Every finding on record at Birmingham Nursing and Rehabilitation CTR LLC

Based on observations, interviews, record review, review of Facility Reported Incidents (FRI), review of the facility investigative files, review of a facility policy titled Abuse Prevention and review of a facility policy titled Behavior Management and Psychopharmacological Medication Monitoring Protocol, the facility failed to provide adequate supervision and ensure appropriate interventions were developed to manage RI #78's psychosis/delusional behaviors and ensure safety of residents in the facility. Because RI #78, a resident with a known history of chronic delusions/psychosis/restlessness/agitation, was not adequately supervised by staff, RI #78 hit RI #119 in the left shoulder on 06/12/25 and hit RI #13 on the left shoulder on 09/15/2025. This was discovered during investigations of abuse. Staff at the facility described RI #78's behaviors as unpredictable, difficult to pinpoint triggers, and to keep RI #78 from abusing other residents it would require supervision of RI #78 when out and about in the presence of other residents.This deficient practice affected RI #78 one of five residents sampled for behavioral health services. Findings Included:Cross Reference F600 A facility policy titled ABUSE PREVENTION dated 01/2025 documented the following: . PREVENTION: .5. Examples of steps that the facility may put in place immediately to prevent further potential abuse includes, but are not limited to, staffing changes, increased supervision, protection from retaliation, and follow-up counseling for the resident(s) . A facility policy titled Behavior Management and Psychopharmacological Medication Monitoring Protocol with an date of revision of 3/2018 documented: . PURPOSE: Residents with behaviors that are displayed routinely, that effect the resident's psychosocial well- being or that of other residents, or behaviors that can have potential for harm to self or others will be assessed with the development of a behavior program.DEFINITIONS: . Behavioral Interventions are individualized non -pharm logical approaches to care that are provided as part of a supportive physical and psychosocial environment, and are directed toward understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities as well as maintaining or improving a resident's mental, physical or psychosocial well-being.PROCEDURE: .2. Established resident with new onset of adverse behaviors:d) The Interdisciplinary Care Team (IDT) will update the care plan to include the problem behavior, goals, and approaches. RI #78 was admitted to the facility on [DATE] and had diagnoses to include Schizoaffective Disorder, Bipolar type, Dementia with Behavioral Disturbance, Restless and Agitation and Personal History of Other Mental and Behavioral Disorders. RI #78's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/30/2025 documented a Brief Mental Status Score of 6 out of 15 which indicated impaired cognition. RI #78's MDS documented resistance to care and wandering the facility one out of three days during the observation period. RI #78's MDS documented receipt of Antipsychotic medication. A review of RI #78's Level I determination dated 03/05/2021 documented the need for a Level II due to Diagnosis of Mental Illness; Mental Disorder of Schizoaffective Disorder, Bipolar Disorder, Psychotic, Manic. RI #78's Level II determination dated 03/15/2021 recommended Psychiatric Follow up Care for Serious Mental Illness of Bipolar, Psychotic Manic, Schizoaffective Disorder (Symptoms Severe) which RI #78 had received since his/her initial evaluation from Integrative Behavioral Health on 02/04/2021.On 03/01/2021 RI #78 had a care plan initiated for a focus area of PASRR Level II related to serious mental illness, Bipolar, psychotic manic, schizoaffective disorder (symptoms severe).On 09/16/2024 RI #78 had a behavioral symptoms care plan initiated for a focus area of history of being verbally aggressive cusses at staff, Dementia, Ineffective coping skills, Mental/Emotional illness, poor impulse control; history of being physically aggressive, Dementia with behavior disturbance, Schizoaffective disorder, Bipolar Disorder towards staff and other residents when agitated. Care Plan Interventions included: Administer medications as ordered; Analysis of key times, places, circumstances, triggers, and what de- escalates behavior and document; Assess resident's coping skills and support system; Assess resident' understanding of the situation. On 09/16/2024 RI #78's behavioral symptoms care plan was initiated for a focus area of having a history of being physically aggressive towards staff/other residents when agitated related to Dementia with behavioral disturbances and Schizoaffective Disorder, Bipolar Disorder. Interventions on the care plan include; Administer medications as ordered; Analyze of key times, places, circumstances, triggers, and what de- escalates behavior and document; Assess and anticipate resident needs, Modify Environment; Adjust room temperature to comfortable level, Reduce Noise, Dim lights, place familiar objects in the room, keep door closed; Monitor/ document/report any signs or symptoms of resident posing a danger to self or others.On 02/24/2024 RI #78 had a care plan initiated for a focus area of having delusions that he/she was working at the facility. Interventions on the care plan were 1) Document and monitor activity 2) Psych consult as needed 3) Redirect resident to preferred activity.RI #78's SOCIAL SERVICE HISTORY & INITIAL ASSESSMENT dated 05/30/2025 documented RI #78 was alert and oriented to person and situation; Mental Health diagnoses included Schizoaffective Disorder, Bipolar Disorder, history of mental and behavioral disorders, Restless and Agitation. Specific behavior factors noted on the assessment include: 1) exit seeking, 2) disruptive behavior, 3) difficulty controlling behavior, 4) wandering, 5) agitation, aggressive or abusive behavior and 6) resistance to care. The facility investigative file contained a typed Witness Statement for RI #78 dated 06/12/2025 which included questions and answers for RI #78 during investigation of physical abuse in which RI #119 was the victim, as follows: . I went in there and (he/she) was dipping in my business. My business. You know, just business. I just reached out and tapped (him/her) on (his/her) arm and told (him/her) to stop dipping in my business. Why would you even touch (him/her)? . Just a reflex. For dipping in my business. To tell (him/her) to stop.The facility investigative file contained a typed Witness Statement for RI #78 dated 09/15/2025 which included questions and answers for RI #78 during investigation of physical abuse in which RI #13 was the victim, as follows: . I hit (him/her) after (he/she) raised (his/her) arm to hit me. (He/she) swung on me and I hit (him/her) . (He/she) was flirting with my husband up there in the front of the room. ({RI #78} has no husband. There was no male in the front of the room, the TV News was on the TV in the front of the room.) . Are you going to hit anyone else? . Only if they try to hit me first. Contained within the facility's investigative file was a typed interview with the eyewitness, Occupational Therapist (OT) #16, dated 09/15/2025, which documented the following questions and answers in response to the OT witnessing RI #78 physically abuse RI #13: . Were you working in the dining room at lunch today? . Yes.Did you observe and interaction between (RI #78) and (RI #13)? . Yes. (RI #78) got up from (his/her) chair at the table and walked over to (RI #13) and pushed or punched (his/her) shoulder. (He/she) said something along the lines of get out of my husbands face, something to that effect.On 12/03/2025 at 2:26 PM an interview was conducted with OT #16 regarding what she witnessed on 09/15/2025 in the dining room. OT #16 said that RI #78 was sitting in the back of the room at a table when RI #78 got up out of his/her chair and walked straight towards RI #13, and punched RI #13 on the shoulder, saying something along the lines of get out of my husband's face. OT #16 said she was seated to the left of the television, about 7 steps away from RI #13 and faced the back of the room, allowing her to see both RI #78 and RI #13. OT #16 said there were no indicators from RI #78 that it was about to occur (no cursing or yelling), but the actions appeared to be intentional and directed towards RI #13. OT #16 said RI #13 screamed and seemed upset and confused as to why RI #78 punched him/her in the shoulder. OT #16 said for this to be prevented, RI #78 would need supervision when out and about in the dining room or courtyard area where other residents were present. On 12/1/2025 at 3:25 PM an interview was conducted with CNA #7 who was familiar with RI #78's mood and behaviors. CNA #7 said RI #78 exhibited resistance to care often and that RI #78's mood/behaviors were unpredictable and would fluctuate daily. CNA #7 said she did not witness RI# 78 hit RI#119, but she was present when RI #78 hit RI #13 in the dining room on 09/15/2025. When asked what level of supervision RI #78 would need to prevent him/her from hitting out at others, CNA #7 said, RI #78 would need someone all the time because RI #78's moods were always changing and unpredictable. On 12/01/2025 at 4:05 PM an interview was conducted with CNA #6 and when asked if she had ever seen RI #78 hit anyone before, she stated no, but she had seen RI #78 get mad and curse at other residents. When asked what curse words RI #78 used, CNA #6 said, RI #78 called people the B word. On 12/3/2025 at 4:40 PM, an interview was conducted with the Director of Social Services (SSD) regarding RI #78 and the incident on 06/12/2025 and 09/15/2025. The SSD said that RI #78 has a history of Psychosis related to Mental Health Issues; in addition, RI #78 had Dementia with behaviors which included resistance to care, wandering, and having delusional expressions. The DSS said RI #78's behaviors were random and it was difficult to pinpoint what may trigger his/her behaviors. When asked about the incident on 06/12/2025, the SSD said RI #78 was placed on one-to-one supervision, sent to the hospital, returned, remained on one to one supervision until the physician discontinued around 06/16/2025, and RI #78 was placed on behavior monitoring. The SSD said the incident on 09/15/2025 occurred when RI #78 believed that RI #13 was trying to take RI #78's man away by showing his/her legs/body while RI #78's husband was performing. The SSD said there was no male preforming that day in the dining room, and residents were watching television. The SSD said she believed RI #78 was acting on his/her delusional thoughts the day of the incidents. After the incident on 09/15/2025, the SSD interviewed RI #78 who felt the hit was justified based on the delusional thoughts that RI #13 was showing his/her body to RI #78's husband. The SSD did not believe the incident could have been prevented due to RI #78's behaviors being unpredictable. On 12/03/2025 at 6:00 PM an interview was conducted with the Director of Nursing (DON) regarding RI #78. The DON said RI #78 had a psychiatric history, exhibited behaviors such as refusing baths and had hallucinations, and was followed by behavioral health services. The DON said RI #78 required more supervision at times when he/she exhibited increased restlessness or agitation related to wanting to go home. The DON said the staff watched RI #78 closely during this time of increased restlessness. The DON said interventions put in place after 06/12/2025 were to refer for consult to behavioral health services if behaviors continued and that the care plan did not note that RI #78 hit/struck another resident on 06/12/2025. When asked what the process was for assessing the level of supervision RI #78 would need to ensure safety of others, the DON said it was discussed in Quality Assurance, and one to one was immediately initiated until a mental health evaluation could be conducted. On 12/4/2025 at 12:53 PM an interview was conducted with the ADM regarding the abuse on 06/12/2025. The ADM said, RI #78 was placed on one-to-one supervision until sent out to the hospital for evaluation. When asked if the facility completed an assessment to determine the level of supervision needed after the incident, the ADM said there was no. The ADM said the incident was investigated, taken to QAPI and the root cause analysis determined RI #78 was having medical issues; the ADM said, RI #78's medications were administered, if RI #78 becomes upset they try to anticipate needs, modify the environment; monitor and report any danger to others, psychiatric consults as needed, keep in an area of high traffic, engage in activity, and if agitated place on one-on-one, but there was not an assessment to determine the level of supervision. The ADM was asked about the abuse on 09/15/2025 and she said, there were no warning signs from RI #78. The Adm said the incident was investigated and taken to QAPI and the root cause analysis was performed. The ADM said they determined the root cause to be environmental, including television noise, music and overall stimulation, and therefore implemented a quiet time during meals. Review of RI #78's medical record did not reveal any interventions or actions were put in place to routinely supervise RI #78 to protect residents in the facility from being abused by RI #78.

Based on interviews, record reviews, review of a facility policy titled, ABUSE PREVENTION, review of Facility Reported Incidents (FRIs) received by the State Agency and review of the facility's investigative files, the facility failed to ensure residents in the facility were free from physical abuse perpetrated by other residents. The facility failed to protect (RI) #119's right to be free from physical abuse perpetrated by RI #78, a resident with a known history of Chronic Delusions, Psychosis, Restlessness, Agitation, and Dementia with Behavioral Disturbance. RI #78 was witnessed walking across the dining room and hit RI #119 in the right upper arm on 06/12/2025. The facility failed to assess and determine the level of staff supervision needed for RI #78, before and after the abuse, to prevent RI #78 from abusing others.Because the facility failed to assess and determine the level of supervision required for RI #78, address behaviors, and implement actions to prevent RI #78 from abusing other residents, on 09/15/2025 during the noon meal RI #78 was witnessed to get up from his/her chair; walk across the dining room and hit RI #13 in the left shoulder. Per the facility investigative file, five staff members who were present in the dining room during the abuse were not aware RI #78 approached and hit RI #13 until RI #13 yelled out. Another staff member, an Occupational Therapist (OT), who was present was the only staff member to witness what occurred. Staff interviewed said, a reasonable person in RI #13's situation would feel upset and confused. The facility failed to ensure the incidences of abuse perpetrated by RI #78 were reviewed and analyzed in a manner to determine causes and implement appropriate and effective corrective actions to prevent recurrence of abuse towards residents in the facility.This deficiency was cited as a result of the investigation of complaint/report numbers 462289 and 2619326 and had the potential to affect three of seven residents sampled for abuse. Findings Include: Cross - Reference F740 On 06/12/2025 at 11:35 AM the State Agency received a Facility Reported Incident (FRI) alleging physical abuse occurred when staff witnessed Resident Identifier (RI) #78 walk up to RI #119 and hit RI #119 in the right upper arm. RI #78 was admitted to the facility on [DATE] and had diagnoses to include Schizoaffective Disorder, Bipolar type, Dementia with Behavioral Disturbance, Restlessness, Agitation, and History of Mental and Behavioral Disorders. RI #78's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/30/2025 documented a Brief Mental Status Score of 6 out of 15 which indicated severely impaired cognition. RI # 78's MDS documented RI #78 was resistive to care and wandered the facility one out of three days during the observation period. A review of RI #78's Level I determination dated 03/05/2021 documented the need for a Level II due to a serious Mental health diagnosis of Schizoaffective Disorder, Bipolar Disorder, and Psychotic Manic. RI #78's Level II determination dated 03/15/2021 recommended Psychiatric Follow up Care for Serious Mental Illness of Bipolar, Psychotic Manic, Schizoaffective Disorder (Symptoms Severe) which RI #78 had received since his/her initial evaluation from Integrative Behavioral Health on 02/04/2021. On 03/01/2021 RI #78's had a care plan initiated for a PASSRR Level 11 r/t (related to) serious mental illness, Bipolar, psychotic manic, schizoaffective disorder (symptoms severe). On 09/16/2024 RI #78's behavioral symptoms care plan was initiated of for focus areas of having a history of being verbally aggressive, cusses at staff, Dementia, Ineffective coping skills, Mental/Emotional Illness, poor impulse control. The care plan was last revised on 06/18/2025. On 09/16/2024 RI #78's care plan with a focus area of history of being physically aggressive, Dementia with behavior disturbance, schizoaffective disorder, bipolar disorder towards staff/other residents when agitated. The care plan was revised last on 06/18/2025. On 02/24/2024 RI #78 had a care plan initiated for focus areas of having delusions that he/she was working at the facility. RI #78's care plans did not contain any interventions to guide staff in the level of routine supervision RI #78 required to prevent him/her from abusing others. RI #119 was admitted to the facility on [DATE] and had diagnoses to include Schizophrenia, Chronic, Pain, Mood Disorder, and Intellectual Disabilities. RI #119's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/02/2025 documented a Brief Mental Status (BIMS) score of 13 out of 15 which indicated intact cognition. The facility investigative file contained a summary signed by the Administrator dated 06/19/2025 which documented: . I (ADM) was notified that (RI #78) had entered the dining room and had struck (RI #119) on the right upper forearm. (RI #78) stated that (RI #119) was in (his/her) business. (RI #78's) explanations then became inconsistent. The allegation that (RI #78) struck (RI #119) is substantiated. The facility investigative file contained a typed Witness Statement for RI #119 dated 06/12/2025 which included questions and answers as follows: . I was sitting at my table and (he/she) came up to me and said something about dipping in (his/her) business and then hit me on my arm. This arm. (Points to right upper arm. Upper arm examined.) . No I wasn't talking about (him/her). I wasn't doing anything. On 12/03/2025 at 3:45 PM an interview was conducted with RI #119 regarding the incident on the morning of 06/12/2025. RI #119 said he/she recalled the incident on 06/12/2025. When asked what occurred, RI #119 said that he/she was sitting in the usual spot in the dining room and RI #78 just came up and hit (him/her) in the shoulder unprovoked, it did not feel good. RI #119 said the hit hurt and that he/she had a sore arm for a while. The facility investigative file contained a typed Witness Statement for RI #78 dated 06/12/2025 which included questions and answers as follows: . I went in there and (he/she) was dipping in my business. My business. You know, just business. I just reached out and tapped (him/her) on (his/her) arm and told (him/her) to stop dipping in my business. Why would you even touch (him/her)? . Just a reflex. For dipping in my