN C, CNA D, CNA E, CNA F, CNA G, CNA H, CNA I, Medication Aide J, housekeeper K, Housekeeping Supervisor, Housekeeper L, Housekeeper M, and Maintenance Man who worked the shifts of 6:00 AM-6:00 PM, 6:00 PM-06:00AM were able to verify education was provided to them; nursing staff were able to accurately summarize abuse and neglect policy, definitions and examples of change of condition and how, who, and when to report changes. The nursing staff expressed understanding of the importance of reporting abuse to the DON and Current Administrator, and how to use the compliance hotline if needed. While the IJ was removed on [DATE] at 03:20 PM, he facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on resident abuse, neglect, misappropriation and following facility policy. 2.Record review of Resident #4's electronic face sheet, dated [DATE], indicated Resident #4 was a [AGE] year-old male who was admitted to the facility on [DATE] and discharged from the facility on [DATE] with diagnoses including functional quadriplegia (completely immobile), Hypertension (high blood pressure), and muscle weakness. Record review of the MDS, dated [DATE], indicated Resident #4 was understood by others and understood others. Resident #4 had a BIMS of 13, which indicated the resident was cognitively intact. Record review of the care plan, dated [DATE], indicated Resident #4 had impaired decision making as evidenced by his poor decision making with interventions that included: 1. Determine if decisions made by Resident #4 endanger the resident or others and intervene if necessary. 2. Give objective feedback when inappropriate decisions are made. Record review of the nursing progress note, dated [DATE], indicated Resident #4 had discharged home from the facility. Record review of Resident #5's electronic face sheet, dated [DATE], indicated Resident #5 was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including schizophrenia (seeing or hearing things that do not exist), Hypertension (high blood pressure), personal history or traumatic brain injury, and muscle weakness. Record review of the MDS, dated [DATE], indicated Resident #5 was understood by others and usually understood others. Resident #5 had a BIMS of 11, which indicated the resident's cognition was mildly impaired. Record review of the care plan, dated [DATE], indicated Resident #5 had psychosocial well-being problems: Resident #5 had absence of personal contact with family/friends related to homelessness. Interventions included: Assess for factors that may impede the resident's ability to interact with others. Record review of Resident #6's electronic face sheet, dated [DATE], indicated Resident #6 was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (disorganized thinking and seeing or hearing things that do not exist), Hypertension (high blood pressure), and other reduced mobility. Record review of the MDS, dated [DATE], indicated Resident #6 was understood by others and usually understood others. Resident #6 had a BIMS of 15, which indicated the resident's cognition was intact. Record review of the care plan, dated [DATE], indicated Resident #6 had cognitive loss/Dementia: Resident #6 had impaired decision making related to schizophrenia, major depressive disorder, and anxiety. Interventions included: Encourage to verbalize feelings, concerns, and fears. Clarify misconceptions. Record review of Resident #7's electronic face sheet, dated [DATE], indicated Resident #7 was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (disorganized thinking and seeing or hearing things that do not exist), chronic obstructive pulmonary disease (breathing related problems), and muscle weakness. Record review of the MDS, dated [DATE], indicated Resident #7 was understood by others and usually understood others. Resident #7 had a BIMS of 09, which indicated the resident's cognition was mildly impaired. Record review of the care plan, dated [DATE], indicated Resident #7 had hallucinations related to paranoid schizophrenia. Interventions included: assign a consistent staff member. Establish a trusting relationship with resident. Record review of Resident #8's electronic face sheet, dated [DATE], indicated Resident #8 was a [AGE] year-old female who was admitted to the facility on [DATE] and expired in the facility on [DATE] with diagnoses including schizoaffective disorder (disorganized thinking and seeing or hearing things that do not exist), hemiplegia following a cerebral infarction (not able to move to move the left side of the body following a stroke) and muscle weakness. Record review of the MDS, dated [DATE], indicated Resident #8 was usually understood by others and usually understood others. Resident #8 had a BIMS of 09, which indicated the resident's cognition was mildly impaired. Record review of the care plan, dated [DATE], indicated Resident #8 had behavioral symptoms and often accused staff/residents of stealing her money, and forgot she bought items such as tobacco products. Interventions included: maintain a calm environment and approach to the resident. During an interview on [DATE] at 03:50 PM Activity Director A said she does work as a CNA occasionally. She said she remembers Resident #4 and said he was a special resident that relied on her a lot. She said someone gave Resident #4 her personal cell phone number and would call her personally, she said that was not a typical practice. She said later after it became a habit of Resident #4 calling her, she stopped answering his calls. She said she reported it to the Previous Administrator. She said Resident #4 did give her money to go get things for him from the store, such as skoal, snacks. She said Resident #4 ordered from store a lot and had things delivered. She said Resident #4 never gave her money in exchange for care she provided for him. She said she does not know how much money he gave her total, but that sometimes he would give it to her twice weekly. She said the most amount of money he gave her at 1 time was ,d+[DATE] dollars. She said sometimes Resident #4 give her cash, sometimes she would take his debit card and sometimes he would cash app her. She said she never used any money he gave her for any personal reasons. She said over the course of 2 years he gave her ,d+[DATE] dollars to go and buy things for him. She said he had her buy him cell phones and phone cards. She said she was always in the position of activity director. She said as the activity director she does shopping for the residents. Normally she has a witness when she exchanges money and stuff she went and bought for the residents. She said normally it would be the ADON, or whatever CNA was working that day. During an interview on [DATE] at 04:17 PM the ADON said Activity Director A is allowed to go to the store for residents. She said if the activity director went to the store for the resident, she is supposed to bring the residents item and a receipt for the item back with her and give the receipt to the BOM. She said the only person that is allowed to shop for the residents is the activity director. She Said she only knows of there being a paper trail if the resident has a trust fund. She said if the resident gave cash, then there would not be a paper trail. She said Resident #8 was confused and made accusations frequently. She said Resident #7 also would make accusations frequently. She said she remembers Resident #4 giving money to the Activity Director A to get skoal but other than that he ordered things from the store and had it delivered to the door. She said she never witnessed Activity Director A give Resident #4 any items she had bought for him or any change from shopping she had done for him. She said Resident #4 had the cell phone numbers to the DON, Previous Administrator, and Activity Director A. She said that Resident #4 complained about his care while he was there and only wanted certain ones to care for him. She said Resident #4 never tried to pay her for providing care. She said Resident #4 wanted care from certain staff and would refuse care by other staff and thought if he refused then the ones he wanted would come and do the care. During an interview and observation on [DATE] beginning at 08:40 AM, Resident #7 said she gave Activity Director A 25.00 dollars for some new socks and shoes. Resident #7 said she had not received the socks and shoes or her 25.00 dollars. During an interview on [DATE] at 08:48 AM the Regional Accounts Manager said in June of 2022 Resident #4 made a $300 dollar payment to the facility and that Activity Director A was able to go and talk the resident in to making. She said Resident did make another 500-dollar payment on [DATE] using his atm card. She said the process for staff going to the store for residents is they are to bring a receipt back and sign a form with the resident stating the resident had received the requested items and change from there purchase. She said under no circumstances are any staff allowed to withdraw any money from a resident's bank account using there debit card. During an interview on [DATE] at 09:10 AM with Resident #4 via phone, he said he had given Activity Director A 1,150.00 dollar via cash app, and Activity Director A had taken his ATM card and withdrew an additional 1000.00 dollars from his bank account. Resident #4 said Activity Director A had agreed to take care of him while he was at the nursing facility if he paid her. He said the agreement was he would pay her 50.00 to 100.00 dollars every couple of weeks, and she would make sure he was cared for. He said Activity Director A had given him Activity Director A's personal cell phone number to call her when he needed care. He said if Activity Director A was at work and he needed care he would call her cell phone and she would come and provide care, if she was not at work then he would call her, and she would call the facility and have someone go to his room to provide the care. He said Activity Director A would occasionally go to the store for him, but all of those purchases were made with Resident #4's debit card and never with cash app. He said Activity Director A would occasionally ask to borrow money from him that was never paid back. He said most of the time when he needed something from the store, he would order it online and have it delivered to the facility. He said he discharged from the facility on [DATE] and received a call from Activity Director A in [DATE], he said she told him that he still owed her 100.00 dollars for taking care of him, so he sent her 100.00 dollars on [DATE] via cash app. Resident #4 said he does not feel like it was right and now wants his money back. During an interview on [DATE] at 09:50 AM the BOM said they have a process they started in august of 2022 they are supposed to follow when going to the store for residents due to multiple complaints of residents not getting there change or items. She said there is a form that is to be filled out, and the employee is supposed to bring the receipt back with the items purchased and the change. She said the resident and the employee are supposed to sign the form stating the resident received the items and change from the transaction. She said that Resident #6 came to her in February of 2023 and wanted to with [TRUNCATED]

Based on observation, interview and record review the facility failed to ensure residents were free from abuse for 2 of 5 residents (Resident #1 and Resident #3) reviewed for Resident Abuse. 1. The facility failed to protect Resident #1 from abuse by Resident #2. On 04/05/2023 Resident #1 wandered into Resident #2's room on the secured unit, and Resident #2 threw water on Resident #1 and then grabbed Resident #1 causing a skin tear to Resident #1's right mid arm. 2. The facility failed to protect Resident #3 from abuse by Resident #2. On 04/15/2023 Resident #2 stabbed Resident #3 with a pen causing a puncture wound to Resident #3's left forearm. 3. The facility failed to protect Resident #3 from abuse by Resident #2. On 05/25/2023 Resident #2 pushed Resident #3 out of her wheelchair causing Resident #3 to fall onto the floor. An IJ was identified on 06/27/2023 at 4:57 PM. The IJ template was provided to the facility on [DATE] at 4:57 PM. While the IJ was removed on 06/28/2023 at 6:15 PM, the facility remained out of compliance at a scope of pattern and a severity level of a potential for more than minimal harm because (e.g.) all staff had not been trained on abuse/neglect, resident to resident altercations, behavioral health training, and when a resident needs a psychiatric health consult. These failures could place residents at risk of physical harm, mental anguish, emotional distress, or death. Findings included: 1. Record review of an Admission Record, not dated, for Resident #2 indicated she was readmitted to the facility on [DATE] with an original admitted [DATE] and was [AGE] years old with diagnoses of senile degeneration of the brain (loss of intellectual ability), paranoid schizophrenia (delusions and hallucinations), need for continuous supervision, personality disorder (mental disorder). Record review of a Quarterly MDS Assessment for Resident #2 dated 05/14/2023 indicated a BIMS score of 11 meaning moderate cognitive impairment. She required limited assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Balance during transitions and walking indicated she was not steady, but was able to stabilize without staff assistance and did not require any mobility devices. The MDS indicated that resident had not exhibited any behaviors. Record review of a care plan for Resident #2 dated 03/17/2016 reflected Resident #2 had episodes of behavioral symptoms. Interventions included: provide psych consult per order. Record review of a care plan for Resident #2 dated 04/16/2018 reflected Resident #2 had episodes of anxiety. Interventions included: psychologist/psychiatrist to provide services as ordered. Record review of a care plan for Resident #2 dated 06/17/2021 indicated Resident #2 had physically abusive behavioral symptoms (resident to resident altercation). The resident had a history of throwing liquids at other residents. Interventions included to avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents), and maintain a calm environment and approach to the resident. Resident #2 resided on the secure unit. Record review of a care plan for Resident #2 dated 06/17/2021 reflected Resident #2 had episodes of behavioral symptoms. Interventions included: obtain a psych consult/psychosocial therapy. Record review of a care plan for Resident #2 dated 04/05/2023 reflected Resident #2 had socially inappropriate/disruptive behavioral symptoms post behavior health hospital. Interventions included administer medications as ordered, assess whether behavior endangers others and intervene if necessary, and avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents). Record review of a care plan for Resident #2 dated 05/25/2023 reflected Resident #2 had episodes of behavioral symptoms. Interventions included: obtain a psych consult/psychosocial therapy. Record Review of physician's orders for Resident #2 dated 05/28/2023 to 06/28/2023 indicated resident #2 had the following physicians' orders: 5. Admit to secure unit due to exit seeking secondary to dementia. Dated 06/28/2021. 6. Psychiatric and Psychological Services to evaluate and treat as needed. Dated 02/28/2023. Record review of nurse progress notes for Resident #2 dated 04/05/2023 at 10:33 PM written by LVN A indicated: Resident #2 was witnessed by LVN A throwing water on Resident #1 who wandered into her room. Resident #2 then grabbed Resident #1 by the wrist resulting in a skin tear to Resident #1's right wrist. Resident #2 was provided on-on-one and separated from Resident #1. Record review of an event report dated 04/05/2023 indicated Resident #2 threw water on Resident #1 and grabbed Resident #1 resulting in a 1-centimeter skin tear to the right wrist. The event report indicated Resident #2 was placed on one-on-one supervision. The event report indicated Resident #2 was being referred to a mental health hospital for observation and was awaiting acceptance for transfer. Record review of nurse progress notes for Resident #2 dated 04/15/2023 at 4:01 PM written by LVN C indicated: Resident was sitting in chair in common room when another resident rolled up in their wheelchair reached out with their arm and this resident stabbed her with a pen. Resident #2 was placed on 1 on 1 supervision for 72 hours. Record review of an event report dated 04/15/2023 at 3:47 PM completed by LVN C indicated: Resident #2 stabbed Resident #3 with a pen. Event report indicated Resident #2 was placed on one-on-one supervision for 72 hours. Record review of nurse progress notes for Resident #2 dated 04/15/2023 indicated: The behavioral health hospital returned a call to the facility. They denied the resident for their services at this time. They stated, We may have availability on Monday. On-call, the ADON was notified. One-on-one monitoring continues. Record review of nurse progress notes for Resident #2 dated 05/25/2023 at 1:22PM completed by LVN B indicated: Resident #2 was with Resident #3 in the secure living area. Staff notified the ADON that Resident had pushed Resident #3 out of her wheelchair and on the floor. The residents were separated at this time and Resident #2 was redirected to her room. Nurse Practitioner notified of incident no new orders for Resident #2 received at that time. Record review of an event report date 06/27/2023 at 9:29 AM completed by the regional clinical nurse indicated: Resident #2 pushed another resident sitting in a wheelchair. The event report indicated the residents were separated and Resident #2 was redirected to her room. The Event report indicated the interventions were somewhat effective. 2. Record review of an Admission Record, not dated, for Resident #1 indicated he was readmitted to the facility on [DATE] with an original admitted [DATE] and was [AGE] years old with diagnoses of dementia (loss of memory and thinking abilities), Alzheimer's (disease that destroys memory and other mental functions), schizoaffective disorder (mood disorder), and psychotic disorder with delusions (unshakable belief in something that is bizarre, implausible, or obviously untrue). Record review of a Quarterly MDS Assessment for Resident #1 dated 06/19/2023 indicated a BIMS score of 05 meaning severe cognitive impairment. He had required limited to extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Balance during transitions and walking indicated he was not steady, but able to stabilize without staff assistance and did not require any mobility devices. The MDS indicated Resident #1 had not exhibited any behaviors. Record review of a care plan for Resident #1 dated 05/21/2023 indicated he was at risk for wandering as evidenced by poor judgement and decision making related to dementia. Resident #1 resided on the secure unit. Record review of a care plan for Resident #1 dated 04/05/2023 reflected Resident #1 had behavioral symptoms as evidenced by grabbing others and wandering into other resident rooms. Interventions included to administer medications as ordered, assess whether behavior endangered others and intervene if necessary, and resident had delusions and to not try to confront or reason with the resident. Record review of a physician's order summary report dated 05/28/2023 to 06/28/2023 indicated: 5. resident to be admitted to the secure unit due to exit seeking secondary to dementia on 02/15/2023. 6. Psychiatric and Psychological Services to evaluate and treat as needed. Dated 02/25/2023. Record review of Resident #1's nurse progress notes dated 04/05/2023 at 9:06 PM written by LVN A indicated Resident #1 wandered into Resident #2's room, Resident #2 became upset and threw water on Resident #1. Unidentified CNA's were present on the hall and assisting other residents. LVN A witnessed Resident #1 and Resident #2 grab each other. Both residents were immediately separated and redirected to their rooms to calm. Resident #1 was noted with a 1 cm scratch to the top of his right wrist. LVN A indicated the nurse practitioner, responsible party, ADON and the DON were notified of the incident. 3.Record review of an Admission Record, not dated, for Resident #3 indicated she was readmitted to the facility on [DATE] with an original admitted [DATE] and was [AGE] years old with diagnoses of dementia with behaviors (loss of memory and thinking abilities), anxiety disorder (mental disorder), pseudobulbar affect (uncontrollable laughing or crying), restlessness and agitation. Record review of a Quarterly MDS Assessment for Resident #3 dated 05/26/2023 indicated a BIMS score was not obtained due to Resident #3 was rarely or never understood. She required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Mobility Devices indicated she used a wheelchair for locomotion due to limited range of motion of both lower extremities. The MDS indicated Resident #3 had a mental status change of inattention and disorganized thinking but did not indicate any behavioral symptoms. Record review of a care plan for Resident #2 dated 06/17/2021 indicated Resident #3 had physically abusive behavioral symptoms (biting and hitting residents). Interventions included to avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents), and maintain a calm environment and approach to the resident, and assess whether behavior endangered others and intervene if necessary. Resident #3 resided on the secure unit. Record Review of physician's orders for Resident #3 dated 05/28/2023 to 06/28/2023 indicated Resident #3 had the following physician's orders: 7. Admit to secure unit due to exit seeking secondary to dementia. Dated 06/28/2021. 8. Psychiatric and Psychological Services to evaluate and treat as needed. Dated 02/28/2023. Record review of nursing progress note for Resident #3 dated 04/15/2023 at 3:43 PM written by LVN C indicated: Resident #3 reached out with her arm to Resident #2 and Resident #2 stabbed her with a writing pen on the left forearm. Minimal bleeding was noted and the skin was broken with a treatment of cleanse with normal saline and band aid applied. Record review of nursing progress note for Resident #3 dated 05/25/2023 at 1:46 PM written by LVN B indicated: Resident #3 was with Resident #2 in the secure living area. Staff notified the nurse that Resident #2 had pushed Resident #3 out of her wheelchair and onto the floor. Record review of an event report dated 05/25/2023 at 1:22 PM completed by the DON indicated: Resident #3 was pushed out of her wheelchair by another resident resulting in Resident #3 lying on the floor beside the wheelchair. Interventions included: Neuro checks initiated and within normal limits, and x-ray of skull to rule out injury. Record review of x-ray dated 05/25/2023 report did not show any acute abnormalities. During an observation of the secured unit on 06/26/2023 at 10:10 AM revealed the TV/dining area with 6 residents and 1 can; 2 residents ambulating in hallway and 7 residents in their rooms. Resident #2 was observed sitting in a wingback chair holding a Bible with papers inside and a pen. Resident #3 was sitting up in her wheelchair 5-6 feet away from Resident #2 with her head down. Resident #1 was observed lying in bed in his room with eyes closed. During an observation and interview on 06/26/2023 at 10:05 AM revealed Resident #2 sitting up in chair in the common area. She said it was year 2025 but they kept telling her it was 2023. She said she did not remember an incident that a resident was stabbed with a pen or pushed out of a wheelchair. Resident #2 said she did not want to answer any more questions. During an interview on 6/26/2023 at 10:15 AM CNA D said she worked for an agency and was not employed by the facility. She said she had been coming to the facility for about 3 weeks and ever since there had only been one CNA that worked on the secured unit per shift. She said there was a CNA that worked on the hall outside of the secured unit that could come and occasionally help if needed. She said Resident #2 only got aggressive if someone went into her room but had not seen any physical aggression by Resident #2. She said Resident #2 did not get aggressive unless someone got in her personal space. She said she had 15 residents on the secured unit. She said if she witnessed a resident to resident altercation she would separate the residents for safety and notify the DON and Administrator. During an interview on 06/26/2023 at 10:22 AM LVN B said she had worked at the facility for about 2 months and was the nurse for the secured unit and the backside of 200 hall. Said she was not able to always be in the secured unit. She said on 05/25/2023 Resident #3 rolled her wheelchair past Resident #2 and Resident #2 pushed Resident #3 out of her wheelchair causing Resident #3 to fall onto the floor. She said Resident #2 and Resident #3 are both combative, so they have had to watch them both. She said Resident #2 becomes aggressive if someone gets in her personal space. She said they tried to keep residents separated when they can. She said Resident #2 just returned from the behavioral hospital about 2 weeks ago and she had seen an improvement in her behaviors. LVN B said when she worked, she has 1 CNA in the unit. During a phone interview on 06/26/2023 at 2:59 PM LVN C said she was the nurse for the secured unit on 04/15/2023. She said she did not know Resident #2 had a pen and was sitting where resident could be seen the whole time. She said Resident #2 wrote on paper a lot. She said Resident #3 went past Resident #2 and Resident #2 stabbed Resident #3 with a pen. She said the residents were immediately separated, assessed, and the pen was taken from Resident #2. She said there was minimal bleeding to Resident #3's arm and first aid was provided to her. She said Resident #2 was placed on one-on-one monitoring for 1-2 days. She said an incident report was done and the ADON, DON and provider was notified of the incident. She said Resident #2 and Resident #3 were watched to make sure they were not in the same area. She said both Resident #2 and Resident #3 can get aggressive at times. She said Resident #2 can become aggressive if someone is in her personal space. She said she could not recall any in-services that were conducted at the time. She said she has not witnessed any abuse/neglect but if she did, she would report it to the Administrator who is the abuse coordinator. During an interview on 06/27/2023 at 9:40 AM the ADM said she remembered calling in a CNA to put with Resident #2 for one-on-one monitoring after the 05/25/2023 incident but did not have any documentation of the one-on-one monitoring. During an interview on 06/27/2023 at 10:00 AM the Psychologist said he had known Resident #2 for a long time due to seeing her at a previous facility. He said he had never seen Resident #2 at the current facility for psych services due to not being able to obtain consent. He said he would see Resident #2 if he had consent to treat the resident. He said Resident #2 had a diagnosis of schizophrenia. He said he did not think psych services would make a difference in Resident #2's behaviors and it would be better to educate the other residents in the secured unit to stay out of Resident #2's personal space. The Psychologist said you cannot educate the other residents of the secured unit because they would not understand or remember the education. During a phone interview on 06/27/2023 at 9:50 AM the Responsible Party of Resident #2 said he was notified of an incident regarding Resident #2 stabbing another resident with a pen. He said he was not asked for consent for counseling services; he said he would have given consent for anything that would help Resident #2. He said he came to the facility for a visit and was notified that approximately 10-14 days earlier that Resident #2 had pushed another resident out of her wheelchair. He said he was never notified of an incident where Resident #2 threw water on and caused a skin tear to another resident. He said the last time he was contacted and asked to give consent for psych services was about a year ago, and he gave consent at that time. He said he was notified on 06/08/2023 that Resident #2 had been transferred to the behavioral health hospital for treatment. During an interview on 06/27/2023 at 10:37 AM the Social Worker said Resident #2 had been at the facility for a long time. He said Resident #2 was delusional and had an area in the day room where she liked to write and read. He said everyone had to approach Resident #2 in a calm manner and did not want any staff or residents in Resident #2's area that he described as a bubble around her. He said if someone stepped into Resident #2's boundary, she could get physically aggressive with them. He said she had a diagnosis of schizophrenia and did not have any family involved in her care but did have a legal guardian. He said from time to time Resident #2 would have behaviors but as long as she was left alone, she was good. He said Resident #2 did not like any residents in her space and most of the residents in the secured unit were not aware of that. The Social Worker said he attempted to send Resident #2 out to a behavioral hospital previously, but the resident's guardian would not give consent. He said Resident #2's guardian said he did not think Resident #2 could understand and felt like it would be pointless. He said there was an incident when another resident went into Resident #2's personal space and she poked that resident with a pen. He said Resident #2's legal guardian was the one who gave consent for her to see the psychologist that visited the facility. He said the psychologist visited the facility every Monday and Resident #2 was being seen by him. He said the Psychologist was who the facility had a contract with, and they also had a contract with another counseling provider. He said overall Resident #2 was ok as long as people stayed out of her personal space. He said they have talked to the staff and instructed them to keep an eye on Resident #2. He said some residents did wander from room to room at times. He said Resident #2 went to a behavioral hospital a few weeks ago following an incident when she stabbed another resident with a pen for about two weeks and had been ok since returning to the facility with medication adjustments. During a phone interview on 06/28/2023 at 10:24 AM LVN A said she had worked for the facility as needed for 1 year. She said there was one CNA that works on the secured unit and covers the backside of 200 hall outside of the unit. She said the nurse normally stepped into to unit while the CNA goes out of the unit to make a round on the backside of 200 hall. She said she witnessed the incident on 04/05/2023 with Resident #2 and Resident #1. She said Resident #1 wandered into Resident #2's room and Resident #2 threw water on Resident #1 and then grabbed his wrist causing a skin tear. She said she immediately separated the residents and redirected Resident #2 to her room. She said that if anyone gets in Resident #2's personal space she becomes physically aggressive. She said the staff tries to keep other residents out of her personal space but that is hard to do when the residents are all in the common area. She said Resident #2 punched an employee in the face about 6-7 months ago and Resident #2 was not sent out to the behavioral health hospital or anything. During an interview on 06/28/2023 at 12:20 PM the DON said on 04/05/2023 Resident #1 wandered into Resident #2's room and Resident #2 threw water on and grabbed Resident #1's wrist causing a skin tear. She said Resident #2 did not like for anyone to get in her personal space and becomes aggressive when they do. She said the Social Worker called Resident #2's responsible party but it is hit and miss when trying to contact him. She said after the incident on 04/15/2023 the behavioral health hospital would not accept the resident due to there not being enough documentation of Resident #2's behaviors in her chart. She said she directed the nursing staff to continue to document all of Resident #2's behaviors so the behavioral health hospital would accept her. She said when residents are placed on one-on-one monitoring there is a Q15 minute checks form staff is supposed to document on but said they did not do it. The DON said she did not feel like 1 CNA was enough staff on the secured unit. She said she would like to have more staffing in the secured unit and to not admit anymore residents with combative behaviors to the secured unit. Record review of a facility policy titled Resident-to-Resident Altercations with a revised date of December 2016 indicated, .G. Document in the resident's clinical record all interventions and their effectiveness. H. Consult psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for intervention and management as necessary or as may be recommended by the attending physician or interdisciplinary care planning team. J. if, after carefully evaluation the situation, it is determined that care cannot be readily given within the facility, transfer the resident. Record review of a facility policy titled Behavioral Assessment, Intervention and Monitoring with a revised date of December 2021 indicated, . 1. The center will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. 2. Behavioral symptoms will be identified using center-approved behavioral screening tools and the comprehensive assessment. Management: 1. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. Record review of a facility policy titled SLP-Prosperity Behavioral and Mental Health Services with a revised date of January 2022.Safety-The creation and maintenance of a safe environment in the Long-Term care setting is the cornerstone of the mental health nurse's (MHN) role and responsibility. The role of the MHN to assess for environmental and individual safety is active and on-going to prevent self-harm or harm to others in the center. Assessment/Evaluation- The interdisciplinary Team (IDT) will consist of a psychiatrist, psychologist, consulting pharmacist, licensed nurse, dietician, social worker, qualified activity assistant, and nursing assistants. The IDT will approach each resident care by addressing their unique individual needs and implementing resident centered interventions promoting overall behavioral and mental health. Psychiatric Assessment- Each resident admitted to a [Provider name]Behavioral/Mental Health Unit will be referred to the center's designated psychiatrist for evaluation and treatment. Psychological Assessment- Each resident admitted to a Behavioral/Mental Health Unit will be referred to the center's designated psychologist for evaluation and treatment Record review of a facility policy titled Abuse Prevention Program with a revised date of 01/09/2023 indicated: .2. Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The facility Administrator was notified on 06/27/2022 at 04:57 PM that an Immediate Jeopardy situation had been identified due to the above failures and the IJ template was given at that time. The facility's plan of removal was accepted on 06/28/2022 at 03:24 PM and included: Residents on the secured unit will have psychiatric service referrals completed by the DON/Rep. Any negative findings will be reported to the Physician. Any residents outside of the secured unit that have been involved with resident-to-resident altercations within the last 60 days will be referred to psych services. The Director of Nurses and/or designee with collaborate with the psychiatric provider and will audit charts to ensure scheduled/routine visits were completed, any missing visits will be reported to psych services to reschedule the visit. This will be completed by 06/28/2023 at 3:00 PM. Resident #2 has been placed on one-on-one until discharge to another facility is completed or determined by IDT not to be a danger. Resident #2 remained in the facility at the time of surveyor exit. All staff were trained/educated on Resident #2's current intervention, at this time Resident #2 is on 1:1 observation for resident safety. Timeline for completion: 06/28/2023 at 3:00 PM The facility will review all resident incidents for the last 30 days to ensure no other additional resident to resident altercations have occurred without appropriate interventions being placed in the care plan, notifications made to psych services and the MD. Timeline for completion: 06/28/2023 at 3:00 PM. The facility will complete safe surveys with all residents on secured unit and outside the secure unit. Residents unable to complete the safe survey will have a head-to-toe skin assessment and RP will be notified for any concerns. Negative findings will be reported to the abuse coordinator. Timeline for completion: 06/28/2023 at 3:00 PM. The safe surveys and head to toe skin assessments had been completed and documented at time of surveyor exit. The facility will Inservice staff on: Abuse/Neglect, Resident to Resident Altercations, Behavioral Health training, when a resident needs to have a psychiatric service consult/mental health evaluation following an aggression event towards residents, all staff will understand they cannot leave the secured unit unattended through education, and the Administrator and Director of Nursing will ensure the secured unit is staffed. Timeline for completion: 06/28/2023 at 3:00 PM. The facility's Administrator, DON, ADON and/or designee will review incidents occurring on the unit, update the facility assessment tool to accurately reflect residents' acuity and will make necessary adjustments, if necessary, to staff the center and unit to provide adequate supervision. Timeline for completion: 06/28/2023 at 3:00 PM. An ad hoc QAPI meeting with the Medical Director, Administrator and Director of Nursing completed regarding IJ templates and plan of removal. Timeline for completion: 06/28/2023 at 3:00 PM. On 06/28/2023, the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: During an observation an interview on 6/28/2023 at 9:40 AM in the secured unit revealed MA E was present. MA E said she was assigned to provide 1 on 1 with Resident#2 and today was her first day of work. She said the facility started 1 on 1 with Resident #2 as of midnight last night, 6/28/2023. She said she had to complete 15-minute check documentation on her. Observation of the secured unit on 06/28/23 at 3:00 pm revealed there were 2 certified nurse aides and 1 nurse on the unit at this time. Observation of secured unit on 06/28/2023 at 5:15 PM revealed there were 2 certified nurse's aides and the Activity Director on the unit at this time. CNA E was observed documenting on Q15 minute monitoring sheet. Record review of the Q15 minute monitoring sheet dated 06/28/2023 indicated resident had not had any behaviors for that day. During interviews on 06/28/2023 from 3:30 PM-5:45 PM, the Business Office Manager, Social Worker, Activity Director, Certified Occupational Therapist, DON, ADON, LVN C, MA E, MA G, and CNA D, CNA I, CNA H, CNA K were able to verbalize the procedure when a resident-to-resident altercation occurred, Resident #2's current staffing, behavioral health training, when a resident needed a psychiatric consult, and the abuse/neglect policy. A record review of the facility's QAPI meeting conducted on 06/27/2023 at 07:14 PM revealed attendees consisting of the Administrator, Company Clinical Leader, Regional Clinical Nurse and the Medical Director (via phone). The meeting was held to discuss incidents and policies and determine system failures and indicated policies were reviewed and 1. Resident place on 1 on 1(Q15 minute checks) to be documented on form provided to staff. 2. Referral made to psych services. 3. Staff trained on abuse policy and resident to resident altercation policy. 4. Staff educated on event reporting to be completed at time of event. 5. Care plans were updated. Staff would be educated and in-serviced on abuse policy resident-to-resident altercations policy, and event reporting to be completed at time of event. Resident #2 was placed on 1:1 monitoring, to be documented on a documentation sheet provided to staff, referrals made to psych services, and care plans were updated. Record review of an in-service dated 06/27/2023 conducted by the Regional Clinical Nurse revealed the topic of the abuse prevention program. The in-service attendees included nurses, CNAs, MAs, the Business Office Manager, housekeeping, and the Dietary Manager. Record review of an in-service dated 06/27/2023 conducted by the Regional Clinical Nurse revealed the topic of resident-to-resident altercations. The in-service attendees included nurses, CNAs, MAs, Business Office Manager, housekeeping, and Dietary Manager. Record review of an in-service dated 06/27/2023 conducted by the Regional Clinical Nurse revealed the topic of behavioral and mental health services. The in-service attendees included nurses, CNAs, CMAs, Business Office Manager, housekeeping, and Dietary Manager. Record review of an in-service dated 06/27/2023 conducted by the Regional Clinical Nurse revealed the topic of abuse and neglect. The in-service attendees included nurses, CNAs, CMAs, Business Office Manager, housekeeping, and Dietary Manager. Record review of psychiatric referrals sent to the psych services provider for 13 of 15 residents residing on the secured unit with 1 resident refusal and 1 resident receiving services with another provider. During an interview on 06/28/2023 at 04:35 PM, the DON said she would review all incident/accident reports in the daily clinical meeting to monitor for aggressive/combative behaviors or resident to resident altercations and take all appropriate actions. On 06/28/2023 at 06:15 PM, the facility was informed the IJ was removed. However, the facility remained out of compliance at a severity of the potential for more than minimal harm that is not immediate jeopardy. The facility continued to monitor and in-service staff to ensure all were in-serviced on abuse/neglect, resident-to-resident altercations, behavioral health tr [TRUNCATED]