business. To tell (him/her) to stop. Contained within the facility's investigative file was a typed Witness Statement with the eyewitness, CNA #13, dated 06/12/2025, which documented the following questions and answers: . Did you observe an interaction between (RI #78) and (RI #119) this am? . Yes. (RI #78) walked in the dining room and walked up to (RI #119) and told (him/her) to stop dipping in (his/her) business and hit it. Opened hand with (his/her) right hand on (RI #119's) Left Shoulder. How did RI #119 react? . (He/she said OK you don't have to hit me. CNA #13 no longer works at the facility and the facility did not have a contact number. On 12/01/2025 at 3:35 PM an interview was conducted with CNA #7 who was familiar with RI #78's mood and behaviors. CNA #7 said RI #78 exhibited resistance to care often and that RI #78's mood/behaviors were unpredictable and would fluctuate daily. CNA #7 said she did not witness RI# 78 hit RI#119, but she was present when RI #78 hit RI #13 in the dining room on 09/15/2025. CNA #7 said one resident hitting another resident would be physical abuse and would make a person feel scared. When asked what level of supervision RI #78 would need to prevent him/her from hitting out at others, CNA #7 said, RI #78 would need someone all the time because RI #78's moods were always changing and unpredictable. On 12/01/2025 at 4:05 PM an interview was conducted with CNA #6 regarding the incident on 06/12/2025. When CNA #6 was asked if she had ever seen RI #78 hit anyone before, she stated no, but she had seen RI #78 get mad and curse at other residents. When asked what curse words RI #78 used, CNA #6 said called people the B word. CNA #6 said a resident hitting another resident is considered physical abuse. On 12/4/2025 at 12:53 PM an interview was conducted with the ADM regarding the abuse on 06/12/2025. The ADM said she was notified by LPN #14 of the of the allegation of physical abuse at 9:35 AM on 6/12/2025 that RI #119 was sitting in the dining room and RI #78 walked up and hit RI #119 in the right upper arm. The ADM said residents in the dining room were attended by staff for safety, residents were assessed for injury with none noted, notifications made, and RI #78 was placed on one-to-one supervision until sent out to the hospital for evaluation. When asked if the facility completed an assessment to determine the level of supervision needed after the incident, the ADM said there was no assessment, and RI #78 was placed on one-to-one supervision. The ADM said, RI #78 was determined to be appropriate for nursing home placement when the Level II was completed on admission. The ADM said the incident was investigated, taken to QAPI and the root cause analysis determined RI #78 was having pain related to medical issues. The ADM said the allegation that RI #78 struck RI #119 was substantiated based on her investigation. The facility failed to assess and determine what level of staff supervision would be required for RI #78 to prevent further abuse of residents in the facility after the one-on-one supervision was discontinued on 06/17/2025. On 09/15/2025 at 1:55 PM the State Agency received a FRI alleging physical abuse occurred in the dining room when RI #13 said, OUCH and reported to staff that RI #78 had hit (him/her) on the left shoulder. RI #13 was admitted to the facility on [DATE] and had diagnoses to include Diabetes Mellitus with Diabetic Chronic Kidney Disease. RI #13's Quarterly MDS with an ARD of 09/04/2025 revealed a 12 out of 15 on the BIMS which indicates mild cognitive impairment. The facility investigative file contained a typed summary of the abuse signed by the ADM which documented: . During the lunch meal on 09/15/2025, (RI #13) stated that (RI #78) had hit (him/her) on the upper left arm. Staff heard (RI #13) say Ouch, I don't know your husband. The dining room was attended by 3 CNAs, DNS, Unit Manager, and an occupational therapist (OT). (RI #78) was immediately assisted form the dining room to (his/her) room for body audit and one:one supervision. An immediate investigation was started. The MD for both resident was notified. The Birmingham Police . was notified. (RI #78) was transferred to ER . and returned with no new orders. One:One supervision was maintained until 9/22/25. Upon investigation, it is noted that only 1 staff member saw the incident. The OT reported that she saw (RI #78) walking towards (RI #13) and told (him/her) something to the effect to get out of (his/her spouse's) face. Staff reports that (RI #78) had no symptoms of agitation as (he/she) approached (RI #13). OT reported that it looked like (RI #13) held (his/her) arm up in a defensive move and (RI #78) hit (RI #13) on the shoulder at the same time. Education for all staff was started on Preventative Measures – Resident to Resident Abuse. The Education was completed on 9/22/25. A QAPI (Quality Assurance Performance Improvement) meeting was held on 9/18/25. It is noted that (RI #78) was seen by . (behavioral health services) on 9/18/25 and medications were changed. (Behavioral health services) suggested (RI #78) remain on one:one supervision through the weekend. one:one was discontinued on 9/22/25 . The allegation of abuse of (RI #13) by (RI #78) is substantiated . On 12/01/2025 at 5:30 PM an interview was conducted with RI #13 regarding the incident on 09/15/2025. When RI #13 was asked what occurred, he/she said while eating lunch, RI# 78 came up from behind and poked him/her on the left arm and said to leave (his/her) man alone. RI #13 said he/she felt scared and confused as to why RI #78 would do this. RI #13 said the poke was not hard, but that it was very frightening because it was not expected. RI #13 said the staff intervened immediately and removed RI #78. Contained within the facility's investigative file was a typed interview with the eyewitness, Occupational Therapist (OT) #16, dated 09/15/2025, which documented the following questions and answers: . Were you working in the dining room at lunch today? . Yes.Did you observe and interaction between (RI #78) and (RI #13)? . Yes. (RI #78) got up from (his/her) chair at the table and walked over to (RI #13) and pushed or punched (his/her) shoulder. (He/she) said something along the lines of get out of my husbands face, something to that effect. On 12/03/2025 at 2:26 PM an interview was conducted with OT #16 regarding what she witnessed on 09/15/2025 in the dining room. OT #16 said that RI #78 was sitting in the back of the room at a table when RI #78 got up out of his/her chair and walked straight towards RI #13, and punched RI #13 on the shoulder, saying something along the lines of get out of my husband's face. OT #16 said she was seated to the left of the television, about 7 steps away from RI #13 and faced the back of the room, allowing her to see both RI #78 and RI #13. OT #16 said there were no indicators from RI #78 that it was about to occur (no cursing or yelling), but the actions appeared to be intentional and directed towards RI #13. OT #16 said RI #13 screamed and seemed upset and confused as to why RI #78 punched him/her in the shoulder. The OT said staff intervened immediately and provided separation. OT #16 said this would be categorized as physical abuse. When asked how a reasonable person may feel in this situation, OT #16 said upset and scared especially since the punch was unexpected. OT #16 said for this to be prevented, RI #78 would need supervision when out and about in the dining room or courtyard area where other residents are present. On 12/4/2025 at 12:53 PM an interview was conducted with the ADM regarding the incident on 09/15/2025. The ADM said she was notified at 11:55 PM on 09/15/2025 that RI #13 was heard to say OUCH, I do not know your husband and reported staff that RI #78 hit him/her on the left shoulder. ADM said there were no warning signs from RI #78, staff intervened, assessed residents and there were no injuries, and RI #78 was placed on one-to-one supervision. The Adm said the incident was investigated and taken to QAPI and the root cause analysis. The ADM said they determined the root cause to be environmental, including television noise, music and overall stimulation, and therefore implemented a quiet time during meals. The ADM said there have been no problems since this time. Based on her investigation, the ADM said the allegation of physical abuse that RI #78 hit RI #13 was substantiated.

Based on observation, interviews, record review, review of a facility policy titled MEDICATION ADMINISTRATION - GENERAL GUIDELINES, review of the RESIDENT BILL OF RIGHTS and review of a Facility Reported Incident (FRI) received by the State Agency, the facility failed to protect Resident Identifier (RI) #1's right to refuse care and treatment on 09/19/2025 when Licensed Practical Nurse (LPN) #5 administered medication to RI #1 and placed his hand over RI #1's mouth and pinched RI #1's nose to prevent RI #1 from spitting out the medication, which was physically and mentally abusive to RI #1. The Certified Nursing Assistant (CNA) witness said, LPN #5 told RI #1 he/she was going to take the medications, and RI #1's face turned red as RI #1 struggled and pushed his/her head from side to side in response to LPN #5's force. Interview with other staff revealed a resident could aspirate when someone placed their hand over a resident's mouth to prevent the resident from spitting out medication. LPN #5 was suspended but returned to work on 09/24/2025 and continued to work in the facility without direct monitoring or oversight until 10/23/2025 during the survey.It was determined the facility's noncompliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.10 Resident Rights. On 10/24/2025 at 2:10 PM the Administrator (ADM), the Director of Nursing (DON), the [NAME] President (VP) of Operations and the Clinical Operations Nurse were provided a copy of the IJ template and notified of the findings of immediate jeopardy in the area of Resident Rights at F578-Request/Refuse/Discontinue Treatment; Formulate Advance Directive. The IJ began on 09/19/2025 and continued until 10/28/2025 when the facility implemented corrective action to remove the immediacy. On 10/29/2025 the immediate jeopardy was removed, F578 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.This deficient practice affected RI #1, had the potential to affect all residents receiving medications from LPN #5, and was cited as the result of the investigation of complaint/report number 2623504.Findings Include: Cross Reference F600, F607, F609, F835 and F837. Review of a facility policy titled MEDICATION ADMINISTRATION - GENERAL GUIDELINES, dated 01/2015, revealed the following: POLICY: Medications are administered as prescribed, in accordance with good nursing principles and practices . RESPONSIBILITY:All Licensed Nursing Personnel/CMT (Certified Medication Technician) PROCEDURE: .14. If a dose of regularly scheduled medication is . refused, . the space provided on the front MAR (Medication Administration Record) . for that dosage administration is initialed and circled . If several doses of a vital medication are . refused, the physician and responsible party are notified and documentation of this notification is made in the nursing notes . Review of the RESIDENT BILL OF RIGHTS, dated 11/2017, revealed the following: Each resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the Facility in a manner and in an environment that promotes maintenance or enhancement to (his/her) quality of life, regardless of diagnosis, severity of condition or payment source and to exercise those rights of the United States without interference, coercion, including those rights specified herein. A. Facility residents shall have the right to: . 6. Request, reuse and/or discontinue treatment. Any refusal and its reason shall be documented in the resident's medical record . 37. The right to be free from abuse . RI #1 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnoses to include Acute Respiratory Failure with Hypoxia, Dementia, Wheezing, Cerebrovascular Disease and Pain. RI #1's Quarterly Minimum Data Set assessment, with an Assessment Reference Date of 09/15/2025 documented a Brief Interview for Mental Status (BIMS) score of three indicating severely impaired cognition. RI #1 was also coded as not exhibiting any behaviors of resisting care during this assessment period. On 09/19/2025 at 12:41 AM an allegation involving abuse - mistreatment of RI #1, perpetrated by LPN #5, was received by the State Agency's Online Incident Reporting System; the alleged CNA #8 saw LPN #5, while administering medications to RI #1, use a paper towel to pinch RI #1's nose to ensure RI #1 would swallow medications; the report indicated an in-service was immediately started on the proper way to administer medications and all staff would be in-serviced on intervening if they observed a resident being mistreated. On 10/21/2025 at 2:54 PM CNA #8 said on 09/19/2025 LPN #5 was in RI #1's room to give RI #1 medications. CNA #8 said LPN #5 asked her (CNA #8) to go in the bathroom and get a paper towel and then told her to close the door. CNA #8 said she went to the bathroom, got the paper towel and she heard LPN #5 tell RI #1 he/she was going to swallow the medications. CNA #8 said LPN #5 had the paper towel over RI #1's nose with his right hand and he had his other hand under RI #1's chin as if attempting to keep RI #1 from opening his/her mouth. CNA #8 said LPN #5 was pinching RI #1's nose, and RI #1 was turning red and turning his/her head from side to side. CNA #8 said she was panicking because of what she saw. CNA #8 said she left the room because she needed to tell someone what she had observed. CNA #8 said LPN #5 was trying to make RI #1 swallow medications. CNA #8 said she considered LPN #5's actions to be abusive. On 10/21/2025 at 3:51 PM an interview was conducted with LPN #5. When asked how RI #1 took medications, LPN #5 said crushed in apple sauce or pudding. LPN #5 said when he went in to administer RI #1's morning medications on 09/19/2025, he put the medication in RI #1's mouth and RI #1 pursed his/her lips like he/she was going to spit the medication out. LPN #5 said he placed his right hand over RI #1's mouth and started saying no, no, no, no, because it looked like RI #1 was going to spit the medication out. LPN #5 said he thought it was RI #1's last pill that he was giving him/her, and that was why he put his hand over RI #1's mouth so RI #1 would not spit the medication out. LPN #5 said CNA #8 was in the room when this occurred. LPN #5 said as a nurse he should have allowed RI #1 to spit out the medication because that was RI #1's right. On 10/22/2024 at 11:28 AM an interview was conducted with LPN #10. The LPN said when a resident refuses to take their medications the nurse asks again, and when they refuse again they let the unit manager know. LPN #10 said the nurse also could ask someone else to see if they could get the resident to take their medication. LPN #10 said if the resident still refused, document and pass it on to the next shift, text the doctor and let him know and see if the doctor wants to do anything else. LPN #10 said a nurse should never place their hand over a resident's mouth to keep the resident from spitting out medications. LPN #10 said it was the residents right to refuse medications. On 10/22/2025 at 4:24 PM an interview was conducted with the Registered Nurse (RN) Unit Manager (UM) #15. When asked what the nurse should do when a resident refuses their medications or attempts to spit them out, UM #15 said let the resident spit the medication out and record refuse, waste them with another nurse if the medication was a narcotic, and let the doctor know. The UM #15 said it would be important to not force a resident to take medications because the resident could aspirate. The UM #15 said forcing a resident to take medication could be perceived as abuse. On 10/22/2025 at 3:17 PM the Social Worker (SW) said if the resident refused care or treatments, staff should make a note that the resident refused. The SW said it was the resident's right to refuse care and their medication. The SW said it would be important to not force a resident to take medication if they refuse because it is within the resident's rights, and that was a violation of their rights as a resident. On 10/22/2025 at 5:26 PM an interview was conducted with LPN #12. The LPN said when a resident refused to swallow their medication the nurse should tell them okay, if they cannot coax them into taking the medication. LPN #12 said the nurse should contact the doctor to let them know the resident refused medications, notify the family and document. LPN #12 said it was resident abuse if the resident was forced to swallow medications. LPN #12 said the resident had the right to spit the medication out. LPN #12 said a nurse should never place their hands over a resident's mouth to prevent them from spitting out medication. On 10/23/2025 at 3:20 PM the ADM said the concern of a nurse placing their hand over a resident's mouth to keep them from spitting medication out was that it was an improper way to administer medications. The ADM said the resident has a right to refuse their medication. The ADM said when RI #1 was getting ready to spit out the medication LPN #5 should have allowed RI #1 to spit the medication out. On 10/24/2025 at 11:49 an interview was conducted with the DON. When asked should a nurse ever place their hand over a resident's mouth to get them to take their medication, the DON said no. The DON said since LPN #5 returned to work he was not being monitored to ensure he was not placing his hands over other residents' mouths to make sure they took or did not spit out their medications. When asked how the facility was ensuring residents who were receiving medication from LPN #5 were not being mistreated, by LPN #5 placing his hand over their mouths to get them to take or not spit out their medications, the DON said they were not. The DON said once they did the education on resident rights and abuse, no one was monitoring LPN #5. On 10/21/2025 at 4:40 PM the surveyor observed LPN #5 administer medications to other residents. There was no staff observing/monitoring LPN #5 during the medication administration to ensure LPN #5 did not place his hand over the resident's mouth to prevent them from spitting out medication.**************************************************** On 10/28/2025, the facility submitted the following as their removal plan for the identified Immediate Jeopardy: 1. Immediate Corrective Action for the Affected Resident RI #1 was immediately assessed for distress and mental abuse by the Director of Nursing (DON) and Unit Manager on 9/19/25 through interview questions. No mental injury was identified by DON. The interview on 9/19/25 revealed resident was smiling and talkative with no signs of any distress or agitation. Body audit was completed on 9/19/25 by Unit Manager and DON, to assess for physical injury. RI #1's body audit (head to toe assessment) determined no physical abuse as evidenced by no unknown redness edema, or discoloration observed. On 10/24/25 another body audit (head to toe assessment) was completed by Wound Nurse to assess for physical injury. Body audit determined no physical abuse as evidenced by no unknown redness edema or discoloration observed. Resident complaint/mistreatment poll for 29 residents was completed 9/19/25 on the unit LPN #5 worked, this was completed by Social Services. This poll was completed to determine if other residents had concerns or issues with medication administration by LPN #5 placing his hand over the residents mouth to get the resident to swallow their medication. This poll was obtained through interviews. Then on 9/22/25 Administrator completed complaint/mistreatment poll on 111 residents in facility to determine if any resident in the facility had issues or concerns from mistreatment or any nurse placing their hands over the resident's mouth to force resident to swallow medication. This poll was obtained through 1 on 1 interviews with residents. A new complaint/mistreatment poll was conducted by Director of Nursing on 10/24/25, this poll was obtained through resident interview for 109 residents to determine mistreatment. Nine residents who were unable to communicate were assessed by body audits (head to toe assessment) these audits determined no evidence of physical abuse as evidence by no unknown redness edema, or discoloration observed. The body audits were completed by Nurse Managers on 10/24/25. To protect RI #1s right's to refuse care and treatment, on 10/25/25 RI #1's plan of care for medication administration was reviewed and revised by IDT (MDS Nurse and Social Services) and family member. Interventions in place starting 08/21/2025: may crush meds and add in applesauce, yogurt or pudding. The facility added a new intervention on 10/25/25: may use sweets as positive reinforcement to take medications, and when administering medications allow ample time to swallow medications. Licensed Nursing Staff notified of care plan revisions on 10/25/25 via 24 hour nursing report that remains on the nursing unit. 2. Identification of Other Residents Who Could Be Affected No other residents were identified as affected or at risk for abuse, mistreatment or right to refused care and treatment. This was determined through complaint/mistreatment poll that was conducted by Director of Nursing on 10/24/25, this poll was obtained through resident interview for 109 residents. Nine residents who were unable to communicate were assessed by body audit (head to toe assessment). These audits determined no evidence of physical abuse as evidence by no unknown redness, edema, or discoloration observed. The body audits were completed by Nurse Managers on 10/24/25. Ninety eight residents were educated of their right to refuse medications and treatments through handouts of Resident's Rights by Social Services and Business Office Staff on 10/24/25. Residents acknowledged they understood their Rights to include refusal of medication by signing Resident's Rights form. Facility notified family members of 14 residents that are unable to communicate and discussed resident's right to refuse medication on 10/24/25 by Social Services. If Social Services were unable to contact a family member by phone, a copy of Resident's Rights were sent via certified mail on 10/25/25 to 6 family members of residents. 3. Systemic Changes to Prevent Recurrence Education was provided to 36 licensed nurses (27 in person, 9 via telephone) on the Medication Administration Policy, resident's right to refuse medication, and staff follow-up after receiving resident information that could be considered abuse which included placing a hand and a paper towel over residents mouth and pinching residents nose in order to prevent residents from spitting out medications on 10/24/25 by Director of Nursing, Unit Managers and Staff Development Coordinator (SDC). The Abuse Prevention Policy was educated to 140 staff, (80 in person, 60 via telephone) emphasizing that any act of coercion or force (forcefully/making resident take medication against his/her will) is considered abuse. Abuse must be reported immediately to the abuse coordinator. Resident cannot be left alone in a potential abuse situation/unsafe situation, stay with resident, intervene, and call for help. This education was completed on 10/25/25, by DON, Unit Managers, and Staff Development Coordinator. One CNA has not completed education, she/he has been removed from the time clock and will not be allowed to work until education is completed. In the event employee cannot get response from abuse coordinator (Administrator) employee will notify Director of Nurses and or Human Resource Director. This education was completed on 10/25/25, by DON, Unit Managers and SDC. No employee will be allowed to work without completion of this education. Telephone numbers of Abuse Coordinator, DON, and Human Resource Director was posted at the time clock. 4. Monitoring to Ensure Ongoing Compliance DON and Weekend Supervisor observed 5 nurses pass 5 resident's medication on 10/25/25, to ensure compliance with resident rights and medication administration procedures. No issues or concerns were identified with medication administration or the resident's right to refuse medication (including covering the mouth or pinching the nose to force a resident to take medication). A Quality Assurance Meeting held on 10/24/25 to review F-tag 578, 600, 607, 609, 835, and 837 at scope and severity level IJ. Members attending the QAPI meeting: Administrator, Human Resources, Clinical Operations Nurse, QA Nurse, [NAME] President of Operations, Medical Director, and Director of Nursing. After receiving education (on 10/24/25 for the Administrator, DON, and [NAME] President of Operations by the [NAME] President of Clinical Services) related to abuse and covering the mouth and pinching the nose of a resident in order to prevent them from spitting out medication, the QAPI team reviewed the allegation of abuse of RI #1 by LPN #5 and the allegation was substantiated. It was determined at this meeting: The Abuse Prevention Policy will be educated to the entire staff emphasizing that any act of coercion or force (forcefully/making resident take medication against his/her will) is considered abuse. Abuse must be reported immediately to the abuse coordinator. Resident cannot be left alone in a potential abuse situation/unsafe situation, stay with resident, intervene, and call for help; Medication Administration Policy, residents right to refuse medication, supervisor/staff follow-up after receiving resident information that could be considered abuse. All residents would be educated on Resident's Rights. The DON reported to the ABON on 10/28/2025 that the allegation of abuse of RI #1 by LPN #5 was substantiated. 5. Date of CompletionThe immediacy corrective actions were completed by [10/28/25].Education was completed [10/28/25]. ************************************************** After reviewing the facility's immediate actions and information provided in their Removal Plan, interviewing staff and verifying the corrective actions had been implemented the Immediate Jeopardy was removed on 10/29/2025. The scope/severity level of F578 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on observation, interviews, record review, review of a facility policy titled ABUSE PREVENTION, review of a Facility Reported Incident (FRI) received by the State Agency, and review of a facility investigative file, the facility failed to ensure residents in the facility were free from physical and mental abuse perpetrated by staff. Specifically:The facility failed to ensure Resident Identifier (RI) #1 was free from abuse perpetrated by Licensed Practical Nurse (LPN) #5 on 09/19/2025 at approximately 8:45 AM when Certified Nursing Assistant (CNA) #8 witnessed LPN #5 physically abuse RI #1 when he placed his hand and a paper towel over RI #1's mouth and he pinched RI #1's nose, while telling RI #1 they were going to take medication. CNA #8 witnessed RI #1's face turning red as RI #1 struggled, pushing his/her head from side to side, while LPN #5 covered RI #1's nose and mouth to prevent RI #1 from spitting out morning medications. CNA #8 failed to protect RI #1 when she left the room, leaving RI #1 alone with LPN #5 at the time of the abuse.CNA #8 failed to report the abuse to anyone immediately and LPN #5 continued working his scheduled shift on 09/19/2025, until after 11:00 AM when administration was made aware. LPN #5 was suspended on 09/19/2025, but because facility administration failed to identify the incident as abuse and take appropriate corrective action to protect residents, LPN #5 returned to work on 09/24/2025 and continued to be employed at the facility. The facility was not monitoring or supervising LPN #5. LPN #5 was observed during the survey on 10/21/2025 administering medications to vulnerable residents who were at risk of being abused by LPN #5.Staff who were familiar with RI #1 said RI #1 could have aspirated on the medications and LPN #5's actions were physically, emotionally, and psychologically abusive. RI #1's responsible party said having a hand placed over RI #1's mouth would have made RI #1 feel very fearful. It was determined the facility's noncompliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.12 Freedom from Abuse, Neglect and Exploitation. On 10/24/2025 at 2:10 PM the Administrator (ADM), the Director of Nursing (DON), the [NAME] President (VP) of Operations and the Clinical Operations Nurse were provided a copy of the IJ template and notified of the findings of substandard quality of care at the level of immediate jeopardy in the area of Freedom from Abuse, Neglect, and Exploitation at F600- Free from Abuse and Neglect. The IJ began on 09/19/2025 and continued until 10/28/2025 when the facility implemented corrective action to remove the immediacy. On 10/29/2025 the immediate jeopardy was removed, F600 was lowered to the severity level of no actual harm with a potential for more than minimal harm level that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficient practice affected RI #1, one of four residents sampled for abuse and was cited as the result of the investigation of complaint/report number 2623504.Finding Include: Cross-Reference F578, F607, F609, F835 and F837. Review of a facility policy titled, ABUSE PREVENTION, dated 01/2025 revealed the following: POLICY: The facility is committed to protecting the resident from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our resident, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. DEFINITIONS: a) Abuse: Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish . Abuse may be resident-to-resident, staff-to-resident, family-to-resident, or visitor-to-resident . d) Physical Abuse: This includes but is not limited to hitting, slapping, punching and kicking . e) Mental Abuse: The use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear . agitation . j) Mistreatment means inappropriate treatment . of a resident . 1) RI #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Acute Respiratory Failure with Hypoxia, Dementia, Unspecified Severity, without Behavioral Disturbance, Wheezing, Cerebrovascular Disease and Pain. Review of RI #1's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 09/15/2025 revealed RI #1 scored a 3 on the Brief Interview for Mental Status (BIMS) indicating RI #1 had severely impaired cognition. RI #1 was also coded as having no behaviors of resisting care during this assessment period. On 09/19/2024 at 12:41 PM an allegation involving Abuse – Mistreatment of RI #1, perpetrated by LPN #5, was received by the State Agency's Online Incident Reporting System. The report revealed CNA #8 alleged she saw LPN #5, while administering medications to RI #1, use a paper towel to pinch RI #1's nose to ensure RI #1 would swallow his/her medications. CNA #8 reported that RI #1 seemed mad. An in-service was immediately started on the proper way to administer medications. The report stated all staff would be in-serviced on intervening if they observed a resident being mistreated and timely reporting of the incident. Contained within the facility's investigative file was a handwritten statement, dated 09/19/2025, which was written and signed by CNA #8 and documented the following: I was in (number of RI #1's room) (name of LPN #5) was given (giving) meds . he told me to hand him a paper towel and close the door I didnt (didn't) close the door all the way because I was like Why So he took the paper towel and Placed it over (his/her) nose and pinched (his/her) nose (he/she) was turning Red he did that so (he/she) could swallow (his/her) meds thats (that is) what he was saying as I walking out the room . On 10/21/2025 at 2:54 PM an interview was conducted with CNA #8. When asked why she wrote the statement, CNA #8 said she told LPN #5 that morning RI #1 was wheezing really bad and LPN #5 said he would get to it. CNA #8 said she preceded to go to do her other rooms and when she went back to RI #1's room LPN #5 was in the room with RI #1's medications on the bedside table. CNA #8 said LPN #5 asked her to go in the bathroom and get a paper towel and told her to close the door. CNA #8 said she went to the bathroom, got a paper towel and handed LPN #5 the paper towel. CNA #8 said as she was turning around to go back to the bedside, she heard LPN #5 talking to RI #1 and telling RI #1 he/she was going to swallow the medications. CNA #8 said LPN #5 had the paper towel over RI #1's nose with his right hand and he had his other hand under RI #1's chin as if he was attempting to keep RI #1 from opening his/her mouth. CNA #8 said LPN #5 was pinching RI #1's nose, and RI #1 was turning red and turning his/her head from side to side. CNA #8 said she was panicking because of what she saw and left the room. CNA #8 said she went and told LPN #10 what she observed, and LPN #10 said she did not see it and did not want to be a part of it. When asked why she left LPN #5 in the room after she observed him do what she said, CNA #8 said she needed to tell someone because what LPN #5 did was not right. CNA #8 said LPN #5's actions of trying to make RI #1 swallow his/her medications would be considered abusive. On 10/22/2024 at 11:28 AM an interview was conducted with LPN #10. LPN #10 said on 09/19/2025, CNA #8 did come to the room where she was providing care for another resident and said she had to tell her something. LPN #10 said when she informed CNA #8 she was with another resident, CNA #8 walked out of the room. Contained within the facility's investigative file was a typed Witness Statement dated 09/23/2025 which was signed by CNA #11 which revealed the following: . Q: Did she (CNA #8) talk to you about seeing a nurse give medications that she was concerned about? A: Yes Q: What time was that? A: Before lunch, morining [morning] time . On 10/22/2025 at 8:53 AM a telephone interview was conducted with CNA #11. CNA #11 said she was doing her orientation with CNA #8 on 09/19/2025. CNA #11 said while she and CNA #8 were in RI #1's room, CNA #8 told her to stay in the room with RI #1 because she had to go and report something. When asked what CNA #8 said she was going to report, CNA #11 said about how the nurse (LPN #5) gave the resident (RI #1) the medicine. CNA #11 said CNA #8 said LPN #5 basically pinched RI #1's nose and tried to force RI #1 to take the medicine. CNA #11 said she thought this occurred before breakfast. CNA #11 said she was never in the room with LPN #5, and she believe as she and CNA #8 were going into the room LPN #5 was leaving out. CNA #11 said when they went in the room, RI #1 was in bed, and she observed RI #1's face to be red. On 10/21/2025 at 3:51 PM an interview was conducted with LPN #5. When asked what happened when he went in RI #1's room on the morning of 09/19/2025, LPN #5 said he went in RI #1's room to give RI #1 a breathing treatment because CNA #8 told him RI #1 was wheezing. LPN #5 said after RI #1 got the breathing treatment he gave RI #1 the morning medication. LPN #5 said he put the medication (Gabapentin) in RI #1's mouth, and RI #1 pursed his/her lips like he/she was going to spit the medication out. LPN #5 said he put his right hand over RI #1's mouth and started saying no, no, no, no because it looked like RI #1 was going to spit the medication out. LPN #5 said CNA #8 was in the room when this occurred. LPN #5 said as a nurse he should have allowed RI #1 to spit the medication out because that was his/her right. When asked when he placed his hand over RI #1's mouth what his actions could have been perceived as, LPN #5 said many negative things, like he was squeezing RI #1's face. LPN #5 said after he did what he did, he was sent home immediately and when he returned to work, he had a one-on-one in-service with the DON. LPN #5 said he also did an in-service in the computer about what he did could have been perceived as abuse. LPN #5 said he was not allowed to pass medications to RI #1 but could still pass medications to other residents. When asked was anyone monitoring him pass medications, LPN #5 said no. A review of RI #1's eMAR revealed on 9/19/2025 RI #1 received two puffs of Albuterol-Budesonide Inhalation at approximately 8:47 AM. On review of RI #5's Time and Attendance - Employee Punch History, LPN #5 was suspended and left the facility at 12:10 PM on 09/19/2025. Review of LPN #5's CATEGORY ONE VIOLATION EMPLOYEE CORRECTIVE COUNSELING MEMORANDUM form, dated and signed by LPN #5, the DON and the ADM on 09/23/2025, revealed LPN #5 was to return to work effective 09/24/2025 after one on one education described below: . 