Based on observation, interviews, and record reviews, the facility failed to implement written policies and procedures that prohibit abuse/neglect for 2 of 5 (Resident #1 and Resident #3) of residents reviewed for incidents. The facility failed to ensure the residents right to be free from abuse, neglect, misappropriation, of resident property and exploitation. The facility failed to implement their policy by not consulting psychiatric services for resident-to-resident altercations after Resident #2 threw water on and then grabbed Resident #1 causing a skin tear to Resident #1's arm. The facility failed to implement their policy by not consulting psychiatric services for resident-to-resident altercations after Resident #2 Stabbed Resident #3 in the arm with a pen. The facility failed to implement their policy by not consulting psychiatric services for resident-to-resident altercations after Resident #2 pushed Resident #3 out of her wheelchair and onto the floor. An IJ was identified on 06/27/2023 at 4:57 PM. The IJ template was provided to the facility on [DATE] at 4:57 PM. While the IJ was removed on 06/28/2023 at 6:15 PM, the facility remained out of compliance at a scope of pattern and a severity level of a potential for more than minimal harm because (e.g.) all staff had not been trained on abuse/neglect, resident to resident altercations, behavioral health training, and when a resident needs a psychiatric health consult. These deficient practices could affect any resident and contribute to further abuse. Findings included: 1. Record review of an Admission Record, not dated, for Resident #2 indicated she was readmitted to the facility on [DATE] with an original admitted [DATE] and was [AGE] years old with diagnoses of senile degeneration of the brain (loss of intellectual ability), paranoid schizophrenia (delusions and hallucinations), need for continuous supervision, personality disorder (mental disorder). Record review of a Quarterly MDS Assessment for Resident #2 dated 05/14/2023 indicated a BIMS score of 11 meaning moderate cognitive impairment. She required limited assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Balance during transitions and walking indicated she was not steady, but was able to stabilize without staff assistance and did not require any mobility devices. The MDS indicated that resident had not exhibited any behaviors. Record review of a care plan for Resident #2 dated 03/17/2016 reflected Resident #2 had episodes of behavioral symptoms. Interventions included: provide psych consult per order. Record review of a care plan for Resident #2 dated 04/16/2018 reflected Resident #2 had episodes of anxiety. Interventions included: psychologist/psychiatrist to provide services as ordered. Record review of a care plan for Resident #2 dated 06/17/2021 indicated Resident #2 had physically abusive behavioral symptoms (resident to resident altercation). The resident had a history of throwing liquids at other residents. Interventions included to avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents), and maintain a calm environment and approach to the resident. Resident #2 resided on the secure unit. Record review of a care plan for Resident #2 dated 06/17/2021 reflected Resident #2 had episodes of behavioral symptoms. Interventions included: obtain a psych consult/psychosocial therapy. Record review of a care plan for Resident #2 dated 04/05/2023 reflected Resident #2 had socially inappropriate/disruptive behavioral symptoms post behavior health hospital. Interventions included administer medications as ordered, assess whether behavior endangers others and intervene if necessary, and avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents). Record review of a care plan for Resident #2 dated 05/25/2023 reflected Resident #2 had episodes of behavioral symptoms. Interventions included: obtain a psych consult/psychosocial therapy. Record Review of physician's orders for Resident #2 dated 05/28/2023 to 06/28/2023 indicated resident #2 had the following physicians' orders: 5. Admit to secure unit due to exit seeking secondary to dementia. Dated 06/28/2021. 6. Psychiatric and Psychological Services to evaluate and treat as needed. Dated 02/28/2023. Record review of nurse progress notes for Resident #2 dated 04/05/2023 at 10:33 PM written by LVN A indicated: Resident #2 was witnessed by LVN A throwing water on Resident #1 who wandered into her room. Resident #2 then grabbed Resident #1 by the wrist resulting in a skin tear to Resident #1's right wrist. Resident #2 was provided on-on-one and separated from Resident #1. Record review of an event report dated 04/05/2023 indicated Resident #2 threw water on Resident #1 and grabbed Resident #1 resulting in a 1-centimeter skin tear to the right wrist. The event report indicated Resident #2 was placed on one-on-one supervision. The event report indicated Resident #2 was being referred to a mental health hospital for observation and was awaiting acceptance for transfer. Record review of nurse progress notes for Resident #2 dated 04/15/2023 at 4:01 PM written by LVN C indicated: Resident was sitting in chair in common room when another resident rolled up in their wheelchair reached out with their arm and this resident stabbed her with a pen. Resident #2 was placed on 1 on 1 supervision for 72 hours. Record review of an event report dated 04/15/2023 at 3:47 PM completed by LVN C indicated: Resident #2 stabbed Resident #3 with a pen. Event report indicated Resident #2 was placed on one-on-one supervision for 72 hours. Record review of nurse progress notes for Resident #2 dated 04/15/2023 indicated: The behavioral health hospital returned a call to the facility. They denied the resident for their services at this time. They stated, We may have availability on Monday. On-call, the ADON was notified. One-on-one monitoring continues. Record review of nurse progress notes for Resident #2 dated 05/25/2023 at 1:22PM completed by LVN B indicated: Resident #2 was with Resident #3 in the secure living area. Staff notified the ADON that Resident had pushed Resident #3 out of her wheelchair and on the floor. The residents were separated at this time and Resident #2 was redirected to her room. Nurse Practitioner notified of incident no new orders for Resident #2 received at that time. Record review of an event report date 06/27/2023 at 9:29 AM completed by the regional clinical nurse indicated: Resident #2 pushed another resident sitting in a wheelchair. The event report indicated the residents were separated and Resident #2 was redirected to her room. The Event report indicated the interventions were somewhat effective. 2. Record review of an Admission Record, not dated, for Resident #1 indicated he was readmitted to the facility on [DATE] with an original admitted [DATE] and was [AGE] years old with diagnoses of dementia (loss of memory and thinking abilities), Alzheimer's (disease that destroys memory and other mental functions), schizoaffective disorder (mood disorder), and psychotic disorder with delusions (unshakable belief in something that is bizarre, implausible, or obviously untrue). Record review of a Quarterly MDS Assessment for Resident #1 dated 06/19/2023 indicated a BIMS score of 05 meaning severe cognitive impairment. He had required limited to extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Balance during transitions and walking indicated he was not steady, but able to stabilize without staff assistance and did not require any mobility devices. The MDS indicated Resident #1 had not exhibited any behaviors. Record review of a care plan for Resident #1 dated 05/21/2023 indicated he was at risk for wandering as evidenced by poor judgement and decision making related to dementia. Resident #1 resided on the secure unit. Record review of a care plan for Resident #1 dated 04/05/2023 reflected Resident #1 had behavioral symptoms as evidenced by grabbing others and wandering into other resident rooms. Interventions included to administer medications as ordered, assess whether behavior endangered others and intervene if necessary, and resident had delusions and to not try to confront or reason with the resident. Record review of a physician's order summary report dated 05/28/2023 to 06/28/2023 indicated: 5. resident to be admitted to the secure unit due to exit seeking secondary to dementia on 02/15/2023. 6. Psychiatric and Psychological Services to evaluate and treat as needed. Dated 02/25/2023. Record review of Resident #1's nurse progress notes dated 04/05/2023 at 9:06 PM written by LVN A indicated Resident #1 wandered into Resident #2's room, Resident #2 became upset and threw water on Resident #1. Unidentified CNA's were present on the hall and assisting other residents. LVN A witnessed Resident #1 and Resident #2 grab each other. Both residents were immediately separated and redirected to their rooms to calm. Resident #1 was noted with a 1 cm scratch to the top of his right wrist. LVN A indicated the nurse practitioner, responsible party, ADON and the DON were notified of the incident. 3.Record review of an Admission Record, not dated, for Resident #3 indicated she was readmitted to the facility on [DATE] with an original admitted [DATE] and was [AGE] years old with diagnoses of dementia with behaviors (loss of memory and thinking abilities), anxiety disorder (mental disorder), pseudobulbar affect (uncontrollable laughing or crying), restlessness and agitation. Record review of a Quarterly MDS Assessment for Resident #3 dated 05/26/2023 indicated a BIMS score was not obtained due to Resident #3 was rarely or never understood. She required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Mobility Devices indicated she used a wheelchair for locomotion due to limited range of motion of both lower extremities. The MDS indicated Resident #3 had a mental status change of inattention and disorganized thinking but did not indicate any behavioral symptoms. Record review of a care plan for Resident #2 dated 06/17/2021 indicated Resident #3 had physically abusive behavioral symptoms (biting and hitting residents). Interventions included to avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents), and maintain a calm environment and approach to the resident, and assess whether behavior endangered others and intervene if necessary. Resident #3 resided on the secure unit. Record Review of physician's orders for Resident #3 dated 05/28/2023 to 06/28/2023 indicated Resident #3 had the following physician's orders: 7. Admit to secure unit due to exit seeking secondary to dementia. Dated 06/28/2021. 8. Psychiatric and Psychological Services to evaluate and treat as needed. Dated 02/28/2023. Record review of nursing progress note for Resident #3 dated 04/15/2023 at 3:43 PM written by LVN C indicated: Resident #3 reached out with her arm to Resident #2 and Resident #2 stabbed her with a writing pen on the left forearm. Minimal bleeding was noted and the skin was broken with a treatment of cleanse with normal saline and band aid applied. Record review of nursing progress note for Resident #3 dated 05/25/2023 at 1:46 PM written by LVN B indicated: Resident #3 was with Resident #2 in the secure living area. Staff notified the nurse that Resident #2 had pushed Resident #3 out of her wheelchair and onto the floor. Record review of an event report dated 05/25/2023 at 1:22 PM completed by the DON indicated: Resident #3 was pushed out of her wheelchair by another resident resulting in Resident #3 lying on the floor beside the wheelchair. Interventions included: Neuro checks initiated and within normal limits, and x-ray of skull to rule out injury. Record review of x-ray dated 05/25/2023 report did not show any acute abnormalities. During an observation of the secured unit on 06/26/2023 at 10:10 AM revealed the TV/dining area with 6 residents and 1 can; 2 residents ambulating in hallway and 7 residents in their rooms. Resident #2 was observed sitting in a wingback chair holding a Bible with papers inside and a pen. Resident #3 was sitting up in her wheelchair 5-6 feet away from Resident #2 with her head down. Resident #1 was observed lying in bed in his room with eyes closed. During an observation and interview on 06/26/2023 at 10:05 AM revealed Resident #2 sitting up in chair in the common area. She said it was year 2025 but they kept telling her it was 2023. She said she did not remember an incident that a resident was stabbed with a pen or pushed out of a wheelchair. Resident #2 said she did not want to answer any more questions. During an interview on 6/26/2023 at 10:15 AM CNA D said she worked for an agency and was not employed by the facility. She said she had been coming to the facility for about 3 weeks and ever since there had only been one CNA that worked on the secured unit per shift. She said there was a CNA that worked on the hall outside of the secured unit that could come and occasionally help if needed. She said Resident #2 only got aggressive if someone went into her room but had not seen any physical aggression by Resident #2. She said Resident #2 did not get aggressive unless someone got in her personal space. She said she had 15 residents on the secured unit. She said if she witnessed a resident to resident altercation she would separate the residents for safety and notify the DON and Administrator. During an interview on 06/26/2023 at 10:22 AM LVN B said she had worked at the facility for about 2 months and was the nurse for the secured unit and the backside of 200 hall. Said she was not able to always be in the secured unit. She said on 05/25/2023 Resident #3 rolled her wheelchair past Resident #2 and Resident #2 pushed Resident #3 out of her wheelchair causing Resident #3 to fall onto the floor. She said Resident #2 and Resident #3 are both combative, so they have had to watch them both. She said Resident #2 becomes aggressive if someone gets in her personal space. She said they tried to keep residents separated when they can. She said Resident #2 just returned from the behavioral hospital about 2 weeks ago and she had seen an improvement in her behaviors. LVN B said when she worked, she has 1 CNA in the unit. During a phone interview on 06/26/2023 at 2:59 PM LVN C said she was the nurse for the secured unit on 04/15/2023. She said she did not know Resident #2 had a pen and was sitting where resident could be seen the whole time. She said Resident #2 wrote on paper a lot. She said Resident #3 went past Resident #2 and Resident #2 stabbed Resident #3 with a pen. She said the residents were immediately separated, assessed, and the pen was taken from Resident #2. She said there was minimal bleeding to Resident #3's arm and first aid was provided to her. She said Resident #2 was placed on one-on-one monitoring for 1-2 days. She said an incident report was done and the ADON, DON and provider was notified of the incident. She said Resident #2 and Resident #3 were watched to make sure they were not in the same area. She said both Resident #2 and Resident #3 can get aggressive at times. She said Resident #2 can become aggressive if someone is in her personal space. She said she could not recall any in-services that were conducted at the time. She said she has not witnessed any abuse/neglect but if she did, she would report it to the Administrator who is the abuse coordinator. During an interview on 06/27/2023 at 9:40 AM the ADM said she remembered calling in a CNA to put with Resident #2 for one-on-one monitoring after the 05/25/2023 incident but did not have any documentation of the one-on-one monitoring. During an interview on 06/27/2023 at 10:00 AM the Psychologist said he had known Resident #2 for a long time due to seeing her at a previous facility. He said he had never seen Resident #2 at the current facility for psych services due to not being able to obtain consent. He said he would see Resident #2 if he had consent to treat the resident. He said Resident #2 had a diagnosis of schizophrenia. He said he did not think psych services would make a difference in Resident #2's behaviors and it would be better to educate the other residents in the secured unit to stay out of Resident #2's personal space. The Psychologist said you cannot educate the other residents of the secured unit because they would not understand or remember the education. During a phone interview on 06/27/2023 at 9:50 AM the Responsible Party of Resident #2 said he was notified of an incident regarding Resident #2 stabbing another resident with a pen. He said he was not asked for consent for counseling services; he said he would have given consent for anything that would help Resident #2. He said he came to the facility for a visit and was notified that approximately 10-14 days earlier that Resident #2 had pushed another resident out of her wheelchair. He said he was never notified of an incident where Resident #2 threw water on and caused a skin tear to another resident. He said the last time he was contacted and asked to give consent for psych services was about a year ago, and he gave consent at that time. He said he was notified on 06/08/2023 that Resident #2 had been transferred to the behavioral health hospital for treatment. During an interview on 06/27/2023 at 10:37 AM the Social Worker said Resident #2 had been at the facility for a long time. He said Resident #2 was delusional and had an area in the day room where she liked to write and read. He said everyone had to approach Resident #2 in a calm manner and did not want any staff or residents in Resident #2's area that he described as a bubble around her. He said if someone stepped into Resident #2's boundary, she could get physically aggressive with them. He said she had a diagnosis of schizophrenia and did not have any family involved in her care but did have a legal guardian. He said from time to time Resident #2 would have behaviors but as long as she was left alone, she was good. He said Resident #2 did not like any residents in her space and most of the residents in the secured unit were not aware of that. The Social Worker said he attempted to send Resident #2 out to a behavioral hospital previously, but the resident's guardian would not give consent. He said Resident #2's guardian said he did not think Resident #2 could understand and felt like it would be pointless. He said there was an incident when another resident went into Resident #2's personal space and she poked that resident with a pen. He said Resident #2's legal guardian was the one who gave consent for her to see the psychologist that visited the facility. He said the psychologist visited the facility every Monday and Resident #2 was being seen by him. He said the Psychologist was who the facility had a contract with, and they also had a contract with another counseling provider. He said overall Resident #2 was ok as long as people stayed out of her personal space. He said they have talked to the staff and instructed them to keep an eye on Resident #2. He said some residents did wander from room to room at times. He said Resident #2 went to a behavioral hospital a few weeks ago following an incident when she stabbed another resident with a pen for about two weeks and had been ok since returning to the facility with medication adjustments. During a phone interview on 06/28/2023 at 10:24 AM LVN A said she had worked for the facility as needed for 1 year. She said there was one CNA that works on the secured unit and covers the backside of 200 hall outside of the unit. She said the nurse normally stepped into to unit while the CNA goes out of the unit to make a round on the backside of 200 hall. She said she witnessed the incident on 04/05/2023 with Resident #2 and Resident #1. She said Resident #1 wandered into Resident #2's room and Resident #2 threw water on Resident #1 and then grabbed his wrist causing a skin tear. She said she immediately separated the residents and redirected Resident #2 to her room. She said that if anyone gets in Resident #2's personal space she becomes physically aggressive. She said the staff tries to keep other residents out of her personal space but that is hard to do when the residents are all in the common area. She said Resident #2 punched an employee in the face about 6-7 months ago and Resident #2 was not sent out to the behavioral health hospital or anything. During an interview on 06/28/2023 at 12:20 PM the DON said on 04/05/2023 Resident #1 wandered into Resident #2's room and Resident #2 threw water on and grabbed Resident #1's wrist causing a skin tear. She said Resident #2 did not like for anyone to get in her personal space and becomes aggressive when they do. She said the Social Worker called Resident #2's responsible party but it is hit and miss when trying to contact him. She said after the incident on 04/15/2023 the behavioral health hospital would not accept the resident due to there not being enough documentation of Resident #2's behaviors in her chart. She said she directed the nursing staff to continue to document all of Resident #2's behaviors so the behavioral health hospital would accept her. She said when residents are placed on one-on-one monitoring there is a Q15 minute checks form staff is supposed to document on but said they did not do it. The DON said she did not feel like 1 CNA was enough staff on the secured unit. She said she would like to have more staffing in the secured unit and to not admit anymore residents with combative behaviors to the secured unit. Record review of a facility policy titled Resident-to-Resident Altercations with a revised date of December 2016 indicated, .G. Document in the resident's clinical record all interventions and their effectiveness. H. Consult psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for intervention and management as necessary or as may be recommended by the attending physician or interdisciplinary care planning team. J. if, after carefully evaluation the situation, it is determined that care cannot be readily given within the facility, transfer the resident. Record review of a facility policy titled Behavioral Assessment, Intervention and Monitoring with a revised date of December 2021 indicated, . 1. The center will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. 2. Behavioral symptoms will be identified using center-approved behavioral screening tools and the comprehensive assessment. Management: 1. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. Record review of a facility policy titled SLP-Prosperity Behavioral and Mental Health Services with a revised date of January 2022.Safety-The creation and maintenance of a safe environment in the Long-Term care setting is the cornerstone of the mental health nurse's (MHN) role and responsibility. The role of the MHN to assess for environmental and individual safety is active and on-going to prevent self-harm or harm to others in the center. Assessment/Evaluation- The interdisciplinary Team (IDT) will consist of a psychiatrist, psychologist, consulting pharmacist, licensed nurse, dietician, social worker, qualified activity assistant, and nursing assistants. The IDT will approach each resident care by addressing their unique individual needs and implementing resident centered interventions promoting overall behavioral and mental health. Psychiatric Assessment- Each resident admitted to a [Provider name]Behavioral/Mental Health Unit will be referred to the center's designated psychiatrist for evaluation and treatment. Psychological Assessment- Each resident admitted to a Behavioral/Mental Health Unit will be referred to the center's designated psychologist for evaluation and treatment Record review of a facility policy titled Abuse Prevention Program with a revised date of 01/09/2023 indicated: .2. Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The facility Administrator was notified on 06/27/2022 at 04:57 PM that an Immediate Jeopardy situation had been identified due to the above failures and the IJ template was given at that time. The facility's plan of removal was accepted on 06/28/2022 at 03:24 PM and included: Residents on the secured unit will have psychiatric service referrals completed by the DON/Rep. Any negative findings will be reported to the Physician. Any residents outside of the secured unit that have been involved with resident-to-resident altercations within the last 60 days will be referred to psych services. The Director of Nurses and/or designee with collaborate with the psychiatric provider and will audit charts to ensure scheduled/routine visits were completed, any missing visits will be reported to psych services to reschedule the visit. This will be completed by 06/28/2023 at 3:00 PM. Resident #2 has been placed on one-on-one until discharge to another facility is completed or determined by IDT not to be a danger. Resident #2 remained in the facility at the time of surveyor exit. All staff were trained/educated on Resident #2's current intervention, at this time Resident #2 is on 1:1 observation for resident safety. Timeline for completion: 06/28/2023 at 3:00 PM The facility will review all resident incidents for the last 30 days to ensure no other additional resident to resident altercations have occurred without appropriate interventions being placed in the care plan, notifications made to psych services and the MD. Timeline for completion: 06/28/2023 at 3:00 PM. The facility will complete safe surveys with all residents on secured unit and outside the secure unit. Residents unable to complete the safe survey will have a head-to-toe skin assessment and RP will be notified for any concerns. Negative findings will be reported to the abuse coordinator. Timeline for completion: 06/28/2023 at 3:00 PM. The safe surveys and head to toe skin assessments had been completed and documented at time of surveyor exit. The facility will Inservice staff on: Abuse/Neglect, Resident to Resident Altercations, Behavioral Health training, when a resident needs to have a psychiatric service consult/mental health evaluation following an aggression event towards residents, all staff will understand they cannot leave the secured unit unattended through education, and the Administrator and Director of Nursing will ensure the secured unit is staffed. Timeline for completion: 06/28/2023 at 3:00 PM. The facility's Administrator, DON, ADON and/or designee will review incidents occurring on the unit, update the facility assessment tool to accurately reflect residents' acuity and will make necessary adjustments, if necessary, to staff the center and unit to provide adequate supervision. Timeline for completion: 06/28/2023 at 3:00 PM. An ad hoc QAPI meeting with the Medical Director, Administrator and Director of Nursing completed regarding IJ templates and plan of removal. Timeline for completion: 06/28/2023 at 3:00 PM. On 06/28/2023, the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: During an observation an interview on 6/28/2023 at 9:40 AM in the secured unit revealed MA E was present. MA E said she was assigned to provide 1 on 1 with Resident#2 and today was her first day of work. She said the facility started 1 on 1 with Resident #2 as of midnight last night, 6/28/2023. She said she had to complete 15-minute check documentation on her. Observation of the secured unit on 06/28/23 at 3:00 pm revealed there were 2 certified nurse aides and 1 nurse on the unit at this time. Observation of secured unit on 06/28/2023 at 5:15 PM revealed there were 2 certified nurse's aides and the Activity Director on the unit at this time. CNA E was observed documenting on Q15 minute monitoring sheet. Record review of the Q15 minute monitoring sheet dated 06/28/2023 indicated resident had not had any behaviors for that day. During interviews on 06/28/2023 from 3:30 PM-5:45 PM, the Business Office Manager, Social Worker, Activity Director, Certified Occupational Therapist, DON, ADON, LVN C, MA E, MA G, and CNA D, CNA I, CNA H, CNA K were able to verbalize the procedure when a resident-to-resident altercation occurred, Resident #2's current staffing, behavioral health training, when a resident needed a psychiatric consult, and the abuse/neglect policy. A record review of the facility's QAPI meeting conducted on 06/27/2023 at 07:14 PM revealed attendees consisting of the Administrator, Company Clinical Leader, Regional Clinical Nurse and the Medical Director (via phone). The meeting was held to discuss incidents and policies and determine system failures and indicated policies were reviewed and 1. Resident place on 1 on 1(Q15 minute checks) to be documented on form provided to staff. 2. Referral made to psych services. 3. Staff trained on abuse policy and resident to resident altercation policy. 4. Staff educated on event reporting to be completed at time of event. 5. Care plans were updated. Staff would be educated and in-serviced on abuse policy resident-to-resident altercations policy, and event reporting to be completed at time of event. Resident #2 was placed on 1:1 monitoring, to be documented on a documentation sheet provided to staff, referrals made to psych services, and care plans were updated. Record review of an in-service dated 06/27/2023 conducted by the Regional Clinical Nurse revealed the topic of the abuse prevention program. The in-service attendees included nurses, CNAs, MAs, the Business Office Manager, housekeeping, and the Dietary Manager. Record review of an in-service dated 06/27/2023 conducted by the Regional Clinical Nurse revealed the topic of resident-to-resident altercations. The in-service attendees included nurses, CNAs, MAs, Business Office Manager, housekeeping, and Dietary Manager. Record review of an in-service dated 06/27/2023 conducted by the Regional Clinical Nurse revealed the topic of behavioral and mental health services. The in-service attendees included nurses, CNAs, MAs, Business Office Manager, housekeeping, and Dietary Manager. Record review of an in-service dated 06/27/2023 conducted by the Regional Clinical Nurse revealed the topic of abuse and neglect. The in-service attendees included nurses, CNAs, MAs, Business Office Manager, housekeeping, and Dietary Manager. Record review of psychiatric referrals sent to the psych services provider for 13 of 15 residents residing on the secured unit with 1 resident refusal and 1 resident receiving services with another provider. During an interview on 06/28/2023 at 04:35 PM, the DON said she would review all incident/accident reports in the daily clinical meeting to monitor for aggressive/combative behaviors or resident to resident altercations and take all appropriate actions. On 06/28/2023 at 06:15 PM, the facility was informed the IJ was removed. However, the facility remained out of compliance at a severity of the potential for more than minimal harm that is not immediate jeopardy. The facility continued to monitor and in-service [TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being 1 of 3 resident (Resident #2) reviewed for behavioral health. 1. The facility failed to assess and implement interventions on 3 separate occasions when Resident #2 had behaviors of aggression. On 04/05/2023 Resident #1 wandered into Resident #2's room on the secured unit, and Resident #2 threw water on Resident #1 and then grabbed Resident #1 causing a skin tear to Resident #1's right mid arm. 2. The facility failed to assess and implement interventions on 3 separate occasions when Resident #2 had behaviors of aggression. On 04/15/2023 Resident #2 stabbed Resident #3 with a pen causing a puncture wound to Resident #3's left forearm. 3. The facility failed to assess and implement interventions on 3 separate occasions when Resident #2 had behaviors of aggression. On 05/25/2023 Resident #2 pushed Resident #3 out of her wheelchair causing Resident #3 to fall onto the floor. The facility failed to immediately provide psychological services for Resident #2 following 3 separate residents to resident altercations on 04/05/2023, 04/15/2023 and 05/25/2023. On 02/28/2023 an order for a psych consult was written for Resident #2 to be evaluated and treated. Resident #2 was not evaluated until 06/08/2023 by psychological services. An IJ was identified on 06/27/2023 at 4:57 PM. The IJ template was provided to the facility on [DATE] at 4:57 PM. While the IJ was removed on 06/28/2023 at 6:15 PM, the facility remained out of compliance at a scope of isolated and a severity level of a potential for more than minimal harm because (e.g.) all staff had not been trained on abuse/neglect, resident to resident altercations, behavioral health training, and when a resident needs a psychiatric health consult. These failures affected residents living in the facility at risk of not receiving behavioral health services, increased anger and behaviors, inflicting harm on others, anxiety and decline in quality of life. The findings included: 1.Record review of an Admission Record not dated for Resident #2 indicated she was readmitted to the facility on [DATE] with an original admitted [DATE] and was [AGE] years old with diagnoses of senile degeneration of the brain (loss of intellectual ability), paranoid schizophrenia (delusions and hallucinations), need for continuous supervision, personality disorder (mental disorder). Record review of a Quarterly MDS Assessment for Resident #2 dated 05/14/2023 indicated a BIMS score of 11 meaning moderate cognitive impairment. She requires limited assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Balance during transitions and walking indicated he was not steady, but able to stabilize without staff assistance and did not require any mobility devices. The MDS indicated that Resident #2 had not exhibited any behaviors. Record review of a care plan for Resident #2 dated 06/17/2021 indicated Resident #2 had physically abusive behavioral symptoms (resident to resident altercation). History of throwing liquids at other residents. Interventions included avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents), and maintain a calm environment and approach to the resident. Resident #2 resides on the secure unit. Record review of a care plan for Resident #2 dated 03/17/2016 reflected Resident #2 had episodes of behavioral symptoms. Interventions included: provide psych consult per order. Record review of a care plan for Resident #2 dated 04/16/2018 reflected Resident #2 had episodes of anxiety. Interventions included: psychologist /psychiatrist to provide services as ordered. Record review of a care plan for Resident #2 dated 04/05/2023 reflected Resident #2 had socially inappropriate/disruptive behavioral symptoms post behavioral hospital. Interventions included administer medications as ordered, assess whether behavior endangers others and intervene if necessary, and Avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents). Record review of a care plan for Resident #2 dated 04/16/2023 reflected Resident #2 had episodes of anxiety. Interventions included: Psychologist/Psychiatrist to provide services as ordered. Record review of a care plan for Resident #2 dated 05/25/2023 reflected Resident #2 had episodes of behavioral symptoms. Interventions included: obtain a psych consult/psychosocial therapy. Record review of a care plan for Resident #2 dated 06/17/2021 reflected Resident #2 had episodes of behavioral symptoms. Interventions included: obtain a psych consult/psychosocial therapy. Record Review of physician's orders for Resident #2 dated 05/28/2023 to 06/28/2023 indicated resident #2 had the following physicians' orders: 1. Admit to secure unit due to exit seeking secondary to dementia. Dated 06/28/2021 2. Psychiatric and Psychological Services to evaluate and treat as needed. Dated 02/28/2023 Record review of nurse progress notes for Resident #2 dated 04/05/2023 indicated: Resident #2 was witnessed by LVN A throwing water on Resident #1 that wandered into her room. Resident #2 then grabbed the Resident #1 by the wrist resulting in a skin tear to Resident #1's right wrist. Resident #2 was provided on-on-one and separated from Resident #1. Record review of event report dated 04/05/2023 indicated: Resident #2 threw water on Resident #1 and grabbed Resident #1 resulting in a 1-centimeter skin tear to the right wrist. Event report indicated Resident #2 was placed on one-on-one supervision. Event report indicated Resident #2 was being referred to a mental health hospital for observation and was awaiting acceptance for transfer. Record review of nurse progress notes for Resident #2 dated 04/15/2023 indicated: Resident #2 was sitting in chair in common room when Resident #3 rolled up in wheelchair reached out with arm and Resident #2 stabbed Resident #3 with a pen. Resident #2 had been placed on 1 on 1 supervision for 72 hours. Record review of event report dated 04/15/2023 indicated: Resident #2 stabbed Resident #3 with a pen. Event report indicated Resident #2 was placed on one-on-one supervision for 72 hours. Record review of nurse progress notes for Resident #2 dated 04/15/2023 indicated: Behavioral Hospital returned a call to the facility. Denies the resident for their services at this time. States, We may have availability on Monday. On-call, ADON was notified. One-on-one monitoring continues. Record review of nurse progress notes for Resident #2 dated 05/25/2023 indicated: Resident #2 was with Resident #3 in the secure living area. Staff notified the ADON that Resident #2 had pushed Resident #3 out of her wheelchair and on the floor. The residents were separated at that time and Resident #2 was redirected to her room. The Nurse Practitioner was notified of incident and no new orders for Resident #2 were received at that time. Record review of event report date 06/27/2023 indicated: Resident #2 pushed Resident #3 sitting in a wheelchair. The event report indicated the residents were separated and Resident #2 was redirected to her room. The Event report indicated the interventions were somewhat effective. . Record review of an Admission Record, not dated, for Resident #1 indicated he was readmitted to the facility on [DATE] with an original admitted [DATE] and was [AGE] years old with diagnoses of dementia (loss of memory and thinking abilities), Alzheimer's (disease that destroys memory and other mental functions), schizoaffective disorder (mood disorder), and psychotic disorder with delusions (unshakable belief in something that is bizarre, implausible, or obviously untrue). Record review of a Quarterly MDS Assessment for Resident #1 dated 06/19/2023 indicated a BIMS score of 05 meaning severe cognitive impairment. He had required limited to extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Balance during transitions and walking indicated he was not steady, but able to stabilize without staff assistance and did not require any mobility devices. The MDS indicated Resident #1 had not exhibited any behaviors. Record review of a care plan for Resident #1 dated 05/21/2023 indicated he was at risk for wandering as evidenced by poor judgement and decision making related to dementia. Resident #1 resided on the secure unit. Record review of a care plan for Resident #1 dated 04/05/2023 reflected Resident #1 had behavioral symptoms as evidenced by grabbing others and wandering into other resident rooms. Interventions included to administer medications as ordered, assess whether behavior endangered others and intervene if necessary, and resident had delusions and to not try to confront or reason with the resident. Record review of a physician's order summary report dated 05/28/2023 to 06/28/2023 indicated: 5. resident to be admitted to the secure unit due to exit seeking secondary to dementia on 02/15/2023. 6. Psychiatric and Psychological Services to evaluate and treat as needed. Dated 02/25/2023. Record review of Resident #1's nurse progress notes dated 04/05/2023 at 9:06 PM written by LVN A indicated Resident #1 wandered into Resident #2's room, Resident #2 became upset and threw water on Resident #1. Unidentified CNAs were present on the hall and assisting other residents. LVN A witnessed Resident #1, and Resident #2 grab each other. Both residents were immediately separated and redirected to their rooms to calm. Resident #1 was noted with a 1 cm scratch to the top of his right wrist. LVN A indicated the nurse practitioner, responsible party, ADON and the DON were notified of the incident. 3.Record review of an Admission Record, not dated, for Resident #3 indicated she was readmitted to the facility on [DATE] with an original admitted [DATE] and was [AGE] years old with diagnoses of dementia with behaviors (loss of memory and thinking abilities), anxiety disorder (mental disorder), pseudobulbar affect (uncontrollable laughing or crying), restlessness and agitation. Record review of a Quarterly MDS Assessment for Resident #3 dated 05/26/2023 indicated a BIMS score was not obtained due to Resident #3 was rarely or never understood. She required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Mobility Devices indicated she used a wheelchair for locomotion due to limited range of motion of both lower extremities. The MDS indicated Resident #3 had a mental status change of inattention and disorganized thinking but did not indicate any behavioral symptoms. Record review of a care plan for Resident #2 dated 06/17/2021 indicated Resident #3 had physically abusive behavioral symptoms (biting and hitting residents). Interventions included to avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents), and maintain a calm environment and approach to the resident, and assess whether behavior endangered others and intervene if necessary. Resident #3 resided on the secure unit. Record Review of physician's orders for Resident #3 dated 05/28/2023 to 06/28/2023 indicated Resident #3 had the following physician's orders: 7. Admit to secure unit due to exit seeking secondary to dementia. Dated 06/28/2021. 8. Psychiatric and Psychological Services to evaluate and treat as needed. Dated 02/28/2023. Record review of nursing progress note for Resident #3 dated 04/15/2023 at 3:43 PM written by LVN C indicated: Resident #3 reached out with her arm to Resident #2 and Resident #2 stabbed her with a writing pen on the left forearm. Minimal bleeding was noted and the skin was broken with a treatment of cleanse with normal saline and band aid applied. Record review of nursing progress note for Resident #3 dated 05/25/2023 at 1:46 PM written by LVN B indicated: Resident #3 was with Resident #2 in the secure living area. Staff notified the nurse that Resident #2 had pushed Resident #3 out of her wheelchair and onto the floor. Record review of an event report dated 05/25/2023 at 1:22 PM completed by the DON indicated: Resident #3 was pushed out of her wheelchair by another resident resulting in Resident #3 lying on the floor beside the wheelchair. Interventions included: Neuro checks initiated and within normal limits, and x-ray of skull to rule out injury. Record review of x-ray dated 05/25/2023 report did not show any acute abnormalities. During an observation of the secured unit on 06/26/2023 at 10:10am observed TV/dining area with 6 residents and 1 CNA, 2 residents ambulating in hallway and 7 residents in their rooms. Resident #2 was observed sitting in a wingback chair holding a bible with papers inside and a pen. Resident #2 was not on any special supervision at that time. During an observation and interview on 06/26/2023 at 10:05 AM observed Resident #2 sitting up in chair in the common area, said it was year 2025 but they keep telling her its 2023. She said she did not remember an incident that a resident was stabbed with a pen or pushed out of a wheelchair. Resident #2 said she did not want to answer anymore questions. During an interview on 6/26/2023 at 10:15 AM CNA D said she worked for an agency and was not employed by the facility. Said she had been coming to the facility for about 3 weeks and said ever since she had been coming, there had only one CNA that worked on the secured unit per shift. She said there is a CNA that worked on the hall outside of the secured unit that can come and occasionally help if needed. She said Resident #2 only gets aggressive if someone goes into her room but has not seen any physical aggression. She said Resident #2 does not get aggressive unless someone gets in her personal space. She said she has 15 residents on the secured unit. During an interview on 06/26/2023 at 10:22 AM LVN B said she has worked at the facility for about 2 months and is the nurse for the secured unit and the backside of 200 hall. Said she is not able to always be in the secured unit. She said on 05/25/2023 another resident rolled her wheelchair past Resident #2 and Resident #2 pushed the other residents out of her wheelchair causing that resident to fall onto the floor. She said Resident #2 and the other resident are both combative, so you have to watch them both. She said Resident #2 becomes aggressive if someone gets in her personal space. She said they try to keep residents separated when they can. She said Resident #2 just returned from the behavioral hospital about 2 weeks ago and has seen an improvement in her behaviors. During a phone interview on 06/26/2023 at 2:59 PM LVN C said she was the nurse for the secured unit on 04/15/2023. She said she did not know Resident #2 had a pen and was sitting there the whole time. She said Resident #2 writes on paper a lot. She said the other went past Resident #2 and Resident #2 stabbed the other with a pen. She said the residents were immediately separated, assessed, and the pen was taken from Resident #2. She said there was minimal bleeding to the other resident's arm and provided first aid to her. She said Resident #2 was placed on one-on-one monitoring for 1-2 days. She said an incident report was done and ADON, DON and provider was notified of the incident. She said Resident #2 and the other resident were watched to make sure they were not in the same area. She said both Resident #2 and the other resident can get aggressive at times. She said Resident #2 can become aggressive if someone is in her personal space. She said she could not recall any in services were conducted at the time. She said she has not witnessed any abuse/neglect but if she did, she would report it to the administrator who is the abuse coordinator. During an interview on 06/27/2023 at 9:40 AM the Administrator said she remembered calling in a CNA to put with Resident #2 for one-on-one monitoring after the 05/25/2023 incident but did not have any documentation of the one-on-one monitoring. During an interview on 06/27/2023 at 10:00 AM the Psychologist said he has known Resident #2 for a long time due to seeing her at a previous facility. He said he has never seen Resident #2 at the current facility for psych services due to not being able to obtain consent. He said he would see Resident #2 if he had consent to treat the resident. He said Resident #2 has a diagnosis of schizophrenia. He said he did not think psych services would make a difference in Resident #2's behaviors and it would be better to educate the other residents in the secured unit to stay out of Resident #2's personal space. During a phone interview on 06/27/2023 at 9:50 AM the Responsible Party said he was notified of an incident of Resident #2 stabbing another resident with a pen. He said he was not asked for consent for counseling services, he said he would have given consent for anything that would help Resident #2. He said he came to the facility for a visit and was notified that approximately 10-14 days earlier that Resident #2 had pushed another resident out of her wheelchair. He said he was never notified of an incident where Resident #2 threw water on and caused a skin tear on another resident. He said the last time he was contacted and asked to give consent for psych services was about a year ago, and he gave consent at that time. He said he was notified on 06/08/2023 that Resident #2 had been transferred to the behavioral hospital for treatment. During an interview on 06/27/2023 at 10:37 AM the Social Worker said Resident #2 had been at the facility for a long time. He said Resident #2 was delusional and had an area in the day room where she liked to write and read. He said everyone had to approach Resident #2 in a calm manner and did not want any staff or residents in Resident #2's area that he described as a bubble around her. He said if someone stepped into Resident #2's boundary, she could get physically aggressive with them. He said she had a diagnosis of schizophrenia and did not have any family involved in her care but did have a legal guardian. He said from time to time Resident #2 would have behaviors but as long as she was left alone, she was good. He said Resident #2 did not like any residents in her space and most of the residents in the secured unit were not aware of that. He said attempted to send Resident #2 out to a behavioral hospital previously, but the residents guardian would not give consent. He said Resident #2's guardian said he did not think Resident #2 could understand and felt like it would be pointless. He said there was an incident when another resident went into Resident #2's personal space and she poked that resident with a pen. He said Resident #2's legal guardian was the one who gave consent for her to see the psychologist that visited the facility. He said the psychologist visited the facility every Monday and Resident #2 was being seen by him. He said Psychologist was who the facility had a contract with, and they also had a contract with another counseling company. He said overall Resident #2 was ok as long as people stayed out of her personal space. He said they have talked to the staff and instructed them to keep an eye on Resident #2. He said some residents do wander from room to room at times. He said Resident #2 went to a behavioral hospital a few weeks ago following an incident when she stabbed another resident with a pen for about two weeks and had been ok since returning to the facility with medication adjustments. During a phone interview on 06/28/2023 at 10:24 AM LVN A said she has worked for the facility as needed for 1 year. She said there is one CNA that works on the secured unit and also covers the backside of 200 hall outside of the unit. She said the nurse normally steps into to unit while the CNA goes out of the unit to make a round on the backside of 200 hall. She said she witnessed the incident on 04/05/2023 with Resident #2 and another resident. She said another resident wandered into Resident #2's room and Resident #2 threw water on that resident and then grabbed his wrist causing a skin tear. She said she immediately separated the residents and redirected Resident #2 to her room. She said that is anyone gets in Resident #2's personal space she becomes physically aggressive. She said the staff tries to keep other residents out of her personal space but that is hard to do when the residents are all in the common area. She said Resident #2 punched an employee in the face about 6-7 months ago and Resident #2 was not sent out to the behavioral hospital or anything. During an interview on 06/28/2023 at 12:20 PM the DON said on 04/05/2023 another resident wandered into Resident #2's room and Resident #2 threw water on and grabbed the other resident's wrist causing a skin tear. She said Resident #2 does not like for anyone to get in her personal space and becomes aggressive when they do. She said the Social Worker called Resident #2's responsible party but it is hit and miss when trying to contact him. She said after the incident on 04/15/2023, the behavioral hospital would not accept resident due to there not being enough documentation of Resident #2's behaviors in her chart. She said she directed the nursing staff to continue to document all of Resident #2's behaviors so the behavioral hospital would accept her. She said when residents are placed on one-on-one monitoring there is a Q15 minute checks form staff is supposed to document on but said they did not do it. She said she would like to have more staffing in the secured unit and to not admit anymore residents with combative behaviors to the secured unit. Record review of a facility policy titled Resident-to-Resident Altercations with a revised date of December 2016 indicated, .G. Document in the resident's clinical record all interventions and their effectiveness. H. Consult psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for intervention and management as necessary or as may be recommended by the attending physician or interdisciplinary care planning team. J. if, after carefully evaluation the situation, it is determined that care cannot be readily given within the facility, transfer the resident. Record review of a facility policy titled Behavioral Assessment, Intervention and Monitoring with a revised date of December 2021 indicated, . 1. The center will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. 2. Behavioral symptoms will be identified using center-approved behavioral screening tools and the comprehensive assessment. Management: 1. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. Record review of a facility policy titled SLP-Prosperity Behavioral and Mental Health Services with a revised date of January 2022.Safety-The creation and maintenance of a safe environment in the Long-Term care setting is the cornerstone of the mental health nurse's (MHN) role and responsibility. The role of the MHN to assess for environmental and individual safety is active and on-going to prevent self-harm or harm to others in the center. Assessment/Evaluation- The interdisciplinary Team (IDT) will consist of a psychiatrist, psychologist, consulting pharmacist, licensed nurse, dietician, social worker, qualified activity assistant, and nursing assistants. The IDT will approach each resident care by addressing their unique individual needs and implementing resident centered interventions promoting overall behavioral and mental health. Psychiatric Assessment- Each resident admitted to a Senior Living Properties Behavioral/Mental Health Unit will be referred to the center's designated psychiatrist for evaluation and treatment. Psychological Assessment- Each resident admitted to a Senior Living Properties Behavioral/Mental Health Unit will be referred to the center's designated psychologist for evaluation and treatment . The facility Administrator was notified on 06/27/2022 at 04:57 PM that an Immediate Jeopardy situation had been identified due to the above failures and the IJ template was given at that time. The facility's plan of removal was accepted on 06/28/2022 at 03:24 PM and included: Residents on the secured unit will have psychiatric service referrals completed by DON/Rep. Any negative findings will be reported to the Physician. Any residents outside of the secured unit that have been involved with resident-to-resident altercations within the last 60 days will be referred to psych services. The Director of Nurses and/or designee with collaborate with the psychiatric provider and will audit charts to ensure scheduled/routine visits were completed, any missing visits will be reported to psych services to reschedule the visit. This will be completed by 06/28/2023 at 3:00 PM. Resident #2 has been placed on one-on-one until discharge to another facility is completed or determined by IDT not to be a danger. All staff were trained/educated on Resident #2's current intervention, at this time Resident #2 is on 1:1 observation for resident safety. Timeline for completion: 06/28/2023 at 3:00 PM Facility will review all resident incidents for the last 30 days to ensure no other additional resident to resident altercations have occurred without appropriate interventions being placed in the care plan, notifications made to psych services and MD. Timeline for completion: 06/28/2023 at 3:00 PM. Facility will complete safe surveys with all residents on secured unit and outside the secure unit. Residents unable to complete will have a head-to-toe skin assessment and RP will be notified for any concerns. Negative findings will be reported to the abuse coordinator. Timeline for completion: 06/28/2023 at 3:00 PM. Facility will Inservice staff on: Abuse/Neglect, Resident to Resident Altercations, Behavioral Health training, when a resident needs to have a psychiatric service consult/mental health evaluation following an aggression event towards residents, All staff will understand they cannot leave the secured unit unattended through education, Administrator and Director of Nursing will ensure secured unit is staffed. Timeline for completion: 06/28/2023 at 3:00 PM. Facility's Administrator, DON, ADON and/or designee will review incidents occurring on the unit, update the facility assessment tool to accurately reflect residents' acuity and will make necessary adjustments, if necessary, to staff the center and unit to provide adequate supervision. Timeline for completion: 06/28/2023 at 3:00 PM. Ad hoc QAPI meeting with Medical Director, Administrator and Director of Nursing completed regarding IJ templates and plan of removal. Timeline for completion: 06/28/2023 at 3:00 PM. On 06/28/2023, the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: During an observation on 6/28/2023 at 9:40 AM in the secured unit MA E was present said she was assigned to provide 1 on 1 with Resident #2 and today was her first day of work. She said the facility started 1 on 1 with Resident # as of midnight last night 6/28/2023. She said she had to complete 15-minute checks on her. Observation of secured unit on 06/28/23 at 3:00 pm revealed that there were 2 Certified nurse's aides and 1 nurse on the unit at this time. Observation of secured unit on 06/28/2023 at 5:15 PM revealed there were 2 certified nurse's aides and the activity director on the unit at this time. CNA E observed documenting on Q15 minute monitoring sheet. During interviews on 06/28/2023 from 3:30 PM-5:45 PM, Business office manager, Social Worker, Activity Director, certified occupational therapist, DON, ADON, 1 LVN, 2 MA's, and 4 CNA's were able to verbalize the procedure when a resident-to-resident altercation occurs, Resident #2's current staffing, behavioral health training, when a resident needs a psychiatric consult, and abuse/neglect policy. A record review of the facility's QAPI meeting conducted on 06/27/2023 at 07:14 PM had attendees of Administrator, company clinical leader, Regional clinical nurse and Medical Director (via phone). The meeting was held to discuss incidents and policies and determine system failures and indicated policies were reviewed and several things were put in place. Staff would be educated and in-serviced on abuse policy resident-to-resident altercations policy, and event reporting to be completed at time of event. Resident #2 was placed on 1:1 monitoring to be documented on documentation sheet provided to staff, referrals made to Senior Psych Services, and care plans were updated. Record review of an in-service dated 06/27/2023 conducted by the Regional Clinical Nurse was on the topic of abuse prevention program. The in-service attendees included nurses, CNAs, MAs, business office manager, housekeeping, and dietary manager. Record review of an in-service dated 06/27/2023 conducted by the Regional Clinical Nurse was on the topic of resident-to-resident altercations. The in-service attendees included nurses, CNAs, MAs, business office manager, housekeeping, and dietary manager. Record review of an in-service dated 06/27/2023 conducted by the Regional Clinical Nurse was on the topic of behavioral and mental health services. The in-service attendees included nurses, CNAs, MAs, business office manager, housekeeping, and dietary manager. Record review of an in-service dated 06/27/2023 conducted by the Regional Clinical Nurse was on the topic of abuse and neglect. The in-service attendees included nurses, CNAs, MAs, business office manager, housekeeping, and dietary manager. Record review of psychiatric referrals sent to Senior Psych Care for 13 of 15 residents residing on the secured unit with 1 resident refusal and 1 resident receiving services with another provider. During an interview on 06/28/2023 at 04:35 PM, the DON said she would review all incident/accident reports in the daily clinical meeting to monitor for aggressive/combative behaviors or resident to resident altercations and take all appropriate actions. On 06/28/2023 at 06:15 PM, the facility was informed the IJ was removed. However, the facility remained out of compliance at a severity of the potential for more than minimal harm that is not immediate jeopardy. The facility continued to monitor and in-service staff to ensure all were in-serviced on abuse/neglect, resident-to-resident altercations, behavioral health training, staffing of the secured unit and psychiatric consults.