3. Supervisor: Describe the specific standards that must be met directly from Company, Employee Handbook, Collective Bargaining Agreement, etc. Employee must follow facility policy and nursing standard of practice for Medication Administration. Employee is to complete one:one education with the DNS (Director of Nursing Services) on 9/24/25 on Facility Abuse Policy and Medication Administration General and Narcotic and Resident Rights. The employee will also complete Relias Modules on Abuse, Dementia, Residents Rights, and Medication Administration with the DNS before being allowed to work the unit . On 10/23/2025 at 11:55 AM an interview was conducted with the DON. When asked what time on 09/19/2025 was she made aware an allegation was being made against LPN #5, the DON said CNA #8 came to her about 11:20 AM while she was in the dining room. The DON said CNA #8 said she needed to talk to her, and they went into the DON's office. The DON said CNA #8 said she had witnessed LPN #5 doing something he should not have done. The DON said CNA #8 said LPN #5 asked her to close the door to RI #1's room and get a napkin out of the bathroom. The DON said CNA #8 said she went to the bathroom, got the napkin and took the napkin to LPN #5 and he placed it over RI #1's nose, pinched his/her nose, and placed his other hand over RI #1's mouth and told RI #1 to not spit, but swallow the medication. The DON said CNA #8 said when she observed this she left out of the room. The DON said LPN #5 did say he asked CNA #8 to shut the door for privacy. The DON said LPN #5 did say RI #1 was trying to spit his/her medicine out and that he knelt down, and asked RI #1 to take the medication. The DON said LPN #5 said he gently tapped RI #1's mouth and told RI #1 to please not spit out the medicine. The DON said she told LPN #5 since he admitted to tapping RI #1's mouth that she had to call the police, and they did come to get a report. The DON said when a resident refuses their medication or attempt to spit the medication out the nurse needs to chart the resident refused the medication. When asked why LPN #5 was given a Corrective Counseling, the DON said LPN #5 did not follow the standard of practice for medication policy. The DON said RI #1 had the right to refuse, and nurses should not place their hand on a resident's mouth. The DON said when a nurse places their hand on a resident's mouth to get them to take their medication that would be an improper way to give medications. The DON said if staff observe a nurse doing this, the first thing they should do is make sure the resident was safe and get some help, by asking the person to leave the room or yell for help. On 10/22/2025 at 4:24 PM an interview was conducted with the Registered Nurse (RN) Unit Manager (UM) #15, the RN UM on the unit RI #1 resides on. When asked when she became aware of an allegation that LPN #5 put a paper towel over RI #1's nose and pinched it to make RI #1 swallow his/her medications on 09/19/2025, the RN UM said she was made aware when she was asked to count the cart LPN #5 worked on because LPN #5 was being sent home. The RN UM said if a resident refuses their medications or attempts to spit the medication out, the nurse should let the resident spit the medication out. The RN UM said it would be important to not force a resident to take their medications because they could aspirate. The RN UM said forcing a resident to take their medications could be perceived as abuse. On 10/24/2025 at 11:49 AM a follow-up interview was conducted with the DON. The DON said a nurse should never place their hand over a resident's mouth to get the resident to take their medication. When asked since LPN #5's return to work how he was being monitored to ensure he is not placing his hands over resident's mouths to make sure they take or do not spit out their medications, the DON said LPN #5 was not being monitored for that. The DON said one-on-one was done with LPN #5 when he returned to work and LPN #5 knows not to ever place his hand over a resident's mouth again. The DON said LPN #5 was no longer allowed to administer medications to RI #1. When asked what RI #1's cognition was, the DON said RI #1 had Dementia. When asked how the facility was ensuring other residents with Dementia who were receiving medication from LPN #5 were not being mistreated, by LPN #5 placing his hand over their mouths to get them to take or not spit out their medications, the DON said they were not. The DON said no one was observing LPN #5 administer medications to residents. On 10/21/2025 at 4:40 PM the surveyor observed LPN #5 administer medications to RI #15. There was no staff observing/monitoring LPN #5 during the medication pass administration. On 10/22/2025 at 5:26 PM an interview was conducted with LPN #12. When asked had RI #1 ever refused to take his/her medication, LPN #12 said there had been times when RI #1 would say no. LPN #12 said she would leave and come back, and RI #1 would say OK and take his/her medication. LPN #12 said when a resident refuses to swallow their medication tell them OK. When asked what it would be considered if a resident is forced to swallow their medications, LPN #12 said resident abuse. LPN #12 said a nurse should never place their hands over a resident's mouth to prevent the resident from spitting out their medication On 10/23/2025 at 8:03 AM a telephone interview was conducted with LPN #13. When asked what it would be considered if a resident is forced in any way to swallow their medications, LPN #13 said abuse. LPN #13 said it would never be appropriate for a nurse to place their hands over a resident's mouth to get them to swallow their medications. On 10/23/2025 at 3:20 PM an interview was conducted with the ADM. When asked what time on 09/19/2025 she was made aware that an allegation had been made against LPN #5, the ADM said it was after 11 AM. The ADM said CNA #8 said LPN #5 put his hand over RI #1's mouth to make RI #1 take his/her medication. The ADM said she and the DON immediately discussed what needed to be done like calling the police, notifying the Medical Doctor, the residents Responsible Party (RP), completing a body audit for the resident, looking to see if the resident had any physical or emotional changes, taking statements from both parties, and placing both parties on administrative leave. The ADM said while that was being done, she did the reportable. The ADM said the incident was reported as an allegation of abuse – mistreatment. When asked why the allegation was not substantiated, the ADM said it was not abuse. The ADM said LPN #5 admitted to placing his hands on the resident's lips without force. The ADM said although she thought it was inappropriate to place your hands on a resident mouth it did not rise to the level of abuse. The ADM said there no intent to harm the resident and the resident was not harmed. When asked should RI #1 had been treated that way, the ADM said no it was an inappropriate medication administration. The ADM said the concern of a nurse placing their hand over a resident's mouth to keep them from spitting the medication out was that it was an improper way to administer medications. The ADM said the resident has a right to refuse to take their medications. The ADM said LPN #5 should have allowed RI #1 to spit out the medication. On 10/24/2025 at 5:25 PM an interview was conducted with the VP of Operations. The VP of Operations said she was made aware of the reportable where LPN #5 placed his hand over RI #1's mouth the day the incident occurred. The VP of Operations said the ADM called and informed her of this. The VP of Operations said she told the ADM to go ahead and suspend per policy, start the investigation and get statements from all staff involved on the shift who could have possibly heard anything regarding the allegation. When asked what input did she give on whether to substantiate or unsubstantiate the allegation, the VP of Operations said the ADM felt since LPN #5 did not have any intent to harm RI #1, he was only trying to ensure that RI #1 swallowed his/her pain medication, and LPN #5 freely admitted to what he did was the rationale for not substantiating. The VP of Operations said she was told that RI #5 placed his hand over RI #1's mouth without force and was saying swallow your medicine, RI #1 was not in any distress at the time, RI #1 had no injury, was the facility's basis for not substantiating the allegation. When asked was she a part of the decision to allow LPN #5 to continue to pass medications with no monitoring or over site, the VP of Operations said she was told by the ADM that LPN #5 had been reeducated on medication administration, he understood the resident had the right to refuse to take the medication and LPN #5 said that he would let the resident spit the medication out from now on. The VP of operations said she and the ADM did not talk about LPN #5 being allowed to continue to pass medications without oversite. When asked how she thought it would make a reasonable feel to have someone put their hands over their mouth to prevent them from spitting out their medications, the VP of Operations said she did not think a reasonable person would like that. The VP of Operations said when LPN #5 placed his hand over RI #1's mouth she could see how that could be perceived as mistreatment of the resident. When asked did mistreatment fall under the definitions of abuse, the VP of Operations said it did. When asked did LPN #5 deliberately place his hand over RI #1's mouth to prevent RI #1 from spitting out his/her medication, the VP of Operations said yes. On 10/25/2025 at 9:55 AM a telephone interview was conducted with RI #1's RP. When asked how she thought it made RI #1 feel to have someone place their hand over RI #1's mouth to prevent RI #1 from spitting out his/her medications, RI #1's RP said it would have made RI #1 feel very fearful. *************************************************** On 09/28/2025, the facility submitted the following as their removal plan for the identified Immediate Jeopardy: *************************************************** 1. Immediate Corrective Action for the Affected Resident RI #1 was immediately assessed for distress and mental abuse by the Director of Nursing (DON) and Unit Manager on 9/19/25 through interview questions. No mental injury was identified by DON. The interview on 9/19/25 revealed resident was smiling and talkative with no signs of any distress or agitation. Body audit was completed on 9/19/25 by Unit Manager and DON, to assess for physical injury. RI #1's body audit (head to toe assessment) determined no physical abuse as evidenced by no unknown redness edema, or discoloration observed. On 10/24/25 another body audit (head to toe assessment) was completed by Wound Nurse to assess for physical injury. Body audit determined no physical abuse as evidenced by no unknown redness edema or discoloration observed. CNA was suspended from resident care pending investigation on 9/19/25. The CNA was educated by the Administrator on 9/22/25 on types of abuse, to include mistreatment, and reporting. Any type of abuse must be reported immediately to the Abuse Coordinator (Administrator) whose telephone number is posted in the lobby; Administrator is on call 24/7 if not in the facility. Residents cannot be left alone in unsafe situations, stay with resident, intervene, and call for help. 1:1 education was provided to LPN, who on 9/19/25 did not follow up to concerns of LPN #5 placing his hand over RI #1's mouth, to ensure RI #1 swallowed the medication, on 10/24/25 by the Director of Nursing on the need to follow up on concerns that could be considered abuse. CNA was returned to resident care on 9/22/25 after education training completed. On 10/24/25 due to substantiation of abuse of RI #1 by LPN #5, CNA was terminated due to failure to protect RI #1 and failure to immediately report to the abuse coordinator. Abuse education provided to the facility Director of Nursing, Administrator, and [NAME] President of Operations on 10/24/25 at 12:30 pm, per [NAME] President of Clinical Services. This education was to ensure understanding of facility abuse policy, and implementation of policy, including reporting timeliness within 2 hours of the abuse. Also to identify occurrences, patterns and trends that may constitute abuse (such as suspicious bruising of residents, including LPN #5 placing his hand and a paper towel over RI #1's mouth and pinching RI #1's nose in order to prevent RI #1 from spitting out medications) and to determine the direction of the investigation and substantiate abuse (Suspected or substantiated cases of resident abuse, neglect, misappropriation of property, or mistreatment shall be thoroughly investigated, documented, and reported to the physician, families, and/or representative), to provide protection of residents from perpetrators of abuse. (All allegations of abuses, neglect, misappropriation or exploitation against any employee must result in his/her immediate suspension to protect the resident.) [NAME] President of Clinical Operations educated the DON and the Administrator on 10/24/25 to utilize a Supervisor Investigation Checklist Form on any allegation of abuse. This checklist will include: providing protection of the resident, monitoring of aggressor, notification of abuse. The [NAME] President of Operations will use this checklist to ensure oversight of each allegation of abuse is completed accurately and to achieve correct outcome after thorough investigation. If any concerns with the checklist are found by the [NAME] President of Operations, the [NAME] President of Operations will guide the facility Administrator on how to implement the abuse policy to identify abuse and protect residents from perpetrators of abuse. On 10/1/25 an employer report was completed to the Alabama Board of Nursing (ABON) to include counseling and disciplinary action regarding improper medication administration to RI #1. On 10/14/25 subpoena received from the ABON for entire investigation related to RI #1, to include written reports of counseling, warnings, disciplinary actions, termination notice, job description, employment application, recent performance appraisal, orientation checklist, verification of employment, medication dispensing reports related to complaint, reports of adverse incidents/ occurrences, and any other reports that are pertinent to the license of LPN #5's practice of nursing. This information was sent to the ABON on 10/20/2025. Resignation of LPN #5 was accepted on 10/24/25. Resident complaint/mistreatment poll for 29 residents was completed 9/19/25 on the unit LPN #5 worked, this was completed by Social Services. This poll was completed to determine if other residents had concerns or issues with medication administration by LPN #5 placing his hand over the residents mouth to get the resident to swallow their medication. This poll was obtained through interviews. Then on 9/22/25 Administrator completed complaint/mistreatment poll on 111 residents in facility to determine if any resident in the facility had issues or concerns from mistreatment or any nurse placing their hands over the resident's mouth to force resident to swallow medication. This poll was obtained through 1 on 1 interviews with residents. A new complaint/mistreatment poll was conducted by Director of Nursing on 10/24/25, this poll was obtained through resident interview for 109 residents to determine mistreatment. Nine residents who were unable to communicate were assessed by body audits (head to toe assessment) these audits determined no evidence of physical abuse as evidence by no unknown redness edema, or discoloration observed. The body audits were completed by Nurse Managers on 10/24/25. To protect RI #1s right's to refuse care and treatment, on 10/25/25 RI #1's plan of care for medication administration was reviewed and revised by IDT (MDS Nurse and Social Services) and family member. Interventions in place starting 08/21/2025: may crush meds and add in applesauce, yogurt or pudding. The facility added a new intervention on 10/25/25: may use sweets as positive reinforcement to take medications, and when administering medications allow ample time to swallow medications. Licensed Nursing Staff notified of care plan revisions on 10/25/25 via 24 hour nursing report that remains on the nursing unit. 2. Identification of Other Residents Who Could Be Affected No other residents were identified as affected or at risk for abuse, mistreatment or right to refused care and treatment. This was determined through complaint/mistreatment poll that was conducted by Director of Nursing on 10/24/25, this poll was obtained through resident interview for 109 residents. Nine residents who were unable to communicate were assessed by body audit (head to toe assessment). These audits determined no evidence of physical abuse as evidence by no unknown redness, edema, or discoloration observed. The body audits were completed by Nurse Managers on 10/24/25. Ninety eight residents were educated of their right to refuse medications and treatments through handouts of Resident's Rights by Social Services and Business Office Staff on 10/24/25. Residents acknowledged they understood their Rights to include refusal of medication by signing Resident's Rights form. Facility notified family members of 14 residents that are unable to communicate and discussed resident's right to refuse medication on 10/24/25 by Social Services. If Social Services were unable to contact a family member by phone, a copy of Resident's Rights were sent via certified mail on 10/25/24 to 6 family members of residents. 3. Systemic Changes to Prevent Recurrence Education was provided to 36 licensed nurses (27 in person, 9 via telephone) on the Medication Administration Policy, resident's right to refuse medication, and staff follow-up after receiving resident information that could be considered abuse which included placing a hand and a paper towel over residents mouth and pinching residents nose in order to prevent residents from spitting out medications on 10/24/25 by Director of Nursing, Unit Managers and Staff Development Coordinator (SDC). The Abuse Prevention Policy was educated to 140 staff, (80 in person, 60 via telephone) emphasizing that any act of coercion or force (forcefully/making resident take medication against his/her will) is considered abuse. Abuse must be reported immediately to the Abuse Coordinator. Resident cannot be left alone in a potential abuse situation/unsafe situation, stay with resident, intervene, and call for help. This education was completed on 10/25/25, by DON, Unit Managers, and Staff Development Coordinator. One CNA has not completed education, she/he has been removed from the time clock and will not be allowed to work until education is completed. In the event employee cannot get a response from Abuse Coordinator (Administrator) employee will notify Director of Nursing and/or Human Resource Director. This education was completed on 10/25/25, by DON, Unit Managers and SDC. This was education to 140 staff (80 in person, 60 via telephone). No employee will be allowed to work without completion of this education. Telephone numbers of Abuse Coordinator, DON, and Human Resource Director was posted at the time clock. 4. Monitoring to Ensure Ongoing Compliance DON and Weekend Supervisor observed 5 nurses pass 5 resident's medication on 10/25/25, to ensure compliance with resident rights and medication administration procedures. No issues or concerns were identified with medication administration or the resident's right to refuse medication (including covering the mouth or pinching the nose to force a resident to take medication). A Quality Assurance Meeting held on 10/24/25 to review F-tag 578, 600, 607, 609, 835, and 837 at scope[