Based on observation, interview, and record review the facility failed to ensure adequate supervision was provided to prevent accidents for 3 of 5 residents reviewed for accidents and supervision. (Resident #1, Resident #2, and Resident #3) 1. The facility failed to adequately provide supervision for Resident #1 and Resident #2. On 04/05/2023 Resident #1 wandered into Resident #2's room on the secured unit, and Resident #2 threw water on Resident #1 and then grabbed Resident #1 causing a skin tear to Resident #1's right mid arm. 2. The facility failed to adequately provide supervision for Resident #2 and Resident #3. On 04/15/2023 Resident #2 stabbed Resident #3 with a pen causing a puncture wound to Resident #3's left forearm. 3. The facility failed to adequately provide supervision for Resident #2 and Resident #3. On 05/25/2023 Resident #2 pushed Resident #3 out of her wheelchair causing Resident #3 to fall onto the floor. An IJ was identified on 06/27/2023 at 4:57 PM. The IJ template was provided to the facility on [DATE] at 4:57 PM. While the IJ was removed on 06/28/2023 at 6:15 PM, the facility remained out of compliance at a scope of pattern and a severity level of a potential for more than minimal harm because (e.g.) all staff had not been trained on abuse/neglect, resident to resident altercations, behavioral health training, and when a resident needs a psychiatric health consult. This failure placed all residents in the secured unit at risk of injury and death. Findings included: 1. Record review of an Admission Record, not dated, for Resident #2 indicated she was readmitted to the facility on [DATE] with an original admitted [DATE] and was [AGE] years old with diagnoses of senile degeneration of the brain (loss of intellectual ability), paranoid schizophrenia (delusions and hallucinations), need for continuous supervision, personality disorder (mental disorder). Record review of a Quarterly MDS Assessment for Resident #2 dated 05/14/2023 indicated a BIMS score of 11 meaning moderate cognitive impairment. She required limited assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Balance during transitions and walking indicated she was not steady but was able to stabilize without staff assistance and did not require any mobility devices. The MDS indicated that resident had not exhibited any behaviors. Record review of a care plan for Resident #2 dated 03/17/2016 reflected Resident #2 had episodes of behavioral symptoms. Interventions included: provide psych consult per order. Record review of a care plan for Resident #2 dated 04/16/2018 reflected Resident #2 had episodes of anxiety. Interventions included: psychologist/psychiatrist to provide services as ordered. Record review of a care plan for Resident #2 dated 06/17/2021 indicated Resident #2 had physically abusive behavioral symptoms (resident to resident altercation). The resident had a history of throwing liquids at other residents. Interventions included to avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents), and maintain a calm environment and approach to the resident. Resident #2 resided on the secure unit. Record review of a care plan for Resident #2 dated 06/17/2021 reflected Resident #2 had episodes of behavioral symptoms. Interventions included: obtain a psych consult/psychosocial therapy. Record review of a care plan for Resident #2 dated 04/05/2023 reflected Resident #2 had socially inappropriate/disruptive behavioral symptoms post behavior health hospital. Interventions included administer medications as ordered, assess whether behavior endangers others and intervene if necessary, and avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents). Record review of a care plan for Resident #2 dated 05/25/2023 reflected Resident #2 had episodes of behavioral symptoms. Interventions included: obtain a psych consult/psychosocial therapy. Record Review of physician's orders for Resident #2 dated 05/28/2023 to 06/28/2023 indicated resident #2 had the following physicians' orders: 5. Admit to secure unit due to exit seeking secondary to dementia. Dated 06/28/2021. 6. Psychiatric and Psychological Services to evaluate and treat as needed. Dated 02/28/2023. Record review of nurse progress notes for Resident #2 dated 04/05/2023 at 10:33 PM written by LVN A indicated: Resident #2 was witnessed by LVN A throwing water on Resident #1 who wandered into her room. Resident #2 then grabbed Resident #1 by the wrist resulting in a skin tear to Resident #1's right wrist. Resident #2 was provided on-on-one and separated from Resident #1. Record review of an event report dated 04/05/2023 indicated Resident #2 threw water on Resident #1 and grabbed Resident #1 resulting in a 1-centimeter skin tear to the right wrist. The event report indicated Resident #2 was placed on one-on-one supervision. The event report indicated Resident #2 was being referred to a mental health hospital for observation and was awaiting acceptance for transfer. Record review of nurse progress notes for Resident #2 dated 04/15/2023 at 4:01 PM written by LVN C indicated: Resident was sitting in chair in common room when another resident rolled up in their wheelchair reached out with their arm and this resident stabbed her with a pen. Resident #2 was placed on 1 on 1 supervision for 72 hours. Record review of an event report dated 04/15/2023 at 3:47 PM completed by LVN C indicated: Resident #2 stabbed Resident #3 with a pen. Event report indicated Resident #2 was placed on one-on-one supervision for 72 hours. Record review of nurse progress notes for Resident #2 dated 04/15/2023 indicated: The behavioral health hospital returned a call to the facility. They denied the resident for their services at this time. They stated, We may have availability on Monday. On-call, the ADON was notified. One-on-one monitoring continues. Record review of nurse progress notes for Resident #2 dated 05/25/2023 at 1:22PM completed by LVN B indicated: Resident #2 was with Resident #3 in the secure living area. Staff notified the ADON that Resident had pushed Resident #3 out of her wheelchair and on the floor. The residents were separated at this time and Resident #2 was redirected to her room. Nurse Practitioner notified of incident no new orders for Resident #2 received at that time. Record review of an event report date 06/27/2023 at 9:29 AM completed by the regional clinical nurse indicated: Resident #2 pushed another resident sitting in a wheelchair. The event report indicated the residents were separated and Resident #2 was redirected to her room. The Event report indicated the interventions were somewhat effective. 2. Record review of an Admission Record, not dated, for Resident #1 indicated he was readmitted to the facility on [DATE] with an original admitted [DATE] and was [AGE] years old with diagnoses of dementia (loss of memory and thinking abilities), Alzheimer's (disease that destroys memory and other mental functions), schizoaffective disorder (mood disorder), and psychotic disorder with delusions (unshakable belief in something that is bizarre, implausible, or obviously untrue). Record review of a Quarterly MDS Assessment for Resident #1 dated 06/19/2023 indicated a BIMS score of 05 meaning severe cognitive impairment. He had required limited to extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Balance during transitions and walking indicated he was not steady, but able to stabilize without staff assistance and did not require any mobility devices. The MDS indicated Resident #1 had not exhibited any behaviors. Record review of a care plan for Resident #1 dated 05/21/2023 indicated he was at risk for wandering as evidenced by poor judgement and decision making related to dementia. Resident #1 resided on the secure unit. Record review of a care plan for Resident #1 dated 04/05/2023 reflected Resident #1 had behavioral symptoms as evidenced by grabbing others and wandering into other resident rooms. Interventions included to administer medications as ordered, assess whether behavior endangered others and intervene if necessary, and resident had delusions and to not try to confront or reason with the resident. Record review of a physician's order summary report dated 05/28/2023 to 06/28/2023 indicated: 5. resident to be admitted to the secure unit due to exit seeking secondary to dementia on 02/15/2023. 6. Psychiatric and Psychological Services to evaluate and treat as needed. Dated 02/25/2023. Record review of Resident #1's nurse progress notes dated 04/05/2023 at 9:06 PM written by LVN A indicated Resident #1 wandered into Resident #2's room, Resident #2 became upset and threw water on Resident #1. Unidentified CNAs were present on the hall and assisting other residents. LVN A witnessed Resident #1, and Resident #2 grab each other. Both residents were immediately separated and redirected to their rooms to calm. Resident #1 was noted with a 1 cm scratch to the top of his right wrist. LVN A indicated the nurse practitioner, responsible party, ADON and the DON were notified of the incident. 3.Record review of an Admission Record, not dated, for Resident #3 indicated she was readmitted to the facility on [DATE] with an original admitted [DATE] and was [AGE] years old with diagnoses of dementia with behaviors (loss of memory and thinking abilities), anxiety disorder (mental disorder), pseudobulbar affect (uncontrollable laughing or crying), restlessness and agitation. Record review of a Quarterly MDS Assessment for Resident #3 dated 05/26/2023 indicated a BIMS score was not obtained due to Resident #3 was rarely or never understood. She required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Mobility Devices indicated she used a wheelchair for locomotion due to limited range of motion of both lower extremities. The MDS indicated Resident #3 had a mental status change of inattention and disorganized thinking but did not indicate any behavioral symptoms. Record review of a care plan for Resident #2 dated 06/17/2021 indicated Resident #3 had physically abusive behavioral symptoms (biting and hitting residents). Interventions included to avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents), and maintain a calm environment and approach to the resident, and assess whether behavior endangered others and intervene if necessary. Resident #3 resided on the secure unit. Record Review of physician's orders for Resident #3 dated 05/28/2023 to 06/28/2023 indicated Resident #3 had the following physician's orders: 7. Admit to secure unit due to exit seeking secondary to dementia. Dated 06/28/2021. 8. Psychiatric and Psychological Services to evaluate and treat as needed. Dated 02/28/2023. Record review of nursing progress note for Resident #3 dated 04/15/2023 at 3:43 PM written by LVN C indicated: Resident #3 reached out with her arm to Resident #2 and Resident #2 stabbed her with a writing pen on the left forearm. Minimal bleeding was noted and the skin was broken with a treatment of cleanse with normal saline and band aid applied. Record review of nursing progress note for Resident #3 dated 05/25/2023 at 1:46 PM written by LVN B indicated: Resident #3 was with Resident #2 in the secure living area. Staff notified the nurse that Resident #2 had pushed Resident #3 out of her wheelchair and onto the floor. Record review of an event report dated 05/25/2023 at 1:22 PM completed by the DON indicated: Resident #3 was pushed out of her wheelchair by another resident resulting in Resident #3 lying on the floor beside the wheelchair. Interventions included: Neuro checks initiated and within normal limits, and x-ray of skull to rule out injury. Record review of x-ray dated 05/25/2023 report did not show any acute abnormalities. During an observation of the secured unit on 06/26/2023 at 10:10 AM revealed the TV/dining area with 6 residents and 1 can; 2 residents ambulating in hallway and 7 residents in their rooms. Resident #2 was observed sitting in a wingback chair holding a Bible with papers inside and a pen. Resident #3 was sitting up in her wheelchair 5-6 feet away from Resident #2 with her head down. Resident #1 was observed lying in bed in his room with eyes closed. During an observation and interview on 06/26/2023 at 10:05 AM revealed Resident #2 sitting up in chair in the common area. She said it was year 2025 but they kept telling her it was 2023. She said she did not remember an incident that a resident was stabbed with a pen or pushed out of a wheelchair. Resident #2 said she did not want to answer any more questions. During an interview on 6/26/2023 at 10:15 AM CNA D said she worked for an agency and was not employed by the facility. She said she had been coming to the facility for about 3 weeks and ever since there had only been one CNA that worked on the secured unit per shift. She said there was a CNA that worked on the hall outside of the secured unit that could come and occasionally help if needed. She said Resident #2 only got aggressive if someone went into her room but had not seen any physical aggression by Resident #2. She said Resident #2 did not get aggressive unless someone got in her personal space. She said she had 15 residents on the secured unit. She said if she witnessed a resident to resident altercation she would separate the residents for safety and notify the DON and Administrator. During an interview on 06/26/2023 at 10:22 AM LVN B said she had worked at the facility for about 2 months and was the nurse for the secured unit and the backside of 200 hall. Said she was not able to always be in the secured unit. She said on 05/25/2023 Resident #3 rolled her wheelchair past Resident #2 and Resident #2 pushed Resident #3 out of her wheelchair causing Resident #3 to fall onto the floor. She said Resident #2 and Resident #3 are both combative, so they have had to watch them both. She said Resident #2 becomes aggressive if someone gets in her personal space. She said they tried to keep residents separated when they can. She said Resident #2 just returned from the behavioral hospital about 2 weeks ago and she had seen an improvement in her behaviors. LVN B said when she worked, she has 1 CNA in the unit. During a phone interview on 06/26/2023 at 2:59 PM LVN C said she was the nurse for the secured unit on 04/15/2023. She said she did not know Resident #2 had a pen and was sitting where resident could be seen the whole time. She said Resident #2 wrote on paper a lot. She said Resident #3 went past Resident #2 and Resident #2 stabbed Resident #3 with a pen. She said the residents were immediately separated, assessed, and the pen was taken from Resident #2. She said there was minimal bleeding to Resident #3's arm and first aid was provided to her. She said Resident #2 was placed on one-on-one monitoring for 1-2 days. She said an incident report was done and the ADON, DON and provider was notified of the incident. She said Resident #2 and Resident #3 were watched to make sure they were not in the same area. She said both Resident #2 and Resident #3 can get aggressive at times. She said Resident #2 can become aggressive if someone is in her personal space. She said she could not recall any in-services that were conducted at the time. She said she has not witnessed any abuse/neglect but if she did, she would report it to the Administrator who is the abuse coordinator. During an interview on 06/27/2023 at 9:40 AM the ADM said she remembered calling in a CNA to put with Resident #2 for one-on-one monitoring after the 05/25/2023 incident but did not have any documentation of the one-on-one monitoring. During an interview on 06/27/2023 at 10:00 AM the Psychologist said he had known Resident #2 for a long time due to seeing her at a previous facility. He said he had never seen Resident #2 at the current facility for psych services due to not being able to obtain consent. He said he would see Resident #2 if he had consent to treat the resident. He said Resident #2 had a diagnosis of schizophrenia. He said he did not think psych services would make a difference in Resident #2's behaviors and it would be better to educate the other residents in the secured unit to stay out of Resident #2's personal space. The Psychologist said you cannot educate the other residents of the secured unit because they would not understand or remember the education. During a phone interview on 06/27/2023 at 9:50 AM the Responsible Party of Resident #2 said he was notified of an incident regarding Resident #2 stabbing another resident with a pen. He said he was not asked for consent for counseling services; he said he would have given consent for anything that would help Resident #2. He said he came to the facility for a visit and was notified that approximately 10-14 days earlier that Resident #2 had pushed another resident out of her wheelchair. He said he was never notified of an incident where Resident #2 threw water on and caused a skin tear to another resident. He said the last time he was contacted and asked to give consent for psych services was about a year ago, and he gave consent at that time. He said he was notified on 06/08/2023 that Resident #2 had been transferred to the behavioral health hospital for treatment. During an interview on 06/27/2023 at 10:37 AM the Social Worker said Resident #2 had been at the facility for a long time. He said Resident #2 was delusional and had an area in the day room where she liked to write and read. He said everyone had to approach Resident #2 in a calm manner and did not want any staff or residents in Resident #2's area that he described as a bubble around her. He said if someone stepped into Resident #2's boundary, she could get physically aggressive with them. He said she had a diagnosis of schizophrenia and did not have any family involved in her care but did have a legal guardian. He said from time to time Resident #2 would have behaviors but as long as she was left alone, she was good. He said Resident #2 did not like any residents in her space and most of the residents in the secured unit were not aware of that. The Social Worker said he attempted to send Resident #2 out to a behavioral hospital previously, but the resident's guardian would not give consent. He said Resident #2's guardian said he did not think Resident #2 could understand and felt like it would be pointless. He said there was an incident when another resident went into Resident #2's personal space and she poked that resident with a pen. He said Resident #2's legal guardian was the one who gave consent for her to see the psychologist that visited the facility. He said the psychologist visited the facility every Monday and Resident #2 was being seen by him. He said the Psychologist was who the facility had a contract with, and they also had a contract with another counseling provider. He said overall Resident #2 was ok as long as people stayed out of her personal space. He said they have talked to the staff and instructed them to keep an eye on Resident #2. He said some residents did wander from room to room at times. He said Resident #2 went to a behavioral hospital a few weeks ago following an incident when she stabbed another resident with a pen for about two weeks and had been ok since returning to the facility with medication adjustments. During a phone interview on 06/28/2023 at 10:24 AM LVN A said she had worked for the facility as needed for 1 year. She said there was one CNA that works on the secured unit and covers the backside of 200 hall outside of the unit. She said the nurse normally stepped into to unit while the CNA goes out of the unit to make a round on the backside of 200 hall. She said she witnessed the incident on 04/05/2023 with Resident #2 and Resident #1. She said Resident #1 wandered into Resident #2's room and Resident #2 threw water on Resident #1 and then grabbed his wrist causing a skin tear. She said she immediately separated the residents and redirected Resident #2 to her room. She said that if anyone gets in Resident #2's personal space she becomes physically aggressive. She said the staff tries to keep other residents out of her personal space but that is hard to do when the residents are all in the common area. She said Resident #2 punched an employee in the face about 6-7 months ago and Resident #2 was not sent out to the behavioral health hospital or anything. During an interview on 06/28/2023 at 12:20 PM the DON said on 04/05/2023 Resident #1 wandered into Resident #2's room and Resident #2 threw water on and grabbed Resident #1's wrist causing a skin tear. She said Resident #2 did not like for anyone to get in her personal space and becomes aggressive when they do. She said the Social Worker called Resident #2's responsible party but it is hit and miss when trying to contact him. She said after the incident on 04/15/2023 the behavioral health hospital would not accept the resident due to there not being enough documentation of Resident #2's behaviors in her chart. She said she directed the nursing staff to continue to document all of Resident #2's behaviors so the behavioral health hospital would accept her. She said when residents are placed on one-on-one monitoring there is a Q15 minute checks form staff is supposed to document on but said they did not do it. The DON said she did not feel like 1 CNA was enough staff on the secured unit. She said she would like to have more staffing in the secured unit and to not admit anymore residents with combative behaviors to the secured unit. Record review of a facility policy titled Resident-to-Resident Altercations with a revised date of December 2016 indicated, .G. Document in the resident's clinical record all interventions and their effectiveness. H. Consult psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for intervention and management as necessary or as may be recommended by the attending physician or interdisciplinary care planning team. J. if, after carefully evaluation the situation, it is determined that care cannot be readily given within the facility, transfer the resident. Record review of a facility policy titled Behavioral Assessment, Intervention and Monitoring with a revised date of December 2021 indicated, . 1. The center will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. 2. Behavioral symptoms will be identified using center-approved behavioral screening tools and the comprehensive assessment. Management: 1. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. Record review of a facility policy titled SLP-Prosperity Behavioral and Mental Health Services with a revised date of January 2022.Safety-The creation and maintenance of a safe environment in the Long-Term care setting is the cornerstone of the mental health nurse's (MHN) role and responsibility. The role of the MHN to assess for environmental and individual safety is active and on-going to prevent self-harm or harm to others in the center. Assessment/Evaluation- The interdisciplinary Team (IDT) will consist of a psychiatrist, psychologist, consulting pharmacist, licensed nurse, dietician, social worker, qualified activity assistant, and nursing assistants. The IDT will approach each resident care by addressing their unique individual needs and implementing resident centered interventions promoting overall behavioral and mental health. Psychiatric Assessment- Each resident admitted to a [Provider name]Behavioral/Mental Health Unit will be referred to the center's designated psychiatrist for evaluation and treatment. Psychological Assessment- Each resident admitted to a Behavioral/Mental Health Unit will be referred to the center's designated psychologist for evaluation and treatment Record review of a facility policy titled Abuse Prevention Program with a revised date of 01/09/2023 indicated: .2. Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The facility Administrator was notified on 06/27/2022 at 04:57 PM that an Immediate Jeopardy situation had been identified due to the above failures and the IJ template was given at that time. The facility's plan of removal was accepted on 06/28/2022 at 03:24 PM and included: Residents on the secured unit will have psychiatric service referrals completed by the DON/Rep. Any negative findings will be reported to the Physician. Any residents outside of the secured unit that have been involved with resident-to-resident altercations within the last 60 days will be referred to psych services. The Director of Nurses and/or designee with collaborate with the psychiatric provider and will audit charts to ensure scheduled/routine visits were completed, any missing visits will be reported to psych services to reschedule the visit. This will be completed by 06/28/2023 at 3:00 PM. Resident #2 has been placed on one-on-one until discharge to another facility is completed or determined by IDT not to be a danger. Resident #2 remained in the facility at the time of surveyor exit. All staff were trained/educated on Resident #2's current intervention, at this time Resident #2 is on 1:1 observation for resident safety. Timeline for completion: 06/28/2023 at 3:00 PM The facility will review all resident incidents for the last 30 days to ensure no other additional resident to resident altercations have occurred without appropriate interventions being placed in the care plan, notifications made to psych services and the MD. Timeline for completion: 06/28/2023 at 3:00 PM. The facility will complete safe surveys with all residents on secured unit and outside the secure unit. Residents unable to complete the safe survey will have a head-to-toe skin assessment and RP will be notified for any concerns. Negative findings will be reported to the abuse coordinator. Timeline for completion: 06/28/2023 at 3:00 PM. The safe surveys and head to toe skin assessments had been completed and documented at time of surveyor exit. The facility will Inservice staff on: Abuse/Neglect, Resident to Resident Altercations, Behavioral Health training, when a resident needs to have a psychiatric service consult/mental health evaluation following an aggression event towards residents, all staff will understand they cannot leave the secured unit unattended through education, and the Administrator and Director of Nursing will ensure the secured unit is staffed. Timeline for completion: 06/28/2023 at 3:00 PM. The facility's Administrator, DON, ADON and/or designee will review incidents occurring on the unit, update the facility assessment tool to accurately reflect residents' acuity and will make necessary adjustments, if necessary, to staff the center and unit to provide adequate supervision. Timeline for completion: 06/28/2023 at 3:00 PM. An ad hoc QAPI meeting with the Medical Director, Administrator and Director of Nursing completed regarding IJ templates and plan of removal. Timeline for completion: 06/28/2023 at 3:00 PM. On 06/28/2023, the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: During an observation an interview on 6/28/2023 at 9:40 AM in the secured unit revealed MA E was present. MA E said she was assigned to provide 1 on 1 with Resident#2 and today was her first day of work. She said the facility started 1 on 1 with Resident #2 as of midnight last night, 6/28/2023. She said she had to complete 15-minute check documentation on her. Observation of the secured unit on 06/28/23 at 3:00 pm revealed there were 2 certified nurse aides and 1 nurse on the unit at this time. Observation of secured unit on 06/28/2023 at 5:15 PM revealed there were 2 certified nurse's aides and the Activity Director on the unit at this time. CNA E was observed documenting on Q15 minute monitoring sheet. Record review of the Q15 minute monitoring sheet dated 06/28/2023 indicated resident had not had any behaviors for that day. During interviews on 06/28/2023 from 3:30 PM-5:45 PM, the Business Office Manager, Social Worker, Activity Director, Certified Occupational Therapist, DON, ADON, LVN C, MA E, MA G, and CNA D, CNA I, CNA H, CNA K were able to verbalize the procedure when a resident-to-resident altercation occurred, Resident #2's current staffing, behavioral health training, when a resident needed a psychiatric consult, and the abuse/neglect policy. A record review of the facility's QAPI meeting conducted on 06/27/2023 at 07:14 PM revealed attendees consisting of the Administrator, Company Clinical Leader, Regional Clinical Nurse and the Medical Director (via phone). The meeting was held to discuss incidents and policies and determine system failures and indicated policies were reviewed and 1. Resident place on 1 on 1(Q15 minute checks) to be documented on form provided to staff. 2. Referral made to psych services. 3. Staff trained on abuse policy and resident to resident altercation policy. 4. Staff educated on event reporting to be completed at time of event. 5. Care plans were updated. Staff would be educated and in-serviced on abuse policy resident-to-resident altercations policy, and event reporting to be completed at time of event. Resident #2 was placed on 1:1 monitoring, to be documented on a documentation sheet provided to staff, referrals made to psych services, and care plans were updated. Record review of an in-service dated 06/27/2023 conducted by the Regional Clinical Nurse revealed the topic of the abuse prevention program. The in-service attendees included nurses, CNAs, MAs, the Business Office Manager, housekeeping, and the Dietary Manager. Record review of an in-service dated 06/27/2023 conducted by the Regional Clinical Nurse revealed the topic of resident-to-resident altercations. The in-service attendees included nurses, CNAs, MAs, Business Office Manager, housekeeping, and Dietary Manager. Record review of an in-service dated 06/27/2023 conducted by the Regional Clinical Nurse revealed the topic of behavioral and mental health services. The in-service attendees included nurses, CNAs, MAs, Business Office Manager, housekeeping, and Dietary Manager. Record review of an in-service dated 06/27/2023 conducted by the Regional Clinical Nurse revealed the topic of abuse and neglect. The in-service attendees included nurses, CNAs, MAs, Business Office Manager, housekeeping, and Dietary Manager. Record review of psychiatric referrals sent to the psych services provider for 13 of 15 residents residing on the secured unit with 1 resident refusal and 1 resident receiving services with another provider. During an interview on 06/28/2023 at 04:35 PM, the DON said she would review all incident/accident reports in the daily clinical meeting to monitor for aggressive/combative behaviors or resident to resident altercations and take all appropriate actions. On 06/28/2023 at 06:15 PM, the facility was informed the IJ was removed. However, the facility remained out of compliance at a severity of the potential for more than minimal harm that is not immediate jeopardy. The facility continued to monitor and in-service staff to ensure all were in-serviced on

580 Based on record review and interviews, 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) of a medication error for 1 of 4 residents (Resident #1) reviewed for resident rights. The facility failed to inform the Physician, NP, or DON when Resident #1 received the wrong medications on 1/4/2023. This failure resulted in identification of Immediate Jeopardy (IJ) on 1/9/2023 at 4:20 p.m. The IJ was removed on 1/10/2023 at 11:47 a.m. While the IJ was removed, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate, due to the facility's need to complete in-servicing and monitoring interventions. This failure could place residents at risk not receiving appropriate care and interventions and/or death. Findings included: Record review of Resident #2's Face Sheet dated January 2022 indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE], with a recent readmitted [DATE]. Resident #2's diagnoses included schizoaffective disorder bipolar type, (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior)., major depressive disorder, and human immunodeficiency virus (a virus that attacks the body's immune system.) Record review of Resident #2's Physician orders dated January 2022 indicated the following medications were to be administered daily to Resident #2 between 7:30 p.m. and 10:00 p.m. Cogentin 1 mg- used to treat symptoms of Parkinson's disease or involuntary movements due to the side effects of certain psychiatric drugs Prolixin 10 mg- used to treat certain types of mental/mood conditions: (psychotic disorders; schizophrenia) Haldol 5 mg- used to treat certain types of mental/mood conditions: schizophrenia, schizoaffective Isentress 400 mg- used to treat human immunodeficiency virus infections Toprol 25 mg- used to treat symptoms used to treat chest pain, heart failure and high blood pressure Seroquel 500 mg- used to treat certain types of mental/mood conditions: Schizophrenia, Bipolar disorder, sudden episodes of mania or depression associated with Bipolar Disorder Risperdal 3 mg- used to treat certain types of mental/mood disorders; Schizophrenia, Bipolar, irritability associated with autistic disorder Glucophage 1000 mg- used to control blood sugar Eskalith 300 mg- mood stabilizer used to treat or control the manic episodes of Bipolar disorder (manic depression) Record review of Resident #1's Face Sheet dated January 2023 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE], with a recent readmitted [DATE]. Resident #1's diagnoses included polyosteoarthritis, (when five or more joints are affected with joint pain), unspecified intellectual disabilities, (when a person has certain limitations in cognitive functioning and skills, including communication, social and self-care skills), diabetes (a chronic (long-lasting) health condition that affects how your body turns food into energy), bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania and lows (depression), epilepsy, (a brain disorder that causes recurring, unprovoked seizures.), hypertension ( when blood pressure is too high), and peripheral vascular disease (a slow and progressive circulation disorder). Record review of Resident #1's MDS dated [DATE] reflected a BIMS score of 9 for cognitive awareness, which indicated she was moderately impaired. The MDS indicated Resident #1 required supervision with set up assistance for transfers, walking in the room or corridor, dressing, eating, toileting, and personal hygiene. Record review of a Facility Event Report dated 1/5/2023 at 9:36 p.m. indicated on 1/4/2023 Resident #1 was given the wrong medications. Resident #1 was sent to the ER. Record review of the nursing progress notes for Resident #1 revealed there were no entries documented on 1/4 or 1/5 2023 by RN A. Record review of a nursing progress note written by LVN B and dated 1/5/2023 at 10:34 a.m. indicated Resident #1 was lying in bed, appeared to be lethargic (lacking mental and physical alertness and activity). with limited speech, and non-reactive pupils. Resident #1 had to have more help than normal. Her BP was 121/63. The Nurse Practitioner was notified and ordered Resident #1 to be sent to the ER for evaluation and treatment. Record review of a nursing progress note written by LVN C dated 1/6/2023 at 3:48 p.m. indicated Resident #1 returned to from the ER related to altered mental status. Resident #1's diagnoses included a UTI and dehydration. Resident #1's mood was pleasant. The NP was notified. Record review of a nursing progress note written by LVN D dated 1/6/2023 at 10:.00 p.m. indicated Resident #1's orientation was within normal baseline with a slightly unsteady gait. Record review of Resident #1's Medication Administration Record dated 1/1/2023-1/7/2023 indicated the following medications were to be administered daily to Resident #1 between 7:30 p.m. and 10:00 p.m. Claritin 10 mg- an antihistamine that treats symptoms such as itching, runny nose, watery eyes, and sneezing from hay fever and other allergies Depakote 500 mg- used to treat seizure disorders, certain psychiatric conditions (manic phase of bipolar disorder) Keppra 1,000 mg- used to treat certain types of seizures Lorazepam 1mg- used to treat anxiety Magnesium 400 mg- used to treat vitamin D deficiency Metformin 500 mg-used to control high blood sugar Vimpat 100 mg- used to prevent and control seizures RN A signed off the medications as being given to Resident #1 on 1/4/2023. Record review of #1's Hospital Discharge Summary dated 1/6/2023 revealed Resident #1 was admitted on [DATE] and discharged back to nursing facility 1/6/2023. Discharge diagnoses included acute urinary tract infection, acute renal failure syndrome (sudden and sustained deterioration of the kidney function) and altered mental status. Hospital course reflected: On 1/6/2023 in discussion with family members it was revealed the patient was given up to 6 medications that were belonging to the patient's neighbor (Resident #2), with most of them being psychiatric with a heavily sedating effect. Upon evaluation in the morning, patient was found alert and orient x3, answering questions appropriately, speaking in full sentences, minimal confusion/disorientation noted in the early morning hours which resolved by the afternoon. Deemed stable for discharge. The hospital record indicated a drug screen was done on 1/5/2023 at 11:10 a.m. The results reflected the resident was negative for methadone, cocaine, THC (psychoactive component in marijuana), barbiturates, benzodiazepines, opiates, amphetamines, and PCP, (Phencyclidine, a sedative narcotic). Record review of a facility Event Report dated 1/5/23 at 9:36 p.m. indicated on 1/4/2023 Resident #1 was given the wrong medications. Resident was sent to the ER. Record review of a Facility Event Summary Report dated from 8/1/2022 to 1/9/20233 indicated that the facility had 1 reported medication error during this period, with date of occurrence 1/4/2023. During an interview on 1/7/2023 at 10:37 a.m. the ADON said RN A worked the 6 p.m.-6 a.m. shift on 1/4/2022. The ADON said RN A did not report the med error until she came to work on 1/5/2022 for her 6 p.m.-6 a.m. shift and found out Resident #1 had been sent to the hospital. The ADON said RN A had 2 med cups with pills, one for Resident #1 and one for Resident #2, who were roommates. The ADON said RN A realized at some point she had given the wrong medicine to Resident #1, which actually belonged to Resident #2. The ADON said the DON was notified at some time around 9:33 p.m. on 1/5/2023. The ADON said Resident #1 usually questioned her meds before taking them. During an interview on 1/7/2023 12:30 p.m. Resident #1 said she was doing well. Resident #1 stated she had returned from the hospital 1/6/2023 and went to the hospital because of too much sugar, and my sugar was high. All the candy I ate at Christmas made my sugars go up, is what the doctor told me. Resident #1 said she took medications in the morning and in the evening and had never had any problems getting the right ones. During an interview on 1/7/2023 12:34 p.m. Resident #2 stated she received medications in the morning and in the evening. Resident #2 said she had problems 2 different times getting the right medications. Resident #2 said she received meds on 1/4/2023, and when she looked at them, she asked the nurse what they were, as they did not look right. Resident #2 said she could not pinpoint the time frame for the first event, but said it was the same nurse, RN A. Resident #2 said RN A gave her meds to her roommate and that was why she went to the hospital. Resident #2 said she did not take any of the meds that were not hers. Resident #2 said RN A was nice and told her she was daydreaming when she was giving the meds. Resident #2 said her roommate is confused at times. During an interview on 1/7/2023 12:40 p.m. the RNC said she was aware of the medication error on 1/4/2022. The RNC said training was started immediately, and that RN A would be called in on this date and suspended until the investigation was completed. During an interview on 1/7/2023 1:45 p.m. RN A stated on 1/4/2022, 6 p.m.-6 a.m. shift she was getting ready to give meds to both Resident #1 and Resident #2. RN A said she got 2 med cups out, filled 1 cup with medications and scooted it back under the computer, filled the other med cup with medications and scooted it back as well. RN A said she went into Resident #1's room, called her name and told her she had her meds. RN A said Resident #1 sat up in bed and she gave Resident #1 the med cup. RN A said Resident #1 looked at the pills and took them. RN A said she walked out of the room and got distracted. RN A said on the evening shift, they were the secretary, they had to answer phones, and the door, and answer call lights so it was 1-2 hours before she went back to give Resident #2 her meds. RN A said she grabbed the other cup of pills that were locked in the med cart, in the same cup she had previously filled. RN A said she handed Resident #2 the cup and Resident #2 looked at the pills said, These don't look right. RN A said she immediately thought oh no what did I do?. RN A said she and Resident #2 went to the med cart. RN A said she looked at the cup and knew she had just given Resident #1 Resident #2's meds. She said she told the resident she did not know what had happened, but she was going to get rid of the meds and start over. RN A said she poured new meds and gave them to Resident #2. RN A said she realized she gave the wrong meds to Resident #1, when Resident #2 said her pills did not look right. RN A stated she did not do what she should have; she should have called the doctor but did not because Resident #1 slept all night. RN A said the next day, 1/5/2023 around 6:30 p.m. she returned to work and saw that Resident #1 had been sent to the hospital. The DON was in the building, and RN A told her what she had done, and was told to complete an incident report. RN A said she probably passed meds to 4-5 residents prior to the incident involving Resident #1 but did not remember for sure. RN A said she did not give any more meds after the incident. RN A said Resident #1 slept all night with no issues noted. RN A said she did not normally fill 2 med cups at one time and had every intention of going back to give Resident #2's meds sooner. RN A said she did not put the residents' names on the medication cups. RN A said she had not made this mistake before, and no other resident had looked at their pills prior to taking them and stated they were the wrong medications. During an interview on 1/9/2023 at 10:22 a.m. LVN B stated she worked the 6:00 a.m.-6:00 p.m. LVN B stated on 1/5/2023 she went into Resident #1's room either during or after breakfast. LVN B stated Resident #2 said she had to help Resident #1 from the bathroom. LVN B stated Resident #1 was lying in her bed. LVN B called Resident #1 by her name and Resident #1 said huh? and nothing else. LVN B stated Resident #1 seemed lethargic. LVN B stated she got the DON and they did an assessment and Resident #1's blood pressure was 103 over something but could not remember exactly but said it was low. LVN B stated a neuro exam was done, and Resident #1's pupils were not reactive. LVN B stated she notified the NP and an order was received to transfer Resident #1 to the hospital. LVN B stated Resident #1 was admitted to the hospital with altered mental status diagnosis. LVN B said she was off the next 3 days and was unsure what all had transpired. LVN B said she passed medications in the morning and had a couple in the afternoon. LVN B said when passing meds, she addressed the resident by name, checked vital signs, pulled medications, and went in the room to administer them. LVN B said on the computer system there was a picture of each resident. She said she also verified the resident by the name on the door, and by addressing them by name. LVN B stated when she put meds in the med cup, there was a place on the electronic medication record to put a check mark by the medication to keep track of what has been put in med cup. LVN B stated she did not click on the given button until the resident had taken the medication in case they refused or were unable to take it for some reason. LVN B stated she only dispensed medications for 1 resident at a time. LVN B stated if she would happen to give the wrong medication to a resident, she would immediately notify the Dr., NP., Administrator and DON. During an interview on 1/9/2023 at 1:57 p.m. The NP stated she had been made aware of the medication error on Resident #1 on 1/5/2022. The NP said there was no harm, no lingering side effects, or no treatments/testing that would be necessary. The NP said she had asked the staff to monitor Resident #1's vital signs and report any changes. The NP said there were no issues with Resident #1 not receiving the actual medications she was prescribed, as they were just 1 series of doses. The NP stated that RN A was not following policies, the right patient, the right med, the right dose. The NP felt RN A needed remediation and reported to the Board of Nursing. Record review of the facility policy Adverse Consequences and Medication Errors, with a revision date of April 2014 indicated, a medication error is defined as the preparation of administration of drugs which are not in accordance with physician orders . In the event of a significant medication related error or adverse consequence, immediate action is taken, as necessary to protect the resident's safety and welfare. Significant is defined as requiring hospitalization . The attending physician is notified promptly of any significant error or adverse consequence. The Plan of Removal was accepted on 9:15 a.m. on 1/10/2023, and included the following: Plan of Removal F760 Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on 1/9/23, for F760 Free of Significant Med Error Action Item: The resident was sent to Hospital on 1/5/23 for assessment. Person Responsible: DON Timeline for completion: 1/10/23 Action Item: Medication administration records were reviewed for all other residents with no other errors identified. Person Responsible: RN Regional Nurse Consultant Timeline for completion: 1/10/23 Action Item: Medication administration training, education and competencies including Medication Administration Policies, Adverse Consequences and Medication Errors, Notification of med error to DON/Physician and med error investigations were completed with the nurses on 1/9/23 by the Regional Nurse Consultant. New nursing staff will complete competency prior to working the floor. Person Responsible: Nursing and administration Timeline for completion: 1/10/23 Action Item: medication administration observations will be completed on weekly basis for all shifts until substantial compliance has been achieved. Person Responsible: DON Timeline for completion: 1/10/23 Verification of the Plan of Removal was as follows: a. Reviewed in-service training on 1/7/23 and 1/10/23 for all nursing staff, on all shifts. The nursing staff were in-serviced on medication administration, error prevention, medication administration policies reviewed. Guidelines for notifying physicians for clinical problems, as well as notifying the NP, and DON. b. Competency Assessment/skills check off for Administering Oral medications was initiated, for all nursing staff, on all shifts. Six had been completed. c. Interviews conducted 1/10/2023 between 11:25 a.m. and 11:43 a.m. revealed LVNs B, F, and G all stated they worked the 6:00 a.m.-6:00 p.m. shift, and had received in-servicing provided by the facility as part of the plan of removal and all had knowledge and understanding of reporting med errors immediately and the proper procedure for medication administration, and proper resident identification. An Immediate Jeopardy (IJ) was identified on 1/9/2023 at 4:20 p.m. The IJ was removed on 1/10/2023 at 11:47 a.m. While the IJ was removed, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with a potential for more than minimal harm due to the facility's need to complete in-servicing and monitoring interventions.

760 Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 4 residents reviewed for pharmacy services. (Resident #1) RN A administered Resident #2's medication to Resident #1, resulting in Resident #1 experiencing an altered mental status requiring transfer to local hospital for evaluation. This failure resulted in identification of Immediate Jeopardy (IJ) on 1/9/2023 at 4:20 p.m. The IJ was removed on 1/10/2023 at 11:47 a.m. While the IJ was removed, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate, due to the facility's need to complete in-servicing and monitoring interventions. This failure could place residents at risk for a serious decline in health, hospitalization and/or death. Findings included: Record review of Resident #2's Face Sheet dated January 2022 indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE], with a recent readmitted [DATE]. Resident #2's diagnoses included schizoaffective disorder bipolar type, (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior)., major depressive disorder, and human immunodeficiency virus (a virus that attacks the body's immune system.) Record review of Resident #2's Physician orders dated January 2022 indicated the following medications were to be administered daily to Resident #2 between 7:30 p.m. and 10:00 p.m. Cogentin 1 mg- used to treat symptoms of Parkinson's disease or involuntary movements due to the side effects of certain psychiatric drugs Prolixin 10 mg- used to treat certain types of mental/mood conditions: (psychotic disorders; schizophrenia) Haldol 5 mg- used to treat certain types of mental/mood conditions: schizophrenia, schizoaffective Isentress 400 mg- used to treat human immunodeficiency virus infections Toprol 25 mg- used to treat symptoms used to treat chest pain, heart failure and high blood pressure Seroquel 500 mg- used to treat certain types of mental/mood conditions: Schizophrenia, Bipolar disorder, sudden episodes of mania or depression associated with Bipolar Disorder Risperdal 3 mg- used to treat certain types of mental/mood disorders; Schizophrenia, Bipolar, irritability associated with autistic disorder Glucophage 1000 mg- used to control blood sugar Eskalith 300 mg- mood stabilizer used to treat or control the manic episodes of Bipolar disorder (manic depression) Record review of Resident #1's Face Sheet dated January 2022 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE], with a recent readmitted [DATE]. Resident #1's diagnoses included polyosteoarthritis, (when five or more joints are affected with joint pain), unspecified intellectual disabilities, (when a person has certain limitations in cognitive functioning and skills, including communication, social and self-care skills), diabetes (a chronic (long-lasting) health condition that affects how your body turns food into energy), bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania and lows (depression), epilepsy, (a brain disorder that causes recurring, unprovoked seizures.), hypertension ( when blood pressure is too high), and peripheral vascular disease (a slow and progressive circulation disorder). Record review of Resident #1's MDS dated [DATE] reflected a BIMS score of 9 for cognitive awareness, which indicated she was moderately impaired. The MDS indicated Resident #1 required supervision with set up assistance for transfers, walking in the room or corridor, dressing, eating, toileting, and personal hygiene. Record review of a Facility Event Report dated 1/5/2023 at 9:36 p.m. indicated on 1/4/2023 Resident #1 was given the wrong medications. Resident #1 was sent to the ER. Record review of the nursing progress notes for Resident #1 revealed there were no entries documented on 1/4 or 1/5 2023 by RN A. Record review of a nursing progress note written by LVN B and dated 1/5/2023 at 10:34 a.m. indicated Resident #1 was lying in bed, appeared to be lethargic (lacking mental and physical alertness and activity). with limited speech, and non-reactive pupils. Resident #1 had to have more help than normal. Her BP was 121/63. The Nurse Practitioner was notified and ordered Resident #1 to be sent to the ER for evaluation and treatment. Record review of a nursing progress note written by LVN C dated 1/6/2023 at 3:48 p.m. indicated Resident #1 returned to from the ER related to altered mental status. Resident #1's diagnoses included a UTI and dehydration. Resident #1's mood was pleasant. The NP was notified. Record review of a nursing progress note written by LVN D dated 1/6/2023 at 10:.00 p.m. indicated Resident #1's orientation was within normal baseline with a slightly unsteady gait. Record review of Resident #1's Medication Administration Record dated 1/1/2023-1/7/2023 indicated the following medications were to be administered daily to Resident #1 between 7:30 p.m. and 10:00 p.m. Claritin 10 mg- an antihistamine that treats symptoms such as itching, runny nose, watery eyes, and sneezing from hay fever and other allergies Depakote 500 mg- used to treat seizure disorders, certain psychiatric conditions (manic phase of bipolar disorder) Keppra 1,000 mg- used to treat certain types of seizures Lorazepam 1mg- used to treat anxiety Magnesium 400 mg- used to treat vitamin D deficiency Metformin 500 mg-used to control high blood sugar Vimpat 100 mg- used to prevent and control seizures RN A signed the medications as being given to Resident #1 on 1/4/2023. Record review of #1's Hospital Discharge Summary dated 1/6/2023 revealed Resident #1 was admitted on [DATE] and discharged back to nursing facility 1/6/2023. Discharge diagnoses included acute urinary tract infection, acute renal failure syndrome (sudden and sustained deterioration of the kidney function) and altered mental status. Hospital course reflected: On 1/6/2023 in discussion with family members it was revealed the patient was given up to 6 medications that were belonging to the patient's neighbor (Resident #2), with most of them being psychiatric with a heavily sedating effect. Upon evaluation in the morning, patient was found alert and orient x3, answering questions appropriately, speaking in full sentences, minimal confusion/disorientation noted in the early morning hours which resolved by the afternoon. Deemed stable for discharge. The hospital record indicated a drug screen was done on 1/5/2023 at 11:10 a.m. The results reflected the resident was negative for methadone, cocaine, THC (psychoactive component in marijuana), barbiturates, benzodiazepines, opiates, amphetamines, and PCP, (Phencyclidine, a sedative narcotic). Record review of a written statement by RN A dated 1/7/2023 indicated the following: On 1/4/23 I mistakenly gave the wrong medications to Resident #1. I was not alerted till I went to give meds to the roommate, and she stated she did not recognize her meds in the cup I gave her. So, I destroyed the meds and repoured in front of the patient and gave her meds at the med cart. I did not notify DON/ADON at this time. Record review of RN A's disciplinary record dated 1/7/2023 indicated the date of violation was 1/4/2023. The rule infracted was medications being given to the wrong resident. RN A was suspended pending an investigation. During an interview on 1/7/2023 at 10:37 a.m. the ADON said RN A worked the 6 p.m.-6 a.m. shift on 1/4/2022. The ADON said RN A did not report the med error until she came to work on 1/5/2022 for her 6 p.m.-6 a.m. shift and found out Resident #1 had been sent to the hospital. The ADON said RN A had 2 med cups with pills, one for Resident #1 and one for Resident #2, who were roommates. The ADON said RN A realized at some point she had given the wrong medicine to Resident #1, which actually belonged to Resident #2. The ADON said the DON was notified at some time around 9:33 p.m. on 1/5/2023. The ADON said Resident #1 usually questioned her meds before taking them. During an interview on 1/7/2023 12:30 p.m. Resident #1 said she was doing well. Resident #1 stated she had returned from the hospital 1/6/2023 and went to the hospital because of too much sugar, and my sugar was high. All the candy I ate at Christmas made my sugars go up, is what the doctor told me. Resident #1 said she took medications in the morning and in the evening and had never had any problems getting the right ones. During an interview on 1/7/2023 12:34 p.m. Resident #2 stated she received medications in the morning and in the evening. Resident #2 said she had problems 2 different times getting the right medications. Resident #2 said she received meds on 1/4/2023, and when she looked at them, she asked the nurse what they were, as they did not look right. Resident #2 said she could not pinpoint the time frame for the first event, but said it was the same nurse, RN A. Resident #2 said RN A gave her meds to her roommate and that was why she went to the hospital. Resident #2 said she did not take any of the meds that were not hers. Resident #2 said RN A was nice and told her she was daydreaming when she was giving the meds. Resident #2 said her roommate is confused at times. During an interview on 1/7/2023 12:40 p.m. the RNC said she was aware of the medication error on 1/4/2022. The RNC said training was started immediately, and that RN A would be called in on this date and suspended until the investigation was completed. During an interview on 1/7/2023 1:45 p.m. RN A stated on 1/4/2022, 6 p.m.-6 a.m. shift she was getting ready to give meds to both Resident #1 and Resident #2. RN A said she got 2 med cups out, filled 1 cup with medications and scooted it back under the computer, filled the other med cup with medications and scooted it back as well. RN A said she went into Resident #1's room, called her name and told her she had her meds. RN A said Resident #1 sat up in bed and she gave Resident #1 the med cup. RN A said Resident #1 looked at the pills and took them. RN A said she walked out of the room and got distracted. RN A said on the evening shift, they were the secretary, they had to answer phones, and the door, and answer call lights so it was 1-2 hours before she went back to give Resident #2 her meds. RN A said she grabbed the other cup of pills that were locked in the med cart, in the same cup she had previously filled. RN A said she handed Resident #2 the cup and Resident #2 looked at the pills said, These don't look right. RN A said she immediately thought oh no what did I do?. RN A said she and Resident #2 went to the med cart. RN A said she looked at the cup and knew she had just given Resident #1 Resident #2's meds. She said she told the resident she did not know what had happened, but she was going to get rid of the meds and start over. RN A said she poured new meds and gave them to Resident #2. RN A said she realized she gave the wrong meds to Resident #1, when Resident #2 said her pills did not look right. RN A stated she did not do what she should have; she should have called the doctor but did not because Resident #1 slept all night. RN A said the next day, 1/5/2023 around 6:30 p.m. she returned to work and saw that Resident #1 had been sent to the hospital. The DON was in the building, and RN A told her what she had done, and was told to complete an incident report. RN A said she probably passed meds to 4-5 residents prior to the incident involving Resident #1 but did not remember for sure. RN A said she did not give any more meds after the incident. RN A said Resident #1 slept all night with no issues noted. RN A said she did not normally fill 2 med cups at one time and had every intention of going back to give Resident #2's meds sooner. RN A said she did not put the residents' names on the medication cups. RN A said she had not made this mistake before, and no other resident had looked at their pills prior to taking them and stated they were the wrong medications. During an interview on 1/9/2023 at 9:35 a.m. the DON stated that on 1/4/2023, RN A did not say anything to her about a medication error. The DON stated on the morning of 1/5/2023 LVN B told her Resident #1 was not looking like herself. The DON stated Resident #1's blood pressure was low (could not remember exactly what it was) and her heart rate went from 60 to 40 beats per minute when aroused. The DON said neuro checks were done and Residents #1's pupils were pinpoint and fixed. The DON said Resident #1 went out to the hospital. The DON said she had called the hospital around 10:00 a.m., and the hospital did not have an update at that time. The DON said the hospital called back later in the day on 1/5/2023 saying Resident #1 was diagnosed with a drug overdose. The DON said she immediately looked at her meds and was puzzled all day, as to what medications Resident #1 had taken to cause a drug overdose. The DON said the hospital did not tell her what, if anything tested positive on the drug screen, or confirm a specific drug. The DON stated the hospital thought it was an overdose based on Resident #1's symptoms of being lethargic. The DON stated Resident #1 was diagnosed with a UTI and encephalopathy (brain disease, damage, or malfunction). The DON said RN A came back to work on 1/5/2023 6p.m.-6a.m. shift. The DON said when RN A saw that Resident #1 was sent to the hospital, she came into her office and said, I think I gave [Resident #2's] medications to [Resident #1]. The DON stated RN A was asked why she was just now reporting it, and never said anything before. The DON said RN A said, I wasn't going to say anything. DON stated she asked RN A why, and RN A said, I don't know. The DON stated RN A said she had 2 med cups of meds, and she gave Resident #1 medications, and when she went to give her roommate, Resident #2, her meds, Resident #2 said the pills were not her medications. The DON stated RN A said she did not give Resident #1 her correct medications, and she had clicked the given button before any meds were given, so the medication administration record reflected the medications Resident #1 was supposed to be given, were not. The DON stated after RN A reported this information to her on 1/5/2023, she notified the Administrator, the RNC, and the NP. The DON stated on 1/6/2022 when Resident #1 returned from the hospital, she was alert and oriented, as she was prior to the event. The DON said she talked to Resident #1 and asked her why she did not look at her meds before taking them, as she usually did. The DON said Resident #1 stated, I was already in bed, and I trusted her. The DON sated Resident #1 said she did not want to get RN A in trouble. The DON stated RN A said after the incident she did not have any more medications to pass. The DON stated RN A should not have signed the medications as being given until after they were administered. The DON stated RN A should only pass medications to 1 resident at a time, according to best practices. She stated RN A should have reported the incident immediately even if she wasn't sure she had made a mistake so Resident #1 could have been sent out for any possible adverse drug reactions. The DON stated she had started in-service training on medication pass, identifying and reporting med errors when she found out the medication error had occurred on 1/5/2023. DON stated she planned to do competency check offs on all nursing staff this week. She stated she also asked staff to do a double check before passing any and all meds; to double check med orders and the right resident. During an interview on 1/9/2023 at 10:22 LVN B stated she worked the 6:00 a.m.-6:00 p.m. LVN B stated on 1/5/2023 she went into Resident #1's room either during or after breakfast. LVN B stated Resident #2 said she had to help Resident #1 from the bathroom. LVN B stated Resident #1 was lying in her bed. LVN B called Resident #1 by her name and Resident #1 said huh? and nothing else. LVN B stated Resident #1 seemed lethargic. LVN B stated she got the DON and they did an assessment and Resident #1's blood pressure was 103 over something but could not remember exactly but said it was low. LVN B stated a neuro exam was done, and Resident #1's pupils were not reactive. LVN B stated she notified the NP and an order was received to transfer Resident #1 to the hospital. LVN B stated Resident #1 was admitted to the hospital with altered mental status diagnosis. LVN B said she was off the next 3 days and was unsure what all had transpired. LVN B said she passed medications in the morning and had a couple in the afternoon. LVN B said when passing meds, she addressed the resident by name, checked vital signs, pulled medications, and went in the room to administer them. LVN B said on the computer system there was a picture of each resident. She said she also verified the resident by the name on the door, and by addressing them by name. LVN B stated when she put meds in the med cup, there was a place on the electronic medication record to put a check mark by the medication to keep track of what has been put in med cup. LVN B stated she did not click on the given button until the resident had taken the medication in case they refused or were unable to take it for some reason. LVN B stated she only dispensed medications for 1 resident at a time. LVN B stated if she would happen to give the wrong medication to a resident, she would immediately notify the Dr., NP., Administrator and DON. During an interview on 1/9/2023 at 10:41 a.m. the ADON said new employees spent 3 days with staff orienting on the med cart. The ADON said she frequently helped administer medications on the floor. The ADON said she looked at the residents' MAR, looked at the pills, and the label on them. The ADON said she made sure she had the right resident. The ADON said she would ask the resident their name if able, she looked at the name on the door, and the picture in Matrix (facility computer system) on the electronic MAR. The ADON stated she only filled meds for 1 resident at a time. She said she checked the residents' medications off by clicking on the prepare button as she put the medication in the pill cup but did not click the given button until after the resident took the meds. The ADON said all staff had been trained/or would be receiving training, including the Mobile Dispatch nurses (nurses working for an inner agency through the corporate office), on the process of reporting med errors, and medication administration. The ADON said RN A did not pay attention to what she was doing, and she did not report a possible med error which should have been reported immediately. During an interview on 1/9/2023 at 10:57 a.m. LVN E stated she usually worked the secured unit. LVN E said she had received training on medication administration/reporting errors. LVN E stated when she passed medications, she first cleaned the cart, then got ice or pudding to have available if needed. She stated she usually got the vital signs on all residents done first. LVN E stated she got medications together and would verify the resident by their picture in the computer. She stated she also asked the resident their name. She stated she would click the prep button and checks off the meds as she put them in the med cup. She stated she then would click the given button after the resident took their medications. LVN E stated if by chance she would give a wrong medication, she would immediately notify the physician, and DON. During an interview on 1/9/2023 at 1:57 p.m. the NP stated she had been made aware of the medication error involving Resident #1 on 1/5/2022. The NP said there was no harm, no lingering side effects, or no treatments/testing that would be necessary. The NP said she had asked the staff to monitor Resident #1's vital signs and report any changes. The NP said there were no issues with Resident #1 not receiving the actual medications she was prescribed, as they were just 1 series of doses. The NP stated RN A was not following policies regarding med pass which included the right patient, the right med, the right dose. Record Review of the facility policy Adverse Consequences and Medication Errors, with a revision date of April 2014 indicated, a medication error is defined as the preparation of administration of drugs which are not in accordance with physician orders . In the event of a significant medication related error or adverse consequence, immediate action is taken, as necessary to protect the resident's safety and welfare. Significant is defined as requiring hospitalization . The attending physician is notified promptly of any significant error or adverse consequence. Record Review of the facility policy Administering Medications, with a revision date of April 2019 indicated Medications are administered in a safe and timely manner as prescribed. Medication errors are document, reported, and reviewed . The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. The individual administering the medications verifies the resident's identity before giving the resident his/her medications . The individual administering the medication document in the resident's electronic record after administering the medication . The RDO, RNC, DON, and ADON were notified of an IJ on 1/9/2023 at 4:20 p.m. A copy of the IJ Template was emailed to the RDO and RNC 1/9/23 4:52 p.m. and a Plan of Removal was requested. The Plan of Removal was accepted on 9:15 a.m. on 1/10/2023, and included the following: Plan of Removal F760 Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on 1/9/23, for F760 Free of Significant Med Error Action Item: The resident was sent to Hospital on 1/5/23 for assessment. Person Responsible: DON Timeline for completion: 1/10/23 Action Item: Medication administration records were reviewed for all other residents with no other errors identified. Person Responsible: RN Regional Nurse Consultant Timeline for completion: 1/10/23 Action Item: Medication administration training, education and competencies including Medication Administration Policies, Adverse Consequences and Medication Errors, Notification of med error to DON/Physician and med error investigations were completed with the nurses on 1/9/23 by the Regional Nurse Consultant. New nursing staff will complete competency prior to working the floor. Person Responsible: Nursing and administration Timeline for completion: 1/10/23 Action Item: medication administration observations will be completed on weekly basis for all shifts until substantial compliance has been achieved. Person Responsible: DON Timeline for completion: 1/10/23 Verification of the Plan of Removal was as follows: a. Reviewed in-service training on 1/7/23 and 1/10/23 for all nursing staff, on all shifts. The nursing staff were in-serviced on medication administration, error prevention, medication administration policies reviewed. Guidelines for notifying physicians for clinical problems, as well as notifying the NP, and DON. b. Competency Assessment/skills check off for Administering Oral medications was initiated, for all nursing staff, on all shifts. Six had been completed. c. Interviews conducted 1/10/2023 between 11:25 a.m. and 11:43 a.m. revealed LVNs B, F, and G said they worked the 6:00 a.m.-6:00 p.m. shift, and had received in-servicing provided by the facility as part of the plan of removal and all had knowledge and understanding of reporting med errors immediately and the proper procedure for medication administration, and proper resident identification. An Immediate Jeopardy (IJ) was identified on 1/9/2023 at 4:20 p.m. The IJ was removed on 1/10/2023 at 11:47 a.m. While the IJ was removed, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with a potential for more than minimal harm due to the facility's need to complete in-servicing and monitoring interventions.

Based on observation, interview and record review, the facility failed to ensure the right of the residents to be free from abuse for 3 of 21 residents reviewed for abuse and neglect. (Resident #29, Resident #49, and Resident #1) - Resident #29 was hit multiple times in the face and bit on the thigh by TCNA O during a physical altercation. -After suspension of 3 days,TCNA O returned to work at the facility which later resulted in TCNA O verbally abusing Resident #49 on [DATE]. TCNA O continued to work until she quit on [DATE]. -The facility did not provide appropriate intervention to protect all residents, after a resident-to-resident altercation in which Resident #1 repeatedly kicked another vulnerable resident in the head. -The facility failed to follow the care plan of assessing Resident #1 for a specially designed therapeutic unit upon readmission to the facility. These failures could place residents at risk abuse, neglect, and serious bodily harm. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 1:15 p.m. While the IJ was lifted on [DATE] at 8:00 p.m. the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of patterned due to the facility's need to evaluate the effectiveness of their corrective systems. Findings included: 1. Record review of a face sheet dated [DATE] indicated Resident #29 is a [AGE] year-old female and was admitted to the facility on [DATE]. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the [DATE] Quarterly MDS assessment indicated Resident #29 was understood and had a BIMs of 06, indicating severely impaired cognition at times. She did reject care for 4 to 6 days of the 7-day review period. She required supervision set-up only for walking. Record review of Resident #29's Comprehensive Care Plan dated [DATE] revealed staff must maintain a calm environment and approach when caring for Resident #29. Record review of complaint intake # 8 and facility investigation dated [DATE] indicated the incident was reported on [DATE], revealed TCNA O bit Resident #29 on the thigh during an altercation, which also resulted in a scrape on Resident #29s left elbow. TCNA O was suspended during the investigation, a police report was completed, a staff in-service on abuse was completed and the completed investigation was faxed to the state on [DATE] with the allegations noted as unconfirmed. Record review of the [local] Police Department Case report dated [DATE] at 08:31 AM revealed an assault against elderly or disabled individual (Resident #29). TCNA O physically assaulted Resident #29 after she wanted to call daughter around 10:00 PM and staff would not allow it. TCNA O came into the resident's room, sat on her bed and hit her. TCNA O entered Resident #29s room again, jumped on her bed and hit her with her fists, causing the resident to become unconscious at times; also told Resident #29 she was in a mental institution. Then when the resident said she would report TCNA O to the administration, both (Resident #29 and TCNA O) fell off the resident's bed and hit the tile floor, the resident wrapped her thighs around TCNA O's neck and then the TCNA O bit the resident on the thigh. TCNA O then hit the resident again in the face with closed fists and left the room. Resident #29 had an injury to her left elbow with a band aid covering it with blood on it, her shirt and sheets, but her right thigh did not have teeth marks. TCNA O was read her [NAME] Rights. Due to the fact that TCNA O was an employee with the nursing home and was working in the Mental health side of the facility she has the duty to protect and care for the residents who she oversees. TCNA O did not show restraint verbally or physically to Resident #29 due to being upset with the threat of being reported to administration. Resident #29 was a [AGE] year-old fragile elderly woman who could not protect herself against a healthy young [AGE] year-old TCNA O. The nursing home did not call for police when this assault occurred, they called 9 hours after the assault to report this to the police. Record review of the CPS/APS Intake Report dated [DATE] revealed Resident #29 resided at facility and had been physically assaulted three times by TCNA O working overnight, between 11:00 PM and 01:00 AM. TCNA O had bit the resident on her inner right thigh with her teeth and punched her multiple times with a closed fist causing the resident to lose consciousness. A wound to Resident #29s left elbow was band aided over and still had bleeding noted. TCNA O was suspended, and a report was filed for assault against elderly or disabled individual. During an interview on [DATE] at 04:48 PM with Resident #29, stated she went down the hallway, and asked TCNA O to talk/call to her family member, and the staff would not let her. I tried to open doors and pulled the fire alarm to get the employees attention. TCNA O asked me to go to my room. So, I did. But I still wanted to call my daughter. TCNA O came into my room, jumped on my bed, saying this was a mental institution. I told her (TCNA O) no, this was a place for the elderly. She came back in my room more than once; I said some things and she said, don't talk to me. I threw a bottle hard at TCNA O that missed her because she kept getting near my face, so I pulled her hair and we both fell to the floor, and then TCNA O did bite me on my thigh. I was in fear for my safety with her working here, none of that had to happen if they would have let me call my family member none of that would have happened. She kept coming back in my room, antagonizing me and then left the building. I had an injury to my left elbow that bled and a bite mark on one of my thighs. I filed a police report and staff talked to me about the incident. I thought TCNA O was fired because she should not treat residents that way. Nothing like that had ever happened before that incident at the facility. In an attempted telephone interview with TCNA O on [DATE] at 04:58 PM revealed message call cannot be completed due to the called party is unavailable. During an interview on [DATE] at 09:00 a.m., with the Administrator and DON, they were asked if they could get ahold of TCNA O. During an interview on [DATE] at 05:37p.m., the Regional Nurse reported she made attempts to reach TCNA O all day and were unsuccessful. The facility eventually had contact with TCNA O on [DATE] and she gave her notice of termination. During an interview on [DATE] at 04:49 PM, CNA CC revealed he stated he was there during the incident with Resident #29 and TCNA O. It was a verbal confrontation between Resident #29 and TCNA O, it then became physical from what I heard, and then when TCNA O went back into the room with Resident #29, I went back to the unit for security reasons. Resident #29 said that TCNA O had bit her, and there was a bite mark on Resident #29's leg. I had abuse training prior to this incident, in-services, and have been a CNA for [AGE] years, I have learned some things. He did not feel TCNA O was abusive towards the resident, even after hearing what took place. Interviews on [DATE] at 12:24 PM with LVN F, revealed she stated I worked the night shift on whatever night that happened, and at approximately 10:00 PM or later, I got back from my break and RN DD and CNA CC were back in the secured unit. TCNA O was the aide on the secure unit and had left the facility after an incident with Resident #29 without telling staff what happened. Resident #29 said she and TCNA O had exchanged words, ended up on the ground, Resident #29s legs around the aide's neck, and the aide bit her. LVN did note a circular red mark on Resident #29s right thigh near her pelvis, but she did not chart a skin assessment. TCNA O was not at work for a while after that incident. She called the DON after that to report what happened. LVN F stated I had abuse training prior to the incident and definitely after the incident. Resident #29 had never been aggressive to any staff physically; this was not like her, so I settled her down and made sure she felt safe, because TCNA O was gone from the building, and she had no other issues that night. LVN F stated allowing the residents to call her family member maybe would have helped prevent this whole incident, she may have asked TCNA O to call her family member, I do not know. During an interview on [DATE] at 02:57 PM with the Police Officer revealed that night ([DATE]) around 11:30 PM on the secured unit at the facility, TCNA O said Resident #29 could not call her family member at night. This upset the resident and so she pushed on alarmed doors to irritate the staff. The resident was just upset, saying she wanted to report TCNA O, and TCNA O was mad that Resident #29 was going to report her. The resident had gone to her room, and TCNA O came into her room, sat on her bed. The resident wrapped her legs around TCNA O's neck, they both fell to ground and TCNA O bit her leg. Resident #29 was protecting herself she said, that was why she protected herself. The resident's elbow was busted open, black, blue and purple and there was dried blood on her bedding and clothing. I took pictures of the teeth marks on her leg/thigh, and TCNA O admitted she had punched Resident #29 in the face and bit her. The facility should have called the police right away when it happened so we could have taken Resident #29 to the hospital to get checked out. TCNA O should have never been seated on the resident's bed, antagonizing her. Resident #29 was with it, she remembered everything. During an interview on [DATE] at 5:00PM, the Administrator stated she was aware of the incident from the DON that morning after the incident between TCNA O and Resident #29 and reported it. It happened because the staff would not allow the resident to call her family member. This upset the resident and she acted out, pulling the fire alarm for attention. It was reported by TCNA O that Resident #29 attacked her, kicked her causing them to fall to the floor. The resident wrapped her legs around the NAs neck and TCNA O bit the thigh of the resident for her to release. The Administrator stated the facility had trained their employees on de-escalation of combative residents and TCNA O should have left the resident alone and allowed her to call her family member to calm the resident down. TCNA O just worked the front hall instead of the secured unit after the incident. During an interview on [DATE] at 5:00PM, the Corporate RN stated police had come out and read TCNA O her [NAME] rights, so the facility thought that meant she had to be terminated. TCNAs references and background check were fine, that is why she was hired. Not firing her could affect every resident in the facility she had contact with after this incident by allowing further abuse. During an interview on [DATE] at 01:04 PM, the DON stated I got a call from LVN F about the incident that morning and reported it to the Administrator right away. Record review of the facility staffing schedules [DATE] to [DATE] revealed TCNA O worked at least 20 shifts at the facility since the abuse to Resident #29 and Resident #49. 2. Record review of the face sheet dated [DATE] revealed Resident #49 was [AGE] years old, male, and admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE] revealed Resident #49 was understood and understood others. The MDS revealed Resident #49 had a BIMS of 7 which indicated severe cognitive impairment and required extensive assistance to total dependence for ADLs. Record review of an undated care plan revealed Resident #49 exhibited verbally abusive behavioral symptoms. Interventions included ignore resident's verbal abuse when directed at you and refocus conversation when resident becomes verbally abusive. During an interview on [DATE] at 11:49 a.m., Resident #49 stated he and a staff member exchanged words one day. He said it made me mad and sad because she talked about his mother, and she was his best friend. During an interview on [DATE] at 4:23 p.m., Resident #30 said last month, TCNA O cursed out a resident because Resident # 49 threw a tray at her. Resident #30 said I could hear her all the way down to my room and she talked about his momma and dad. She stated TCNA O said, Your mom is [OBSCENITY] and Your dad is a __ and my auntie works here. She said TCNA O was CNA N's niece. During an interview on [DATE] at 2:30 p.m., Resident #30 said a verbal altercation between a resident and a CNA happened. She said the altercation was so loud, staff from the front of the building came to the back to see what was happening. She said she was not sure what occurred, but TCNA O cursed a resident down the hall and talking about his mom was a whore and stated, she was going to lose her job today. She said TCNA O cursed the resident out. During an anonymous interview on [DATE] at 11:00 a.m., AR said ,d+[DATE] weeks ago, he/she heard an aide cursed out a resident. AR said the resident threw his tray and the aide screamed, your mom is a [OBSCENITY] . AR said it happened on [DATE]. AR said he/she did not know who the resident or aide were. During an interview on [DATE] at 10:03 a.m., TCNA L said on [DATE], TCNA O did curse out Resident #49. She said the facility was short staffed that weekend and TCNA O came to the back hall to help. She said TCNA O went into Resident #49's room to drop off his lunch tray and screaming started. She said Resident #49 did not throw a plate at TCNA O, put tossed the plate cover on the floor and it did not touch her. TCNA L said her and LVN A pulled TCNA O out of the room and told her to go outside. TCNA L said she told CNA N, the CNA supervisor, about the verbal altercation. She said she had received abuse training upon hire. During an interview on [DATE] at 8:45 a.m., LVN A said a loud altercation happened between TCNA O and Resident #49 on [DATE]. She said Resident #49 threw the lid to the plate and it almost hit TCNA O. TCNA O then cursed Resident #49 and screamed at her aunt who worked here and stated she would lose her job today. LVN A said she attempted to deescalate the situation by separating TCNA O from Resident #49 and told her to go outside for a while then back to the front hall. LVN A said the CNA N showed up at the facility and took TCNA O outside. LVN A said she did not see TCNA O for the rest of the day. She was not sure if TCNA O went home or just stayed down on the front hall. LVN A said she did not assess Resident #49 after the altercation, physically or mentally. LVN A said she felt the altercation was verbal abuse. LVN A said because the on-call nurse and CNA N, who was the CNA supervisor, were in the building they would report the abuse to the administrator. During an interview on [DATE] at 5:43 p.m., LVN C said Resident #57 told him about a ruckus that happened over the weekend. He said Resident #57 attempted to play a recording, but it was not working properly. LVN C said he could hear people screaming at each other, but he only heard it for a few seconds. He said Resident #57 said he did not know who was in the recording, but they created a big ruckus. LVN C said he called the administrator on [DATE] and told her about the recording because he felt obligated to notify her in case it was verbal abuse. During an interview on [DATE] at 10:37 a.m., CNA N said TCNA O and Resident #49 did have an altercation on [DATE]. She said TCNA O called her and told her about it. She said TCNA O told her Resident #49 threw a plate at her and called her out of her name. She said she told her to leave, and she could not talk to residents like that even if they call you the N word. She said on [DATE], LVN C told the Administrator about a recording Resident #57 had on his phone, but he could not hear enough to decipher who it was. LVN C told the administrator Resident #57's phone was not acting right but he felt like she should look into it. CNA N said the Administrator called her to investigate the recording Resident #57 had. She said she asked Resident #57 to listen to the recording he told LVN C about, but he said he did not have it. She said since I could not hear the recording, then there was nothing to investigate. She said the altercation between TCNA O and Resident #49 was abuse. She said TCNA O did not have sufficient abuse and deescalating training before hire. She said the facility was so short staffed when she started, we just need her to work and did not have time to give her sufficient training. She said she did not fire TCNA O because she asked other residents about her care, and no one complained and some even requested her to work on their hall. She said she asked staff about her behaviors, and no one complained. During an interview on [DATE] at 12:45 p.m., the Administrator was notified by this surveyor and the team lead of the survey, of reports from staff and residents, verbal abuse had occurred between a resident and staff. The Administrator was also notified of reports from staff, she was notified of the verbal altercation prior to the survey. The Administrator denied any knowledge of abuse in the facility. The Administrator indicated TCNA O was suspended from [DATE] to [DATE]. TCNA O returned to work and quit on [DATE], but her last day worked was [DATE]. During an interview on [DATE] at 5:40 p.m., the DON said TCNA O's last day worked was [DATE]. She said she was not told about the incident with Resident #49 and TCNA O. She said she was out of town, and no one called her. She said after the first incident with, she did in-service on the prosperity unit, and asked staff about her behavior towards other residents. She said no one complained about her. She said TCNA O was suspended for ,d+[DATE] days but disciplinary action was not done. She said she only probably signed the suspension paperwork. She said it should be in her personnel file. During an interview on [DATE] at 6:30 p.m., the Administrator said abuse was not tolerated and everyone had been educated on the chain of reporting. She stated she was unaware of the verbal abuse that occurred between TCNA O and Resident #49. She said verbal abuse could make a resident feel threatened and scared. She said it could make residents not trust the staff and have decreased quality of life. 3. Record review of the face sheet revealed Resident #62 was a [AGE] year old male with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a progress noted dated [DATE] indicated Resident #62 was up ambulating at 7:25pm, was found on the floor non responsive at 9:00PM, CPR was initiated, and at 9:15pm Resident #62 was transported by EMS to the local hospital where he was pronounced dead. Record review of the face sheet revealed Resident #1 was [AGE] year-old male that admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the quarterly MDS dated [DATE] indicated Resident #1 had a BIMS of 15, which indicated no cognitive impairment. The MDS indicated he required limited assistance with ADLs, and he had physical behavioral symptoms directed towards others and verbal behavioral symptoms directed toward others exhibited 1 to 3 days. Record review of a care plan for Resident #1 dated [DATE] stated: -Resident has socially inappropriate/disruptive behavioral symptoms as evidenced by aggressive behavior. Resident was noted kicking another resident in the head. -The goal stated: Resident will not harm self or others secondary to socially inappropriate/disruptive behavior. Current behavior pattern: physically aggressive behavior (kicking another resident). -The approaches stated: Assess resident for placement in a special designated therapeutic unit. Assess whether the behavior endangers the resident, and/or other residents. Intervene if necessary. Remove resident and/or other resident's unsafe situations. When resident begins to become socially inappropriate/ disruptive, remove from situation, assess needs, and provide care if needed. Record review of a nurses note dated [DATE] at 7:55AM, written by LVN C indicated I could hear the resident yelling from his room as I was assisting CNA to pass breakfast trays, I stopped, ran to the resident's room, and noted him kicking another resident who was on the floor in the head, I immediately stopped the altercation and assessed both residents (Resident #1 and Resident #62). I removed fell ow resident (Resident #62) from the floor once I assessed him only noted he had a reopened skin tear above right brow from a previous fall. Resident #1 stated that Resident #62 came in his room and grabbed his shirt and would not let go so he pushed him off him and when he fell , he began to kick him (Resident #62) in the head. DON notified who is to notify the administrator. Record review of a nurses note dated [DATE] at 8:15 AM written by LVN C, indicated NP Q was notified of the altercation, but no new orders and ISNP R called no answer. Record review of a nurses note dated [DATE] at 8:19AM, written by LVN C, indicated ISNP R was made aware of the altercation with no new orders. Record review of nurses note dated [DATE] at 2:44PM, written by LVN R indicated Resident (Resident #1) requested to talk to his family member, Called family member. Resident #1 got upset after talked. Shouting move, [OBSCENITY] es. Redirected resident and took him to his room. Record review of nurses note dated [DATE] at 10:45 AM, written by the SW indicated, Resident # 1 had been referred to [local] Behavioral hospital . Record review of progress notes dated [DATE] at 6:09 PM written by LVN P revealed Resident #1 returned to facility on [DATE] from [local] Behavioral Hospital. Record review of progress notes revealed Resident #1 was seen by psychologist on [DATE], one month after readmission from the behavioral hospital. Record review of EHR on [DATE] revealed, no assessment for placement in a special designated therapeutic unit upon readmission to the facility. During an observation on [DATE] at 8:45am, Resident #1 was observed yelling at another resident, I will kill you! Get out of my room. Resident #26 was noted wandering in and out of several rooms on the central hallway that morning. Resident #26 was removed from Resident #1's room and redirected by TCNA L. During an interview on [DATE] at 10:08AM, the SW revealed Resident #1 had been to the behavioral hospital several times since his admission for being verbally and physically aggressive. The SW also revealed, Resident #1 did not want to discharge to the behavioral hospital again after the incident on [DATE], so the facility made a deal with him. If he would go to the behavioral hospital, take his medications, and had no behaviors while he was gone then the facility would try him outside of the secure unit. The SW indicated Resident #1 had no further physically aggressive behavior and he did not feel his roommate was in any danger of physical or verbal abuse. During an interview on [DATE] at 10:37 AM, CNA N revealed that Resident #1 had a temper problem. CNA N revealed Resident #1 had to be redirected several times a week for yelling and cursing at residents and staff members. Resident #1 did not like other people in his room and would become irate and throw things if residents wandered into his room. CNA stated there were several little ladies that wandered on the central hall where Resident #1 lived. CNA N stated the staff tried to keep an extra eye on him and answer his call light as quickly as possible because he had zero patience. CNA N revealed Resident #1 was still having these behaviors since his readmission from the behavioral hospital. During an interview on [DATE] at 5:40pm the DON stated she was unaware of Resident #1 being verbally aggressive with wandering residents. The DON stated, Resident #1 had no reported behavior problems since he returned from [local] Behavioral Hospital. During an interview on [DATE] at 6:40pm the Administrator stated she was unaware of any verbal aggression with wandering residents. Resident #1 had no reported behavioral problems since he returned from the behavioral hospital. Resident #1 was seen by the psychologist and no aggression was noted during that assessment. A facility policy titled Resident to Resident Altercations dated February 2021 stated the facility will make any necessary changes in the care plan approaches to any or all of the involved individuals; review the events with the nursing supervisor and possible measures to try to prevent additional incidents; document in the resident's clinical record all interventions and their effectiveness. Record review of the facility Abuse Prevention Program Policy dated February 2021 revealed our residents have the right to be free from abuse, including verbal, mental or physical abuse. Our center will protect residents from harm during investigations of all abuse investigations. All reports of resident abuse shall be promptly reported to local, state and federal agencies and thoroughly investigated by management. The administrator was notified on [DATE] at 3:19 p.m., an Immediate Jeopardy situation was identified due to the above failures and the IJ template was emailed to the administrator on [DATE] at 3:37 p.m. The facility's plan of removal was accepted on [DATE] at 6:55p.m. and included: Plan of Removal Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on [DATE], for abuse. Action Item: The Temporary C.N.A. is suspended pending investigation - Person Responsible: Nursing and administration - Timeline for completion: [DATE] Action Item: Verbal abuse allegation reported to the administrator by the surveyor on [DATE] was reported to the state on [DATE]. Resident safe surveys were completed on [DATE] no other resident concerns were noted. Staff interviews will be completed by [DATE]. Investigation on verbal abuse will be completed by [DATE]. - Person Responsible: Nursing and administration - Timeline for completion: [DATE] Action Item: The aggressor was assessed at [behavioral center]and deemed not to be a risk to others on [DATE] and was sent back to the center on [DATE]. The psychologist assessed the resident on [DATE] and deemed the resident not to be a risk to others. The Regional Nurse Manager reviewed the residents care plan and interventions in place to care for the resident on [DATE], one intervention was resolved as related to the approaches: assess for placement in a therapeutic unit. The resident was treated at [behavioral center] and did not need the therapeutic unit post care. Duplicate interventions were resolved on [DATE] by the Regional Nurse Manager. A staff member will be present outside of the resident's room to protect other residents until resident is deemed not a threat to others. Referral to psychiatric/behavioral service provider on [DATE]. Care plan updated to reflect monitoring on [DATE] by the Regional Nurse Manager. - Person Responsible: Nursing and administration - Timeline for completion: [DATE] Action Item: Staff education completed on abuse prevention, abuse reporting, abuse investigation, de-escalation, managing unwanted behaviors, and interventions to protect other residents from altercations. Staff will receive education prior to working their next shift. The center performance improvement plan was initiated on [DATE] and updated on [DATE] by the Regional Nurse Manager. - Person Responsible: Nursing and administration - Timeline for completion: [DATE] MONITORING: On [DATE], the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: - Interview on [DATE] at 10:10am, the administrator stated she suspended temporary CNA O pending investigation of abuse. - Observation on [DATE] at 8:20 am, Resident #1 had an employee stationed in front of door. - Interview on [DATE] at 2:15pm, the administrator stated a tele visit was held between Resident #1 and psychologist. - Record review of psychologist note dated [DATE] revealed Resident #1was calm, sociable, upbeat. Resident #1 interacted well, and mood appeared stable. No behavioral symptoms noted. - Interviews on [DATE] at (8:20 p.m., LVNC); (8:25 p.m., Med Aide D); (6:08 p.m. CNA E), (6:30pm LVN F); (6:35 p.m. G), (6:21 p.m. CNAN), (6:38 p.m. LVN I), (6:50p.m. SSD), (6:51p.m. BOM) and (6:52pm TCNA L) revealed they had received education on abuse prevention, abuse reporting, abuse investigation, de-escalation, managing unwanted behaviors, and interventions to protect other residents from altercations. - Inservice records dated [DATE] revealed they had received education on abuse prevention, abuse reporting, abuse investigation, de-escalation, managing unwanted behaviors, and interventions to protect other residents from altercations. - Safe surveys for all cognitive residents revealed no reported abuse. Family surveys for all cognitively impaired residents revealed no suspicions of abuse. On [DATE] at 8:00 p.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of patterned due to the facility's need to continue to monitor the effectiveness of their plan of correction.

Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided with such care, consistent with professional standards of practices for 1 of 1 resident (Resident #34) reviewed for respiratory care related to [CONDITION(S)] care. The facility failed to ensure nursing staff had the needed competencies to care for a resident with a [CONDITION(S)] (Resident #34). The facility failed to ensure nursing staff were knowledgeable of how to administer inhalation medications for a resident with a [CONDITION(S)] (Resident #34). An Immediate Jeopardy (IJ) situation was identified on 08/19/2022 at 4:43 p.m. While the IJ was lifted on 08/22/2022 at 1:36 p.m. the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of patterned due to the facility's need to evaluate the effectiveness of their corrective systems. Findings included: Record review of a face sheet dated 8/1/22 revealed Resident #34 was a [AGE] year-old male that admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of an admission MDS dated [DATE] indicated Resident #34 was unable to perform the BIMS. Resident #34 was total dependent and required the assistance of two people for all ADLs. Resident #34 was always incontinent (unable to control) of bowel, and he had a foley catheter (tube into the bladder to drain urine). Resident #34 had a [CONDITION(S)] (direct airway into the trachea (windpipe) through a surgical incision in the neck). Resident #34 was unable to communicate with others. Record review of Resident #34's care plan dated 06/23/2022 revealed it did not address he had a [CONDITION(S)] or the care of the [CONDITION(S)]. Record review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 8/01/22 at 12:42 PM revealed LVN W removed a mask with a nebulizer (device to deliver inhalation medication) attached from over Resident #34's nose/mouth and the resident had a [CONDITION(S)] (artificial airway made through the lower neck). During an observation and interview on 8/01/22 at 4:29 PM with LVN W, she said she was giving Resident #34 a nebulizer treatment with [MEDICATION(S)]-[MEDICATION(S)] and his [MEDICATION(S)] by inhalation. The resident had a mask over his nose and mouth with a nebulizer attached. Resident has a [CONDITION(S)] in his neck that he breathes through. During an observation on 8/01/22 at 5:22 PM revealed Resident #34's humidifier tubing was not attached to the resident's [CONDITION(S)] and was lying in the floor during a linen change followed by wound care being provided by LVN W and TCNA V. LVN W realized after four minutes, the tubing was not attached to Resident #34's [CONDITION(S)], and she picked it up off the floor and reattached the humidifier tubing to the resident's [CONDITION(S)] without sanitizing it. During an interview on 8/01/22 at 6:05 PM with LVN W , she said she had been employed with this company for 2 months as the corporate mobile staffing nurse, but she had worked for the company since 2018 as an agency staffing nurse. She said she did not know any other way to give Resident #34's breathing treatment except over his nose/mouth, because he also had to have his oxygen on at all times, so his oxygen wouldn't drop. Surveyor asked LVN W how was Resident #34 inhaling the inhalation medication when the mask was over his nose/mouth, and he breathed through his [CONDITION(S)] located in his lower neck? LVN W said, you don't think he can get it through his nose? She then said, I get what you are saying, and he probably should have an attachment for the [CONDITION(S)] to give his breathing treatments. She said she had been checked off on [CONDITION(S)] care at another company owned facility and she had been providing care to residents with tracheostomies for a long time. She said she picked the tubing off the floor in a hurry be cause Resident #34 needed his oxygen quickly and she did not want his oxygen level to drop. The tubing she referred to was the humidified air tubing and did not contain oxygen. She said she checked his heart rate and oxygen level before and after giving Resident #34 his breathing treatments or suctioning him. She said she would report any changes to the physician and the DON and/or would call emergency services if needed. During an interview on 8/02/22 at 9:59 PM with LVN Y, she said she had been administering Resident #34's nebulized inhalation treatments with a mask over his nose/mouth, since the resident was admitted to the facility. She said she was just told that day the facility was ordering the attachment to be able to administer the inhalation medications through his [CONDITION(S)]. She said she would notify the physician with any changes in condition and/or would call 911 emergency services if needed. During an interview on 8/03/22 at 11:11 AM with LVN Z, she said she had been administering Resident #34's nebulized inhalation breathing treatments by putting the medication in the nebulizer and placing the face mask on his face. She said she checked his heart rate and oxygen levels before and after the breathing treatments. She said she made sure his head was elevated to ensure he was getting the medication. Surveyor asked LVN Z how she was ensuring the inhalation medication was reaching the resident's lungs through the face mask over his nose/mouth, when he breathed through his [CONDITION(S)] in his neck. She said she was told this week they had ordered an adapter so they could administer the inhalation medications through the [CONDITION(S)] mask. She said if Resident #34 was not getting the inhalation breathing treatment medications to his lungs, it could affect his breathing. She said she would notify the physician or nurse practitioner if the resident had a change in condition and/or would call emergency services if needed. During an interview on 8/4/2022 at 8:45 AM with LVN A , she said she had not had any trainings related to tracheostomies or [CONDITION(S)] care. She was unaware of how to do anything with a [CONDITION(S)] other than how to give breathing treatments. She said there was a box in there and she had no idea what the dials did or what it was for. She said she did not touch it. She said if anything ever happened to the resident's [CONDITION(S)], it could be dangerous if there was not a RN in the building to ask what to do. She said she would call 911 for emergency services in the event of an emergency. During an interview on 8/04/22 at 10:56 AM LVN Z, she said a Respiratory Therapist had come and taught her how to take the [CONDITION(S)] inner cannula out and clean it and put back in, how to and how long to suction a resident with a [CONDITION(S)] about 2 years ago. She said she was only able to take the inner cannula of the [CONDITION(S)] out and clean it. She said if the [CONDITION(S)] was to come out, she could not put it back in. She said a Register Nurse was the only one that could put it back it. She said there was not always a Registered Nurse in the building. She said she would call 911 and make sure the resident was breathing good if the [CONDITION(S)] was to come out and there was not a Registered Nurse in the building. She said the Big box was the humidifier, and it was to keep his [MEDICATION(S)] thin in his lungs. She said she felt comfortable providing care for a [CONDITION(S)] resident and would feel comfortable caring for him in an emergency. During an interview on 8/04/22 at 7:00 PM with the DON , she said a resident with a [CONDITION(S)] would not receive the inhalation medication in the nebulizer treatment by inhalation when the mask was placed over the nose/mouth, because the resident breathed through the [CONDITION(S)] in his neck. She said the resident would not receive the benefits of the medication. She said she was working on ordering an adapter to be able to administer the nebulized inhalation medications through the [CONDITION(S)]. She said she was responsible for ensuring staff had the knowledge and skills to care for all residents in the facility, including the resident with the [CONDITION(S)]. She said she was working on getting a respiratory therapist to come and provide training to all nursing staff in caring for residents with tracheostomies. She said no staff had voiced to her not knowing how to care for the resident with a [CONDITION(S)]. She said she did not have the competencies of the nursing staff related to caring for a resident with a [CONDITION(S)] and care of the equipment. She said the nursing staff would not know how to put the resident's [CONDITION(S)] back in if it became dislodged. She said there was not a replacement [CONDITION(S)] tube at Resident #34's bedside, but she kept them in her office. She said the nursing staff would either need to call the registered nurse (RN), if the RN was in the building, or they would need to call 911 for emergency services in case of an emergency. She said it would be an infection control issue if the humidifier tubing was on the floor and then hooked back up to the resident without first disinfecting it. She said Resident #34 already had a respiratory infection. She said she was responsible to ensure the staff had the knowledge and skills to provide appropriate care to a resident with a [CONDITION(S)]. During an interview on 8/04/22 at 7:34 PM with the Administrator, she said she would expect the nursing staff to have the appropriate knowledge to care for all residents. Record review of LVN W's orientation checklist trainings dated 6/20/22 revealed there was no training related to [CONDITION(S)] care. Requested nursing competencies on all nursing staff that performed [CONDITION(S)] care for Resident #34 on 8/03/22 at 3:00 PM and twice on 8/04/22 at 2:30 PM and 7:00 PM from the Regional Nurse and was not provided with the requested documentation. The surveyor reentered the building on 8/19/2022 at 2:00 PM, during observation and interview with the DON it was revealed there were internal agency nurses working at the facility that had not been trained on [CONDITION(S)] care. The DON stated there was no spare cannula in Resident #34's room because the Respiratory therapist that came in on 8/9/2022 to do in-service training used the spare cannula to teach [CONDITION(S)] care. The DON retrieved a new cannula from her office to leave at bedside. The DON explained it was extremely important to have a spare cannula for Resident #34 because if it becomes clogged or dislodged it would leave Resident #34 with no air way causing respiratory failure and potentially death. The surveyor notified the DON on 8/19/2022 at 4:43 p.m., that they had a current Immediate Jeopardy related to respiratory/[CONDITION(S)] care. The IJ template was emailed to the DON on 8/19/2022 at 4:53 p.m. and a Plan of Removal was requested. The plan of removal was accepted on 8/19/2022 at 8:06 p.m. by the Program Manager and included: Plan of Removal: Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on 8/19/2022, for Respiratory and [CONDITION(S)] Care. Action Item: The resident was assessed on 8/18/22 by LVN Z. No adverse outcomes noted. Person Responsible: DON Timeline for completion: 8/19/22 Action Item: Respiratory training, education and competencies including [CONDITION(S)] care, the administration of inhalation medication and oxygen services were completed with the nursing staff on 8/9/22 by the Lincare Respiratory therapist. LVN Q was reeducated on 8/18/22 by the RN ADON education included Respiratory training, education and competencies including [CONDITION(S)] care, the administration of inhalation medication and oxygen services. All nursing staff will be retrained on [CONDITION(S)] care, the administration of inhalation medication, oxygen services via [CONDITION(S)] and the location of the second cannula by 8/20/22. New nursing staff will complete education and competency prior to working with residents with [CONDITION(S)]. Person Responsible: Nursing and administration Timeline for completion: 8/20/22 Action Item: A second cannula was verified to be at bedside by on 8/19/22 by DON. Person Responsible: DON Timeline for completion: 8/19/22 Monitoring: -The resident was assessed on 8/19/2022 for signs and symptoms of respiratory distress. - Respiratory training, education and competencies including [CONDITION(S)] care, the administration of inhalation medication and oxygen services were completed with the nursing staff on 8/9/22 by the Lincare Respiratory therapist. - LVN Q was reeducated on 8/18/22 by the RN ADON education included Respiratory training, education and competencies including [CONDITION(S)] care, the administration of inhalation medication and oxygen services. All nursing staff will be retrained on [CONDITION(S)] care, the administration of inhalation medication, oxygen services via [CONDITION(S)] and the location of the second cannula by 8/20/22. - New nursing staff will complete education and competency prior to working with residents with [CONDITION(S)] - A second cannula was verified to be at bedside by on 8/19/22 by DON. On 08/22/2022 at 1:36 p.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of patterned due to the facility's need to continue to monitor the effectiveness of their plan of correction. Record review of the facility's policy titled [CONDITION(S)] Care dated August 2019 revealed . a replacement [CONDITION(S)] tube must be available at the bedside at all times . There was a blank Competency Assessment [CONDITION(S)] Care check off list attached to the policy.

Based on interviews and record reviews, the facility failed to ensure residents were free from involuntary seclusion for 1 (Resident #50) of 21 residents reviewed for involuntary seclusion. The facility failed to ensure Resident #50 was free from involuntary seclusion. This failure could place residents at risk of feeling isolated, fearful, hopelessness uncomfortable, disrespected, decreased self-esteem, and diminished quality of life. Findings included: Review of the resident face sheet revealed, Resident #50 was a [AGE] year-old male that admitted to the facility on [DATE]. The face sheet revealed Resident #50 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS dated [DATE] revealed, Resident # 50 had a BIMS (brief interview of mental status) of a 14, which indicated no memory impairment. The MDS also indicated Resident #50 had 1-3 days of physical and verbal behaviors during the assessment period. Resident # 50 required extensive assist for bed mobility, transfer, and toileting. Record review of care plan dated 6/22/2022 indicated behaviors of Resident # 50 included the refusal of ADL care, thinking his remote is a cell phone, and becoming upset when redirected and masturbating in front of staff. Interventions for Resident #50's behaviors were to approach in a calm manner and provide a calm environment. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] June 2022: -[MEDICATION(S)] 300mg twice daily-Start date 11/27/2019 -[MEDICATION(S)] 400mg at bedtime-Start date 3/14/2021 During an interview on 8/3/2022 at 2:30PM, Resident #30 informed the survey team that an incident occurred on 7/3/2022 with Resident #50 and LVN A. Resident #30 stated Resident #50 had been hollering about being able to get up but there were no CNAs on the back hall that day. The nurse finally went to get Resident #50 up after he had been yelling out to get up for hours. Resident #50 continued to scream and kick the wall even after they got him up. LVN A took Resident #50 and locked him in the room across the hall from his room. LVN A shut the door on Resident #50, and he screamed, knocked into things in the room for an hour or more screaming for them to let him out. LVN A then took Resident #50 and wheeled him to the secure unit and told him he would stay there until he calmed down. Resident #30 stated she never felt threatened or endangered by the behavior of Resident #50. On 8/3/2022 at 2:45 PM the Administrator was notified of an allegation of mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8/4/2022 at 11:10am, Resident #52 revealed he was the roommate of Resident #50 on 7/3/2022 when Resident #50 was hollering out to get up. Resident #52 stated on the morning of 7/3/2022 it was announced by LVN A several times, there was no CNA on the back hallway and Resident #50 had been asking for a while that morning to get out of bed. Resident #52 continued, Resident #50 does not have the mental capacity to understand there was no one to get him up and Resident #50 was like a small child mentally. Resident # 50 cried out to get up. That went on for almost 2 hours, then Resident #50 started getting louder and shaking the bed and kicked over his bedside table. Resident #52 stated LVN A and a medication aide came in and told him to cut it out or he was going to lock down. Resident #52 stated he knew Resident #50 feared the lockdown unit because he would say 'no no no' and was quiet for 15 or 20 minutes after LVN A threatened Resident # 50 that he would be put back there. LVN A came back in around lunch time when Resident #50 began screaming out again and told Resident #50 that was it, he was getting locked up. LVN A and the medication aide got Resident #50 up and put him in his wheelchair and rolled him into the room across the hall from their room and shut the door. Resident #50 was in there for an hour or two at the most and began to tear the room up. Resident #52 recalled being able to hear him kicking and hitting things in the room. LVN A pulled Resident #50 from the room and wheeled him backwards down the hallway while he was screaming no, no, no and put him in the locked down unit. Resident #52 said the entire day was chaotic on the back hallway. When Resident #50 returned from the lock down unit he was calm as a kitten. Resident #52 stated it was after supper that Resident #50 returned to his room. Resident #50 slept in his chair until they put him in the bed a few hours later. Resident # 52 stated he never felt scared or threatened by the behaviors of Resident # 50. During an interview with CNA E on 8/4/2022 at 2:20 PM, she revealed that Resident # 50 was brought back to the secured unit or lock down as staff called it, just before lunch time. Resident # 50 ate lunch and supper on the secured unit. CNA E stated she was instructed by LVN A to keep Resident #50 insight because of aggressive behaviors. CNA E stated, Resident #50 called out a few times but was not acting out while he was on the secured unit. CNA E stated the lock down unit had been used a few times in the past to calm residents down. CNA E stated she had not been trained specifically on deescalating people with behaviors but that she did know that you should just leave the resident alone if they are upset. CNA E responded that being brought to a 'lock down' unit against your will could be frightening and cause stress to the residents that have experienced it. CNA E stated Resident #50 was not physically or verbally aggressive while on the lock down unit. During an interview on 8/4/2022 at 8:45am, LVN A revealed she was the nurse on duty on 7/3/2022 and was assigned to Resident #50 and the back hall and secured unit. LVN A stated that Resident #50 was screaming and kicking because he wanted up. LVN A revealed there was just not enough staff to get Resident #50 out of bed as quickly as he wanted. She revealed that she and Medication Aide D got Resident #50 up and he began showing physical and verbal aggression by kicking over his bedside table and screaming. LVN A stated there was not enough staff to watch him, so she put him in the room across the hall from him that was empty. LVN A stated she did not close the door. She stated Resident #50 just stayed in the room with the door open and Resident #50 began tearing the room up by running into the wall and tearing the blinds down. Resident #50 attempted to throw himself out of the wheelchair and into the floor. LVN A stated that she and Medication Aide D attempted to calm Resident #50, but he would not calm down. LVN A stated she and Medication Aide D wheeled him to the behavioral unit so that the CNA E could watch after him until he calmed down. LVN A instructed CNA E to watch Resident #50 until he calmed down. LVN A stated about 3 hours later Resident # 50 calmed down and LVN A let Resident #50 out to go back to his room. LVN A stated, Resident # 50's behaviors were reported to the psychologist the next day on 7/4/2022 and medication adjustments were made. LVN A stated she did not at the time feel like her actions were inappropriate or could be considered abuse of any type to put Resident #50 in a room alone or on the unit to calm his behavior. LVN A stated looking back on it now, she should have taken Resident #50 to the nurse's station and sat with Resident # 50 for a while to calm down or called the MD for medication to calm Resident # 50 down that day. Review of the progress note written by LVN A dated 7/3/2022 11:26 am revealed: resident destructive, throwing things around the room, pulling on blinds, and pushing over tables, resident verbally and physically aggressive toward staff, redirected and assisted up to wheelchair, resident continued to yell and curse at staff and attempted to pull down blinds. Review of the progress note written by Psychologist B dated 7/4/2022 at 12:54PM revealed: Resident #50 was seen for a follow up. Records and reports from other residents and staff indicated that Resident #50 had been aggressive and destructive lately .he suffers from serious [CONDITION(S)] disorder and low intellect, and lately it appeared that he underwent some psychiatric decompensation. He was provided counseling to help him stop any form of aggression, follow staff's recommendations, and engage with others in a calm and pleasant manner. Review of progress notes written by LVN C on 7/4/2022 at 1:25pm revealed: New orders per NP K per psych PHD B recommendations to decrease [MEDICATION(S)] to 200mg orally twice daily, add [MEDICATION(S)] 0.5mg orally twice daily, add [MEDICATION(S)] 20mg orally once a day. Review of Resident #50 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 0.5mg twice daily- Start date 7/5/2022; Stop date 7/14/2022 -[MEDICATION(S)] 0.5mg once daily- Start date 7/15/2022 -[MEDICATION(S)] 20mg once daily- Start date 7/5/2022; Stop date 7/14/2022 -[MEDICATION(S)] 300mg twice daily- Start date 11/27/2019; Stop date 7/5/2022 -[MEDICATION(S)] 400mg at bedtime-Start date 3/14/2021; Stop date 7/4/2022 -[MEDICATION(S)] 400mg twice daily- Start date 7/4/2022 Review of progress notes written by LVN C on 7/8/2022 at 11:28 AM revealed: Day 5 new order per NP K per psych PHD B recommendations decrease [MEDICATION(S)] to 200mg orally twice daily, add [MEDICATION(S)] 0.5mg orally twice daily, and add [MEDICATION(S)] 20 mg once a day. Resident has been noted sleeping a lot since med changes, slept through breakfast and ate only small bites of lunch due to sleeping in a wheelchair, to continue to monitor for tolerance of med changes. During record review of the EHR on 8/4/2022 at 2:30 PM the following information was revealed: -no incident report was noted -no documentation was noted about the isolation of Resident #50 in the room across the hall from his room or the secured unit -no notification of the family, administration, or MD on the 7/3/2022. -no other interventions for behaviors documented in Resident #50's chart. During an interview on 8/4/2022 at 4:00 PM, Resident #50 stated yes when asked if he remembered being put in a room with the door closed and then put on the lock down unit about a month ago. Resident # 50 responded, she closed me in that room. Resident #50 agreed that he knocked over a bedside table and torn the blinds up. Resident #50 stated they would not let me up. Resident #50 responded yes when asked if he was scared of lock down. Resident # 50 responded mean people back there. Resident # 50 stated I will be good now. During an interview on 8/4/2022 at 5:30 PM the DON stated that she had no idea Resident #50 had behavioral issues or that the staff put him in a room and closed the door, then put him on the secured unit to calm down. The DON stated it was not in the facility policy to ever seclude residents as a means of behavior modification. The DON stated involuntary seclusion could lead to psychological damage and move behaviors. The DON stated the first time she heard of the incident was when the state surveyor reported it the day prior. During an interview on 8/4/2022 at 9:50 PM, the Administrator stated abuse and involuntary seclusion are not tolerated and everyone had been educated on the chain of reporting. The Administrator stated putting Resident #50 in isolation as a form of punishment would not be tolerated. The Administrator stated she did not know the isolation occurred. Seclusion can make a resident feel threatened and scared. It can make them not trust the staff and have decreased quality of life. LVN A was suspended. The investigation remained underway upon exit. Review of the facility's abuse policy dated 02/01/21 reflected the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, and physical and chemical restraint not required to treat the resident's symptoms, involuntary seclusion, and corporal punishment. Review of the facility's involuntary seclusion policy dated February 2021 reflected: as part of the abuse prevention strategy, volunteers, employees, and contractors hired by this facility are expected to be able to identify involuntary seclusion and or unauthorized restraint of residents. Involuntary seclusion is defined as a separation of a resident from other residents or from his or her room or confinement to his or her room with or without roommates against the residents will. Examples of involuntary seclusion include: any attempt to keep a resident confined to certain area by blocking the exit with furniture or a closed door; placing a resident in an area without access to a call light or other method of direct communication with staff; placing a resident in a locked or secure unit of the facility without meeting the criteria for the unit; or confining a resident to his or her room for punishment or staff convenience. Secluding or confining a resident against his or her will is prohibited.

Based on observation, interview and record review, the facility failed to fully investigate, prevent and correct an alleged violation of abuse for 2 of 18 residents reviewed for alleged violations. (Resident #29 and Resident #49) The facility did not thoroughly investigate and correct an allegation of abuse that resulted in Resident #29 being bitten by a CNA, incorrectly unconfirmed abuse, and allowed alleged perpetrator to continue working with residents in the facility. The facility did not throughly investigate and correct an allegation of verbal abuse by TCNA O when she used derogatory lanuage towards Resident #49. These failures could place residents at risk for poor investigations, further allegations of abuse and actual abuse. Findings included: 1. A record review of face sheet and current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the 06/04/22 Quarterly MDS assessment indicated Resident #29 was understood and had a BIMs of 06, indicating severely impaired cognition at times. She did reject care for 4 to 6 days of the 7-day review period. She required supervision set-up only for walking. Record review of the 11/06/21 Comprehensive Care Plan revealed for Resident #29 staff must maintain a calm environment and approach. Record review of complaint intake # 8 and facility investigation dated 06/29/22 indicated the incident was reported on 06/28/22, revealed TCNA O bit Resident #29 on the thigh during an altercation, which also resulted in a scrape on Resident #29s left elbow. TCNA O was suspended during the investigation, a police report was completed, a staff in-service on abuse was completed and the completed investigation was faxed to the state on 07/04/22 with the allegations noted as unconfirmed. Record review of the Police Department Case #P 55 dated 06/28/22 at 08:31 AM revealed assault against elderly or disabled individual (Resident #29). TCNA O physically assaulted Resident #29 after she wanted to call family member around 10:00 PM and staff would not allow it. TCNA O came into the resident's room, sat on her bed and hit her. TCNA O entered Resident #29s room again, jumped on her bed and hit her with her fists, causing the resident to become unconscious at times; also told Resident #29 she was in a mental institution. Then when the resident said she would report TCNA O to administration, both fell off the resident's bed and hit the tile floor, the resident wrapped her thighs around TCNA Os neck and then the TCNA bit the resident on the thigh. TCNA O then hit the resident again in the face with closed fists and left the room. Resident #29 had an injury to her left elbow with a band aid covering it with blood on it, her shirt and sheets, but her right thigh did not have teeth marks. TCNA O was read her [NAME] Rights. Due to the fact that TCNA O is an employee with the nursing home and was working in the Mental health side of the facility she has the duty to protect and care for the residents who she oversees. TCNA O did not show restraint verbally or physically to Resident #29 due to being upset with the threat of being reported to administration. Resident #29 is a [AGE] year-old fragile elderly woman who could not protect herself against a healthy young [AGE] year-old TCNA. The nursing home did not call for police when this assault occurred, they called 9 hours after the assault to report this to the police. Record review of the CPS/APS Intake Report dated 06/28/22 revealed Resident #29 resides at facility and had been physically assaulted three times by TCNA O working overnight. between 11:00 PM and 01:00 AM. TCNA O had bit the resident on her inner right thigh with her teeth and punched her multiple times with a closed fist causing the resident to lose consciousness. A wound to Resident #29s left elbow was band aided over and still had bleeding noted. TCNA O was suspended, and a report was filed for assault against elderly or disabled individual. Record review of the facility staffing schedules 07/01/22 to 08/02/22 revealed TCNA O worked at least 20 shifts at the facility since the abuse to Resident #29. During an interview on 08/02/22 at 04:48 PM with Resident #29, stated she went down the hallway, and asked TCNA O to talk/call to her family member, and the staff would not let her. I tried to open doors and pulled the fire alarm to get the employees attention. TCNA O asked me to go to my room. So, I did. But I still wanted to call my daughter. TCNA O came into my room, jumped on my bed, saying this was a mental institution. I told her (TCNA O) no, this was a place for the elderly. She came back in my room more than once; I said some things and she said, don't talk to me. I threw a bottle hard at TCNA O that missed her because she kept getting near my face, so I pulled her hair and we both fell to the floor, and then TCNA O did bite me on my thigh. I was in fear for my safety with her working here, none of that had to happen if they would have let me call my family member none of that would have happened. She kept coming back in my room, antagonizing me and then left the building. I had an injury to my left elbow that bled and a bite mark on one of my thighs. I filed a police report and staff talked to me about the incident. I thought TCNA O was fired because she should not treat residents that way. Nothing like that had ever happened before that incident at the facility. In an attempted telephone interview with TCNA O on 08/02/22 at 04:58 PM revealed message call cannot be completed due to the called party is unavailable. During an interview on 08/03/22 at 09:00 a.m., with the Administrator and DON, they were asked if they could get ahold of TCNA O. During an interview on 8/03/22 at 05:37p.m., the Regional Nurse reported she made attempts to reach TCNA O all day and were unsuccessful. The facility eventually had contact with TCNA O on 08/04/22 and she gave her notice of termination. During an interview on 08/02/22 at 04:49 PM, CNA CC revealed he stated he was there during the incident with Resident #29 and TCNA O. It was a verbal confrontation between Resident #29 and TCNA O, it then became physical from what I heard, and then when TCNA O went back into the room with Resident #29, I went back to the unit for security reasons. Resident #29 said that TCNA O had bit her, and there was a bite mark on Resident #29s leg. I had abuse training prior to this incident, in-services, and have been a CNA for [AGE] years, I have learned some things. He did not feel TCNA O was abusive towards the resident, even after hearing what took place. Interviews on 08/03/22 at 12:24 PM with LVN F, revealed she stated I worked the night shift on whatever night the incident between Resident #29 and TCNA O occurred, and at approximately 10:00 PM or later, I got back from my break and RN DD and CNA CC were back in the secured unit. TCNA O was the aide on the secure unit and had left the facility after an incident with Resident #29 without telling staff what happened. Resident #29 said she and TCNA O had exchanged words, ended up on the ground, Resident #29s legs around the aide's neck, and the aide bit her. LVN did note a circular red mark on Resident #29s right thigh near her pelvis, but she did not chart a skin assessment. TCNA O was not at work for a while after that incident. She called the DON after that to report what happened. LVN F stated I had abuse training prior to the incident and definitely after the incident. Resident #29 had never been aggressive to any staff physically; this was not like her, so I settled her down and made sure she felt safe, because TCNA O was gone from the building, and she had no other issues that night. LVN F stated allowing the residents to call her family member maybe would have helped prevent this whole incident, she may have asked TCNA O to call her family member, I do not know. During an interview on 08/03/22 at 02:57 PM with the Police Officer revealed that night (06/27/22) around 11:30 PM on the secured unit at the facility, TCNA O said Resident #29 could not call her family member at night. This upset the resident and so she pushed on alarmed doors to irritate the staff. The resident was just upset, saying she wanted to report TCNA O, and TCNA O was mad that Resident #29 was going to report her. The resident had gone to her room, and TCNA O came into her room, sat on her bed. The resident wrapped her legs around TCNA O's neck, they both fell to ground and TCNA O bit her leg. Resident #29 was protecting herself she said, that was why she protected herself. The resident's elbow was busted open, black, blue and purple and there was dried blood on her bedding and clothing. I took pictures of the teeth marks on her leg/thigh, and TCNA O admitted she had punched Resident #29 in the face and bit her. The facility should have called the police right away when it happened so we could have taken Resident #29 to the hospital to get checked out. TCNA O should have never been seated on the resident's bed, antagonizing her. Resident #29 was with it, she remembered everything. During an interview on 08/02/22 at 5:00PM, the Administrator stated she was aware of the incident from the DON that morning after the incident between TCNA O and Resident #29 and reported it. It happened because the staff would not allow the resident to call her family member. This upset the resident and she acted out, pulling the fire alarm for attention. It was reported by TCNA O that Resident #29 attacked her, kicked her causing them to fall to the floor. The resident wrapped her legs around the NAs neck and TCNA O bit the thigh of the resident for her to release. The Administrator stated the facility had trained their employees on de-escalation of combative residents and TCNA O should have left the resident alone and allowed her to call her family member to calm the resident down. TCNA O just worked the front hall instead of the secured unit after the incident. During an interview on 08/02/22 at 5:00PM, the Corporate RN stated police had come out and read TCNA O her [NAME] rights, so the facility thought that meant she had to be terminated. TCNAs references and background check were fine, that is why she was hired. Not firing her could affect every resident in the facility she had contact with after this incident by allowing further abuse. During an interview on 08/16/22 at 01:04 PM, the DON stated I got a call from LVN F about the incident that morning and reported it to the Administrator right away. During an interview on 08/03/22 at 02:57 PM with the Police Officer who was dispatched to this incident revealed that night around 11:30 PM on the secured unit at the facility, TCNA O said Resident #29 could not call her family member at night. This upset the resident and so she pushed on alarmed doors to irritate the staff. The resident was just upset, saying she wanted to report TCNA O, and TCNA O was mad that Resident #29 was going to report her. The resident had gone to her room, and TCNA O came into her room, sat on her bed. The resident wrapped her legs around TCNA O's neck, they both fell to ground and TCNA O bit her leg. Resident #29 was protecting herself she said, that was why she protected herself. The resident's elbow was busted open, black, blue and purple and there was dried blood on her bedding and clothing. The office said he took pictures of the teeth marks on her leg/thigh, and TCNA O admitted she had punched Resident #29 in the face and bit her. He said the facility should have called the police right away when it happened so we could have taken Resident #29 to the hospital to get checked out. TCNA O should have never been seated on the resident's bed, antagonizing her. Resident #29 was with it, she remembered everything. 2. Record review of the face sheet dated 8/2/22 revealed Resident #49 was [AGE] years old, male, and admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE] revealed Resident #49 was understood and understood others. The MDS revealed Resident #49 had a BIMS of 7 which indicated severe cognitive impairment and required extensive assistance to total dependence for ADLs. Record review of an undated care plan revealed Resident #49 exhibited verbally abusive behavioral symptoms. Interventions included ignore resident's verbal abuse when directed at you and refocus conversation when resident becomes verbally abusive. During an interview on 8/3/22 at 11:49 a.m., Resident #49 stated he and a staff member exchanged words one day. He said it made me mad and sad because she talked about his mother, and she was his best friend. During an interview on 8/2/22 at 4:23 p.m., Resident #30 said last month, TCNA O cursed out a resident because Resident # 49 threw a tray at her. Resident #30 said I could hear her all the way down to my room and she talked about his momma and dad. She stated TCNA O said, Your mom is [OBSCENITY] and Your dad is a __ and my auntie works here. She said TCNA O was CNA N's niece. During an interview on 8/3/22 at 2:30 p.m., Resident #30 said a verbal altercation between a resident and a CNA happened. She said the altercation was so loud, staff from the front of the building came to the back to see what was happening. She said she was not sure what occurred, but TCNA O cursed a resident down the hall and talking about his mom was a whore and stated, she was going to lose her job today. She said TCNA O cursed the resident out. During an anonymous interview on 8/1/22 at 11:00 a.m., AR said 2-3 weeks ago, he/she heard an aide cursed out a resident. AR said the resident threw his tray and the aide screamed, your mom is a [OBSCENITY] . AR said it happened on 07/03/22. AR said he/she did not know who the resident or aide were. During an interview on 8/3/22 at 10:03 a.m., TCNA L said on 07/03/22, TCNA O did curse out Resident #49. She said the facility was short staffed that weekend and TCNA O came to the back hall to help. She said TCNA O went into Resident #49's room to drop off his lunch tray and screaming started. She said Resident #49 did not throw a plate at TCNA O, put tossed the plate cover on the floor and it did not touch her. TCNA L said her and LVN A pulled TCNA O out of the room and told her to go outside. TCNA L said she told CNA N, the CNA supervisor, about the verbal altercation. She said she had received abuse training upon hire. During an interview on 8/4/22 at 8:45 a.m., LVN A said a loud altercation happened between TCNA O and Resident #49 on 07/03/22. She said Resident #49 threw the lid to the plate and it almost hit TCNA O. TCNA O then cursed Resident #49 and screamed at her aunt who worked here and stated she would lose her job today. LVN A said she attempted to deescalate the situation by separating TCNA O from Resident #49 and told her to go outside for a while then back to the front hall. LVN A said the CNA N showed up at the facility and took TCNA O outside. LVN A said she did not see TCNA O for the rest of the day. She was not sure if TCNA O went home or just stayed down on the front hall. LVN A said she did not assess Resident #49 after the altercation, physically or mentally. LVN A said she felt the altercation was verbal abuse. LVN A said because the on-call nurse and CNA N, who was the CNA supervisor, were in the building they would report the abuse to the administrator. During an interview on 8/3/22 at 5:43 p.m., LVN C said Resident #57 told him about a ruckus that happened over the weekend. He said Resident #57 attempted to play a recording, but it was not working properly. LVN C said he could hear people screaming at each other, but he only heard it for a few seconds. He said Resident #57 said he did not know who was in the recording, but they created a big ruckus. LVN C said he called the administrator on 07/04/22 and told her about the recording because he felt obligated to notify her in case it was verbal abuse. During an interview on 8/3/22 at 10:37 a.m., CNA N said TCNA O and Resident #49 did have an altercation on 07/03/22. She said TCNA O called her and told her about it. She said TCNA O told her Resident #49 threw a plate at her and called her out of her name. She said she told her to leave, and she could not talk to residents like that even if they call you the N word. She said on 07/04/22, LVN C told the Administrator about a recording Resident #57 had on his phone, but he could not hear enough to decipher who it was. LVN C told the administrator Resident #57's phone was not acting right but he felt like she should look into it. CNA N said the Administrator called her to investigate the recording Resident #57 had. She said she asked Resident #57 to listen to the recording he told LVN C about, but he said he did not have it. She said since I could not hear the recording, then there was nothing to investigate. She said the altercation between TCNA O and Resident #49 was abuse. She said TCNA O did not have sufficient abuse and deescalating training before hire. She said the facility was so short staffed when she started, we just need her to work and did not have time to give her sufficient training. She said she did not fire TCNA O because she asked other residents about her care, and no one complained and some even requested her to work on their hall. She said she asked staff about her behaviors, and no one complained. During an interview on 8/3/22 at 12:45 p.m., the Administrator was notified by this surveyor and the team lead of the survey, of reports from staff and residents, verbal abuse had occurred between a resident and staff. The Administrator was also notified of reports from staff, she was notified of the verbal altercation prior to the survey. The Administrator denied any knowledge of abuse in the facility. During an interview on 8/4/22 at 5:40 p.m., the DON said TCNA O's last day worked was 7/31/22. She said she was not told about the incident with Resident #49. She said she was out of town, and no one called her. She said after the first incident with, she did in-service on the prosperity unit, and asked staff about her behavior towards other residents. She said no one complained about her. She said TCNA O was suspended for 2-3 days but disciplinary action was not done. She said she only probably signed the suspension paperwork. She said it should be in her personnel file. During an interview on 8/4/22 at 6:30 p.m., the Administrator said abuse was not tolerated and everyone had been educated on the chain of reporting. She stated she was unaware of the verbal abuse that occurred between TCNA O and Resident #49. She said verbal abuse could make a resident feel threatened and scared. She said it could make residents not trust the staff and have decreased quality of life. Record review of the facility Abuse Prevention Program Policy dated 02/2021 revealed our residents have the right to be free from abuse, including verbal, mental or physical abuse. Our center will protect residents from harm during investigations of all abuse investigations. All reports of resident abuse shall be promptly reported and thoroughly investigated by management.