Based on observation, interviews, record review and review of a facility policy titled ABUSE PREVENTION, the facility failed to implement their abuse policy and take appropriate actions to protect Resident Identifier (RI) #1 from abuse on 09/19/2025 after Licensed Practical Nurse (LPN) #5 physically and mentally abused RI #1 and LPN #5 was observed during the survey on 10/21/2025 continuing to administer medications to residents, placing residents at risk of being abused by LPN #5.Certified Nursing Assistant (CNA) #8 who witnessed LPN #5 abuse RI #1 on 09/19/2025 at approximately 8:47 AM failed to ensure RI #1 was protected from LPN #5 after he placed his hand over RI #1's nose and mouth to force RI #1 to swallow medications, placing RI #1 at risk of aspiration of the medications and being fearful. CNA #8 left RI #1's room leaving RI #1 alone with LPN #5. RI #1's roommate was also on the other side of the room with the curtain pulled. CNA #8 failed to report the abuse to anyone until 11:20 AM while LPN #5 continued to work his shift.Although LPN #5 was suspended, the facility failed to identify and substantiate abuse during their investigation and failed to take action to protect residents and remove LPN #5 from access to residents in the facility and instead, the facility allowed LPN #5 to continue employment and have access to residents at the facility until 10/23/2025 during the survey. It was determined the facility's noncompliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.12 Freedom from Abuse, Neglect and Exploitation. On 10/24/2025 at 2:10 PM the Administrator (ADM), the Director of Nursing (DON), the [NAME] President (VP) of Operations and the Clinical Operations Nurse were provided a copy of the IJ template and notified of the findings of substandard quality of care at the level of immediate jeopardy in the area of Freedom from Abuse, Neglect, and Exploitation at F607-Develop/Implement Abuse/Neglect, etc. Policies. The IJ began on 09/19/2025 and continued until 10/28/2025 when the facility implemented corrective action to remove the immediacy. On 10/29/2025 the immediate jeopardy was removed, F607 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficient practice affected RI #1, one of four residents sampled for abuse and was cited as a result of the investigation of complaint/report number 2623504. Findings Include: Cross Reference F 578, F600, F609, F835 and F837. A facility policy titled ABUSE PREVENTION dated 01/2025, documented the following:POLICY: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, .DEFINITIONS:a) Abuse: Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.d) Physical Abuse: This includes but is not limited to hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment.e) Mental Abuse: The use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation .j) Mistreatment means inappropriate treatment or exploitation of a resident. PROCEDURE:A. STEPS TO PREVENT, DETECT AND REPORT: .PREVENTION:1. Staff members, volunteers, family members and others shall be encouraged to report incidents of abuse. When an incident of resident abuse is suspected or determined, such incident must be reported to facility management regardless of the time lapse since the incident occurred.IDENTIFICATION:1. Identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation .PROTECTION:1. Any allegation of abuses, neglect, misappropriation or exploitation against any employee must result in his/her immediate suspension to protect the resident.3. It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatments shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse, neglect, or mistreatment. Care will be monitored so that the resident's care plan is followed.On 09/19/2024 at 12:41 PM the State Agency received a FRI alleging Abuse and Mistreatment after CNA #8 reported having witnessed LPN #5 use a paper towel to pinch RI #1's nose to ensure RI #1 would swallow medications; CNA #8 reported RI #1 was mad; the administrator was made aware at 11:24 AM; the facility started in-service on the proper way to administer medications and on intervention for mistreatment of residents, and timely reporting.RI #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Acute Respiratory Failure with Hypoxia, Dementia, Wheezing, Cerebrovascular Disease, Seizures, and Pain. RI #1's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 09/15/2025 documented a Brief Interview for Mental Status (BIMS) score of three which indicated severely impaired cognition; RI #1 was coded as having no behaviors of resisting care during the assessment period.A review of RI #1's Electronic Medication Administration Record (eMAR) revealed on 9/19/2025 RI #1 received medication at approximately 8:47 AM administered by LPN #5.The facility investigative file contained a handwritten statement signed by CNA #8, dated 09/19/2025, which documented after she witnessed LPN #5 abuse RI #1 she left RI #1's room as follows: I was in (number of RI #1's room) (LPN #5) was . (giving) meds (medications) . he told me to hand him a paper towel and close the door I . (did not) close the door all the way because I was like why So he took the paper towel and Placed it over (his/her) nose and pinched (his/her) nose (he/she) was turning Red he did that so (he/she) could swallow (his/her) meds thats (that is) what he was saying as I walking out the room because it scared so I got a piece of paper and went to the DON . The facility investigative file contained a summary of the FRI investigation dated 09/25/2025, signed by the Administrator (ADM) concluding abuse was not substantiated and LPN #5 was allowed to return to work at the facility on 09/24/2025, leaving residents at risk of abuse by LPN #5. The summary documented the following: . On 09/19/25, . (CNA #8) reported to . Director of Nursing (DON) that she had seen (LPN #5) use a paper towel to hold over (RI #1's) mouth and pinch (his/her) nose closed to (ensure) that (RI #1) would swallow (his/her) medication. Police Department was notified . (LPN #5) and (CNA #8) were placed on administrative leave . The investigation concludes with no substantiation of abuse. (LPN #5) admitted ly, did not follow the procedure for (medication) administration and refusal of medication. (LPN #5) admitted to covering the resident's mouth with his hand, . to facilitate swallowing. (LPN #5) was overly concerned with (ensuring) . (RI #1) took the medication . (CNA #8) returned to work on 9/22/25 . (LPN #5) returned to work on 9/24/25. received a Category 1 disciplinary action with a 4 day un-paid suspension. (LPN #5) will not be allowed to provide routine care to (RI #1).On 10/21/2025 at 2:54 PM CNA #8 stated, on 09/19/2025 LPN #5 had the paper towel over RI #1's nose with his right hand and he had his other hand under RI #1's chin as if he was attempting to keep RI #1 from opening his/her mouth. CNA #8 said LPN #5 was pinching RI #1's nose, and RI #1 was turning red and turning his/her head from side to side. CNA #8 said she was panicking because of what she saw and left the room. She stated she went and told LPN #10 what she observed, and LPN #10 said she did not see it and did not want to be a part of it. CNA #8 said, she went to tell the DON, but she was in a meeting. When CNA #8 was asked why she left the room, she said she needed to tell someone because what LPN #5 did was not right. CNA #8 said, she told CNA #11 what she saw and was going to report it but did not report to anyone until she saw the DON in the dining room and notified her of occurrence, which was at 11:20 AM. CNA #8 said LPN #5's actions of trying to make RI #1 swallow his/her medications would be considered abusive. On 10/22/2024 at 11:28 AM an interview was conducted with LPN #10. LPN #10 said on 09/19/2025, CNA #8 did come to the room where she was providing care for another resident and CNA #8 said she had to tell her something and LPN #10 informed CNA #8, she was with another resident. LPN #10 was asked should a nurse place their hand over a resident's mouth to keep the resident from spitting out their medications. LPN #10 said, never She further replied anytime you find a resident being abused you need to report to the Abuse Coordinator right away. On 10/22/2025 at 4:24 PM the Registered Nurse (RN) Unit Manager (UM) #15, was asked when she became aware of an allegation that LPN #5 put a paper towel over RI #1's nose and pinched it to make RI #1 swallow his/her medications on 09/19/2025. UM #15 said she was made aware when she was asked to count the cart LPN #5 worked on because LPN #5 was being sent home. UM #15 said CNA #8 should have immediately reported it to the Abuse Coordinator. When asked how CNA #8 could have protected the resident, UM #15 said she should have opened the door and called for help. On 10/23/2025 at 11:55 AM an interview was conducted with the DON. When asked what time on 09/19/2025 she was made aware of the allegation against LPN #5, the DON said CNA #8 came to her about 11:20 AM while she was in the dining room. The DON said CNA #8 said she needed to talk to her, and they went into the DON's office. The DON said CNA #8 said she had witnessed LPN #5 doing something he should not have done. The DON said CNA #8 said LPN #5 placed a napkin over RI #1's nose, pinched his/her nose, and placed his hand over his/her mouth and told RI #1 to not spit but swallow the medication. The DON said CNA #8 said when she observed this she left out of the room. The DON said when CNA #8 came to her door and she was on telephone, she should have told her an emergency occurred right then. When asked did CNA #8 follow the facility's abuse policy for protecting residents, she replied not in a timely manner. On 10/23/2025 at 3:20 PM an interview was conducted with the ADM, who is also the Abuse Coordinator. When asked what time on 09/19/2025 was she made aware that an allegation had been made against LPN #5, the ADM said it was after 11 AM. The ADM said from the facility's investigation it was after 8:00 AM when the allegation occurred. The ADM said when CNA #8 saw something inappropriate it should have been reported immediately. When asked did CNA #8 follow the facility's abuse policy for protecting the resident and reporting what she observed, ADM replied, no. The ADM said she reported to the State Agency as an allegation of abuse - mistreatment but the facility did not substantiate abuse.During the survey on 10/21/2025 LPN #5 was observed administering medications to residents in the facility without any monitoring or observations of LPN #5's work or conduct. Because the facility failed to identify the abuse LPN #5 continued working at the facility and residents remained at risk of being abused by LPN #5.****************************************************On 10/28/2025, the facility submitted the following as their removal plan for the identified Immediate Jeopardy: *****************************************************1. Immediate Corrective Action for the Affected Resident RI #1 was immediately assessed for distress and mental abuse by the Director of Nursing (DON) and Unit Manager on 9/19/25 through interview questions. No mental injury was identified by DON. The interview on 9/19/25 revealed resident was smiling and talkative with no signs of any distress or agitation. Body audit was completed on 9/19/25 by Unit Manager and DON, to assess for physical injury. RI #1's body audit (head to toe assessment) determined no physical abuse as evidenced by no unknown redness edema, or discoloration observed. On 10/24/25 another body audit (head to toe assessment) was completed by Wound Nurse to assess for physical injury. Body audit determined no physical abuse as evidenced by no unknown redness edema or discoloration observed. * CNA was suspended from resident care pending investigation on 9/19/25. The CNA was educated by the administrator on 9/22/25 on types of abuse, to include mistreatment, and reporting. Any type of abuse must be reported immediately to the Abuse Coordinator (Administrator) whose telephone number is posted in the lobby; Administrator is on call 24/7 if not in the facility. Residents cannot be left alone in unsafe situations, stay with resident, intervene, and call for help. 1:1 education was provided to LPN, who on 9/19/25 did not follow up to concerns of LPN #5 placing his hand over RI #1's mouth, to ensure RI #1 swallowed the medication, on 10/24/25 by the Director of Nursing on the need to follow up on concerns that could be considered abuse. CNA was returned to resident care on 9/22/25 after education training completed. On 10/24/25 due to substantiation of abuse of RI #1 by LPN #5, CNA was terminated due to failure to protect RI #1 and failure to immediately report to the abuse coordinator. Abuse education provided to the facility Director of Nursing, Administrator, and [NAME] President of Operations on 10/24/25 at 12:30pm, per [NAME] President of Clinical Services. This education was to ensure understanding of facility abuse policy, and implementation of policy, including reporting timeliness within 2 hours of the abuse. Also to identify occurrences, patterns and trends that may constitute abuse (such as suspicious bruising of residents, including LPN #5 placing his hand and a paper towel over RI #1's mouth and pinching RI #1's nose in order to prevent RI #1 from spitting out medications) and to determine the direction of the investigation and substantiate abuse (Suspected or substantiated cases of resident abuse, neglect, misappropriation of property, or mistreatment shall be thoroughly investigated, documented, and reported to the physician, families, and/or representative), to provide protection of residents from perpetrators of abuse. (All allegations of abuses, neglect, misappropriation, or exploitation against any employee must result in his/her immediate suspension to protect the resident.) [NAME] President of Clinical Operations educated the DON and the Administrator on 10/24/25 to utilize a Supervisor Investigation Checklist Form on any allegation of abuse. This checklist will include providing protection of the resident, monitoring of aggressor, notification of abuse. The [NAME] President of Operations will use this checklist to ensure oversight of each allegation of abuse is completed accurately and to achieve correct outcome after thorough investigation. If any concerns with the checklist are found by the [NAME] President of Operations, the [NAME] President of Operations will guide the facility Administrator on how to implement the abuse policy to identify abuse and protect residents from perpetrators of abuse. Resident complaint/mistreatment poll for 29 residents was completed 9/19/25 on the unit LPN #5 worked, this was completed by Social Services. This poll was completed to determine if other residents had concerns or issues with medication administration by LPN #5 placing his hand over the resident's mouth to get the resident to swallow their medication. This poll was obtained through interviews. Then on 9/22/25 Administrator completed complaint/mistreatment poll on 111 residents in facility to determine if any resident in the facility had issues or concerns from mistreatment or any nurse placing their hands over the resident's mouth to force resident to swallow medication. This poll was obtained through 1 on 1 interviews with residents. A new complaint/mistreatment poll was conducted by Director of Nursing on 10/24/25, this poll was obtained through resident interview for 109 residents to determine mistreatment. Nine residents who were unable to communicate were assessed by body audits (head to toe assessment) these audits determined no evidence of physical abuse as evidence by no unknown redness edema, or discoloration observed. The body audits were completed by Nurse Managers on 10/24/25. On 10/25/25 all allegations of abuse since 9/19/25 were reviewed by the [NAME] President of Operations to ensure that facility implemented the abuse policy and took appropriate actions to protect residents from abuse. The [NAME] President of Operations reviewed the only allegation/misappropriation of resident property that occurred was on 9/29/25 and found DON and Administrator had implemented the abuse policy correctly. To protect RI #1s rights to refuse care and treatment, on 10/25/25 RI #1's plan of care for medication administration was reviewed and revised by IDT (MDS Nurse and Social Services) and family member. Interventions in place starting 08/21/2025: may crush meds and add in applesauce, yogurt, or pudding. The facility added a new intervention on 10/25/25: may use sweets as positive reinforcement to take medications, and when administering medications allow ample time to swallow medications. Licensed Nursing Staff notified of care plan revisions on 10/25/25 via 24-hour nursing report that remains on the nursing unit. 2. Identification of Other Residents Who Could Be Affected No other residents were identified as affected or at risk for abuse/mistreatment for needing protection. This was determined through complaint/mistreatment poll that was conducted by Director of Nursing on 10/24/25, this poll was obtained through resident interview for 109 residents. Nine residents who were unable to communicate were assessed by body audit (head to toe assessment). These audits determined no evidence of physical abuse as evidence by no unknown redness, edema, or discoloration observed. The body audits were completed by Nurse Managers on 10/24/25. Ninety-eight residents were educated of their right to refuse medications and treatments through handouts of Resident's Rights by Social Services and Business Office Staff on 10/24/25. Residents acknowledged they understood their Rights to include refusal of medication by signing Resident's Rights form. Facility notified family members of 14 residents that are unable to communicate and discussed resident's right to refuse medication on 10/24/25 by Social Services. If Social Services were unable to contact a family member by phone, a copy of Resident's Rights was sent via certified mail on 10/25/24 to 6 family members of residents. 3. Systemic Changes to Prevent Recurrence Education was provided to 36 licensed nurses (27 in person, 9 via telephone) on the Medication Administration Policy, resident's right to refuse medication, and staff follow-up after receiving resident information that could be considered abuse which included placing a hand and a paper towel over residents mouth and pinching residents nose in order to prevent residents from spitting out medications on 10/24/25 by Director of Nursing, Unit Managers and Staff Development Coordinator (SDC). The Abuse Prevention Policy was educated to 140 staff, (80 in person, 60 via telephone) emphasizing that any act of coercion or force (forcefully/making resident take medication against his/her will) is considered abuse. Abuse must be reported immediately to the Abuse Coordinator. Resident cannot be left alone in a potential abuse situation/unsafe situation, stay with resident, intervene, and call for help. This education was completed on 10/25/25, by DON, Unit Managers, and Staff Development Coordinator. One CNA has not completed education, she/he has been removed from the time clock and will not be allowed to work until education is completed. In the event employee cannot get a response from abuse coordinator (Administrator) employee will notify Director of Nursing and/or Human Resource Director. This education was completed on 10/25/25, by DON, Unit Managers and SDC. This was education to 140 staff (80 in person, 60 via telephone). No employee will be allowed to work without completion of this education. Telephone numbers of Abuse Coordinator, DON, and Human Resource Director was posted at the time clock. 