Based on observation, interview, and record review, the facility failed to provide sufficient number of CNAs on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans and the facility assessment for 8 of 21 residents reviewed for care and services. (Residents #1, #23, #32, #10, #49, #30, #57 and #56) The facility failed to provide sufficient staff on the 6 am-6 pm (07/01/2022-08/02/2022) and the 6 pm-6 am (07/01/2022-08/02/2022) shifts to meet the needs of the residents who required assistance with transfers, incontinent care, and activities of daily living. These failures lead to residents being transferred unsafely with one person for mechanical lifts, not receiving timely incontinent care leading to skin irritations, and not receiving baths leading to embarrassment and harm to health and safety of residents This failure could place residents who required assistance from staff for ADLs at risk for infection, skin breakdown, low self-esteem, and or depression. Findings included: Upon entrance into the facility on [DATE] at 9:00am the Administrator took the surveyors through the building to the back hall to an empty room. On the way there was a resident walking in the hall with t-shirt and soggy brief down to her knees, no pants with hair in disarray. The pungent odor made surveyors gag all the way down the hall and eyes water from the ammonia smell. Breakfast was still being served at this time. On the way down the hall the Administrator kicked a large (2-3 inch) water bug with her foot to the side. The survey team was placed in room with yellow stains on the wall with a strong urine odor. Brown stains were noted on the bathroom walls also. Record review of the Facility Assessment Tool updated on 7/26/2022, revealed the facility's average census for the past 12 months was 62 residents and the number of staff needed to work was 5 CNAs on day shift and 5 CNAs on evening/night shift, for a total of 10 CNAs in a 24 hour period. Updated on 7/26/2022 related to the addition of the specialized behavioral unit and 12-hour CNA shifts. Record review of the 2021 Facility Assessment Tool with the average census of 61 required 11 CNA's in a 24-hour period. Record review of the Daily Staffing Sheets dated 7/1/2022 to 8/2/2022 showed the following worked: average census 62 *07/01/2022 (6am-6pm) 2 CNAs and 2 CNAs (6pm-6am) *07/02/2022 (6am-6pm) 3 CNAs and 4 CNAs (6pm-6am) *07/03/2022 (6am-6pm) 3 CNAs and 3 CNAs (6pm-6am) *07/04/2022 (6am-6pm) 2.5 CNAs and 3 CNAs (6pm-6am) *07/05/2022 (6am-6pm) 2 CNAs and 3 CNAs (6pm-6am) *07/06/2022 (6am-6pm) 3 CNAs and 3 CNAs (6pm-6am) *07/07/2022 (6am-6pm) 3 CNAs and 3 CNAs (6pm-6am) *07/08/2022 (6am-6pm) 2 CNAs and 3 CNAs (6pm-6am) *07/09/2022 (6am-6pm) 2 CNAs and 2 CNAs (6pm-6am) *07/10/2022 (6am-6pm) 2 CNAs and 3 CNAs (6pm-6am) *07/11/2022 (6am-6pm) 3 CNAs and 3 CNAs (6pm-6am) *07/12/2022 (6am-6pm) 2 CNAs and 4 CNAs (6pm-6am) *07/13/2022 (6am-6pm) 3 CNAs and 3 CNAs (6pm-6am) *07/14/2022 (6am-6pm) 3 CNAs and 4 CNAs (6pm-6am) *07/15/2022 (6am-6pm) 4 CNAs and 4 CNAs (6pm-6am) *07/16/2022 (6am-6pm) 4 CNAs and 4 CNAs (6pm-6am) *07/17/2022 (6am-6pm) 4 CNAs and 4 CNAs (6pm-6am) *07/18/2022 (6am-6pm) 3 CNAs and 3 CNAs (6pm-6am) *07/19/2022 (6am-6pm) 3 CNAs and 3 CNAs (6pm-6am) *07/20/2022 (6am-6pm) 4 CNAs and 4 CNAs (6pm-6am) *07/21/2022 (6am-6pm) 3 CNAs and 3 CNAs (6pm-6am) *07/22/2022 (6am-6pm) 4 CNAs and 3 CNAs (6pm-6am) *07/23/2022 (6am-6pm) 2 CNAs and 3 CNAs (6pm-6am) *07/24/2022 (6am-6pm) 2 CNAs and 3 CNAs (6pm-6am) *07/25/2022 (6am-6pm) 3 CNAs and 3 CNAs (6pm-6am) *07/26/2022 (6am-6pm) 4 CNAs and 3 CNAs (6pm-6am) *07/27/2022 (6am-6pm) 3 CNAs and 4 CNAs (6pm-6am) *07/28/2022 (6am-6pm) 4 CNAs and 4 CNAs (6pm-6am) *07/29/2022 (6am-6pm) 3 CNAs and 4 CNAs (6pm-6am) *07/30/2022 (6am-6pm) 3 CNAs and 4 CNAs (6pm-6am) *07/31/2022 (6am-6pm) 3 CNAs and 4 CNAs (6pm-6am) *08/01/2022 (6am-6pm) 3 CNAs and 1 CNAs (6pm-6am) *08/02/2022 (6am-6pm) 4 CNAs and 2 CNAs (6pm-6am) Record review of the CMS 672 dated 08/01/2022 indicated a census of 62 with the following: *20 residents required assist of one or two staff for bathing. *39 residents were dependent for bathing. *53 residents required assist of one or two staff for dressing. *9 residents were dependent for dressing. *51 residents required assist of one or two staff for transfers. *10 residents were dependent for transfers. *44 residents required assist of one or two staff for toilet use. *18 residents were dependent for toilet use. *58 residents required assist of one or two staff for eating: and *3 residents were dependent for eating. 1. Record review of the face sheet revealed Resident #1 was [AGE] year-old male that was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the annual MDS dated [DATE] indicated Resident #1 had a BIMS of 15, which indicated no cognitive impairment. The MDS indicated he required limited assistance with ADLs, and he had physical behavioral symptoms directed towards others and verbal behavioral symptoms directed toward others exhibited 1 to 3 days. During an interview on 8/3/2022 at 8:12 am, Resident #1 stated he was upset and wanted to file a grievance because he did not get a supper tray the previous night and did not get any nighttime medication. Resident #1 stated he had his call light on for hours without it being answered and when they came in the aide said she was the only one here. Resident #1 stated there is never enough staff. It does not matter the day of the week of the time of day, it takes forever to get assistance. 2. Record review of a face sheet revealed Resident #23 was a [AGE] year-old male, that admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of an MDS dated 6 /08/2022 indicated Resident #23 had a BIMS of 08, which indicated a mild cognitive deficit. Resident #23 required extensive to extensive assistance with ADLs of personal hygiene and bathing. Resident #32 was understood and understood others. Record review of a care plan dated 7/27/2022 titled ADL care listed an intervention to aid with bathing/showering 3 times per week and a sponge bed bath on non-shower days if needed. During an observation on 8/1/2022 at 9:33AM, Resident #23 stated he only got a bath about once every 2 weeks and had not had his hair washed in a couple months. Resident #23's hair was noted to be greasy. There was a strong smell of urine noted when entering the room. When asked if he would like a bath 3 days a week, he stated at least twice a week would be nice since he peed on himself so he could keep my skin clean. Resident #23 was noted to have long dirty fingernails. They were noted to be 3/4 inch from fingertips with a brown substance under all nails. There were yellow stains noted to his pillowcase when he lifted his head. Gray stubble covered Resident #23s face, approximately 1/2 inch long. Resident #23 stated the facility shaved him last week when he got his bath, but he liked to be shaved clean. Resident #23 stated he would like more than one bath a week but not every day. He stated he liked to feel clean it made him feel and smell better. Record review of the point of care ADL report dated 5/26/2022-6/30/2022, there was documentation of 5 baths being given (6/11,6/21, 6/23,6/25, and 6/30). According to the bath schedule Resident #23 should have received 15 baths in this time. No refusals were documented, or care planned for Resident #23. 3.Record review of a face sheet revealed Resident #32 was a [AGE] year-old-male that was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE] revealed Resident #32 was usually understood and usually understood others. Resident #32 was noted to have a BIMS of 04 which indicated a significant cognitive impairment and he required extensive assistance with ADLs such as transfer, bathing, and bed mobility. Record review of a care plan for Resident #32 dated 6/29/2022 titled general had interventions listed for nail care to be done every Tuesday, Thursday, and Saturday on the 6pm to 6am shift. The interventions also listed bathing to occur every Tuesday, Thursday, and Saturday on the 6pm-6am shift. During an observation and interview on 8/1/2022 at 9:33AM, Resident #32 was noted to have a foul odor of ammonia and feces. The resident had dirty long fingernails with thick brown gummy like substance underneath that were 3/4 to 1 inch from the tip of fingers. When asked if he would like a bath, Resident #32 shook his head yes and stated yeah. Record review of the point of care ADL report dated 5/26/2022-6/30/2022, there was documentation of 6 baths being given of the 15 baths due during this time frame. No refusals were documented, or care planned for Resident #32. 4. Record review of the face sheet dated 8/4/22 revealed Resident #10 was [AGE] years old, male, and admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE] revealed Resident #10 was understood and understood others. The MDS revealed Resident #10 had adequate vision. The MDS revealed Resident #10 had a BIMS of 14 which indicated intact cognition and required extensive assistance with two people assist for dressing, bed mobility, and transfers. And required total dependence with two people assist for toilet use, personal hygiene, and bathing. Record review of the care plan dated 7/13/22 revealed Resident #10 had self-care deficit related to [CONDITION(S)] as evidence by required assistance with ADLs. Intervention included total x 1-2 assistance with bath/showering 3 times a week. The care plan revealed Resident #10 had episodes of resisting care including showers. Interventions included monitor for early signs of behavior, approach in calm manner, and when refuses care re-approach later, notify nurse to document in chart. Record review of a care plan dated 7/13/22 revealed Resident #10 required total assist x2 (with lift) for transfers. Record review of the point of care history dated 5/4/22-8/4/22 revealed Resident #10 received no baths documented in May 2022. In June 2022, Resident #10 received 3 (6/23/22,6/25/22,6/27/22) partial bed baths (bathing the following areas: face, hands, underarms, back, buttocks and genital) and showers (6/24/22, 6/25/22, 6/30) out of 13 days. In July 2022, Resident #10 received 12 partial bed baths (7/1/22,7/3/22, 7/6/22,7/7/22, 7/8/22, 7/11/22,7/12/22, 7/25/22, 7/26/22, 7/27/22, 7/29/22, 7/30/22) 2 showers (7/5/22,7/23/22), and 1 complete bed bath (7/26/22) out of 13 days. No refusals were documented on the point of care history. During an interview and observation on 8/1/22 at 10:30 a.m., Resident #10 said he had not had a shower since Wednesday (7/27/22). Resident #10 had greasy hair with dry, white patched noted to his scalp. Resident #10 said his hall only had one CNAs for a lot of residents. He said on the weekends, folks barely came to work. 5. Record review of the face sheet dated 8/4/22 revealed Resident #49 was [AGE] years old, male, and admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE] revealed Resident #49 was understood and understood others. The MDS revealed Resident #49 had a BIMS of 7 which indicated severe cognitive impairment and required extensive assistance for bed mobility, transfers, and personal hygiene. And total dependence for dressing and bathing. The MDS dated [DATE] revealed Resident #49 was a tobacco user. Record review of the undated care plan revealed Resident #49 was a fall, safety, elopement risk with interventions of encourage use of call light and keep call light within reach. The undated care plan revealed Resident #49 would have the following tasks documented in POC. Intervention included bath/showers on Tuesday, Thursday, and Saturday on the 6am-6pm shift. Bathing/hygiene assist amount not specified. Record review of the undated care plan revealed Resident #49 was a smoker. Intervention included need to wear a smoking apron. During an observation and interview on 8/1/22 at 10:30 a.m., Resident #49 was in bed with his call light on the floor. Resident #49 said he did not know where his call light was but even if he had it, staff do not answer it. He said if he needed assistance then he must holler out but he said his voice was not that loud so he could not be heard. During an interview on 8/2/22 at 10:00 p.m., Resident #49 said he was out of snuff and the person who used to buy it for him does not anymore. He said he would really like to smoke a cigarette, but no one will get him up. He said staff do not want to get him up to smoke because he needs to be put back to bed soon afterwards. He said he cannot sit up for long periods of time because of his back issues. He said he has been a smoker for half of his life, and it sucked he could not do it now. During an interview on 8/3/22 at 10:37 a.m., CNA N said Resident #49 was a smoker, but he wanted staff to immediately put him back to be afterwards. She said due to lack of staffing, she could not accommodate him. She said she normally worked the back hall which had 15 residents and most to all required some type of assistance with ADLs. She said the back hall had a lot of smokers so that took a lot of time and non-smoking resident's call lights were not being answered timely. She said since she was the CNA coordinator, if she could not find staffing after call ins, she had to come in to cover the shift. During an interview on 8/4/22 at 5:40 p.m., the DON said it was not right for Resident #49 to be denied smoke breaks because staff did not want to put him back to bed. She said it infringed on his right to smoke. She said Resident #49 being denied his smoke breaks could cause depression because he cannot do something he likes. She said he already had depression issues because of his loss of independence. During an interview on 8/4/22 at 6:30 p.m., the Administrator said not allowing Resident #49 to smoke due to lack of staffing was not an excuse. She said Resident #49 had the right to smoke and to be assisted out of bed to smoke. She said she did not know that Resident #49 wanted to smoke cigarettes and was being denied by staff. She said the resident rights were supposed to be reviewed in resident council meetings but a copy of it was in the admission packet. She said not all residents sign their admission packets and may not have received a copy of the resident rights. She said residents not knowing their residents' rights could make them feel unheard with no voice in their home leading to depression and anxiety. 6. Record review of the face sheet dated 8/1/22 revealed Resident #57 was [AGE] years old, male, and admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE] revealed Resident #57 was understood and understood others. The MDS revealed Resident #57 had a BIMS of 15 which indicated intact cognition and required total dependence for all ADLs. The MDS revealed Resident #57 rejected evaluation or care 1 to 3 days. Record review of the undated care plan revealed Resident #57 the following tasks will be documented in POC. Interventions included bath/showers and nail care on Tuesday, Thursday, and Saturday on the 6pm-6am shift. The care plan revealed Resident #57 had limited physical mobility, bedfast all or most of the time related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Intervention included reposition every 2 hours. Record review of the point of care history dated 5/4/22-8/4/22 revealed Resident #57 received 2 complete bed bath (5/28/22,5/29/22) and 1 partial bed bath (5/31/22) out 13 days in May 2022. In June 2022, Resident #57 received 5 complete bed baths (6/1/22, 6/2/22, 6/3/22, 6/7/22, 6/8/22), 3 partial bed baths (6/4/22, 6/5/22, 6/8/22), and 2 showers (6/3/22, 6/9/22) out of 13 days. In July 2022, Resident #57 had no documentation of bed bath or shower. No refusals were documented on the point of care history. Record review of the progress notes dated 7/11/22 -8/1/22 revealed no nursing documentation of bed bath/shower refusals. During an observation and interview on 8/1/22 at 11:27 a.m., Resident #57 was lying in bed with a large, yellow stained pillow. Resident #57 had greasy hair, flaky, dry skin to his face with redness noted, and long nails with brown matter underneath. Resident #57 said he had not had his hair washed since he was admitted . He said he sometimes gets bed bath, but they do not wash his hair. He said on 7/31/22, his urinal overflowed on to his sheets and no one came to change his linens for 12 hours. He said on the weekends and nights staffing was short, which is when he has the most issues. He said he had to call 911 to get help sometimes because they did not answer his call light or phone call to the front desk. Record review of meal report dated 7/3/22-8/3/22 revealed on 8/2/22 at 10:29 p.m. and 10:30 p.m., 51-75% supplements were taken by Resident #57 given by LVN I. The meal report revealed Resident #57 last documentation of intake on 8/2/22 was at 1:10 p.m. During an interview on 8/2/22 at 9:41 p.m., CNA H said she was doing the best she could as the only CNA for the back hall (15 residents) and the secured unit (21 residents). She said she did not have time to feed Resident #57. During an interview on 8/2/22 at 10:00 p.m., Resident #57 said he had not been fed supper yet. He said staff brought his dinner tray around 5:45 p.m., and he did not like the look of the pureed food, so he asked for a sandwich or bowl of fruit loops. He said staff took his tray and never came back. During an interview on 8/2/22 at 10:10 p.m., LVN I said she was unsure if Resident #57 was fed his supper, she said she had not fed him. She said she would not be surprised if he was not fed because night shift was short staffed. During an interview on 8/3/22 at 8:45 a.m., the Administrator said she sent the CNA, who came in to work to help night shift, feed Resident #57 a bowl of cereal around 10:45 p.m. 7. Record review of the face sheet dated 8/3/22 revealed Resident #30 was [AGE] years old, female, and admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE] revealed Resident #30 was understood and understood others. The MDS revealed Resident #30 had a BIMS of 15 which indicated intact cognition and required total dependence with 2 plus people assist with all ADLs. Record review of the care plan dated 4/27/22 revealed Resident #30 required total x 2 people with lift for transfers. During an interview on 8/2/22 at 4:23 p.m., Resident #30 said call lights were not regularly answered timely. She said the facility was short staffed especially on the weekends and if there was not enough staff, CNAs will not get you up. She said she was transferred with lift x 1 person 98% of the time. 8. Record review of the face sheet dated 8/4/22 revealed Resident #56 was [AGE] years old, female, and admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE] revealed Resident #56 was understood and understood others. The MDS revealed Resident #56 had a BIMS of 7 which indicated severe cognitive impairment and required total dependence with transfers. Record review of a care plan dated 7/27/22 revealed Resident #56 had self-care deficit related to dementia/[CONDITION(S)]/muscle weakness as evidence by required assistance with ADLs. Intervention included total assist x 1-2 people for transfers. During an interview on 8/1/22 at 2:50 p.m., Resident #56 said she had not been changed since breakfast time around 7:00 a.m. She said it burned when she urinated and the odor when they change her was embarrassing. She said she got a bed bath about once a week. She said staff took about 1-2 hours to answer call lights and it happened about three times a week. During an interview on 8/2/22 at 9:41 p.m., CNA H said she was doing the best she could as the only CNA for the back hall and the secured unit. She said she had not given any bathes this evening. She said there was no way she could do that by herself. She said it was short staffed 90% of the time. CNA H stated she had no choice but to leave the secured unit unattended to help the nurse get people to bed. CNA H said occasionally there will be a day we have 4 CNA on night shift. During an interview on 8/2/22 at 10:30 p.m., the Administrator said the staffing numbers for the facility was to have 5 CNAs on day and night shifts, but she felt the facility ran well with 3 staff members. The Administrator was made aware of having only 2 CNA's this night shift, no showers had been given, and the secure unit was left unattended. During an interview on 8/3/22 at 10:03 a.m., TCNA L said she had been at the facility for a month. She said she normally worked the front and center halls. She said residents do not get their scheduled bed baths or showers due to lack of staff. She said if a resident was scheduled for a bed bath or shower on the night shift, it probably was not going to get done. During an interview on 8/3/22 at 10:37 a.m., CNA N said she was the CNA staff coordinator and worked the floor. She said call lights should be always in reach and functioning. She said due to lack of staffing, call lights were not answered timely, and residents did complain to her about call light response time. She said call lights not being in reach or non-functioning could cause falls and resident's needs not being met. She said due to lack of staff, residents did not get their scheduled bath/showers, nail care or oral care. She said she tells the CNAs to at least wash the residents face and hands. She said CNAs did not wash resident's hair if they got bed baths. During an interview on 8/4/22 at 5:40 p.m., the DON said call lights not being answered, in reach, or non-functioning could cause more falls. She said anyone that enters the room to provide care for the residents, was responsible for the call light being in reach. She said resident having to wait for long period of time to get changed could cause skin issues. She said it could make the resident feel sad because they may not feel important or seen. The DON said she knew ADLs were not getting done due to staffing issues. She said staff are burnout and don't want to come in on their off day. She said residents not getting showers/bed baths, hair washed, nail care, and overall personal hygiene could cause skin integrity issues and infections. She said resident can become depressed from not getting ADLs done. She said residents needs not being met can cause behaviors. The DON stated the administrator and corporate come up with the staffing numbers based on census and acuity and those are the numbers that the staffing coordinator are instructed to staff. However, it was a matter of not having enough people employed to fill those positions. She stated it had been discussed several times in the past to slow down on or stop taking admissions until the facility was staffed properly but corporate would not hear of it. During an interview on 8/4/22 at 6:30 p.m., the Administrator said residents having their call light in reach and functioning was very important for everyone. She said having non-functioning call light or call light not within reach could lead to falls, increased skin problems, and unhappy residents. She said all CNAs and nurses were responsible for ensuring call lights in reach and functioning properly. She said if staff found a call light out of reach, they need to put it within reach. The Administrator said being short of staff can affect resident care and make them miss baths, grooming, activities, have skin issues, miss medications, and have decreased quality of life. The Administrator stated she was responsible for making the facility assessment and she did include thing like acuity of residents and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During record review an in service titled Secure Unit Staffing form 3/2/2022 stated: The secure unit will have a minimum of two nursing staff members on the unit at all times. If one member leaves the unit, the nurse must be notified so that a replacement can be placed. The secure unit nurse is accountable for having appropriate staff on the unit at all times. During an observation on 8/2/2022 at 9:50PM there were no employees on the secured unit with 18 residents present. The one CNA assigned to the unit was outside of the unit assisting the nurse to put other residents to bed. There were 2 CNAs and 2 nurses in the entire building with 63 residents at that time. Record review of grievances and in services revealed grievances filed concerning call lights not being answered timely on 2/11/2022 (Resident #1), 3/18/2022(Resident #56), 4/14/2022 (family member), 4/14/2022 (ombudsman), and 8/3/2022 (Resident #1). An in service was done on 3/2/2022 by that revealed: call lights will be answered promptly and in a timely manner. Residents are to be addressed in a professional manner using their last name unless they are direct otherwise. If upon entering the resident's room, you are not able to address the resident's need you will leave the call light on and get the appropriate help. If you are able to meet the resident's need you will turn off the light and complete the desired task. Call lights must always be within reach and in working order. During an interview on 8/3/2022 at 10:03 am TCNA L stated residents do not get scheduled baths or call lights answered timely. TCNA L stated it was hard to get help because the facility was always short staffed. TCNA L said she was seriously considering quitting because how stressful the job was. TCNA L stated some of the resident's behaviors are due to not having enough staff and waiting such a long time for help. During an interview on 8/3/2022 at 10:37 pm CNA N stated there was supposed to be 10 CNAs staffed in the building every 24 hours due to the number and type of residents they cared for. CNA N stated they staffed 4 CNAs on day shift which included her and 3 on night shift on average. CNA N stated everyone was aware of shortage and it was because they paid $9.00 or $10.00 an hour and the gas station across the street paid $13.00 an hour. CNA N stated the population in the building was difficult to work with and people were not going to do it for nothing. CNA N stated she was aware that call lights were not answered timely, of the lack of showers and bed baths given, and that the residents did not get their hair washed when getting a bed bath. CNA N stated she knew mechanical lifts should always be done with 2 people, but she did them on her own because there was not enough staff and she considered herself a seasoned CNA. A policy was requested on 8/3/2022 at 3:45pm for sufficient staffing from the administrator. The policy was requested again on 8/4/2022 at 1:10pm from the RN consultant. No policy was given regarding sufficient staffing.

Based on interviews and record review, the facility failed to ensure a resident did not receive medications without an indication for use for 1 (Resident #8) of 1 resident reviewed for unnecessary medications. The facility administered Resident #8 [MEDICATION(S)] (antipsychotic used to treat [CONDITION(S)]) without trying other medication interventions, after behaviors exhibited from COVID-19 isolation. This failure could place residents at risk for receiving unnecessary medications. Findings included: Record review of the face sheet dated 8/1/22 revealed Resident #8 was [AGE] years old, female, and was admitted from the psychiatric hospital on 9/27/21 and 7/11/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE] revealed Resident #8 was currently considered by the state level II PASRR process to have serious mental illness. The MDS revealed Resident #8 was understood and understood others. The MDS revealed Resident #8 had a BIMS of 14 which indicated intact cognition and required supervision-total dependence for ADLs. The MDS revealed Resident #8 did not exhibit physical, verbal, other behavioral symptoms. The MDS revealed Resident #8 liked to do things with groups of people, doing favorite activities, and go outside to get fresh air when weather is good was very important. The MDS revealed Resident #8 used a wheelchair for mobility. Record review of the care plan dated 6/22/22 revealed Resident #8 had impaired decision making related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included clarify misconceptions, encourage self-evaluate, respect rights to make decisions, support, and reassure in new situations. The care plan indicated Resident #8 had emotional distress related to missing limbs. The care plan revealed [CONDITION(S)] drug use with interventions of monitor side effects and target behaviors. Record review of the consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] Sprinkles (a mood stabilizer medication that works in the brain) 125 mg 2 capsules once a day in the morning (7am-10am) start date 7/11/22, -[MEDICATION(S)] Sprinkles 125 mg 4 capsules at bedtime (7pm-10pm) start date of 7/11/22, - [MEDICATION(S)] (works in the brain to prevent seizures and relieve pain for certain conditions in the nervous system) 100mg 2 capsules three times a day (morning, mid-day, and bedtime) started 9/27/21, -[MEDICATION(S)] (used to treat seizures and panic disorder) 1mg 1 tablet twice a day (morning and bedtime) started 8/1/22, -[MEDICATION(S)] (helps with the timing of your circadian rhythms (24-hour internal clock) and with sleep) 3mg 3 tablets at bedtime started 7/12/22, and -[MEDICATION(S)] (an antidepressant medication that works in the brain. It is approved for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the progress notes dated 7/11/22 at 8:00 p.m., written by RN DD revealed Resident #8 arrived at the facility from a psychiatric hospital with COVID-19. The progress note revealed [MEDICATION(S)] was increased to 1 mg at bedtime for anxiety and [MEDICATION(S)] decreased to 10 mg once a day. The progress note revealed new orders for [MEDICATION(S)] 9mg at bedtime and [MEDICATION(S)] sprinkle 250mg in the morning and 500 mg at bedtime. The progress note revealed discontinue [MEDICATION(S)] (is used to treat confusion (dementia) related to Alzheimer's disease), bio freeze, [MEDICATION(S)] (is used to treat pain and redness, swelling, and heat (inflammation) from [CONDITION(S)]), and [MEDICATION(S)] (is a strong pain medication used to treat moderate to severe pain that is not being relieved by other types of pain medicines). Record review of the progress note dated 7/13/22 at 9:13 a.m., written by the DON revealed Resident #8 was in the hallway refusing to abide by quarantine rules due to her being covid positive. Resident redirected multiples times by this nurse and administrator. Resident verbally aggressive to staff but returned to room. Encouraged to use call light for needs and stay in her room and follow quarantine guidelines. Record review of the progress note dated 7/13/22 at 12:16 p.m., written by the DON, revealed Resident #8 in hall yelling and cussing at staff and trying to hit CNA in room. Attempted to throw self on the floor. Unable to redirect at this time NP K in facility and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] given to Left deltoid at time. Encouraged resident to calm down. And that she had to quarantine per CDC guidelines and that she could go back to her old room after 14 days. She agreed and apologized stated that she was claustrophobic. Explained that she could sit in doorway just could not go down the hall Record review of the progress note written by LVN GG dated 7/13/22 at 1:40 p.m., revealed due to Resident #8 being noncompliant with isolation and having multiple behaviors NP K was contacted. NP K gave orders for [MEDICATION(S)] 5mg q6h prn x 5 days then review with NP K to extend orders or dc all together. Record review of the Resident #8's progress notes dated 7/16/22, 7/18/22, and 7/19/22 had no behaviors documented. Record review of Resident #8 clinical record revealed there was no documentation of a verbal or written consent for [MEDICATION(S)]. Record review of the Behavior Monitoring dated 5/4/22-8/4/22 revealed Resident #8 had no behaviors documented on 7/13/22. Record review of the aggressive/combative behavior report dated 1/1/22-8/2/22 revealed no events involving Resident #8. During an interview and observation on 8/1/22 at 3:30 p.m., Resident #8 was sitting in her wheelchair in the common area. When this surveyor approached Resident #8 to interview her, she appeared nervous, she said Do you have shot? I have been good. During an interview on 8/4/22 at 9:00 a.m., NP K said she was informed by the DON, Resident #8 was slapping at staff and residents, see things, and trying to hurt herself. She said the DON told her they had attempted to redirect and remove Resident #8, but she was uncooperative. NP K said for safety I ordered [MEDICATION(S)]. NP K said staff did not inform her if Resident #8 had received her morning medications or not. She said she did not order [MEDICATION(S)] because it had not worked in the past. She said when resident displayed aggressive behaviors or agitation, we first try redirection then benzodiazepines (work to calm or sedate a person, by raising the level of the inhibitory neurotransmitter GABA in the brain. Common benzodiazepines include [MEDICATION(S)] ([MEDICATION(S)]), [MEDICATION(S)] ([MEDICATION(S)]), and [MEDICATION(S)] ([MEDICATION(S)]), among others) or a psychiatric hospital. She said Resident #8 had just left a psychiatric hospital two days ago, so we did not want to send her back. She said Resident #8 was putting others in jeopardy because she had COVID. She said Resident #8 was on the hall with one other COVID resident. She said the COVID positive hall was about 10-12 rooms down from non-COVID residents. She said we gave Resident #8 [MEDICATION(S)] to keep her in the room for the safety of residents and staff. She said Resident #8's agitation may have been caused by being isolated. On 8/4/22 at 10:52 a.m., attempted to call Resident #8's responsible party, no answer, left message. On 8/4/22 at 10:54 a.m., attempted to call Resident #8's responsible party's relative, no answer, left message. During an interview on 8/4/22 at 3:46 p.m., LVN GG said she said she was not on duty when Resident #8 received the [MEDICATION(S)] IM. She said she had to leave for a family emergency and the DON took over her hall. She said when she returned later, they told her what happened. They told her Resident #8 was upset because she did not want to stay in her room and acted out. She said she never had to use [MEDICATION(S)] on her or other residents. She said Resident #8 was a social butterfly, so she probably did not like being isolated. She said there was one other resident on the hall who was a new admission. She said the non-isolated residents were 8-10 rooms down from the hot (COVID positive) hall. She said the facility normally tried snacks and activities before medications. She said snacks normally worked for residents. She said she thought Resident #8 had taken her morning medications. She said it was sad Resident #8 assumed new people were going to give her a shot and told them she had been good. During an interview on 8/4/22 at 5:40 p.m., the DON said she worked the hall the day Resident #8 received the [MEDICATION(S)] injection. She said Resident #8 was yelling and being aggressive to staff members. She said Resident #8 was on isolation due to being COVID positive. She said Resident #8 kept coming out of her room and going out the back door. She said they offered Resident #8 to sit in the doorway, snacks, tv, activities, and music but it would only help for a while. She said Resident #8 had calmed down then we gave her the [MEDICATION(S)] shot. She said Resident #8 was fine afterwards. She said she did not know if Resident #8 had refused her morning medication and they did not try other medications for agitation. She said she did not see giving Resident #8 [MEDICATION(S)] IM as unnecessary medication. During an interview on 8/4/22 at 6:30 p.m., the Administrator said the facility did not use chemical restraints on residents. The Administrator said she did not feel Resident #8 was chemically restrained. The Administrator said the medication was given to keep Resident #8 from spreading COVID to the rest of the building. She said nursing staff had a doctor's order for the medication, [MEDICATION(S)]. The Administrator said she was not aware of other medications Resident #8 was taking or if they had tried other interventions prior to injecting Resident #8 with [MEDICATION(S)]. Record review of a facility Behavioral assessment, intervention, and monitoring policy dated July 2019 revealed behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment .residents will have minimal complications associated with the management of altered or impaired behavior .the facility will comply with regulatory requirements related to the use of medications to manage behavioral changes . Behavior is the response of an individual to a wide variety of factors. These factors may include medical, physical, functional, psychosocial, emotional, psychiatric, or environmental causes . Behavior is regulated by the brain and is influenced by past experiences, personality traits, environment, and interactions with other people. Behavior can be a way for an individual in distress to communicate unmet needs, indicate discomfort, or express thoughts that cannot be articulated . Appropriate assessment and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition, including . Onset, duration, intensity, and frequency of behavioral symptoms . b. Any precipitating or relevant factors, or environmental triggers (e.g., medication changes, infection, recent transfer from hospital); and .c. Appearance and alertness of the resident and related observations .New onset or changes in behavior will be documented regardless of the degree of risk to the resident or others .The resident and/or resident surrogate will have the right to refuse treatment .Non-pharmacologic approaches will be utilized to the extent possible to avoid or reduce the use of antipsychotic medications to manage behavioral symptoms .When medications are prescribed for behavioral symptoms, documentation will include .Rationale for use .Potential underlying causes of the behavior .Other approaches and interventions tried prior to the use of antipsychotic medications .Potential risks and benefits of medications as discussed with the resident and/or family .Specific target behaviors and expected outcomes .Dosage . Duration .Monitoring for efficacy and adverse consequences .The Director of Nursing, or designee, will evaluate whether the staffing needs have changed based on acuity of the residents and their plans of care .

Based on interview and record review, the facility failed to ensure1 of 5 residents reviewed for medications was free from significant medication errors. (Resident #2) Resident #2 had orders for [MEDICATION NAME] sprinkles, [MEDICATION NAME], and levetiracetam to control convulsions. Resident #2 did not receive the doses of these medications as ordered on 2 consecutive days. The following day, Resident #2 experienced a [MEDICAL CONDITION] and was sent to the hospital. This failure could place 15 residents with [MEDICAL CONDITION] [DIAGNOSES REDACTED]. Findings included: The current physician orders [REDACTED].#2 indicated she was [AGE] years and admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. Medication orders included: * [MEDICATION NAME] (anticonvulsant), 1 milligram, three times a day, 8:00 a.m., 12:00 p.m., 6:00 p.m. * [MEDICATION NAME] sprinkles (anticonvulsant), 1000 milligrams, once a day, 6:00 p.m. * levetiracetam (anticonvulsant), 10 milliliters (500 milligrams per 5 milliliters), once a day, 6:00 p.m. The Medication Administration Records for Resident #2 showed the following medications and times which were initialed and circled on the document. There were no indications on the front or the back of the document as to why the medications were not administered. * 01/24/17, 6:00 p.m., [MEDICATION NAME], 1 milligram * 01/24/17, 6:00 p.m., [MEDICATION NAME] sprinkles, 1000 milligrams * 01/25/17, 8:00 a.m. and 12:00 p.m., [MEDICATION NAME], 1 milligram * 01/25/17, 8:00 a.m., levetiracetam, 10 milliliters (500 milligrams per 5 milliliters) During an interview on 02/23/17 at 11:31 a.m., MA C said she attempted to provide medications to Resident #2 on 01/25/17, but the resident was too drowsy and she did not take them. She said she initialed and circled the medications on the Medication Administration Record, [REDACTED]. She said she did not document the reason for not giving the medications, but she did tell the charge nurse. She said another staff was responsible for the medication pass on 1/24/17. The nursing notes for Resident #2 showed no documentation during 01/24/17 or 01/25/17, that the resident was not given her medications and why. There was no documentation that the resident was unusually drowsy during those days. During an interview on 02/23/17 at 1:09 p.m., the DON said a circle around staff's initial on Medication Administration Record [REDACTED]. She said the staff are supposed to document on the back of the sheet as to why the medication was not given. They are also supposed to report to the charge nurse. The nursing notes for Resident #2 indicated on 01/26/17 the resident had a [MEDICAL CONDITION] and was subsequently sent to the hospital (on that date). The resident was in the hospital through 01/30/17. A hospital laboratory report for [MEDICATION NAME] acid ([MEDICATION NAME]) dated 01/26/17 at 3:31 p.m. indicated Resident #2 had a result of less than 3.0. The report indicated the normal range was 50 to 100. According to https://www.drugs.com/ accessed 3/10/17 [MEDICATION NAME], and levetiracetam are anticonvulsants used to prevent [MEDICAL CONDITION]. A report from the DON, dated 03/03/17, indicated there were 15 residents with [MEDICAL CONDITION] [DIAGNOSES REDACTED].

Based on observation, interview, and record review, the facility failed to ensure the residents' environment was free from accidents hazards for 1 of 8 residents reviewed for accidents. (Resident #1) Resident #1 was transported in the facility van in his wheelchair without shoulder straps. The facility did not ensure the van had functional shoulder straps to secure residents. The van was involved in an accident causing Resident #1 to be ejected from his wheelchair resulting in fractures to his nose and leg. An Immediate Jeopardy was identified that existed from July 7, 2015 through July 7, 2015. Prior to entrance, the van was taken to a local salvage yard and will no longer be used to transport residents. However, the facility remained out of compliance at a pattern of actual harm due to the need to correct the failure that led to the immediate jeopardy. This failure could place 43 residents who required a wheelchair at risk for injury. Findings included: A physician order [REDACTED].#1 was a [AGE] year old male, admitted on [DATE], with [DIAGNOSES REDACTED]. A MDS dated [DATE] indicated Resident #1 was totally dependent on staff in performing all ADLs, mobility and required the use of a wheelchair. A care plan dated 07/09/15 indicated Resident #1 had swelling, abrasions, pain related to a fractured knee and nose due to a motor vehicle accident. He required total assistance of two to five staff for bed mobility and transfers due to recent fractures. Hospital records dated 07/07/15 indicated Resident #1 arrived at the hospital via ambulance. Resident #1 was in a wheelchair in the back of a van when he was ejected from the wheelchair sustaining injuries to his head and left knee. An X-ray report dated 07/07/15 indicated fractures of the right nasal bone and oblique fracture through the distal femur. A Provider Investigation Report dated 07/08/15 indicated on 07/07/15 Resident #1 was being transported in the facility van when it was involved in an accident causing Resident #1 to be ejected from his wheelchair resulting in a fracture to the right side of his nose and left femur. During an observation and interview on 08/04/15 at 9:30 a.m., Resident #1 was sitting on the front porch. He was noted with a brace on his left knee. There was no noted swelling or bruises to his face. He said he remembered the incident, but could not give any details of what happened. During an interview on 08/04/15 at 9:10 a.m., CNA A said on 07/07/15 she was transporting Resident #1 in the van when a car in front of her stopped suddenly and she had to apply the brakes. She said she hit the rear end of the car. She said she turned around to check on Resident #1 and he was on the floor. CNA A said Resident #1's nose was bleeding and he was in pain. She said she buckled Resident #1 using a seatbelt across his lap. She said there was no shoulder strap. She said the only available strap was a lap belt. She said shoulder straps were hanging in the van, but she never used a shoulder strap because there was no latch to buckle the belt into. She said she worked as a transportation aide for five years and never used a shoulder strap on this van to secure residents. During an observation and interview on 08/04/15 at 11:00 a.m., the van involved in the accident was at the salvage yard and the front bumper was bent toward the middle of the vehicle. Two airbags were sticking out of the dashboard. A wheelchair was secured to the floorboard of the van with straps. A lap strap across the wheelchair was fastened and had detached from the anchor hook on the passenger side floorboard. Shoulder straps were hanging from above the windows to the floorboard on both sides of the wheelchair but there were no latches to secure the straps into. CNA A said she did not know where the shoulder straps connected. The maintenance director said he could not find a place to connect the shoulder straps and the straps were not functional. The maintenance director said he did not check the safety belts on the vans as part of his regular inspections and would only make repairs if a problem was reported by staff. The Transportation Policy and Procedures dated 05/23/12 indicated Always ensure that the shoulder strap is properly extended over the shoulder and across the upper torso. During an interview on 08/04/15 at 12:30 p.m., the administrator said after the incident the van was taken to a local salvage yard and will not be used until all needed repairs are made including the shoulder straps. These failures placed Resident #1 in an Immediate Jeopardy (IJ) situation from 07/07/15 through 07/07/15; at 9:40 a.m., the DON was informed the IJ was removed however, the facility remained out of compliance at a pattern of actual harm. A CMS 672 dated 07/16/15 indicated 43 residents used wheelchairs all or most of the time.

Based on observation, interview, and record review, the facility failed to consult with the physician when a pressure sore worsened for 1 of 4 residents reviewed for pressure sores. (Resident #1) Resident #1 sustained a shear to her right upper thigh that worsened to a Stage III pressure sore in two days. The physician ordered for the resident to be sent to the wound care center. There was a two week delay in obtaining an appointment at the wound care center. The wound enlarged and developed a foul odor. The facility did not consult the physician regarding the wound worsening or of the delay in obtaining an appointment with the wound care center. This failure could place 2 residents with pressure sores at risk for development of new pressure sores or worsening of existing pressure sores. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 had intact cognition, required extensive to total dependence on staff for all activities of daily living including bed mobility, was incontinent, and had no pressure sores. A care plan dated 12/22/14 indicated Resident #1 was at risk for skin breakdown. A current skin concerns care plan dated 01/06/15 indicated Resident #1 had excoriation/friction/shear to right upper outer thigh. The goal indicated areas would heal without complications over the next 90 days. Approaches indicated to "...2. Monitor areas for increase (sic) breakdown, s/s (signs/symptoms) of infections -- report to MD (medical doctor)...5. Keep MD and RP (responsible party) informs of resident's progress. 6. Assess for possible reasons for skin concerns, report findings to MD." A weekly skin documentation record dated 01/06/15 indicated Resident #1 had an area of excoriation/friction/shear to her right upper outer thigh measuring 8.0 cm (centimeters) x 6.0 cm x < (less than) 0.1 cm. The physician was notified 01/06/15 and ordered Dermaseptine (barrier cream), ProMod (protein powder) daily, and a multivitamin daily. A current skin concerns care plan dated 02/02/15 indicated Resident #1 had a Stage III pressure sore to her right upper outer thigh. The interventions were the same as for the care plan dated 01/06/15. A weekly skin documentation record dated 02/02/15 indicated Resident #1 had a Stage III pressure sore to her right upper outer thigh measuring 8.2 cm x 4.9 cm x 0.1 cm. The wound bed contained 50 percent (%) yellow slough (necrotic tissue). The physician was notified 02/02/15 and ordered Mesalt ([MEDICATION NAME] agent) on Monday, Wednesday, and Friday. A daily pressure ulcer documentation record for Resident #1 dated 02/02/15 indicated, a Stage III pressure sore to her right upper outer thigh. "...Noted marked deterioration. Site has advanced to Stage III pressure ulcer (sore(. Site with moderate amt (amount) of serosanguinous (serum and blood) drg (drainage). (No) foul odor noted...50% thick stringy yellow slough to wound bed. Surrounding tissue c/d/i (clean/dry/intact) (with no) redness or abnormal warmth..." During an interview on 02/25/15 at 12:20 p.m., the treatment nurse said she conducted weekly skin assessments for all residents. She said Dermaseptine treatment was used for Resident #1 ' s excoriation/friction/shear to her right upper thigh daily. She said Resident #1 was very large and had an over-sized wheelchair. She said the resident may have rubbed the side of the wheelchair so sheep skin was added to the inner sides of the wheelchair. The treatment nurse said Resident #1's wound was unchanged on Friday 01/30/15 when she did the treatment. She said the day shift nurses on the weekend did the dressing changes. She said when she returned on Monday 02/02/15, the wound had deteriorated to a Stage III. During an observation on 02/25/15 at 3:05 p.m., the room Resident #1 was had her name on the door. There was an over-sized bed in the room and an over-sized wheelchair by the door with sheepskin on the inner sides of the chair. Resident #1 remained hospitalized . During an interview on 02/25/15 at 12:53 p.m., LVN A said she worked on Saturday 01/31/15. She said she did the dressing change on Resident #1 ' s right upper thigh. She said the wound was red, excoriated, not open, and had no yellow slough. She said she did not measure the wound. She said she applied Dermaseptine and covered the wound with a dressing. During an interview on 02/25/15 at 1:05 p.m., LVN B said he worked on Sunday 02/01/15. He said he did the dressing change on Resident #1 ' s right upper thigh. He said the wound bed was red and "looked scraped." He said the wound had no open areas or slough and there was no depth to the wound. LVN B said he did not measure the wound. He said he applied Dermaseptine and covered the wound with a dressing. Daily pressure ulcer documentation records for Resident #1 dated 02/04/15 and 02/06/15 indicated the Stage III pressure sore to her right upper outer thigh remained unchanged from the 02/02/15 documentation. The record was not documented daily. A weekly skin documentation record dated 02/09/15 indicated the Stage III pressure sore to her right upper outer thigh increased in size from 02/02/15 and measured 10.2 cm x 6.0 cm x 0.9 cm. A daily pressure ulcer documentation record for Resident #1 ' s Stage III pressure sore to her right upper outer thigh dated 02/09/15 (first following the documentation on 02/06/15), indicated, "Upon removal of old drsg noted copious amts (amounts) of thick serosanguinous drg (with) slight musty odor noted. Noted continued deterioration of wound at this time...80% thick stringy yellow slough...Surrounding tissue c/d/i (with no) redness or abnormal warmth...Call placed to NP (nurse practitioner)...Received order to refer resident to wound care center for evaluation of wound & possibility (sic) of underlying causes of formation & rapid deterioration..." The next daily pressure ulcer documentation record for Resident #1 ' s Stage III pressure sore to her right upper outer thigh dated 02/11/15 indicated the wound remained unchanged from 02/09/15. A nursing note dated 02/12/15 indicated a wound care center appointment was made for Resident #1 ' s Stage III pressure sore to her right upper outer thigh for 02/18/15. The appointment was not made until 3 days after the order was given (02/09/15) and the appointment was for 9 days following the order to send her to the wound care center. There was no documentation the physician was notified of the delay in getting an appointment with the wound care center. The next daily pressure ulcer documentation record for Resident #1 dated 02/13/15 indicated the Stage III pressure sore to her right upper outer thigh had "...large amt of thick serosanguinous drg -- slight foul odor noted. Cont. (continues) (with) 80% thick stringy yellow slough...no further undermining present; increased depth..." The note indicated Resident #1 had an appointment with the wound care center on 02/18/15. The note did not indicate the physician was notified regarding worsening of the wound or of the delay in the wound care appointment. A weekly skin documentation record dated 02/16/15 indicated Resident #1 ' s Stage III pressure sore to her right upper outer thigh increased in size from 02/09/15 and measured 14.2 cm x 5.6 cm x 1.6 cm. The next daily pressure ulcer documentation record for Resident #1 dated 02/16/15 indicated the dressing was changed 45 minutes after giving pain medication. Resident #1 ' s Stage III pressure sore to her right upper outer thigh It noted, "large amt of sersanguinous drg -- cont (with) slight musty odor. Cont (with) 80% thick stringy yellow slough...F/U (follow up) (with local) WCC (wound care center) on 2/18 d/t (due to) rapid deterioration. The note did not indicate the physician was notified regarding worsening of the wound or of the delay in the wound care appointment. The next daily pressure ulcer documentation record for Resident #1 ' s Stage III pressure sore to her right upper outer thigh dated 02/18/15 indicated the resident would not allow the treatment nurse to change the dressing. The note indicated the charge nurse told the treatment nurse the resident's wound care center appointment had to be re-scheduled because no ambulances were available for transport. Due to her size, an ambulance was the only means of transport for the resident. The charge nurse told the treatment nurse the new appointment was for Monday 02/23/15. There was no documentation the treatment nurse notified the physician the wound care center appointment was again delayed, 14 days following the order to send her to the wound care center. The record indicated the treatment nurse increased the dressing changes to daily following the appointment change. The daily pressure ulcer documentation record for Resident #1 ' s Stage III pressure sore to her right upper outer thigh dated 02/19/15 indicated , "...large amt of sersanguinous drg (with) slight musty odor noted...80% thick stringy yellow slough...Surrounding tissue c/d/i (with no) redness or abnormal warmth. ([MEDICAL TREATMENT] physician) notified of deteriorated wound status...to report to WCC Monday." There was no documentation her primary physician was notified of the deterioration of the wound or delay in the wound care center appointment. The daily pressure ulcer documentation record for Resident #1 ' s Stage III pressure sore to her right upper outer thigh dated 02/20/15 was unchanged from 02/19/15. The note indicated, "...to WCC 2/23 d/t wound deterioration..." There was no documentation the physician was notified of the continued deterioration of the wound or the delay in the wound care center appointment." The next daily pressure ulcer documentation record for Resident #1 ' s Stage III pressure sore to her right upper outer thigh dated 02/23/15 indicated, "...dressing noted that dsg is partially saturated (with) wound drainage...Upon removal of old dsg noted copious amts of serosanguinous drg -- increased odor note. Wound bed cont to show deterioration (with) increasing measurements. 80% thick stringy yellow slough...Surrounding tissue c/d/i (with no) redness or abnormal warmth...to WCC for assessment via ambulance." During an interview on 02/25/15 at 12:55 p.m., the treatment nurse said nurse practitioner was notified of the deterioration of Resident #1 ' s Stage III pressure sore to her right upper outer thigh on 02/09/15 and ordered for the resident to be sent to the wound care center. She said an appointment was not obtained until 02/12/15 and the soonest the wound care center could see Resident #1 was 02/18/15 because they needed to make accommodations for her size. The treatment nurse said she did not notify the physician that there had been a delay in getting a wound care center appointment of 9 days following the order. She said when the wound worsened and increased in size on 02/16/15, the physician was not notified. When the wound care center appointment had been changed from 02/18/15 to 02/23/15 (14 days following the order to send her there), the treatment nurse said the physician was not notified. During an interview on 02/26/15 at 4:15 p.m., the treatment nurse said she only changed Resident #1's dressing because it was saturated with drainage. She said normally, she did not change the dressing on the day a resident was going to the wound care center. The treatment nurse said she did not do wound measurements on 02/23/15. A wound care center note dated 02/23/15 at 2:45 p.m., indicated Resident #1 had one wound to her right upper thigh. A wet-to-dry dressing was applied and she was transferred to a local hospital. A hospital emergency room note dated 02/24/15 at 1:10 a.m., indicated Resident #1 had an open wound to her right thigh, but no measurements were documented. A hospital wound photo dated 02/24/15 at 12:42 p.m., indicated the wound to Resident #1 ' s right thigh measured 16.0 cm x 4.0 cm x 7.0 cm and had 8.0 cm tunneling at the top of the wound and 8.0 cm undermining at the bottom of the wound. A hospital consultation impression dated 02/24/15 indicated, "The patient is a [AGE] year old supermorbidly obese female with multiple medical problems who presents with a large wound on her right hip. I agree with (physician name) it is at least a stage III if not a stage IV lesion. Surgical debridement would certainly be of benefit...I would certainly sample bone while I was there. The [DIAGNOSES REDACTED]. A faxed a note signed by Resident #1's nurse practitioner dated 03/02/15 indicating LVN G called her about another resident on 02/18/15 and also informed her Resident #1's wound care center appointment was canceled that day and she gave no new orders. The CMS 672 dated 02/25/15 indicated the census was 66.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent the developing and worsening of pressure sores for 2 of 4 residents reviewed for pressure sores. (Resident #s 1 and 2) 1. Resident #1 sustained a shear to her right upper thigh that worsened to a Stage III pressure sore in two days. The physician ordered for the resident to be sent to the wound care center. There was a two week delay in obtaining an appointment at the wound care center. The wound enlarged and developed a foul odor. The facility did not consult the physician regarding the wound worsening or of the delay in obtaining an appointment with the wound care center. 2. The facility did not identify a pressure sore to Resident #2's right shoulder until it was a Stage II. The pressure sore worsened to unstageable in two days. After debridement, the wound was a Stage III. This failure could place 2 residents with pressure sores at risk for development of new pressure sores and decline in existing pressure sores. Findings included: 1. Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 had intact cognition, required extensive to total dependence on staff for all activities of daily living including bed mobility, was incontinent, and had no pressure sores. A care plan dated 12/22/14 indicated Resident #1 was at risk for skin breakdown. A current skin concerns care plan dated 01/06/15 indicated Resident #1 had excoriation/friction/shear to right upper outer thigh. The goal indicated areas would heal without complications over the next 90 days. Approaches indicated to "...2. Monitor areas for increase (sic) breakdown, s/s (signs/symptoms) of infections -- report to MD (medical doctor)...5. Keep MD and RP (responsible party) informs of resident's progress. 6. Assess for possible reasons for skin concerns, report findings to MD." A weekly skin documentation record dated 01/06/15 indicated Resident #1 had an area of excoriation/friction/shear to her right upper outer thigh measuring 8.0 cm (centimeters) x 6.0 cm x < (less than) 0.1 cm. The physician was notified 01/06/15 and ordered Dermaseptine (barrier cream), ProMod (protein powder) daily, and a multivitamin daily. A current skin concerns care plan dated 02/02/15 indicated Resident #1 had a Stage III pressure sore to her right upper outer thigh. The interventions were the same as for the care plan dated 01/06/15. A weekly skin documentation record dated 02/02/15 indicated Resident #1 had a Stage III pressure sore to her right upper outer thigh measuring 8.2 cm x 4.9 cm x 0.1 cm. The wound bed contained 50 percent (%) yellow slough (necrotic tissue). The physician was notified 02/02/15 and ordered Mesalt ([MEDICATION NAME] agent) on Monday, Wednesday, and Friday. A daily pressure ulcer documentation record for Resident #1 dated 02/02/15 indicated, a Stage III pressure sore to her right upper outer thigh. "...Noted marked deterioration. Site has advanced to Stage III pressure ulcer (sore(. Site with moderate amt (amount) of serosanguinous (serum and blood) drg (drainage). (No) foul odor noted...50% thick stringy yellow slough to wound bed. Surrounding tissue c/d/i (clean/dry/intact) (with no) redness or abnormal warmth..." During an interview on 02/25/15 at 12:20 p.m., the treatment nurse said she conducted weekly skin assessments for all residents. She said Dermaseptine treatment was used for Resident #1 ' s excoriation/friction/shear to her right upper thigh daily. She said Resident #1 was very large and had an over-sized wheelchair. She said the resident may have rubbed the side of the wheelchair so sheep skin was added to the inner sides of the wheelchair. The treatment nurse said Resident #1's wound was unchanged on Friday 01/30/15 when she did the treatment. She said the day shift nurses on the weekend did the dressing changes. She said when she returned on Monday 02/02/15, the wound had deteriorated to a Stage III. During an observation on 02/25/15 at 3:05 p.m., the room Resident #1 was had her name on the door. There was an over-sized bed in the room and an over-sized wheelchair by the door with sheepskin on the inner sides of the chair. Resident #1 remained hospitalized . During an interview on 02/25/15 at 12:53 p.m., LVN A said she worked on Saturday 01/31/15. She said she did the dressing change on Resident #1 ' s right upper thigh. She said the wound was red, excoriated, not open, and had no yellow slough. She said she did not measure the wound. She said she applied Dermaseptine and covered the wound with a dressing. During an interview on 02/25/15 at 1:05 p.m., LVN B said he worked on Sunday 02/01/15. He said he did the dressing change on Resident #1 ' s right upper thigh. He said the wound bed was red and "looked scraped." He said the wound had no open areas or slough and there was no depth to the wound. LVN B said he did not measure the wound. He said he applied Dermaseptine and covered the wound with a dressing. Daily pressure ulcer documentation records for Resident #1 dated 02/04/15 and 02/06/15 indicated the Stage III pressure sore to her right upper outer thigh remained unchanged from the 02/02/15 documentation. The record was not documented daily. A weekly skin documentation record dated 02/09/15 indicated the Stage III pressure sore to her right upper outer thigh increased in size from 02/02/15 and measured 10.2 cm x 6.0 cm x 0.9 cm. A daily pressure ulcer documentation record for Resident #1 ' s Stage III pressure sore to her right upper outer thigh dated 02/09/15 (first following the documentation on 02/06/15), indicated, "Upon removal of old drsg noted copious amts (amounts) of thick serosanguinous drg (with) slight musty odor noted. Noted continued deterioration of wound at this time...80% thick stringy yellow slough...Surrounding tissue c/d/i (with no) redness or abnormal warmth...Call placed to NP (nurse practitioner)...Received order to refer resident to wound care center for evaluation of wound & possibility (sic) of underlying causes of formation & rapid deterioration..." The next daily pressure ulcer documentation record for Resident #1 ' s Stage III pressure sore to her right upper outer thigh dated 02/11/15 indicated the wound remained unchanged from 02/09/15. A nursing note dated 02/12/15 indicated a wound care center appointment was made for Resident #1 ' s Stage III pressure sore to her right upper outer thigh for 02/18/15. The appointment was not made until 3 days after the order was given (02/09/15) and the appointment was for 9 days following the order to send her to the wound care center. There was no documentation the physician was notified of the delay in getting an appointment with the wound care center. The next daily pressure ulcer documentation record for Resident #1 dated 02/13/15 indicated the Stage III pressure sore to her right upper outer thigh had "...large amt of thick serosanguinous drg -- slight foul odor noted. Cont. (continues) (with) 80% thick stringy yellow slough...no further undermining present; increased depth..." The note indicated Resident #1 had an appointment with the wound care center on 02/18/15. The note did not indicate the physician was notified regarding worsening of the wound or of the delay in the wound care appointment. A weekly skin documentation record dated 02/16/15 indicated Resident #1 ' s Stage III pressure sore to her right upper outer thigh increased in size from 02/09/15 and measured 14.2 cm x 5.6 cm x 1.6 cm. The next daily pressure ulcer documentation record for Resident #1 dated 02/16/15 indicated the dressing was changed 45 minutes after giving pain medication. Resident #1 ' s Stage III pressure sore to her right upper outer thigh It noted, "large amt of sersanguinous drg -- cont (with) slight musty odor. Cont (with) 80% thick stringy yellow slough...F/U (follow up) (with local) WCC (wound care center) on 2/18 d/t (due to) rapid deterioration. The note did not indicate the physician was notified regarding worsening of the wound or of the delay in the wound care appointment. The next daily pressure ulcer documentation record for Resident #1 ' s Stage III pressure sore to her right upper outer thigh dated 02/18/15 indicated the resident would not allow the treatment nurse to change the dressing. The note indicated the charge nurse told the treatment nurse the resident's wound care center appointment had to be re-scheduled because no ambulances were available for transport. Due to her size, an ambulance was the only means of transport for the resident. The charge nurse told the treatment nurse the new appointment was for Monday 02/23/15. There was no documentation the treatment nurse notified the physician the wound care center appointment was again delayed, 14 days following the order to send her to the wound care center. The record indicated the treatment nurse increased the dressing changes to daily following the appointment change. The daily pressure ulcer documentation record for Resident #1 ' s Stage III pressure sore to her right upper outer thigh dated 02/19/15 indicated , "...large amt of sersanguinous drg (with) slight musty odor noted...80% thick stringy yellow slough...Surrounding tissue c/d/i (with no) redness or abnormal warmth. ([MEDICAL TREATMENT] physician) notified of deteriorated wound status...to report to WCC Monday." There was no documentation her primary physician was notified of the deterioration of the wound or delay in the wound care center appointment. The daily pressure ulcer documentation record for Resident #1 ' s Stage III pressure sore to her right upper outer thigh dated 02/20/15 was unchanged from 02/19/15. The note indicated, "...to WCC 2/23 d/t wound deterioration..." There was no documentation the physician was notified of the continued deterioration of the wound or the delay in the wound care center appointment." The next daily pressure ulcer documentation record for Resident #1 ' s Stage III pressure sore to her right upper outer thigh dated 02/23/15 indicated, "...dressing noted that dsg is partially saturated (with) wound drainage...Upon removal of old dsg noted copious amts of serosanguinous drg -- increased odor note. Wound bed cont to show deterioration (with) increasing measurements. 80% thick stringy yellow slough...Surrounding tissue c/d/i (with no) redness or abnormal warmth...to WCC for assessment via ambulance." During an interview on 02/25/15 at 12:55 p.m., the treatment nurse said nurse practitioner was notified of the deterioration of Resident #1 ' s Stage III pressure sore to her right upper outer thigh on 02/09/15 and ordered for the resident to be sent to the wound care center. She said an appointment was not obtained until 02/12/15 and the soonest the wound care center could see Resident #1 was 02/18/15 because they needed to make accommodations for her size. The treatment nurse said she did not notify the physician that there had been a delay in getting a wound care center appointment of 9 days following the order. She said when the wound worsened and increased in size on 02/16/15, the physician was not notified. When the wound care center appointment had been changed from 02/18/15 to 02/23/15 (14 days following the order to send her there), the treatment nurse said the physician was not notified. During an interview on 02/26/15 at 4:15 p.m., the treatment nurse said she only changed Resident #1's dressing because it was saturated with drainage. She said normally, she did not change the dressing on the day a resident was going to the wound care center. The treatment nurse said she did not do wound measurements on 02/23/15. A wound care center note dated 02/23/15 at 2:45 p.m., indicated Resident #1 had one wound to her right upper thigh. A wet-to-dry dressing was applied and she was transferred to a local hospital. A hospital emergency room note dated 02/24/15 at 1:10 a.m., indicated Resident #1 had an open wound to her right thigh, but no measurements were documented. A hospital wound photo dated 02/24/15 at 12:42 p.m., indicated the wound to Resident #1 ' s right thigh measured 16.0 cm x 4.0 cm x 7.0 cm and had 8.0 cm tunneling at the top of the wound and 8.0 cm undermining at the bottom of the wound. A hospital consultation impression dated 02/24/15 indicated, "The patient is a [AGE] year old supermorbidly obese female with multiple medical problems who presents with a large wound on her right hip. I agree with (physician name) it is at least a stage III if not a stage IV lesion. Surgical debridement would certainly be of benefit...I would certainly sample bone while I was there. The [DIAGNOSES REDACTED]. A faxed a note signed by Resident #1's nurse practitioner dated 03/02/15 indicating LVN G called her about another resident on 02/18/15 and also informed her Resident #1's wound care center appointment was canceled that day and she gave no new orders. 2. Physician orders [REDACTED].#2 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. A treatment order with a start date of 12/05/14 indicated to cleanse the right shoulder with normal saline, apply Opticel AG, and cover with dressing on Monday, Wednesday, and Friday. The most recent MDS dated [DATE] indicated Resident #2 had severely impaired cognition, could sometimes be understood, required extensive assistance for activities of daily living, was frequently incontinent, and had one Stage III pressure sore. A telephone order dated 02/23/15 indicated Calcium Alginate Ag could be substituted if Opticel AG was unavailable. A weekly skin documentation report dated 10/10/14 indicated Resident #2 had no skin issues. A weekly skin documentation report dated 10/17/14 indicated Resident #2 had a Stage II pressure sore to his right shoulder measuring 2.0 cm x 1.7 cm x 0.1 cm. A daily pressure ulcer documentation record for Resident #2 dated 10/17/14 indicated, "Resident noted (with) 2 cm x 1.7 cm x 0.1 cm Stage II decubitus (pressure sore) to (R) upper arm/shoulder. Inner aspect pink & healthy (with) scan amt of serous drainage (no) foul odor. Surrounding tissue red in color however blanches to touch. Resident claims slight pain (with) stimulation upon cleansing. To perform wound care daily." An order was obtained for a foam dressing. A care plan dated 10/17/14 indicated Resident #2 had a Stage II pressure sore to his right upper arm/shoulder. The goal was, "Areas will heal without complications over next 90 days. Approaches were: "1. Perform treatments per order if no improvement x 2 weeks -- report to MD. 2. Monitor areas for increase breakdown, s/s of infection -- report to MD...5. Keep MD and RP informed of resident's progress. 6. Assess for possible reasons for skin concerns, report findings to MD." A weekly skin documentation report dated 10/20/14 indicated Resident #2's Stage II pressure sore to his right upper arm/shoulder was unchanged in stage or size. The next daily pressure ulcer documentation records for Resident #2 dated 10/20/14, 10/21/14, 10/22/14, 10/23/14, and 10/24/14 indicated there was no change in the pressure sore to his right upper arm/shoulder, except for a moderate amount of serosanguinous drainage. A weekly skin documentation record for Resident #2 dated 10/27/14 indicated the pressure sore to his right upper arm/shoulder was unstageable, covered 100% in dark brown necrotic (dead) tissue, and measured 3.2 cm x 3.8 cm x unable to determine depth. The next daily pressure ulcer documentation record for Resident #2 dated 10/27/14 indicated the pressure sore to his right upper arm/shoulder was "...noted deterioration of wound. Increased measurements & site with dark brown necrotic tissue. Scan amt of serosanguinous drg (with no) foul odor noted...Call placed to (name omitted) NP at this time d/t (due to) wound deterioration. Would consult (with) wound care center ordered." Also, wound care was changed to Santyl ([MEDICATION NAME] agent) and change dressing daily. The resident was also placed on a low air loss mattress. There were no care plans or care plan updates in Resident #2's clinical record for the unstageable pressure sore to his right upper arm/shoulder. A daily pressure ulcer documentation record dated 10/29/14 indicated Resident #2 went to the wound care center. A daily pressure ulcer documentation record dated 11/04/14 indicated Resident #2 went to the wound care center and wound care was changed to Mesalt with daily dressing change. A weekly skin documentation report for Resident #2 dated 11/05/14 indicated the pressure sore to his right upper arm/shoulder status was post-debridement and measured 4.0 x 4.0 x unable to determine depth. A daily pressure ulcer documentation record for Resident #2 ' s pressure sore to his right upper arm/shoulder dated 11/05/14 indicated the wound bed was 80% thick yellow slough and 20% dark gray tissue following cauterization at the wound care clinic. A weekly skin documentation report for Resident #2 dated 11/24/14 indicated the pressure sore to his right upper arm/shoulder was a Stage III, had 50% slough, and measured 3.7 cm x 3.8 cm x 0.3 cm. There was no care plan or care plan updates in Resident #2's clinical record for the Stage III pressure sore to his right upper arm/shoulder. A weekly skin documentation report for Resident #2 dated 12/10/15 indicated the pressure sore to his right upper arm/shoulder was a Stage III, had 30% yellow slough, and measured 2.8 cm x 2.8 cm x 0.3 cm. Wound care orders were changed to Opticel AG (aids wound healing) with daily dressing changes. The most recent weekly skin documentation report for Resident #2 dated 02/23/15 indicated the pressure sore to his right upper arm/shoulder was a Stage III, had 20% yellow slough, and measured 1.8 cm x 1.8 cm x 0.1 cm. During an observation and interview on 02/25/15 at 2:20 p.m., Resident #2 was sitting up in his wheelchair on the secure unit. There was nothing on his wheelchair that put pressure on his right upper arm/shoulder. The treatment nurse said Resident #2 "favored" lying on his right side when in bed. She said he needed staff assistance with turning and positioning and was placed on a low air loss mattress when his pressure sore became unstageable. The treatment nurse removed the old dressing from Resident #2's right shoulder which had a moderate amount of serosanguinous drainage. There was approximately 20% yellow slough at the right outer aspect of the wound, which the treatment nurse said was unchanged. The treatment nurse said the wound was a Stage III as most of the wound bed was not covered with slough. She measured the wound and it was 2.8 cm x 1.8 cm by 0.1 cm. The treatment nurse said the pressure sore had increased in size. She said the wound was first identified as a Stage II. She said on Friday 10/24/14, the wound was a Stage II. When said when she re-assessed the wound on Monday 10/27/14, the wound was covered in dark brown eschar and was unstageable. She said the day shift (6:00 a.m. to 2:00 p.m) nurses on the weekend 10/25/14 and 10/26/14 performed wound care. She said she never came back on Monday and found dressings still dated from Friday. She said the pressure sore had increased in size today from when she assessed it on 02/23/15. The treatment nurse said she notified the physician if a pressure sore rapidly deteriorated and he usually ordered the resident to be sent to the wound care center. During an interview on 02/26/15 at 11:35 a.m., CNA E said she worked the day shift on the secure unit and was the only CNA. She said she worked weekdays and weekends. CNA E said she had been employed at the facility for [AGE] years and knew Resident #2 well. She said Resident #2 usually stayed up all day in his wheelchair. She said on rare occasions, he would be agitated and would lie down for a nap, but did not stay in bed for long periods. She said he did not stay in bed on the weekends, he was usually up in his wheelchair. She said he favored lying on his right side. She said he could turn himself, but sometimes needed assistance. CNA E said she knew Resident #2 had a dressing on his right shoulder, but she never noticed the date. She said if the dressing was saturated or coming off, she would notify the charge nurse. During an interview on 02/26/15 at 11:46 a.m., LVN F said she was the day shift charge nurse for the secure unit. LVN F said she had only worked at the facility for one month. She said Resident #2's dressing changes were Monday, Wednesday, and Friday so they were always done by the treatment nurse. LVN F said the dressing had never come off while she was working, so she had never seen the pressure sore. She said Resident #2 was usually up all day every day in his wheelchair. LVN F said she had not noticed that Resident #2 favored lying on one side or the other. LVN F said Resident #2 could turn and re-position himself in bed. During an interview on 02/26/25 at 11:58 a.m., the DON said all residents' care plans should be on their charts, but some might be in the computer. During an interview on 02/26/15 at 12:14 p.m., the MDS coordinator brought care plans for Resident #2 and said they were the most updated. There was no care plan for the unstageable or Stage III pressure sore. A care plan for Resident #2 dated 06/06/14, edited 02/26/15, indicated, "I am not as mobile as I used to be, my skin is fragile and I favor my right side in bed and may have problems with: skin tear, bruising, and breakdown." During an interview on 02/27/15 at 1:40 p.m., the DON said she did not know why pressure sores were not being identified at Stage I or why pressure sores deteriorated over the weekend. The DON said she did not know why the weekend nurses did not consult with the physician for new orders if a pressure sore deteriorated during the weekend. An undated general skin protocols noted, "This General Skin Protocol must be followed for all Residents...7. If pressure ulcer is present, also complete the Daily Pressure Ulcer Documentation Sheet...8. Any change in the Resident's skin condition must be documented, the physician and responsible party notified, and the Skin Treatments initiated." A skin system policy and procedure revised 05/20/14 indicated, "...4. If the resident has a pressure ulcer, daily documentation on the Daily Pressure Ulcer Documentation Form will occur until the Pressure Ulcer is healed..." During an interview on 02/25/15 at 3:02 p.m., the DON said their policies, procedures, and protocols did not address notification of the physician regarding wounds or pressures sores. The DON said her expectation would be for the nurse to notify the physician if a resident had wound changes. The National Pressure Ulcer Advisory Panel website http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/ accessed 03/02/15 indicated the following: " ...Category/Stage II: Partial thickness Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation. *Bruising indicates deep tissue injury. Category/Stage III: Full thickness skin loss Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage IV: Full thickness tissue loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable ..." The CMS 672 dated 02/25/15 indicated 2 residents had pressure sores.

Based on interview and record review, the facility failed to implement their policies and procedures to ensure 4 of 4 residents reviewed for abuse were protected after allegations of sexual abuse and resident to resident abuse. The facility also failed to thoroughly investigate and report to the state agency these incidents. (Resident #s 1, 2, 3, and 4) Resident #1 made an allegation of sexual abuse and had bruises of unknown origin. The allegation and injuries of unknown origin were reported to the administrator and DON. The resident was not protected from further abuse, the incident was not thoroughly investigated, and the incident was not reported to the state agency because the administrator and DON said they disregarded the sexual abuse allegation because the nurse reporting the allegation was "overly dramatic." Resident #2 had a history of [REDACTED]. The resident did not have interventions in place to prevent aggressive behaviors toward other residents. Resident #2 hit Resident #4 causing a laceration to his head and threatened to kill Resident #3. The residents was not protected from further incidents, the incidents were not thoroughly investigated, and the incidents were not reported to the state agency because the administrator said the residents were cognitively impaired and resided on the locked unit. An Immediate Jeopardy situation was identified on 7/18/12 and had existed since 6/19/12. The Immediate Jeopardy was removed 7/19/12. The facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to monitor and evaluate the effectiveness of the corrective systems. This failure could place the 11 residents on the locked unit at risk of abuse, neglect, and injury. Findings included: 1. Physician orders [REDACTED]. The latest MDS dated [DATE] indicated Resident #1's cognitive status was moderately impaired. A physician telephone order dated 6/12/12 indicated Resident #1 was admitted to the secure unit. A care plan dated 6/12/12 indicated Resident #1 had a problem of "being confused and able to remember, it may affect my moods, my speech, and my way of reacting and interacting with other people. I need staff to help me with reminding me about activities, medications, things I may forget, I have dementia, I wander and I live on a secure unit." Approaches listed were, "Help me with remembering by reminding me of your name if I cannot remember it. Be respectful and positive about the things I can remember and understand that they might not all be good memories." An incident report dated 6/19/12 at 1:00 a.m. noted Resident #1 alleged sexual abuse. The resident had bruises on both arms. The resident exhibited a change in condition as evidenced by new confusion. Resident # 1 said, "A man was trying to get her poodle." The report indicated the resident pointed to her vaginal area when she used the word poodle. The report indicated the resident asked the nurse not to let him "get her again." Nursing notes dated 6/19/12 indicated: At 1:00 a.m., Resident #1 was agitated and uncooperative. She was verbally abusive to staff. She had a "large soft ball" size bruise on her upper left arm and another "tennis ball" size bruise just below the large bruise. Resident #1 was uncooperative and combative. She did not want anyone to touch her. At 1:45 a.m., Resident #1 was knocking on a glass door with her knuckles saying, "Come get me." And, ."..res has dark purple and green bruises on her right arm as well as her left arm." At 2:00 a.m., Resident #1 had a "bewildered look of hopeless on her face" She continued to knock on doors and asked to be let out repeatedly. When the nurse asked Resident #1 what caused the bruises, the resident said, "He did it." He was trying to get her "poodle" (pointing to her vaginal area). Resident #1 "asked this nurse not to let him get her again." Resident #1 wanted someone to stay with her "so he would not come back." The administrator and DON were notified. Resident #1 was sent to the ER for an evaluation. At 3:20 a.m., the police arrived and took a statement from LVN B, the nurse to whom Resident #1 reported the sexual abuse allegation. At 5:30 a.m., Resident #1 returned to the facility. The hospital nurse who called report to the facility indicated no rape evaluation was performed at the hospital. At 11:30 a.m., the resident allowed the nurse to measure the bruises on her arms. The left arm had a 12.0 cm x 10.0 cm with various stages of discoloration. The inner aspect of the area was red and purple in color. The outer aspect of the area was yellow green and blackish in color. There was a smaller bruise to the side measuring 1.0 cm x 1.0 cm and black in color. The right arm had a bruise that measured 1.8 cm x 4.3 cm in size and was purple to black in color. A provider investigation report dated 6/19/12 indicated Resident #1 was wandering the halls in a sleeveless nightgown and LVN B tried to redirect her back to bed and noted bruises of an unknown origin. The incident report said the resident did not remember what happened and the resident denied that anyone hurt her or being in an altercation. A written statement by CNA C that accompanied the incident report dated 6/19/12 noted she was asked to help get Resident #1 back to bed. The statement said the CNA asked the resident twice to go to bed and Resident #1 said she was ready the second time. The statement said CNA C went back to her hall after Resident #1 was in bed. The investigation report did not contain interviews with employees, residents who may have knowledge of the alleged incident. The facility did not make reasonable efforts to determine the cause of the alleged incident, and they did not take corrective action to eliminate any ongoing dangers to the resident or other residents. During an interview on 7/5/12 at 9:40 a.m., the administrator said Resident #1 was confused and combative with staff at times. The administrator said she talked with the son of Resident #1 about the bruises and the son said the whole family bruised easily. The administrator said she talked with CNA C who said she was with Resident #1 the whole night and did not witness anything unusual. She said she talked with the charge nurse who said the resident was restless and walked a lot that night. The administrator said it was "undetermined" how the resident got the bruises. She said the secure unit did not have any aggressive residents. She said they did have one incident where Resident #2 hit Resident # 4 and Resident #2 was sent to the behavioral hospital on [DATE]. During a telephone interview on 7/5/12 at 10:28 a.m., LVN B said Resident #1 did not appear to be herself on 6/19/12; she was upset and exhibiting behaviors LVN B had not seen before. LVN B said Resident #1 said, "He came in my room messing around, and laughing hee, hee, hee." LVN B said Resident # 1 said he tried to get her "poodle." LVN B said the resident pointed to her vaginal area when she said "poodle." She said the resident was forgetful but sometimes made perfect sense. She said the resident was afraid, did not want to be left alone, was irritated, and did not want the staff to touch her. LVN B said the resident would not go to bed. LVN B said the bruises on her arms could have been "hand prints." The largest one had smaller bruises that could have being "finger bruises." LVN B said she called the DON and the administrator and reported the allegation of sexual abuse. They told her to send the resident to the hospital to have a rape kit completed. LVN B said she gave the resident [MEDICATION NAME] (anti-anxiety) to calm her down and asked CNA D to stay with the resident until EMS arrived. She said she did not assess the resident. She said the hospital was unable to complete a rape examination due to lack of equipment and qualified staff. During an interview on 7/5/12 at 10:57 a.m., the administrator and DON said they were aware LVN B reported Resident #1 made a sexual abuse allegation. They said the nurse called both of them early on the morning of 6/19/12 and reported the sexual abuse allegation. They said they told the LVN to send the resident to the hospital. They said they spoke to the resident about the allegation later and she did not remember what happened. They said the ADON assessed the resident and did not see anything out of the ordinary except the unexplained bruises on her arms. They said because of the information the family gave about the resident bruising easily and the aide saying she was with the resident all night, they disregarded the sexual abuse allegation. The facility abuse policy last updated 11/11/11 indicated, "...upon receiving reports of sexual abuse, the charge nurse shall immediately examine the resident." During an interview on 7/5/12 at 11:07 a.m., the ADON said she completed a head to toe assessment of Resident #1 late on the evening of 6/19/12. She said she was not there the morning of the incident. The ADON said Resident #1 could not remember how she got the bruises. During an interview on 7/5/12 at 11:23 a.m., LVN E said LVN B told her Resident #1 made an allegation of sexual abuse. LVN E said she saw the bruises on Resident #1's arms around 11:00 a.m. and they looked like they could have been "hand prints." She said she did not look at the resident's vaginal area. She said Resident #2 always laughed inappropriately and often. She said Resident #2 was a "registered sex offender" and he was sent to the behavioral hospital on [DATE] for hitting another resident. During an interview on 7/5/12 at 12:40 p.m., CNA C said around 12:00 a.m. or 1:00 a.m., LVN B asked her to see if she could get Resident #1 to go to bed. She said the resident was walking around the unit. CNA C said she was not scheduled to provide care for Resident #1 that night, so she got the resident back to bed and went back to her hall. During an interview on 7/5/12 at 1:28 p.m., CNA D said Resident #1 was asleep in bed when she arrived at 10:00 p.m. to work. She said she started her rounds around 1:00 a.m. She said Resident #1 allowed her to change her brief and followed her out of the room. She said after 1:00 a.m., the resident was confused, wandering the unit and agitated. She said the resident did not want to go back to bed and felt like someone was after her. CNA D said CNA C got the resident to go back to bed and CNA D stayed with her until EMS arrived. CNA D said the resident seemed fearful and afraid to be alone. During an interview on 7/5/12 at 2:50 p.m., the social worker said he interviewed Resident #1 about the bruises and she told him she did not recall anything traumatic that happened. He said he was not aware of a sexual abuse allegation, but was told by staff the bruises on her arms looked like "hand prints." During an interview on 7/5/12 at 3:10 p.m., the administrator/abuse coordinator said her investigation for Resident #1's allegation of sexual abuse consisted of interviews with CNA C, the family members, and the resident. The administrator said those interviews indicated no concerns, but she could not determine the origin of the bruises. She said she did not notify the state agency of the allegation of sexual abuse and did not look into the issue. She said the nurse that reported the allegation was "overly dramatic at times." 2. Physician orders [REDACTED]. A psychiatric hospital discharge summary dated 12/1/11 indicated Resident # 2 continued to be "very psychotic with bizarre behaviors, at times, although it appeared to be fewer episodes of bizarre behaviors." There were no reports of sexually inappropriate behaviors. Resident #2 had sexual assault charges in the past. The resident was alert, but his memory orientation could not be tested . He appeared somewhat functionally demented and it was hard to determine if he was demented or just had chronic [MEDICAL CONDITION]. He was hospitalized and institutionalized over the last [AGE] years. He was able to answer simple questions with appropriate answers. In a conversation, he was much disorganized in his thoughts and would talk about things that were totally irrelevant. His affect seemed okay. He was very childlike at times, at others violent [MEDICAL CONDITION] which he did act out towards this internal stimuli. He was diagnosed with [REDACTED]. The website http://trialx.com/curetalk/2011/02/what-is-[MEDICAL CONDITION]-disorder-[MEDICAL CONDITION]-type-symptoms-diagnosis-treatments/ accessed 7/24/12 indicated [MEDICAL CONDITION] disorder [MEDICAL CONDITION] type is "phases of extreme euphoria, recklessness and [MEDICAL CONDITION], usually termed as mania, which is punctuated with phases of extreme depression and normal moods", but "may have psychotic visual and auditory hallucinations even during the normal moods." A psychiatric hospital physician discharge order inquiry dated 2/3/12 indicated Resident #2 was "...very disorganized, tangential, irrational in his thought patterns and his mood control. He followed directions well enough." The report also indicated, " ...His history showed that one occasion he has attempted to touch female staff inappropriately in a sexual manner..." An initial psychological psychiatric evaluation dated 2/6/12 indicated Resident #2 was referred for psychiatric services due to mood swings and psychotic symptoms. The presenting symptoms were depressed mood, anxiety, irritability, agitation, anger, verbal aggression, physical aggression, combativeness, suspiciousness, paranoia, delusional belief-persecutory/grandiose, disorganized thinking, and mental confusion. His mental status was described as a superficially cooperative attitude. His orientation was disoriented to place and time. His memory was remote-mildly impaired, recent-seriously impaired, immediate-mildly impaired. His thought process was disorderly slightly and thought content was paranoid and delusional. His mood was varied and was potentially violent. A psychology progress note dated 3/26/12 indicated Resident #2 was seen for allegedly threatening to kill another resident. When he was seen by the psychologist he was restless but not severely upset. He said his father talked like that to him when he was young. The resident was cooperative. The latest MDS dated [DATE] indicated Resident #2 was severely impaired cognitively. A social services dated 5/19/12 indicated Resident #2 had short and long term memory problem and moderately impaired daily decision making skills. There have been delusional and disorganized thinking, inappropriate behaviors of verbal abuse, and other behaviors of sexual suggestiveness. A care plan last updated 5/24/12 indicated Resident #2 did not have a care plan that addressed his aggressive behaviors. 3. A psychological consulting noted dated 7/2/12 indicated Resident #4 had [DIAGNOSES REDACTED]. The most recent MDS for Resident #4 dated 6/19/12 indicated his cognition was moderately impaired. A care plan updated 6/21/12 indicated Resident #4 had "...a problem with being confused and able to remember, it may affect my moods, my speech, and my way of reacting and interacting with other people...I have Alzheimer's, I wander, and I live on a secured unit" and "I may get agitated when you try to help with my personal care..." Approaches included, "Please tell me what you are going to do before you do it. If I get upset, stop for a minute and talk quietly to me...If I get too upset, leave me alone for a few minutes and send someone else to take care of me I might respond better..." An incident report dated 7/1/12 at 6:45 p.m. indicated Resident #2 was in his room when Resident #4 entered. When the aide entered the room, Resident #4 was on the floor and Resident #2 was standing over him. Resident #4 said Resident #2 hit him. Resident #4 had a gash to the head. A written statement by CNA A that accompanied the incident report dated 7/1/12 said she heard two men yelling and a loud thump. When she entered the room, Resident #4 was on the floor and Resident #2 was standing over him laughing and smiling. Resident #4 was holding his head saying Resident #2 hit him. The nurse that wrote the report said the resident was rambling about Resident #4 taking his boot, cutting of his head, and cutting him in half. A nursing note dated 7/1/12 indicated Resident #4 was pushed or hit and he subsequently fell to the floor. Resident #4 complained of severe back pain. He received a 3.5 x 2.0 x 0.5 cm laceration to the crown of his head. He was sent to the ER. The resident returned with no new orders. During an interview on 7/5/12 at 1:53 p.m., Resident #4 said he remembered Resident #2 hitting him and falling on the floor. During an interview on 7/5/12 at 1:57 p.m., CNA F said Resident #2 was aware of the things that he did. CNA F said, "He knows what he is doing." During an interview on 7/5/12 at 2:30 p.m., the DON said Resident #2 did not have a care plan that addressed his aggressive behaviors. The DON said Resident #2 was aware of what was going on and he could talk to you and tell you what he wanted. The DON said the resident came when his name was called, he knew to take his medication, when to eat, he was continent, and could bathe himself. During an interview on 7/5/12 at 3:03 p.m., CNA A said she was the person that heard the altercation between Resident #2 and #4. Resident #4 was lying on the floor bleeding, and Resident #2 was standing over him laughing. CNA A said Resident #2 told Resident #4 to get out of his room. Resident #2 told her and other staff he intended to hit Resident #4. He gave different reasons, but initially said, "He was in my room." During an interview on 7/5/12 at 3:10 p.m., the administrator said she did not call the incident between Resident #2 and #4 to the state agency because they were both on the locked unit and both cognitively impaired. The administrator said Resident #2 did not know what he was doing. Resident #4 was sent to the hospital, but only received first aid. She said she was not aware of the incident when Resident #2 threatened to kill Resident #3. She said if she had been made aware of the threat, she may have handled the situation differently. 4. A physician order [REDACTED]. He had a [DIAGNOSES REDACTED]. The latest MDS dated [DATE] indicated Resident #3's cognitive status was moderately impaired. A care plan dated 5/10/12 indicated Resident #3 was impaired cognitively due to short and long term memory impairment. One of the objectives was to avoid circumstances that may result in injury. A social services referral form dated 3/26/12 indicated Resident #2 threatened to kill Resident #3. Resident #2 agreed to exercise more self-control in regard to yelling and threatening. During an interview on 7/5/12 at 9:43 a.m., the administrator said Resident #2 resided on the secure unit and had no indications of aggressive behavior prior to 7/1/12 (A psychological psychiatric evaluation dated 2/6/12, and interviews with staff documented prior indications of aggressive behavior). During an interview on 7/5/12 at 2:55 p.m., the social worker said he talked to Resident #2 after the incident with Resident #3, and Resident #2 seemed to understand what he did was wrong. The social worker said Resident #2's speech was hard to understand, but the staff that worked with him all the time understood him well. He said Resident #3, who resided on the secure unit, did not remember the incident at all. The social worker said Resident #2 appeared to be oriented to self, time, and situation and his outbursts were "deliberate" and Resident #2 could control them. The facility abuse and neglect policy revised 11/11/11 indicated allegations were "immediately reported to the appropriate agencies and then thorough investigation is initiated." Identification of abuse/neglect was to "assess care-plan and monitor residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors." "An investigation of all suspected any reported allegations of abuse or any injuries of unknown cause." "The investigation should include interviews of the employee, visitors, or residents who may have knowledge of the alleged incident." "The facility shall make reasonable efforts to determine the cause of the alleged incident, take corrective action consisting with investigation findings, to eliminate any ongoing dangers to the resident." On 7/18/12 at 10:00 a.m., the enforcement team determined the failure to ensure incidents of potential abuse/neglect were thoroughly investigated which contributed to an Immediate Jeopardy situation that had existed since 6/19/12. On 7/18/12 at 5:07 p.m., the administrator was informed of the Immediate Jeopardy situation. On 7/19/12 at 10:47 a.m., the facility's Plan of Removal was accepted and included the following: "*Facility will thoroughly investigate all incidents/accidents; including obtaining statements from staff members that had contact with the resident the prior 24 hours. *Resident #2 was discharged from the facility on 7/01/12. Resident #4 was discharged to a behavioral unit at a hospital on [DATE]. *Facility will in-service staff members on current reporting guidelines provider letter dated 1/03/07 regarding reporting abuse/neglect by 7/19/12. *Facility will in-service all staff on abuse and neglect policy and procedures by 7/19/12. *No staff will be allowed to work until in-service on abuse prohibition has been completed. *Facility will re-investigate incident of alleged sexual abuse. Facility will protect resident by placing her on one-on-one supervision. *A quality assurance meeting on 7/18/12 with the medical director, DON, administrator, and regional nurse consultant in reference to immediate jeopardy. *In the event of allegations of verbal threats made by residents regardless of cognitive impairment, the DON and the administrator will be notified immediately. Assessments will be completed and a thorough investigation will be done to ensure safety of all potential affected residents. The surveyor confirmed the POR had been implemented sufficiently to remove the Immediate Jeopardy by: As of 7/19/12, all staff (with the exception of those who had not returned to work) had received the in-service training and testing related to abuse, neglect, and misappropriation of resident's property. Three floor nurses, two administrative nurses, and the social worker were interviewed and provided correct responses about identifying abuse/neglect, how to handle incident/accident and allegations of abuse/neglect/misappropriation investigations, and abuse/neglect reporting. If they did not know whether the incident was a reportable, they knew the time frame of reporting the incident and where to locate the abuse policy with the attachment of reporting guidelines to make the report if necessary. Four nurse aides were interviewed and were able to identify types of abuse/neglect, who to report suspected abuse, neglect, and misappropriation of residents' property to, and what to do if the party the incident was reported did not act accordingly. All staff interviewed was knowledgeable of how to protect residents if an incident of possible abuse, neglect, or misappropriation were to occur. Surveyor observed staff being present (one-on-one) with Resident #1 and documenting accordingly." On 7/19/12 at 10:47a.m., the administrator, DON, and regional nurse consultant were informed the Immediate Jeopardy was removed. The facility remained out of compliance at a pattern of potental for more than minimal harm due to the facility's need to complete all proficiency audits, and monitor and evaluate the effectiveness of the corrective systems. The facility census report dated 7/5/12 indicated 11 residents were in the locked unit.