4. Monitoring to Ensure Ongoing Compliance Starting 10/25/25 Administrator will forward to the [NAME] President of Operations, by email, the investigation of all allegations of abuse. The [NAME] President of Operations will review all allegations of abuse to ensure that the facility has correctly implemented the abuse policy and took appropriate actions to protect residents from abuse by correctly identifying and substantiating abuse as appropriate. [NAME] President of Operations educated the DON and the Administrator on 10/24/25 to utilize a Supervisor Investigation Checklist Form on any allegation of abuse. This checklist will include providing protection of the resident, monitoring of aggressor, notification of abuse. The [NAME] President of Operations will use this checklist to ensure oversight of each allegation of abuse is completed accurately and to achieve correct outcome after thorough investigation. If any concerns with the checklist are found by the [NAME] President of Operations, the [NAME] President of Operations will guide the facility Administrator on how to implement the abuse policy to identify abuse and protect residents from perpetrators of abuse. A Quality Assurance Meeting held on 10/24/25 to review F-tag 578, 600, 607, 609, 835, and 837 at scope and severity level IJ. Members attending the QAPI meeting: Administrator, Human Resources, Clinical Operations Nurse, QA Nurse, [NAME] President of Operations, Medical Director, and Director of Nursing. After receiving education (on 10/24/25 for the Administrator, DON, and [NAME] President of Operations by the [NAME] President of Clinical Services) related to abuse and covering the mouth and pinching the nose of a resident to prevent them from spitting out medication, the QAPI team reviewed the allegation of abuse of RI #1 by LPN #5 and the allegation was substantiated. It was determined at this meeting: The Abuse Prevention Policy will be educated to the entire staff emphasizing that any act of coercion or force (forcefully/making resident take medication against his/her will) is considered abuse. Abuse must be reported immediately to the abuse coordinator. Resident cannot be left alone in a potential abuse situation/unsafe situation, stay with resident, intervene, and call for help; Medication Administration Policy, residents right to refuse medication, supervisor/staff follow-up after receiving resident information that could be considered abuse. All residents would be educated on Resident's Rights. The DON reported to the ABON on 10/28/2025 that the allegation of abuse of RI #1 by LPN #5 was substantiated.5. Date of CompletionThe immediacy corrective actions were completed by [10/28/25]. Education was completed [10/28/25]. ********************************************* After reviewing the facility's immediate actions and information provided in their Removal Plan, interviewing staff and verifying the corrective actions had been implemented the Immediate Jeopardy was removed on 10/29/2025. The scope/severity level of F607 was lowered to no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on interviews, record review and review of a facility policy titled ABUSE PREVENTION, the facility failed to ensure Certified Nursing Assistant (CNA) #8 immediately reported abuse she observed when Licensed Practical Nurse (LPN) #5 placed his hands over RI #1's mouth and nose to prevent RI #1 from spitting out medication on 09/19/2025 at approximately 8:47 AM, placing RI #1 at risk of aspirating the medications and being fearful, as RI #1 struggled, pushing his/her head from side to side and turning red in the face. CNA #8 said she tried to tell LPN #10, but LPN #10 did not want to be involved. CNA #8 failed to understand the importance of reporting immediately to facility administration about abuse she observed and instead waited until 11:20 AM to report to the Director of Nursing (DON), while LPN #5 continued working his shift. The abuse was not reported to the State Agency until 12:41 PM on 09/19/2025.LPN #5 was suspended but returned to work on 09/24/2025 and continued to work in the facility without direct monitoring or oversight until 10/23/2025 during the survey.The IJ began on 09/19/2025 and continued until 10/28/2025 when the facility implemented corrective action to remove the immediacy. On 10/29/2025 the immediate jeopardy was removed, F609 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficient practice affected RI #1, one of four residents sampled for abuse. This deficiency was cited as the result of the investigation of complaint/report number 2623504. Findings Include:Review of a facility policy titled, ABUSE PREVENTION, dated 01/2025, revealed the following:POLICY: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily to: facility staff, other residents .DEFINITIONS:a) Abuse: Willful infliction of injury .d) Physical Abuse: This includes but is not limited to hitting, slapping, pinching and kicking .e) Mental Abuse: The use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear .PROCEDURE:A. STEPS TO PREVENT, DETECT AND REPORT: . REPORTING: .Alleged violations involving abuse, neglect, exploitation or mistreatment, including injures of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made . to the administrator of other officials .RI #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Acute Respiratory Failure with Hypoxia, Dementia, Unspecified Severity, without Behavioral Disturbance, Wheezing, Cerebrovascular Disease and Pain. Review of RI #1's Quarterly Minimum Data Set assessment, with an Assessment Reference Date of 09/15/2025 revealed RI #1 scored a three on the Brief Interview for Mental Status indicating RI #1 had severely impaired cognition. On 09/19/2024 at 12:41 PM an allegation involving Abuse - Mistreatment of RI #1, perpetrated by LPN #5, was received by the State Agency's Online Incident Reporting System. The report revealed CNA #8 observed LPN # 5 the morning of 09/19/2024 administering medications to RI #1 and used a paper towel to pinch RI #1's nose to ensure RI #1 would swallow the medication; the incident was reported to the ADM at 11:24 AM; and all staff would be in-serviced on intervening if they observed a resident being mistreated and timely reporting of the incident. On 10/21/2025 at 2:54 PM an interview was conducted with CNA #8 regarding the incident on 09/19/2024. CNA #8 said while assisting residents with care that morning, LPN #5 was passing medications; LPN #5 was in RI #1's room and asked CNA #8 to go in the bathroom and get a paper towel and to close the door. CNA #8 said she went to the bathroom, got a paper towel and gave it to LPN #5; as she was leaving the room, CNA #8 heard LPN #5 telling RI #1 he/she was going to swallow the medications. CNA #8 said LPN #5 had the paper towel over RI #1's nose with his right hand and he had his other hand under RI #1's chin as if he was attempting to keep RI #1 from opening his/her mouth. CNA #8 said she was panicking because of what she saw and left the room. CNA #8 said she went and told LPN #10 what she observed, and LPN #10 said she did not see it and did not want to be a part of it. CNA #8 said, she then walked down the hall to report the incident to the DON and she was in a meeting, so she did not actually report it to administration until she told the DON at 11:20 AM. Contained within the facility's investigative file was a typed Witness Statement dated 09/23/2025 signed by CNA #11 which revealed the following: . Q: Did she (CNA #8) talk to you about seeing a nurse give medications that she was concerned about?A: YesQ: What time was that? A: Before lunch, morining [morning] time . On 10/22/2025 at 8:53 AM a telephone interview was conducted with CNA #11 who CNA #8 had told about the abuse. CNA #11 said she was doing her orientation with CNA #8 on 09/19/2025. CNA #11 said while she and CNA #8 were in RI #1's room, CNA #8 told her to stay in the room with RI #1 because she had to go and report something. When asked what CNA #8 said she was going to report, CNA #11 said about how the nurse (LPN #5) gave the resident (RI #1) the medicine. CNA #11 said CNA #8 told her, LPN #5 pinched RI #1's nose and tried to force RI #1 to take the medicine. CNA #11 said she thought this occurred before breakfast. On 10/22/2024 at 11:28 AM LPN #10 said on 09/19/2025, CNA #8 did come to the room where she was providing care for another resident and CNA #8 said she had to tell her something and LPN #10 informed CNA #8, she was with another resident. LPN #10 said, anytime a resident was found being abused staff needed to report to the Abuse Coordinator right away. On 10/23/2025 at 11:55 AM an interview was conducted with the Director of Nursing (DON) regarding the incident on 09/19/2024. The DON confirmed she was notified of the incident of alleged abuse by CNA #8 around 11:20 AM while in the dining room. When asked if the CNA #8 reported the allegation timely to her, DON said no that she should have reported it immediately. On 10/23/2024 at 3:20 PM an interview was conducted with the Administrator (ADM) regarding the incident on 09/19/2024. The ADM said she was notified by the DON of the incident on 09/19/2024 around 11:00 AM that morning. When asked when the incident occurred, the ADM said it was reported to have occurred around 8:00 AM or around the time when RI #1 was receiving morning medications (8:47 AM per RI #1's Medication Administration Record). When asked if the incident was reported to the ADM timely, she said no. The ADM said, when CNA #8 saw something she thought was inappropriate she should have reported it; she preferred the staff call her as her name and number are posted in the facility; and she should have at least reported to the supervisor or the DON. The ADM said, CNA #8 told her she had reported to LPN #10 but LPN #10 blew her off and said she did not see it and did not want to be involved; and when she tried to tell the Supervisor, she was not in her office; she went to tell the DON and she was on the phone. ******************************************************************************** On 09/28/2025, the facility submitted the following as their removal plan for the identified Immediate Jeopardy: *********************************************** 1. Immediate Corrective Action for the Affected Resident CNA was suspended from resident care pending investigation on 9/19/25. The CNA was educated by the administrator on 9/22/25 on types of abuse, to include mistreatment, and reporting. Any type of abuse must be reported immediately to the Abuse Coordinator (Administrator) whose telephone number is posted in the lobby; Administrator is on call 24/7 if not in the facility. Residents cannot be left alone in unsafe situations, stay with resident, intervene, and call for help. 1:1 education was provided to LPN, who on 9/19/25 did not follow up to concerns of LPN #5 placing his hand over RI #1's mouth, to ensure RI #1 swallowed the medication, on 10/24/25 by the Director of Nursing on the need to follow up on concerns that could be considered abuse. CNA was returned to resident care on 9/22/25 after education training completed. On 10/24/25 due to substantiation of abuse of RI #1 by LPN #5, CNA was terminated due to failure to protect RI #1 and failure to immediately report to the Abuse Coordinator. Abuse education provided to the facility Director of Nursing, Administrator, and [NAME] President of Operations on 10/24/25 at 12:30pm, per [NAME] President of Clinical Services. This education was to ensure understanding of facility abuse policy, and implementation of policy, including reporting timeliness within 2 hours of the abuse. Also to identify occurrences, patterns and trends that may constitute abuse (such as suspicious bruising of residents, including LPN #5 placing his hand and a paper towel over RI #1's mouth and pinching RI #1's nose in order to prevent RI #1 from spitting out medications) and to determine the direction of the investigation and substantiate abuse (Suspected or substantiated cases of resident abuse, neglect, misappropriation of property, or mistreatment shall be thoroughly investigated, documented, and reported to the physician, families, and/or representative), to provide protection of residents from perpetrators of abuse. (All allegations of abuses, neglect, misappropriation or exploitation against any employee must result in his/her immediate suspension to protect the resident.) [NAME] President of Clinical Operations educated the DON and the Administrator on 10/24/25 to utilize a Supervisor Investigation Checklist Form on any allegation of abuse. This checklist will include: providing protection of the resident, monitoring of aggressor, notification of abuse. The [NAME] President of Operations will use this checklist to ensure oversight of each allegation of abuse is completed accurately and to achieve correct outcome after thorough investigation. If any concerns with the checklist are found by the [NAME] President of Operations, the [NAME] President of Operations will guide the facility Administrator on how to implement the abuse policy to identify abuse and protect residents from perpetrators of abuse. Education was provided to 36 licensed nurses (27 in person, 9 via telephone) on the Medication Administration Policy, resident's right to refuse medication, and staff follow-up after receiving resident information that could be considered abuse which included placing a hand and a paper towel over residents mouth and pinching residents nose in order to prevent residents from spitting out medications on 10/24/25 by Director of Nursing, Unit Managers and Staff Development Coordinator (SDC). 2. Identification of Other Residents Who Could Be Affected No other residents were identified as affected or at risk for abuse, mistreatment or right to refused care and treatment. This was determined through complaint/mistreatment poll that was conducted by Director of Nursing on 10/24/25, this poll was obtained through resident interview for 109 residents. Nine residents who were unable to communicate were assessed by body audit (head to toe assessment). These audits determined no evidence of physical abuse as evidence by no unknown redness, edema, or discoloration observed. The body audits were completed by Nurse Managers on 10/24/25.3. Systemic Changes to Prevent Recurrence The Abuse Prevention Policy was educated to 140 staff, (80 in person, 60 via telephone) emphasizing that any act of coercion or force (forcefully/making resident take medication against his/her will) is considered abuse. Abuse must be reported immediately to the Abuse Coordinator. Resident cannot be left alone in a potential abuse situation/unsafe situation, stay with resident, intervene, and call for help. This education was completed on 10/25/25, by DON, Unit Managers, and Staff Development Coordinator. One CNA has not completed education, she/he has been removed from the time clock and will not be allowed to work until education is completed. In the event employee cannot get a response from Abuse Coordinator (Administrator) employee will notify Director of Nursing and/or Human Resource Director. This education was completed on 10/25/25, by DON, Unit Managers and SDC. This was education to 140 staff (80 in person, 60 via telephone). No employee will be allowed to work without completion of this education. Telephone numbers of Abuse Coordinator, DON, and Human Resource Director was posted at the time clock. 4. Monitoring to Ensure Ongoing Compliance On 10/25/25 DON, SDC and Nurse Mangers selected 3 employees off each shift to interview to ensure staff recognizes and knows whom and how to report immediately, and understand protection for residents. The staff were asked if they understood abuse-when to report and whom to report, reporting timely, protecting the resident/intervene when the resident could be at risk and call for help. 9 out of 9 employees answered the questions correctly. These interviews will occur weekly going forward. A Quality Assurance Meeting held on 10/24/25 to review F-tag 578, 600, 607, 609, 835, and 837 at scope and severity level IJ. Members attending the QAPI meeting: Administrator, Human Resources, Clinical Operations Nurse, QA Nurse, [NAME] President of Operations, Medical Director, and Director of Nursing. After receiving education (on 10/24/25 for the Administrator, DON, and [NAME] President of Operations by the [NAME] President of Clinical Services) related to abuse and covering the mouth and pinching the nose of a resident in order to prevent them from spitting out medication, the QAPI team reviewed the allegation of abuse of RI #1 by LPN #5 and the allegation was substantiated. It was determined at this meeting: The Abuse Prevention Policy will be educated to the entire staff emphasizing that any act of coercion or force (forcefully/making resident take medication against his/her will) is considered abuse. Abuse must be reported immediately to the abuse coordinator. Resident cannot be left alone in a potential abuse situation/unsafe situation, stay with resident, intervene, and call for help; Medication Administration Policy, residents right to refuse medication, supervisor/staff follow-up after receiving resident information that could be considered abuse. All residents would be educated on Resident's Rights. The DON reported to the ABON on 10/28/2025 that the allegation of abuse of RI #1 by LPN #5 was substantiated.5. Date of CompletionThe immediacy corrective actions were completed by [10/28/25].Education was completed [10/28/25]. ************************************************ After reviewing the facility's immediate actions and information provided in their Removal Plan, interviewing staff and verifying the corrective actions had been implemented the Immediate Jeopardy was removed on 10/29/2025. The scope/severity level of F609 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on interviews, review of the Administrator's (ADM) and Director of Nursing (DON) Job Responsibilities, and review of the facility's ABUSE PREVENTION policy, the facility's ADM and DON failed to provide oversight and guidance to facility staff to ensure the facility's abuse policy was implemented to identify abuse, report suspected abuse, and take corrective actions to protect residents following an incident of abuse. On 09/19/2025 Resident Identifier (RI) #1 was abused by Licensed Practical Nurse (LPN) #5 when LPN #5 placed his hand over RI #1's mouth and pinched RI #1's nose to prevent RI #1 from spitting out medication during medication administration. Two staff reported that RI #1's face was red after the incident. The Certified Nursing Assistant (CNA) who witnessed the incident left RI #1 alone with LPN #5 at the time of the abuse and failed to report immediately. The CNA reported to a nurse who did not act to intervene but instead did not want to be involved. LPN #5 continued working at the facility without any oversight or monitoring and was observed during the survey administering medications on 10/21/2025. Nurses interviewed stated what occurred was abuse and RI #1 was likely to aspirate the medications during the abuse.The facility's administration failed to ensure staff: 1) intervened to protect RI #1 from further potential abuse suspected abuse;2) reported suspected abuse to the ADM or DON timely;3) understood the protocol and importance of reporting allegations of abuse immediately (including the CNA witness and the nurse who did not want to be involved);4) understood the residents' right to refuse treatment. Further, the ADM and DON failed to identify the incident as abuse and develop and implement appropriate corrective actions to ensure RI #1 and other residents were protected when LPN #5 was allowed to return to work and administer medications to residents. The facility did not have a plan to monitor LPN #5 to ensure residents' safety. It was determined the facility's noncompliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.70 Administration. On 10/24/2025 at 6:58 PM the Administrator (ADM), the Director of Nursing (DON), the [NAME] President (VP) of Operations and the Clinical Operations Nurse were provided a copy of the IJ template and notified of the findings of immediate jeopardy in the area of Administration at F835-Administration. The IJ began on 09/19/2025 and continued until 10/28/2025 when the facility implemented corrective action to remove the immediacy. On 10/29/2025 the immediate jeopardy was removed, F835 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficient practice affected RI #1 and had the potential to affect all residents residing the facility. This deficiency was cited as the result of the investigation of complaint/report number 2623504.Findings Include:Cross-Reference F578, F600, F607, F609 and F837.Review of a facility policy titled, ABUSE PREVENTION, dated 01/2025 revealed the following: POLICY: The facility is committed to protecting the resident from abuse by anyone including, but not necessarily limited to: facility staff, other residents, .DEFINITIONS:a) Abuse: Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish . Abuse may be resident-to-resident, staff-to-resident, .d) Physical Abuse: This includes but is not limited to hitting, slapping, punching and kicking .e) Mental Abuse: The use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear . agitation .j) Mistreatment means inappropriate treatment. of a resident . IDENTIFICATION: .2. The Executive Director and the Director of Nursing Services must be promptly notified of suspected abuse or incidents of abuse . PROTECTION:1. Any allegations of abuses, . against any employee must result in his/her immediate suspension to protect the resident .3. It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatments shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse . or mistreatment .REPORTING: .Alleged violations involving abuse, . or mistreatment . are reported immediately, but no later than 2 hours after the allegation is made, . to the administrator of the facility and to other officials (including State Survey Agency .) Review of the Executive Director's Job Description, signed and dated by the ADM on 04/03/2020, revealed the following: General DescriptionThe