Based on interview and record review, the facility failed to provide measures to prevent further abuse, to ensure allegations of sexual abuse and resident to resident abuse were thoroughly investigated, and to report to the state agency allegations of abuse for 4 of 4 residents reviewed for abuse. (Resident #s 1, 2, 3, and 4) Resident #1 made an allegation of sexual abuse and had bruises of unknown origin. The allegation and injuries of unknown origin were reported to the administrator and DON. The resident was not protected from further abuse, the incident was not thoroughly investigated, and the incident was not reported to the state agency because the administrator and DON said they disregarded the sexual abuse allegation because the nurse reporting the allegation was "overly dramatic." Resident #2 had a history of [REDACTED]. The resident did not have interventions in place to prevent aggressive behaviors toward other residents. Resident #2 hit Resident #4 causing a laceration to his head and threatened to kill Resident #3. The residents was not protected from further incidents, the incidents were not thoroughly investigated, and the incidents were not reported to the state agency because the administrator said the residents were cognitively impaired and resided on the locked unit. An Immediate Jeopardy situation was identified on 7/18/12 and had existed since 6/19/12. The Immediate Jeopardy was removed 7/19/12. The facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to monitor and evaluate the effectiveness of the corrective systems. This failure could place the 11 residents in the locked unit at risk of abuse, neglect, and injury. Findings included: 1. Physician orders [REDACTED]. The latest MDS dated [DATE] indicated Resident # 1's cognitive status was moderately impaired. A physician telephone order dated 6/12/12 indicated Resident #1 was admitted to the secure unit. A care plan dated 6/12/12 indicated Resident #1 had a problem of "being confused and able to remember, it may affect my moods, my speech, and my way of reacting and interacting with other people. I need staff to help me with reminding me about activities, medications, things I may forget, I have dementia, I wander and I live on a secure unit." Approaches listed were, "Help me with remembering by reminding me of your name if I cannot remember it. Be respectful and positive about the things I can remember and understand that they might not all be good memories." An incident report dated 6/19/12 at 1:00 a.m. noted Resident #1 alleged sexual abuse. The resident had bruises on both arms. The resident exhibited a change in condition as evidenced by new confusion. Resident # 1 said, "A man was trying to get her poodle." The report indicated the resident pointed to her vaginal area when she used the word poodle. The report indicated the resident asked the nurse not to let him "get her again." Nursing notes dated 6/19/12 indicated: At 1:00 a.m., Resident #1 was agitated and uncooperative. She was verbally abusive to staff. She had a "large soft ball" size bruise on her upper left arm and another "tennis ball" size bruise just below the large bruise. Resident #1 was uncooperative and combative. She did not want anyone to touch her. At 1:45 a.m., Resident #1 was knocking on a glass door with her knuckles saying, "Come get me." And, ."..res has dark purple and green bruises on her right arm as well as her left arm." At 2:00 a.m., Resident #1 had a "bewildered look of hopeless on her face" She continued to knock on doors and asked to be let out repeatedly. When the nurse asked Resident #1 what caused the bruises, the resident said, "He did it." He was trying to get her "poodle" (pointing to her vaginal area). Resident #1 "asked this nurse not to let him get her again." Resident #1 wanted someone to stay with her "so he would not come back." The administrator and DON were notified. Resident #1 was sent to the ER for an evaluation. At 3:20 a.m., the police arrived and took a statement from LVN B, the nurse to whom Resident #1 reported the sexual abuse allegation. At 5:30 a.m., Resident #1 returned to the facility. The hospital nurse who called report to the facility indicated no rape evaluation was performed at the hospital. At 11:30 a.m., the resident allowed the nurse to measure the bruises on her arms. The left arm had a 12.0 cm x 10.0 cm with various stages of discoloration. The inner aspect of the area was red and purple in color. The outer aspect of the area was yellow green and blackish in color. There was a smaller bruise to the side measuring 1.0 cm x 1.0 cm and black in color. The right arm had a bruise that measured 1.8 cm x 4.3 cm in size and was purple to black in color. A provider investigation report dated 6/19/12 indicated Resident #1 was wandering the halls in a sleeveless nightgown and LVN B tried to redirect her back to bed and noted bruises of an unknown origin. The incident report said the resident did not remember what happened and the resident denied that anyone hurt her or being in an altercation. A written statement by CNA C that accompanied the incident report dated 6/19/12 noted she was asked to help get Resident #1 back to bed. The statement said the CNA asked the resident twice to go to bed and Resident #1 said she was ready the second time. The statement said CNA C went back to her hall after Resident #1 was in bed.The investigation report did not contain interviews with employees, residents who may have knowledge of the alleged incident. The facility did not make reasonable efforts to determine the cause of the alleged incident, and they did not take corrective action to eliminate any ongoing dangers to the resident or other residents. During an interview on 7/5/12 at 9:40 a.m., the administrator said Resident #1 was confused and combative with staff at times. The administrator said she talked with the son of Resident #1 about the bruises and the son said the whole family bruised easily. The administrator said she talked with CNA C who said she was with Resident #1 the whole night and did not witness anything unusual. She said she talked with the charge nurse who said the resident was restless and walked a lot that night. The administrator said it was "undetermined" how the resident got the bruises. She said the secure unit did not have any aggressive residents. She said they did have one incident where Resident #2 hit Resident # 4 and Resident #2 was sent to the behavioral hospital on [DATE]. During a telephone interview on 7/5/12 at 10:28 a.m., LVN B said Resident #1 did not appear to be herself on 6/19/12; she was upset and exhibiting behaviors LVN B had not seen before. LVN B said Resident #1 said, "He came in my room messing around, and laughing hee, hee, hee." LVN B said Resident # 1 said he tried to get her "poodle." LVN B said the resident pointed to her vaginal area when she said "poodle." She said the resident was forgetful but sometimes made perfect sense. She said the resident was afraid, did not want to be left alone, was irritated, and did not want the staff to touch her. LVN B said the resident would not go to bed. LVN B said the bruises on her arms could have been "hand prints." The largest one had smaller bruises that could have being "finger bruises." LVN B said she called the DON and the administrator and reported the allegation of sexual abuse. They told her to send the resident to the hospital to have a rape kit completed. LVN B said she gave the resident [MEDICATION NAME] (anti-anxiety) to calm her down and asked CNA D to stay with the resident until EMS arrived. She said she did not assess the resident. She said the hospital was unable to complete a rape examination due to lack of equipment and qualified staff. During an interview on 7/5/12 at 10:57 a.m., the administrator and DON said they were aware LVN B reported Resident #1 made a sexual abuse allegation. They said the nurse called both of them early on the morning of 6/19/12 and reported the sexual abuse allegation. They said they told the LVN to send the resident to the hospital. They said they spoke to the resident about the allegation later and she did not remember what happened. They said the ADON assessed the resident and did not see anything out of the ordinary except the unexplained bruises on her arms. They said because of the information the family gave about the resident bruising easily and the aide saying she was with the resident all night, they disregarded the sexual abuse allegation. The facility abuse policy last updated 11/11/11 indicated "...upon receiving reports of sexual abuse, the charge nurse shall immediately examine the resident." During an interview on 7/5/12 at 11:07 a.m., the ADON said she completed a head to toe assessment of Resident #1 late on the evening of 6/19/12. She said she was not there the morning of the incident. The ADON said Resident #1 could not remember how she got the bruises. During an interview on 7/5/12 at 11:23 a.m., LVN E said LVN B told her Resident #1 made an allegation of sexual abuse. LVN E said she saw the bruises on Resident #1's arms around 11:00 a.m. and they looked like they could have been "hand prints." She said she did not look at the resident's vaginal area. She said Resident #2 always laughed inappropriately and often. She said Resident #2 was a "registered sex offender" and he was sent to the behavioral hospital on [DATE] for hitting another resident. During an interview on 7/5/12 at 12:40 p.m., CNA C said around 12:00 a.m. or 1:00 a.m., LVN B asked her to see if she could get Resident #1 to go to bed. She said the resident was walking around the unit. CNA C said she was not scheduled to provide care for Resident #1 that night, so she got the resident back to bed and went back to her hall. During an interview on 7/5/12 at 1:28 p.m., CNA D said Resident #1 was asleep in bed when she arrived at 10:00 p.m. to work. She said she started her rounds around 1:00 a.m. She said Resident #1 allowed her to change her brief and followed her out of the room. She said after 1:00 a.m., the resident was confused, wandering the unit and agitated. She said the resident did not want to go back to bed and felt like someone was after her. CNA D said CNA C got the resident to go back to bed and CNA D stayed with her until EMS arrived. CNA D said the resident seemed fearful and afraid to be alone. During an interview on 7/5/12 at 2:50 p.m., the social worker said he interviewed Resident #1 about the bruises and she told him she did not recall anything traumatic that happened. He said he was not aware of a sexual abuse allegation, but was told by staff the bruises on her arms looked like "hand prints." During an interview on 7/5/12 at 3:10 p.m., the administrator/abuse coordinator said her investigation for Resident #1's allegation of sexual abuse consisted of interviews with CNA C, the family members, and the resident. The administrator said those interviews indicated no concerns, but she could not determine the origin of the bruises. She said she did not notify the state agency of the allegation of sexual abuse and did not look into the issue. She said the nurse that reported the allegation was "overly dramatic at times." 2. Physician orders [REDACTED]. A psychiatric hospital discharge summary dated 12/1/11 indicated Resident # 2 continued to be "very psychotic with bizarre behaviors, at times, although it appeared to be fewer episodes of bizarre behaviors." There were no reports of sexually inappropriate behaviors. Resident #2 had sexual assault charges in the past. The resident was alert, but his memory orientation could not be tested . He appeared somewhat functionally demented and it was hard to determine if he was demented or just had chronic [MEDICAL CONDITION]. He was hospitalized and institutionalized over the last [AGE] years. He was able to answer simple questions with appropriate answers. In a conversation, he was much disorganized in his thoughts and would talk about things that were totally irrelevant. His affect seemed okay. He was very childlike at times, at others violent [MEDICAL CONDITION] which he did act out towards this internal stimuli. He was diagnosed with [REDACTED]. The website http://trialx.com/curetalk/2011/02/what-is-[MEDICAL CONDITION]-disorder-[MEDICAL CONDITION]-type-symptoms-diagnosis-treatments/ accessed 7/24/12 indicated [MEDICAL CONDITION] disorder [MEDICAL CONDITION] type is "phases of extreme euphoria, recklessness and [MEDICAL CONDITION], usually termed as mania, which is punctuated with phases of extreme depression and normal moods", but "may have psychotic visual and auditory hallucinations even during the normal moods." A psychiatric hospital physician discharge order inquiry dated 2/3/12 indicated Resident #2 was "...very disorganized, tangential, irrational in his thought patterns and his mood control. He followed directions well enough." The report also indicated, " ...His history showed that one occasion he has attempted to touch female staff inappropriately in a sexual manner..." An initial psychological psychiatric evaluation dated 2/6/12 indicated Resident #2 was referred for psychiatric services due to mood swings and psychotic symptoms. The presenting symptoms were depressed mood, anxiety, irritability, agitation, anger, verbal aggression, physical aggression, combativeness, suspiciousness, paranoia, delusional belief-persecutory/grandiose, disorganized thinking, and mental confusion. His mental status was described as a superficially cooperative attitude. His orientation was disoriented to place and time. His memory was remote-mildly impaired, recent-seriously impaired, immediate-mildly impaired. His thought process was disorderly slightly and thought content was paranoid and delusional. His mood was varied and was potentially violent. A psychology progress note dated 3/26/12 indicated Resident #2 was seen for allegedly threatening to kill another resident. When he was seen by the psychologist he was restless but not severely upset. He said his father talked like that to him when he was young. The resident was cooperative. The latest MDS dated [DATE] indicated Resident #2 was severely impaired cognitively. A social services dated 5/19/12 indicated Resident #2 had short and long term memory problem and moderately impaired daily decision making skills. There have been delusional and disorganized thinking, inappropriate behaviors of verbal abuse, and other behaviors of sexual suggestiveness. A care plan last updated 5/24/12 indicated Resident #2 did not have a care plan that addressed his aggressive behaviors. 3. A psychological consulting noted dated 7/2/12 indicated Resident #4 had [DIAGNOSES REDACTED]. The most recent MDS for Resident #4 dated 6/19/12 indicated his cognition was moderately impaired. A care plan updated 6/21/12 indicated Resident #4 had "...a problem with being confused and able to remember, it may affect my moods, my speech, and my way of reacting and interacting with other people...I have Alzheimer's, I wander, and I live on a secured unit" and "I may get agitated when you try to help with my personal care..." Approaches included, "Please tell me what you are going to do before you do it. If I get upset, stop for a minute and talk quietly to me...If I get too upset, leave me alone for a few minutes and send someone else to take care of me I might respond better..." An incident report dated 7/1/12 at 6:45 p.m. indicated Resident #2 was in his room when Resident #4 entered. When the aide entered the room, Resident #4 was on the floor and Resident #2 was standing over him. Resident #4 said Resident #2 hit him. Resident #4 had a gash to the head. A written statement by CNA A that accompanied the incident report dated 7/1/12 said she heard two men yelling and a loud thump. When she entered the room, Resident #4 was on the floor and Resident #2 was standing over him laughing and smiling. Resident #4 was holding his head saying Resident #2 hit him. The nurse that wrote the report said the resident was rambling about Resident #4 taking his boot, cutting of his head, and cutting him in half. A nursing note dated 7/1/12 indicated Resident #4 was pushed or hit and he subsequently fell to the floor. Resident #4 complained of severe back pain. He received a 3.5 x 2.0 x 0.5 cm laceration to the crown of his head. He was sent to the ER. The resident returned with no new orders. During an interview on 7/5/12 at 1:53 p.m., Resident #4 said he remembered Resident #2 hitting him and falling on the floor. During an interview on 7/5/12 at 1:57 p.m., CNA F said Resident #2 was aware of the things that he did. CNA F said, "He knows what he is doing." During an interview on 7/5/12 at 2:30 p.m., the DON said Resident #2 did not have a care plan that addressed his aggressive behaviors. The DON said Resident #2 was aware of what was going on and he could talk to you and tell you what he wanted. The DON said the resident came when his name was called, he knew to take his medication, when to eat, he was continent, and could bathe himself. During an interview on 7/5/12 at 3:03 p.m., CNA A said she was the person that heard the altercation between Resident #2 and #4. Resident #4 was lying on the floor bleeding, and Resident #2 was standing over him laughing. CNA A said Resident #2 told Resident #4 to get out of his room. Resident #2 told her and other staff he intended to hit Resident #4. He gave different reasons, but initially said, "He was in my room." During an interview on 7/5/12 at 3:10 p.m., the administrator said she did not call the incident between Resident #2 and #4 to the state agency because they were both on the locked unit and both cognitively impaired. The administrator said Resident #2 did not know what he was doing. Resident #4 was sent to the hospital, but only received first aid. She said she was not aware of the incident when Resident #2 threatened to kill Resident #3. She said if she had been made aware of the threat, she may have handled the situation differently. 4. A physician order [REDACTED]. He had a [DIAGNOSES REDACTED]. The latest MDS dated [DATE] indicated Resident #3's cognitive status was moderately impaired. A care plan dated 5/10/12 indicated Resident #3 was impaired cognitively due to short and long term memory impairment. One of the objectives was to avoid circumstances that may result in injury. A social services referral form dated 3/26/12 indicated Resident #2 threatened to kill Resident #3. Resident #2 agreed to exercise more self-control in regard to yelling and threatening. During an interview on 7/5/12 at 9:43 a.m., the administrator said Resident #2 resided on the secure unit and had no indications of aggressive behavior prior to 7/1/12 (A psychological psychiatric evaluation dated 2/6/12, and interviews with staff documented prior indications of aggressive behavior). During an interview on 7/5/12 at 2:55 p.m., the social worker said he talked to Resident #2 after the incident with Resident #3, and Resident #2 seemed to understand what he did was wrong. The social worker said Resident #2's speech was hard to understand, but the staff that worked with him all the time understood him well. He said Resident #3, who resided on the secure unit, did not remember the incident at all. The social worker said Resident #2 appeared to be oriented to self, time, and situation and his outbursts were "deliberate" and Resident #2 could control them. The facility abuse and neglect policy revised 11/11/11 indicated allegations were "immediately reported to the appropriate agencies and then thorough investigation is initiated." Identification of abuse/neglect was to "assess care-plan and monitor residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors." "An investigation of all suspected any reported allegations of abuse or any injuries of unknown cause." "The investigation should include interviews of the employee, visitors, or residents who may have knowledge of the alleged incident." "The facility shall make reasonable efforts to determine the cause of the alleged incident, take corrective action consisting with investigation findings, to eliminate any ongoing dangers to the resident." On 7/18/12 at 10:00 a.m., the enforcement team determined the failure to ensure incidents of potential abuse/neglect were thoroughly investigated which contributed to an Immediate Jeopardy situation that had existed since 6/19/12. On 7/18/12 at 5:07 p.m., the administrator was informed of the Immediate Jeopardy situation. On 7/19/12 at 10:47 a.m., the facility's Plan of Removal was accepted and included the following: "*Facility will thoroughly investigate all incidents/accidents; including obtaining statements from staff members that had contact with the resident the prior 24 hours. *Resident #2 was discharged from the facility on 7/01/12. Resident #4 was discharged to a behavioral unit at a hospital on [DATE]. *Facility will in-service staff members on current reporting guidelines provider letter dated 1/03/07 regarding reporting abuse/neglect by 7/19/12. *Facility will in-service all staff on abuse and neglect policy and procedures by 7/19/12. *No staff will be allowed to work until in-service on abuse prohibition has been completed. *Facility will re-investigate incident of alleged sexual abuse. Facility will protect resident by placing her on one-on-one supervision. *A quality assurance meeting on 7/18/12 with the medical director, DON, administrator, and regional nurse consultant in reference to immediate jeopardy. *In the event of allegations of verbal threats made by residents regardless of cognitive impairment, the DON and the administrator will be notified immediately. Assessments will be completed and a thorough investigation will be done to ensure safety of all potential affected residents. As of 7/19/12, all staff (with the exception of those who had not returned to work) had received the in-service training and testing related to abuse, neglect, and misappropriation of resident's property. Three floor nurses, two administrative nurses, and the social worker were interviewed and provided correct responses about identifying abuse/neglect, how to handle incident/accident and allegations of abuse/neglect/misappropriation investigations, and abuse/neglect reporting. If they did not know whether the incident was a reportable, they knew the time frame of reporting the incident and where to locate the abuse policy with the attachment of reporting guidelines to make the report if necessary. Four nurse aides were interviewed and were able to identify types of abuse/neglect, who to report suspected abuse, neglect, and misappropriation of residents' property to, and what to do if the party the incident was reported did not act accordingly. All staff interviewed was knowledgeable of how to protect residents if an incident of possible abuse, neglect, or misappropriation were to occur. Surveyor observed staff being present (one-on-one) with Resident #1 and documenting accordingly." On 7/19/12 at 10:47a.m., the administrator, DON, and regional nurse consultant were informed the Immediate Jeopardy was lifted. The facility remained out of compliance at a pattern of potental for more than minimal harm due to the facility's need to complete all proficiency audits, and monitor and evaluate the effectiveness of the corrective systems. The facility census report dated 7/5/12 indicated 11 residents were in the locked unit.

Based on interview and record review, the facility failed to implement their written policies and procedures to prevent further abuse, to ensure allegations of sexual abuse and resident to resident abuse were thoroughly investigated, and to report to the state agency allegations of abuse for 4 of 4 residents reviewed for abuse. (Resident #s 1, 2, 3, and 4) Resident #1 made an allegation of sexual abuse and had bruises of unknown origin. The allegation and injuries of unknown origin were reported to the administrator and DON. The resident was not protected from further abuse, the incident was not thoroughly investigated, and the incident was not reported to the state agency because the administrator and DON said they disregarded the sexual abuse allegation because the nurse reporting the allegation was "overly dramatic." Resident #2 had a history of [REDACTED]. The resident did not have interventions in place to prevent aggressive behaviors toward other residents. Resident #2 hit Resident #4 causing a laceration to his head and threatened to kill Resident #3. The residents was not protected from further incidents, the incidents were not thoroughly investigated, and the incidents were not reported to the state agency because the administrator said the residents were cognitively impaired and resided on the locked unit. An Immediate Jeopardy situation was identified on 7/18/12 and had existed since 6/19/12. The Immediate Jeopardy was removed 7/19/12. The facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to monitor and evaluate the effectiveness of the corrective systems. This failure could place the 11 residents in the locked unit at risk of abuse, neglect, and injury. Findings included: The facility abuse and neglect policy revised 11/11/11 indicated allegations were, "immediately reported to the appropriate agencies and then thorough investigation is initiated." Identification of abuse/neglect was to, "assess care-plan and monitor residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors...An investigation of all suspected any reported allegations of abuse or any injuries of unknown cause...The investigation should include interviews of the employee, visitors, or residents who may have knowledge of the alleged incident...The facility shall make reasonable efforts to determine the cause of the alleged incident, take corrective action consisting with investigation findings, to eliminate any ongoing dangers to the resident." 1. Physician orders [REDACTED]. The latest MDS dated [DATE] indicated Resident #1's cognitive status was moderately impaired. A physician telephone order dated 6/12/12 indicated Resident #1 was admitted to the secure unit. A care plan dated 6/12/12 indicated Resident #1 had a problem of "being confused and able to remember, it may affect my moods, my speech, and my way of reacting and interacting with other people. I need staff to help me with reminding me about activities, medications, things I may forget, I have dementia, I wander and I live on a secure unit." Approaches listed were, "Help me with remembering by reminding me of your name if I cannot remember it. Be respectful and positive about the things I can remember and understand that they might not all be good memories." An incident report dated 6/19/12 at 1:00 a.m. noted Resident #1 alleged sexual abuse. The resident had bruises on both arms. The resident exhibited a change in condition as evidenced by new confusion. Resident #1 said, "A man was trying to get her poodle." The report indicated the resident pointed to her vaginal area when she used the word poodle. The report indicated the resident asked the nurse not to let him "get her again." Nursing notes dated 6/19/12 indicated: At 1:00 a.m., Resident #1 was agitated and uncooperative. She was verbally abusive to staff. She had a "large soft ball" size bruise on her upper left arm and another "tennis ball" size bruise just below the large bruise. Resident #1 was uncooperative and combative. She did not want anyone to touch her. At 1:45 a.m., Resident #1 was knocking on a glass door with her knuckles saying, "Come get me." And, ."..res has dark purple and green bruises on her right arm as well as her left arm." At 2:00 a.m., Resident #1 had a "bewildered look of hopeless on her face" She continued to knock on doors and asked to be let out repeatedly. When the nurse asked Resident #1 what caused the bruises, the resident said, "He did it." He was trying to get her "poodle" (pointing to her vaginal area). Resident #1 "asked this nurse not to let him get her again." Resident #1 wanted someone to stay with her "so he would not come back." The administrator and DON were notified. Resident #1 was sent to the ER for an evaluation. At 3:20 a.m., the police arrived and took a statement from LVN B, the nurse to whom Resident #1 reported the sexual abuse allegation. At 5:30 a.m., Resident #1 returned to the facility. The hospital nurse who called report to the facility indicated no rape evaluation was performed at the hospital. At 11:30 a.m., the resident allowed the nurse to measure the bruises on her arms. The left arm had a 12.0 cm x 10.0 cm with various stages of discoloration. The inner aspect of the area was red and purple in color. The outer aspect of the area was yellow green and blackish in color. There was a smaller bruise to the side measuring 1.0 cm x 1.0 cm and black in color. The right arm had a bruise that measured 1.8 cm x 4.3 cm in size and was purple to black in color. A provider investigation report dated 6/19/12 indicated Resident #1 was wandering the halls in a sleeveless nightgown and LVN B tried to redirect her back to bed and noted bruises of an unknown origin. The incident report said the resident did not remember what happened and the resident denied that anyone hurt her or being in an altercation. A written statement by CNA C that accompanied the incident report dated 6/19/12 noted she was asked to help get Resident #1 back to bed. The statement said the CNA asked the resident twice to go to bed and Resident #1 said she was ready the second time. The statement said CNA C went back to her hall after Resident #1 was in bed. The investigation report did not contain interviews with employees, residents who may have knowledge of the alleged incident. The facility did not make reasonable efforts to determine the cause of the alleged incident, and they did not take corrective action to eliminate any ongoing dangers to the resident or other residents. During an interview on 7/5/12 at 9:40 a.m., the administrator said Resident #1 was confused and combative with staff at times. The administrator said she talked with the son of Resident #1 about the bruises and the son said the whole family bruised easily. The administrator said she talked with CNA C who said she was with Resident #1 the whole night and did not witness anything unusual. She said she talked with the charge nurse who said the resident was restless and walked a lot that night. The administrator said it was "undetermined" how the resident got the bruises. She said the secure unit did not have any aggressive residents. She said they did have one incident where Resident #2 hit Resident # 4 and Resident #2 was sent to the behavioral hospital on [DATE]. During a telephone interview on 7/5/12 at 10:28 a.m., LVN B said Resident #1 did not appear to be herself on 6/19/12; she was upset and exhibiting behaviors LVN B had not seen before. LVN B said Resident #1 said, "He came in my room messing around, and laughing hee, hee, hee." LVN B said Resident # 1 said he tried to get her "poodle." LVN B said the resident pointed to her vaginal area when she said "poodle." She said the resident was forgetful but sometimes made perfect sense. She said the resident was afraid, did not want to be left alone, was irritated, and did not want the staff to touch her. LVN B said the resident would not go to bed. LVN B said the bruises on her arms could have been "hand prints." The largest one had smaller bruises that could have being "finger bruises." LVN B said she called the DON and the administrator and reported the allegation of sexual abuse. They told her to send the resident to the hospital to have a rape kit completed. LVN B said she gave the resident [MEDICATION NAME] (anti-anxiety) to calm her down and asked CNA D to stay with the resident until EMS arrived. She said she did not assess the resident. She said the hospital was unable to complete a rape examination due to lack of equipment and qualified staff. During an interview on 7/5/12 at 10:57 a.m., the administrator and DON said they were aware LVN B reported Resident #1 made a sexual abuse allegation. They said the nurse called both of them early on the morning of 6/19/12 and reported the sexual abuse allegation. They said they told the LVN to send the resident to the hospital. They said they spoke to the resident about the allegation later and she did not remember what happened. They said the ADON assessed the resident and did not see anything out of the ordinary except the unexplained bruises on her arms. They said because of the information the family gave about the resident bruising easily and the aide saying she was with the resident all night, they disregarded the sexual abuse allegation. The facility abuse policy last updated 11/11/11 indicated "...upon receiving reports of sexual abuse, the charge nurse shall immediately examine the resident." During an interview on 7/5/12 at 11:07 a.m., the ADON said she completed a head to toe assessment of Resident #1 late on the evening of 6/19/12. She said she was not there the morning of the incident. The ADON said Resident #1 could not remember how she got the bruises. During an interview on 7/5/12 at 11:23 a.m., LVN E said LVN B told her Resident #1 made an allegation of sexual abuse. LVN E said she saw the bruises on Resident #1's arms around 11:00 a.m. and they looked like they could have been "hand prints." She said she did not look at the resident's vaginal area. She said Resident #2 always laughed inappropriately and often. She said Resident #2 was a "registered sex offender" and he was sent to the behavioral hospital on [DATE] for hitting another resident. During an interview on 7/5/12 at 12:40 p.m., CNA C said around 12:00 a.m. or 1:00 a.m., LVN B asked her to see if she could get Resident #1 to go to bed. She said the resident was walking around the unit. CNA C said she was not scheduled to provide care for Resident #1 that night, so she got the resident back to bed and went back to her hall. During an interview on 7/5/12 at 1:28 p.m., CNA D said Resident #1 was asleep in bed when she arrived at 10:00 p.m. to work. She said she started her rounds around 1:00 a.m. She said Resident #1 allowed her to change her brief and followed her out of the room. She said after 1:00 a.m., the resident was confused, wandering the unit and agitated. She said the resident did not want to go back to bed and felt like someone was after her. CNA D said CNA C got the resident to go back to bed and CNA D stayed with her until EMS arrived. CNA D said the resident seemed fearful and afraid to be alone. During an interview on 7/5/12 at 2:50 p.m., the social worker said he interviewed Resident #1 about the bruises and she told him she did not recall anything traumatic that happened. He said he was not aware of a sexual abuse allegation, but was told by staff the bruises on her arms looked like "hand prints." During an interview on 7/5/12 at 3:10 p.m., the administrator/abuse coordinator said her investigation for Resident #1's allegation of sexual abuse consisted of interviews with CNA C, the family members, and the resident. The administrator said those interviews indicated no concerns, but she could not determine the origin of the bruises. She said she did not notify the state agency of the allegation of sexual abuse and did not look into the issue. She said the nurse that reported the allegation was "overly dramatic at times." 2. Physician orders [REDACTED]. A psychiatric hospital discharge summary dated 12/1/11 indicated Resident # 2 continued to be "very psychotic with bizarre behaviors, at times, although it appeared to be fewer episodes of bizarre behaviors." There were no reports of sexually inappropriate behaviors. Resident #2 had sexual assault charges in the past. The resident was alert, but his memory orientation could not be tested . He appeared somewhat functionally demented and it was hard to determine if he was demented or just had chronic [MEDICAL CONDITION]. He was hospitalized and institutionalized over the last [AGE] years. He was able to answer simple questions with appropriate answers. In a conversation, he was much disorganized in his thoughts and would talk about things that were totally irrelevant. His affect seemed okay. He was very childlike at times, at others violent [MEDICAL CONDITION] which he did act out towards this internal stimuli. He was diagnosed with [REDACTED]. The website http://trialx.com/curetalk/2011/02/what-is-[MEDICAL CONDITION]-disorder-[MEDICAL CONDITION]-type-symptoms-diagnosis-treatments/ accessed 7/24/12 indicated [MEDICAL CONDITION] disorder [MEDICAL CONDITION] type is "phases of extreme euphoria, recklessness and [MEDICAL CONDITION], usually termed as mania, which is punctuated with phases of extreme depression and normal moods", but "may have psychotic visual and auditory hallucinations even during the normal moods." A psychiatric hospital physician discharge order inquiry dated 2/3/12 indicated Resident #2 was "...very disorganized, tangential, irrational in his thought patterns and his mood control. He followed directions well enough." The report also indicated, " ...His history showed that one occasion he has attempted to touch female staff inappropriately in a sexual manner..." An initial psychological psychiatric evaluation dated 2/6/12 indicated Resident #2 was referred for psychiatric services due to mood swings and psychotic symptoms. The presenting symptoms were depressed mood, anxiety, irritability, agitation, anger, verbal aggression, physical aggression, combativeness, suspiciousness, paranoia, delusional belief-persecutory/grandiose, disorganized thinking, and mental confusion. His mental status was described as a superficially cooperative attitude. His orientation was disoriented to place and time. His memory was remote-mildly impaired, recent-seriously impaired, immediate-mildly impaired. His thought process was disorderly slightly and thought content was paranoid and delusional. His mood was varied and was potentially violent. A psychology progress note dated 3/26/12 indicated Resident #2 was seen for allegedly threatening to kill another resident. When he was seen by the psychologist he was restless but not severely upset. He said his father talked like that to him when he was young. The resident was cooperative. The latest MDS dated [DATE] indicated Resident #2 was severely impaired cognitively. A social services dated 5/19/12 indicated Resident #2 had short and long term memory problem and moderately impaired daily decision making skills. There have been delusional and disorganized thinking, inappropriate behaviors of verbal abuse, and other behaviors of sexual suggestiveness. A care plan last updated 5/24/12 indicated Resident #2 did not have a care plan that addressed his aggressive behaviors. 3. A psychological consulting noted dated 7/2/12 indicated Resident #4 had [DIAGNOSES REDACTED]. The most recent MDS for Resident #4 dated 6/19/12 indicated his cognition was moderately impaired. A care plan updated 6/21/12 indicated Resident #4 had "...a problem with being confused and able to remember, it may affect my moods, my speech, and my way of reacting and interacting with other people...I have Alzheimer's, I wander, and I live on a secured unit" and "I may get agitated when you try to help with my personal care..." Approaches included, "Please tell me what you are going to do before you do it. If I get upset, stop for a minute and talk quietly to me...If I get too upset, leave me alone for a few minutes and send someone else to take care of me I might respond better..." An incident report dated 7/1/12 at 6:45 p.m. indicated Resident #2 was in his room when Resident #4 entered. When the aide entered the room, Resident #4 was on the floor and Resident #2 was standing over him. Resident #4 said Resident #2 hit him. Resident #4 had a gash to the head. A written statement by CNA A that accompanied the incident report dated 7/1/12 said she heard two men yelling and a loud thump. When she entered the room, Resident #4 was on the floor and Resident #2 was standing over him laughing and smiling. Resident #4 was holding his head saying Resident #2 hit him. The nurse that wrote the report said the resident was rambling about Resident #4 taking his boot, cutting of his head, and cutting him in half. A nursing note dated 7/1/12 indicated Resident #4 was pushed or hit and he subsequently fell to the floor. Resident #4 complained of severe back pain. He received a 3.5 x 2.0 x 0.5 cm laceration to the crown of his head. He was sent to the ER. The resident returned with no new orders. During an interview on 7/5/12 at 1:53 p.m., Resident #4 said he remembered Resident #2 hitting him and falling on the floor. During an interview on 7/5/12 at 1:57 p.m., CNA F said Resident #2 was aware of the things that he did. CNA F said, "He knows what he is doing." During an interview on 7/5/12 at 2:30 p.m., the DON said Resident #2 did not have a care plan that addressed his aggressive behaviors. The DON said Resident #2 was aware of what was going on and he could talk to you and tell you what he wanted. The DON said the resident came when his name was called, he knew to take his medication, when to eat, he was continent, and could bathe himself. During an interview on 7/5/12 at 3:03 p.m., CNA A said she was the person that heard the altercation between Resident #2 and #4. Resident #4 was lying on the floor bleeding, and Resident #2 was standing over him laughing. CNA A said Resident #2 told Resident #4 to get out of his room. Resident #2 told her and other staff he intended to hit Resident #4. He gave different reasons, but initially said, "He was in my room." During an interview on 7/5/12 at 3:10 p.m., the administrator said she did not call the incident between Resident #2 and #4 to the state agency because they were both on the locked unit and both cognitively impaired. The administrator said Resident #2 did not know what he was doing. Resident #4 was sent to the hospital, but only received first aid. She said she was not aware of the incident when Resident #2 threatened to kill Resident #3. She said if she had been made aware of the threat, she may have handled the situation differently. 4. A physician order [REDACTED]. He had a [DIAGNOSES REDACTED]. The latest MDS dated [DATE] indicated Resident #3's cognitive status was moderately impaired. A care plan dated 5/10/12 indicated Resident #3 was impaired cognitively due to short and long term memory impairment. One of the objectives was to avoid circumstances that may result in injury. A social services referral form dated 3/26/12 indicated Resident #2 threatened to kill Resident #3. Resident #2 agreed to exercise more self-control in regard to yelling and threatening. During an interview on 7/5/12 at 9:43 a.m., the administrator said Resident #2 resided on the secure unit and had no indications of aggressive behavior prior to 7/1/12 (A psychological psychiatric evaluation dated 2/6/12, and interviews with staff documented prior indications of aggressive behavior). During an interview on 7/5/12 at 2:55 p.m., the social worker said he talked to Resident #2 after the incident with Resident #3, and Resident #2 seemed to understand what he did was wrong. The social worker said Resident #2's speech was hard to understand, but the staff that worked with him all the time understood him well. He said Resident #3, who resided on the secure unit, did not remember the incident at all. The social worker said Resident #2 appeared to be oriented to self, time, and situation and his outbursts were "deliberate" and Resident #2 could control them. On 7/18/12 at 10:00 a.m., the enforcement team determined the failure to ensure incidents of potential abuse/neglect were thoroughly investigated which contributed to an Immediate Jeopardy situation that had existed since 6/19/12. On 7/18/12 at 5:07 p.m., the administrator was informed of the Immediate Jeopardy situation. On 7/19/12 at 10:47 a.m., the facility's Plan of Removal was accepted and included the following: "*Facility will thoroughly investigate all incidents/accidents; including obtaining statements from staff members that had contact with the resident the prior 24 hours. *Resident #2 was discharged from the facility on 7/01/12. Resident #4 was discharged to a behavioral unit at a hospital on [DATE]. *Facility will in-service staff members on current reporting guidelines provider letter dated 1/03/07 regarding reporting abuse/neglect by 7/19/12. *Facility will in-service all staff on abuse and neglect policy and procedures by 7/19/12. *No staff will be allowed to work until in-service on abuse prohibition has been completed. *Facility will re-investigate incident of alleged sexual abuse. Facility will protect resident by placing her on one-on-one supervision. *A quality assurance meeting on 7/18/12 with the medical director, DON, administrator, and regional nurse consultant in reference to immediate jeopardy. *In the event of allegations of verbal threats made by residents regardless of cognitive impairment, the DON and the administrator will be notified immediately. Assessments will be completed and a thorough investigation will be done to ensure safety of all potential affected residents. As of 7/19/12, all staff (with the exception of those who had not returned to work) had received the in-service training and testing related to abuse, neglect, and misappropriation of resident's property. Three floor nurses, two administrative nurses, and the social worker were interviewed and provided correct responses about identifying abuse/neglect, how to handle incident/accident and allegations of abuse/neglect/misappropriation investigations, and abuse/neglect reporting. If they did not know whether the incident was a reportable, they knew the time frame of reporting the incident and where to locate the abuse policy with the attachment of reporting guidelines to make the report if necessary. Four nurse aides were interviewed and were able to identify types of abuse/neglect, who to report suspected abuse, neglect, and misappropriation of residents' property to, and what to do if the party the incident was reported did not act accordingly. All staff interviewed was knowledgeable of how to protect residents if an incident of possible abuse, neglect, or misappropriation were to occur. Surveyor observed staff being present (one-on-one) with Resident #1 and documenting accordingly." On 7/19/12 at 10:47a.m., the administrator, DON, and regional nurse consultant were informed the Immediate Jeopardy was lifted. The facility remained out of compliance at a pattern of potental for more than minimal harm due to the facility's need to complete all proficiency audits, and monitor and evaluate the effectiveness of the corrective systems. The facility census report dated 7/5/12 indicated 11 residents were in the locked unit.