Executive Director leads and directs the overall operation of the Facility in accordance with resident needs, government regulations and Facility policies so as to maintain quality care for the residents while achieving the Facility's business objectives . Essential Duties .13. Demonstrates knowledge of all State Department of Health rules and regulations and provides adequate instruction regarding such rules and regulations to appropriate staff .Standard Requirements1. Supports the Mission, Values and Vision of the Facility.2. Is knowledgeable of resident rights and supports an atmosphere which allows for the privacy, dignity and well-being of all residents in a safe, secure environment .4. Adheres to: .c. Quality Assurance requirements and compliance with regulatory requirements . Review of the Director of Nursing Services Job Description, signed and dated by the DON on 07/28/2025, revealed the following:General DescriptionResponsible for the overall management of resident care 24 hours a day, seven days per week. Functions include: performing a variety of duties to provide quality nursing care to residents and to coordinate total nursing care for residents; implementing specific procedures . complying with operating policies and procedures, state requirements, Department of Health regulations .Standard Requirements1. Supports the Mission, Values and Visions of the facility.2. Is knowledgeable of resident rights and supports an atmosphere which allows for the privacy, dignity and well-being of all residents in a safe, secure environment .4. Adheres to: .c. Quality Assurance requirements and compliance with regulatory requirements . On 10/23/2025 at 11:55 AM an interview was conducted with the DON. The DON said she became aware that an allegation was being made against LPN #5 when CNA #8 came to her about 11:20 AM while she was in the dining room. The DON said CNA #8 informed her LPN #5 placed a paper towel over RI #1's nose, pinched it, and placed his other hand over RI #1's mouth and told RI #1 to, do not spit, swallow the medication. The DON said she asked CNA #8 what she did at that time and CNA #8 said she went out of the room. The DON said she informed CNA #8 that this was something that had to be reported and they had to make sure RI #1 was safe. The DON said when she asked LPN #5 what occurred, LPN #5 said RI #1 was trying to spit his/her medicine out and he knelt beside RI #1 and told RI #1 that he/she needed to take the medication. The DON said LPN #5 said he gently tapped RI #1's mouth and told RI #1 please don't spit your medicine out. The DON said LPN #5 was given a Corrective Counseling Violation write-up because he did not follow the standard practice for medication policy. The DON said RI #1 had the right to refuse, and nurses should not place their hand on a resident's mouth. The DON said it was an improper way to give medication when a nurse placed their hand on a resident's mouth to get them to take their medication. The DON said when staff observes a nurse doing this, the first thing they should do is make sure the resident is safe and get some help, by asking the person to leave the room or yell for help. The DON said CNA #8 did not do this. The DON said CNA #8 said she came to her (the DON's) door, and she was on the phone, and she left, then she came back, and the DON had someone in her office, and she left. The DON said she told CNA #8 that was an emergency, and she should have told her right then. The DON said CNA #8 did not follow the facility's abuse policy for protecting the resident or reporting the incident in a time manner. The DON said after this allegation occurred, staff were in-serviced on reporting abuse, mistreatment, and how to intervene if you see or suspect abuse. The DON said you do not leave the resident alone. On 10/23/2025 at 3:20 PM an interview was conducted with the ADM. The ADM said on 09/19/2025 a little after 11 AM she was made aware that an allegation had been made against LPN #5. The ADM said the DON informed her of the allegation and she was informed that CNA #8 said LPN #5 put his hand over RI #1's mouth to make him/her take medications. The ADM said around 11:24 AM she reported the allegation to the State Agency as an allegation of abuse - mistreatment. The ADM said the allegation should have been reported to her immediately. The ADM said the allegation was not substantiated because it was not abuse. The ADM said there was no intent to harm the resident and the resident was not harmed. When asked should RI #1 have been treated that way, the ADM said no. The ADM said LPN #5 should have let RI #1 spit the medication out. On 10/24/2025 at 11:49 AM a follow-up interview was conducted with the DON. The DON said when LPN #5 returned to work after suspension, he was not being monitoring to ensure he was not placing his hands over resident's mouths to make them sure they take or do not spit out their medications. The DON said no one was observing LPN #5 administer medications, and once education on resident rights and abuse was done, LPN #5 said he would never do that again. *********************************************************** On 10/28/2025, the facility submitted the following as their removal plan for the identified Immediate Jeopardy: ************************************ Immediate Corrective Action for the Affected Resident Abuse education provided to the facility Director of Nursing, Administrator, and [NAME] President of Operations on 10/24/25 at 12:30 pm, per [NAME] President of Clinical Services. This education was to ensure understanding of facility abuse policy, and implementation of policy, including reporting timeliness within 2 hours of the abuse. Also to identify occurrences, patterns and trends that may constitute abuse (such as suspicious bruising of residents, including LPN #5 placing his hand and a paper towel over RI #1's mouth and pinching RI #1's nose in order to prevent RI #1 from spitting out medications) and to determine the direction of the investigation and substantiate abuse (Suspected or substantiated cases of resident abuse, neglect, misappropriation of property, or mistreatment shall be thoroughly investigated, documented, and reported to the physician, families, and/or representative), to provide protection of residents from perpetrators of abuse. (All allegations of abuses, neglect, misappropriation or exploitation against any employee must result in his/her immediate suspension to protect the resident.) [NAME] President of Clinical Operations educated the DON and the Administrator on 10/24/25 to utilize a Supervisor Investigation Checklist Form on any allegation of abuse. This checklist will include: providing protection of the resident, monitoring of aggressor, notification of abuse. The [NAME] President of Operations will use this checklist to ensure oversight of each allegation of abuse is completed accurately and to achieve correct outcome after thorough investigation. If any concerns with the checklist are found by the [NAME] President of Operations, the [NAME] President of Operations will guide the facility Administrator on how to implement the abuse policy to identify abuse and protect residents from perpetrators of abuse.On 10/25/25 all allegations of abuse since 9/19/25 were reviewed by the [NAME] President of Operations to ensure that facility implemented the abuse policy and took appropriate actions to protect residents from abuse. The [NAME] President of Operations reviewed the only allegation/misappropriation of resident property that occurred was on 9/29/25 and found DON and Administrator had implemented the abuse policy correctly. 2. Identification of Other Residents Who Could Be Affected No other residents were identified as affected or at risk for abuse, mistreatment or right to refused care and treatment. This was determined through complaint/mistreatment poll that was conducted by Director of Nursing on 10/24/25, this poll was obtained through resident interview for 109 residents. Nine residents who were unable to communicate were assessed by body audit (head to toe assessment). These audits determined no evidence of physical abuse as evidence by no unknown redness, edema, or discoloration observed. The body audits were completed by Nurse Managers on 10/24/25.3. Systemic Changes to Prevent Recurrence Abuse education provided to the facility Director of Nursing, Administrator, and [NAME] President of Operations on 10/24/25 at 12:30 pm, per [NAME] President of Clinical Services. This education was to ensure understanding of facility abuse policy, and implementation of policy, including reporting timeliness within 2 hours of the abuse. Also to identify occurrences, patterns and trends that may constitute abuse (such as suspicious bruising of residents, including LPN #5 placing his hand and a paper towel over RI #1's mouth and pinching RI #1's nose in order to prevent RI #1 from spitting out medications) and to determine the direction of the investigation and substantiate abuse (Suspected or substantiated cases of resident abuse, neglect, misappropriation of property, or mistreatment shall be thoroughly investigated, documented, and reported to the physician, families, and/or representative), to provide protection of residents from perpetrators of abuse. (All allegations of abuses, neglect, misappropriation or exploitation against any employee must result in his/her immediate suspension to protect the resident.) [NAME] President of Clinical Operations educated the DON and the Administrator on 10/24/25 to utilize a Supervisor Investigation Checklist Form on any allegation of abuse. This checklist will include: providing protection of the resident, monitoring of aggressor, notification of abuse. The [NAME] President of Operations will use this checklist to ensure oversight of each allegation of abuse is completed accurately and to achieve correct outcome after thorough investigation. If any concerns with the checklist are found by the [NAME] President of Operations, the [NAME] President of Operations will guide the facility Administrator on how to implement the abuse policy to identify abuse and protect residents from perpetrators of abuse 4. Monitoring to Ensure Ongoing ComplianceStarting 10/25/25 Administrator will forward to the [NAME] President of Operations, by email, the investigation of all allegations of abuse. The [NAME] President of Operations will review all allegations of abuse to ensure that the facility has correctly implemented the abuse policy and took appropriate actions to protect residents from abuse by correctly identifying and substantiating abuse as appropriate. [NAME] President of Operations educated the DON and the Administrator on 10/24/25 to utilize a Supervisor Investigation Checklist Form on any allegation of abuse. This checklist will include: providing protection of the resident, monitoring of aggressor, notification of abuse. The [NAME] President of Operations will use this checklist to ensure oversight of each allegation of abuse is completed accurately and to achieve correct outcome after thorough investigation. If any concerns with the checklist are found by the [NAME] President of Operations, the [NAME] President of Operations will guide the facility Administrator on how to implement the abuse policy to identify abuse and protect residents from perpetrators of abuse.A Quality Assurance Meeting held on 10/24/25 to review F-tag 578, 600, 607, 609, 835, and 837 at scope and severity level IJ. Members attending the QAPI meeting: Administrator, Human Resources, Clinical Operations Nurse, QA Nurse, [NAME] President of Operations, Medical Director, and Director of Nursing. After receiving education (on 10/24/25 for the Administrator, DON, and [NAME] President of Operations by the [NAME] President of Clinical Services) related to abuse and covering the mouth and pinching the nose of a resident in order to prevent them from spitting out medication, the QAPI team reviewed the allegation of abuse of RI #1 by LPN #5 and the allegation was substantiated. It was determined at this meeting: The Abuse Prevention Policy will be educated to the entire staff emphasizing that any act of coercion or force (forcefully/making resident take medication against his/her will) is considered abuse. Abuse must be reported immediately to the abuse coordinator. Resident cannot be left alone in a potential abuse situation/unsafe situation, stay with resident, intervene, and call for help; Medication Administration Policy, residents right to refuse medication, supervisor/staff follow-up after receiving resident information that could be considered abuse. All residents would be educated on Resident's Rights. The DON reported to the ABON on 10/28/2025 that the allegation of abuse of RI #1 by LPN #5 was substantiated.5. Date of CompletionThe immediacy corrective actions were completed by [10/28/25].Education was completed [10/28/25]******************************************************** After reviewing the facility's immediate actions and information provided in their Removal Plan, interviewing staff and verifying the corrective actions had been implemented the Immediate Jeopardy was removed on 10/29/2025. The scope/severity level of F835 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on observations, interviews, record review, review of Facility Reported Incidents (FRI), review of the facility investigative files, review of a facility policy titled Abuse Prevention and review of a facility policy titled Behavior Management and Psychopharmacological Medication Monitoring Protocol, the facility failed to provide adequate supervision and ensure appropriate interventions were developed to manage RI #78's psychosis/delusional behaviors and ensure safety of residents in the facility. Because RI #78, a resident with a known history of chronic delusions/psychosis/restlessness/agitation, was not adequately supervised by staff, RI #78 hit RI #119 in the left shoulder on 06/12/25 and hit RI #13 on the left shoulder on 09/15/2025. This was discovered during investigations of abuse. Staff at the facility described RI #78's behaviors as unpredictable, difficult to pinpoint triggers, and to keep RI #78 from abusing other residents it would require supervision of RI #78 when out and about in the presence of other residents.This deficient practice affected RI #78 one of five residents sampled for behavioral health services.Findings Included:Cross Reference F600 A facility policy titled ABUSE PREVENTION dated 01/2025 documented the following: . PREVENTION: .5. Examples of steps that the facility may put in place immediately to prevent further potential abuse includes, but are not limited to, staffing changes, increased supervision, protection from retaliation, and follow-up counseling for the resident(s) . A facility policy titled Behavior Management and Psychopharmacological Medication Monitoring Protocol with an date of revision of 3/2018 documented: . PURPOSE: Residents with behaviors that are displayed routinely, that effect the resident's psychosocial well- being or that of other residents, or behaviors that can have potential for harm to self or others will be assessed with the development of a behavior program.DEFINITIONS: . Behavioral Interventions are individualized non -pharm logical approaches to care that are provided as part of a supportive physical and psychosocial environment, and are directed toward understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities as well as maintaining or improving a resident's mental, physical or psychosocial well-being.PROCEDURE: .2. Established resident with new onset of adverse behaviors:d) The Interdisciplinary Care Team (IDT) will update the care plan to include the problem behavior, goals, and approaches. RI #78 was admitted to the facility on [DATE] and had diagnoses to include Schizoaffective Disorder, Bipolar type, Dementia with Behavioral Disturbance, Restless and Agitation and Personal History of Other Mental and Behavioral Disorders. RI #78's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/30/2025 documented a Brief Mental Status Score of 6 out of 15 which indicated impaired cognition. RI #78's MDS documented resistance to care and wandering the facility one out of three days during the observation period. RI #78's MDS documented receipt of Antipsychotic medication. A review of RI #78's Level I determination dated 03/05/2021 documented the need for a Level II due to Diagnosis of Mental Illness; Mental Disorder of Schizoaffective Disorder, Bipolar Disorder, Psychotic, Manic. RI #78's Level II determination dated 03/15/2021 recommended Psychiatric Follow up Care for Serious Mental Illness of Bipolar, Psychotic Manic, Schizoaffective Disorder (Symptoms Severe) which RI #78 had received since his/her initial evaluation from Integrative Behavioral Health on 02/04/2021.On 03/01/2021 RI #78 had a care plan initiated for a focus area of PASRR Level II related to serious mental illness, Bipolar, psychotic manic, schizoaffective disorder (symptoms severe).On 09/16/2024 RI #78 had a behavioral symptoms care plan initiated for a focus area of history of being verbally aggressive cusses at staff, Dementia, Ineffective coping skills, Mental/Emotional illness, poor impulse control; history of being physically aggressive, Dementia with behavior disturbance, Schizoaffective disorder, Bipolar Disorder towards staff and other residents when agitated. Care Plan Interventions included: Administer medications as ordered; Analysis of key times, places, circumstances, triggers, and what de- escalates behavior and document; Assess resident's coping skills and support system; Assess resident' understanding of the situation. On 09/16/2024 RI #78's behavioral symptoms care plan was initiated for a focus area of having a history of being physically aggressive towards staff/other residents when agitated related to Dementia with behavioral disturbances and Schizoaffective Disorder, Bipolar Disorder. Interventions on the care plan include; Administer medications as ordered; Analyze of key times, places, circumstances, triggers, and what de- escalates behavior and document; Assess and anticipate resident needs, Modify Environment; Adjust room temperature to comfortable level, Reduce Noise, Dim lights, place familiar objects in the room, keep door closed; Monitor/ document/report any signs or symptoms of resident posing a danger to self or others.On 02/24/2024 RI #78 had a care plan initiated for a focus area of having delusions that he/she was working at the facility. Interventions on the care plan were 1) Document and monitor activity 2) Psych consult as needed 3) Redirect resident to preferred activity.RI #78's SOCIAL SERVICE HISTORY & INITIAL ASSESSMENT dated 05/30/2025 documented RI #78 was alert and oriented to person and situation; Mental Health diagnoses included Schizoaffective Disorder, Bipolar Disorder, history of mental and behavioral disorders, Restless and Agitation. Specific behavior factors noted on the assessment include: 1) exit seeking, 2) disruptive behavior, 3) difficulty controlling behavior, 4) wandering, 5) agitation, aggressive or abusive behavior and 6) resistance to care. The facility investigative file contained a typed Witness Statement for RI #78 dated 06/12/2025 which included questions and answers for RI #78 during investigation of physical abuse in which RI #119 was the victim, as follows: . I went in there and (he/she) was dipping in my business. My business. You know, just business. I just reached out and tapped (him/her) on (his/her) arm and told (him/her) to stop dipping in my business. Why would you even touch (him/her)? . Just a reflex. For dipping in my business. To tell (him/her) to stop.The facility investigative file contained a typed Witness Statement for RI #78 dated 09/15/2025 which included questions and answers for RI #78 during investigation of physical abuse in which RI #13 was the victim, as follows: . I hit (him/her) after (he/she) raised (his/her) arm to hit me. (He/she) swung on me and I hit (him/her) . (He/she) was flirting with my husband up there in the front of the room. ({RI #78} has no husband. There was no male in the front of the room, the TV News was on the TV in the front of the room.) . Are you going to hit anyone else? . Only if they try to hit me first. Contained within the facility's investigative file was a typed interview with the eyewitness, Occupational Therapist (OT) #16, dated 09/15/2025, which documented the following questions and answers in response to the OT witnessing RI #78 physically abuse RI #13: . Were you working in the dining room at lunch today? . Yes.Did you observe and interaction between (RI #78) and (RI #13)? . Yes. (RI #78) got up from (his/her) chair at the table and walked over to (RI #13) and pushed or punched (his/her) shoulder. (He/she) said something along the lines of get out of my husbands face, something to that effect.On 12/03/2025 at 2:26 PM an interview was conducted with OT #16 regarding what she witnessed on 09/15/2025 in the dining room. OT #16 said that RI #78 was sitting in the back of the room at a table when RI #78 got up out of his/her chair and walked straight towards RI #13, and punched RI #13 on the shoulder, saying something along the lines of get out of my husband's face. OT #16 said she was seated to the left of the television, about 7 steps away from RI #13 and faced the back of the room, allowing her to see both RI #78 and RI #13. OT #16 said there were no indicators from RI #78 that it was about to occur (no cursing or yelling), but the actions appeared to be intentional and directed towards RI #13. OT #16 said RI #13 screamed and seemed upset and confused as to why RI #78 punched him/her in the shoulder. OT #16 said for this to be prevented, RI #78 would need supervision when out and about in the dining room or courtyard area where other residents were present. On 12/1/2025 at 3:25 PM an interview was conducted with CNA #7 who was familiar with RI #78's mood and behaviors. CNA #7 said RI #78 exhibited resistance to care often and that RI #78's mood/behaviors were unpredictable and would fluctuate daily. CNA #7 said she did not witness RI# 78 hit RI#119, but she was present when RI #78 hit RI #13 in the dining room on 09/15/2025. When asked what level of supervision RI #78 would need to prevent him/her from hitting out at others, CNA #7 said, RI #78 would need someone all the time because RI #78's moods were always changing and unpredictable. On 12/01/2025 at 4:05 PM an interview was conducted with CNA #6 and when asked if she had ever seen RI #78 hit anyone before, she stated no, but she had seen RI #78 get mad and curse at other residents. When asked what curse words RI #78 used, CNA #6 said, RI #78 called people the B word. On 12/3/2025 at 4:40 PM, an interview was conducted with the Director of Social Services (SSD) regarding RI #78 and the incident on 06/12/2025 and 09/15/2025. The SSD said that RI #78 has a history of Psychosis related to Mental Health Issues; in addition, RI #78 had Dementia with behaviors which included resistance to care, wandering, and having delusional expressions. The DSS said RI #78's behaviors were random and it was difficult to pinpoint what may trigger his/her behaviors. When asked about the incident on 06/12/2025, the SSD said RI #78 was placed on one-to-one supervision, sent to the hospital, returned, remained on one to one supervision until the physician discontinued around 06/16/2025, and RI #78 was placed on behavior monitoring. The SSD said the incident on 09/15/2025 occurred when RI #78 believed that RI #13 was trying to take RI #78's man away by showing his/her legs/body while RI #78's husband was performing. The SSD said there was no male preforming that day in the dining room, and residents were watching television. The SSD said she believed RI #78 was acting on his/her delusional thoughts the day of the incidents. After the incident on 09/15/2025, the SSD interviewed RI #78 who felt the hit was justified based on the delusional thoughts that RI #13 was showing his/her body to RI #78's husband. The SSD did not believe the incident could have been prevented due to RI #78's behaviors being unpredictable. On 12/03/2025 at 6:00 PM an interview was conducted with the Director of Nursing (DON) regarding RI #78. The DON said RI #78 had a psychiatric history, exhibited behaviors such as refusing baths and had hallucinations, and was followed by behavioral health services. The DON said RI #78 required more supervision at times when he/she exhibited increased restlessness or agitation related to wanting to go home. The DON said the staff watched RI #78 closely during this time of increased restlessness. The DON said interventions put in place after 06/12/2025 were to refer for consult to behavioral health services if behaviors continued and that the care plan did not note that RI #78 hit/struck another resident on 06/12/2025. When asked what the process was for assessing the level of supervision RI #78 would need to ensure safety of others, the DON said it was discussed in Quality Assurance, and one to one was immediately initiated until a mental health evaluation could be conducted. On 12/4/2025 at 12:53 PM an interview was conducted with the ADM regarding the abuse on 06/12/2025. The ADM said, RI #78 was placed on one-to-one supervision until sent out to the hospital for evaluation. When asked if the facility completed an assessment to determine the level of supervision needed after the incident, the ADM said there was no. The ADM said the incident was investigated, taken to QAPI and the root cause analysis determined RI #78 was having medical issues; the ADM said, RI #78's medications were administered, if RI #78 becomes upset they try to anticipate needs, modify the environment; monitor and report any danger to others, psychiatric consults as needed, keep in an area of high traffic, engage in activity, and if agitated place on one-on-one, but there was not an assessment to determine the level of supervision. The ADM was asked about the abuse on 09/15/2025 and she said, there were no warning signs from RI #78. The Adm said the incident was investigated and taken to QAPI and the root cause analysis was performed. The ADM said they determined the root cause to be environmental, including television noise, music and overall stimulation, and therefore implemented a quiet time during meals. Review of RI #78's medical record did not reveal any interventions or actions were put in place to routinely supervise RI #78 to protect residents in the facility from being abused by RI #78.

Based on observations, interviews, and facility policies titled Procedure for Infection Control for Laundry Department, and CONTACT PRECAUTIONS, the facility failed to ensure: 1)The north hall clean linen closet was clean and free from contaminants. This deficient practice had the potential to affect one of two linen closets observed. 2) Resident's laundry was handled in a manner to prevent the spread of infection. This deficient practice had the potential to affect 129 of 129 residents in the facility. 3) A staff member implemented Enhanced Barrier Precautions as indicated when providing care to Resident Identifier (RI) #8. This deficient practice affected Resident Identifier (RI) #8, one of one resident reviewed for transmission-based precautions. Findings include: 1) On 03/24/2025 at 11:51 AM, surveyor observed north hall linen closet. Surveyor observed five used dirty gloves around the closet, used tissues on both the floor and shelves, hair tracks on the floor, and hair on three PPE gowns. On 03/24/2025 at 12:02 PM, an interview was conducted with the Infection Preventionist (IP) during an observation of the north hall linen closet. The IP stated she saw trash on the floor, linen balled up, dirty gloves, lift pads that should be in bags, pillow that need to be in bags, hair tracks, a resident's leg brace that should not be in there, gloves in the corner, and hair on gowns. The IP said she could not tell if the items were dirty or clean. The IP stated, it looked like a nightmare in there and the closet looked that way every Monday. The IP stated the concern of the linen closet being in that condition was everything was contaminated. 2) Review of an undated facility's polity titled, Procedure for infection Control for Laundry Department, revealed, . When handling clean linen, all laundry employees will: . not allow linen to touch their uniform or body . Wear gloves and gowns during separation of laundry and folding laundry . Our goal is to ensure that the facility has a consistent access to clean linen . On 03/24/2025 at 12:16 PM, surveyor observed, the Floor Tech (FT) assisting with folding residents' laundry. During the observation the FT was folding residents' personal clothing items with the clothing items contacting his body and clothing. On 03/24/2025 at 12:28 PM, an interview was conducted with the FT. He stated when folding clothes the clothing should not touch staff's body or clothing. The FT stated the concern of clean laundry touching his body or clothing was cross-contamination. On 03/25/2025 at 11:08 AM, an interview was conducted with the Housekeeping Supervisor. She stated the concern of staff allowing clean linen to come in contact with their clothing was cross-contamination. 39580 3) A review of an undated facility policy titled, CONTACT PRECAUTIONS, revealed: POLICY: Contact Precautions are a transmission based precaution that will be utilized to reduce the risk if transmission of epidemiologically important micro-organisms by direct or indirect contact . DEFINTION: . B. Enhanced Barrier Precautions expands the use of PPE (Personal Protective Equipment) beyond situations in which expose to blood or body fluids is anticipate(d), refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (Multi-Drug Resistant Bacterias) to staff hands and clothing. EQUIPMENT: 1. Door sign that reads Contact Precautions . PROCEDURE: . 3. Apply protective equipment as indicated upon entering the room . The facility's door sign for EBP stated: ENHANCED BARRIER PRECAUTIONS . STOP . PROVIDERS AND STAFF MUST ALSO: . Wear gloves and a gown for the following High-Contact Resident Care Activities. Transferring Changing Linens . RI #8 was admitted to the facility on [DATE]. RI #8 had diagnoses that included Pressure Ulcer of Right Hip, Stage 4; Pruritus; and Disorder of the Skin and Subcutaneous Tissue. A review of RI #8's physician orders revealed an order dated 01/23/2025 for . ENHANCED BARRIER PRECAUTIONS DUE TO WOUND . The orders also contained an order for wound care to be provided for . PRESSURE ULCER OF RIGHT HIP, STAGE 4 . On 03/24/2024 at 4:13 PM an observation was made of CNA #3 as she entered RI #8's room without applying a gown. RI #8's door had the facility's sign which indicated that RI #8 was on EBP. CNA #3 was observed making contact with RI #8, the bed's linen, and the bed. CNA #3 repositioned resident up in the bed and covered RI #8 with a blanket. On 03/24/2025 at 4:14 PM, an interview was conducted with CNA #3 who said that RI #8 had an EBP sign on his/her door. CNA #3 said she was only wearing gloves when she repositioned RI #8 up in the bed. CNA #3 said she would don (put on) gloves only (not a gown) if she performed perineal care or bathed RI #8 unless resident was on a certain precaution that would require her wearing more PPE. CNA #3 said RI #8 was not on any type of precautions. On 03/26/2025 at 4:24 PM, an interview was conducted with the Infection Preventionist Nurse (IPN) who said RI #8 was on EBP for his/her wound. The IPN said signage was placed on RI #8's door to alert staff that EBP was in place and so the staff would know what type of PPE should be worn. The IPN said according to the facility's policy staff should don gloves and gown when entering a resident's room with EBP to prevent the spread of germs from one resident to another and cross-contamination. The IPN said for a resident on EBP staff should wear gloves and a gown when repositioning the resident and adjusted his/her linen. The IPN said staff not wearing the appropriate PPE for residents with EBP was an infection control concern.

Based on interviews, record review, review of a facility policy titled ABUSE PREVENTION, review of a Facility Reported Incident (FRI) submitted by the facility to the State Agency, and review of the facility's investigative file, the facility failed to ensure Resident Identifier (RI) #3 and RI #4 were free from physical abuse. On 01/26/2025, Certified Nursing Assistant (CNA) was transferring RI #3 back to the room when RI #4 hit RI #3 and they got into a physical altercation. This deficient practice affected RI #3 and RI #4, two of four residents sampled for abuse. This deficiency was cited as a result of the investigation of complaint/report number AL00050195. Findings include: A review of an undated facility policy titled, ABUSE PREVENTION, revealed: POLICY: The facility is committed to protecting the residents from abuse by anyone including, but not limited to: . other residents . DEFINITIONS: a) Abuse: Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse may be resident to resident, . d) Physical Abuse: This includes but is not limited to hitting, slapping, pinching and kicking. RI #3 was admitted to the facility on [DATE] with diagnosis to include Depression, Generalized Anxiety Disorder, Adjustment Disorder with Depressed Mood, and Pseudobulbar Disorder. RI #3's Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/11/2024 indicated that RI #3 had a Brief Interview for Mental Status (BIMS) of 14 of 15 which indicated that RI #3 was cognitively intact. RI #4 was admitted to the facility on [DATE] with diagnosis to include Bipolar and Depression. RI #4's Admission MDS assessment with an ARD of 12/10/2024, indicated RI #4 had a BIMS of 11 of 15 which indicated that RI #4 was cognitively intact. On 01/26/2025 at 6:39 PM the facility submitted a FRI to the State Agency that alleged physical abuse had occurred between RI #3 and RI #4. The report indicated RI #3 going back in his/her room from the dining room. RI #4 was on RI #3's side of the room adjusting heat unit and RI #3 hit RI #4 on both forearms. A review of the facility's signed investigation summary dated 01/31/2025, documented, (CNA #4) was the only witness to the incident. (CNA #4) took (RI #3) via wheelchair to room . (RI #3) noticed that (RI #4) had a bag on (his/her) bed that had potato chips sticking out the top. (RI #3) asked if they were (his/hers) and grabbed at the bag. (RI #4) hit (RI #3) on the R (right) shoulder. (RI #3) started slapping back . CNA (#4) separated the residents and called for the charge nurse. On 03/24/2025 at 4:21 PM, an interview was conducted with RI #4 who said his/her previous roommate cursed him/her. RI #4 stated RI #3 beat him/her up with his/her good hand. RI #4 stated a nurse had to come and get RI #3 off him/her and the police had to be called. RI #4 stated after the incident he/she was moved another room. On 03/25/2025 at 5:49 PM an interview was conducted with RI #3 who stated he/she got into a fight with his/her previous roommate because the roommate was in his/her snacks. RI #3 stated the nurse stopped them. RI #3 stated the facility sent him/her out and moved RI #4. On 03/25/2025 at 4:25 PM, an interview was conducted with CNA #4. She stated the altercation happened when RI #3 noticed his/her chips hanging out of RI #4's bag. He/she asked RI #4 if he/she had his/her chips and went to take the chips when he/she was going past the bed. RI #4 hit RI #3 and RI #3 hit back. CNA #4 said she called for the nurse. On 03/26/2025 at 10:01 AM, an interview was conducted with the Administrator regarding the incident. The Administrator stated RI #3 thought RI #4 had his/her bag of chips and attempted to grab them. RI #4 hit RI #3 and they started hitting each other. The Administrator stated the facility's investigation determined the residents made contact by hitting each other on the arms. During the interview on 03/26/2025 at 10:01 AM, the Administrator stated interventions that were implemented was RI #4 was moved permanently, both residents were seen by Integrated Behavior Health (IBH), care plans were updated, RI #3's Celexa was increased due to mood changes, urinalysis was obtained for both residents, staff were educated on how to recognize behaviors that were potential dangers to others and abuse training, and monitoring of all residents behaviors for potential dangers to others. ******************* The facility implemented the following corrective actions: - 01/26/2025, RI #3 and RI #4 separated - 01/26/2025, Body audits of both RI #3 and RI #4, No injury noted. - 01/26/,2025, RI #3 sent out to emergency room for psych evaluation. resident returned to facility no new orders. - 01/26/2025, RI #3 placed on 1:1 until seen by Integrated Behavior Health (IBH). - 01/26/2025, RI #4 room change - 01/26/2025, Medical Doctor and Representatives notified. - 01/26/2025 Emergency QAPI - 01/27/2025, RI #3 Urinalysis completed -Negative - 01/28/2025, RI #4 Urinalysis completed -Positive for UTI, Nitrofurantoin 100 mg ordered. - 01/27/2025- 02/07/2025, employee training on Recognizing and reporting Behaviors that may cause inappropriate resident to resident interactions/Abuse Prevention. - 01/27/2025, RI #3 and RI #4 care plans updated to include Resident Physically aggressive to peers. - 01/30/2025, RI #3 and RI #4 seen by IBH - 01/27/2025, Audits of Behavior Monitoring sheets for 5 weeks by social service. Administrator will review for completeness and accuracy. ************************* Upon review of the facility's corrective actions, it was determined the facility implemented changes with newly developed and ongoing monitoring to effectively prevent re-occurrence following the incident of resident-on-resident abuse that occurred on 01/26/2025. The facility is in compliance with F600. Correction date 02/07/2025.

Based on interviews, medical record review and review of a facility policy titled, Behavior Management and Psychopharmacological Medication Monitoring Protocol, review of Facility Reported Incidents (FRIs) received by the Alabama State Survey Agency, and review of the facility's investigative file, the facility failed to ensure appropriate interventions were developed to manage Resident Identifier (RI) #2's wandering behaviors and ensure residents' safety. This deficient practice affected RI #2, one of four residents sampled for behaviors. This deficiency was cited as a result of the investigation of complaint/report number AL00049492. Findings include: A review of the Facility's policy titled, Behavior Management and Psychopharmacological Medication Monitoring Protocol, with a date of revision date of 2/25, documented, . PURPOSE: Residents with behaviors that are displayed routinely, that effect the resident's psychosocial well-being or that of other residents, or behaviors that can have potential for harm to self or others will be assessed with the development of a behavior program. DEFINITIONS: . Behavioral Interventions are the individualized non-pharmacological approaches to care that are provided as part of a supportive physical and psychosocial environment, and are directed toward understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities as well as maintaining or improving a resident's mental, physical or psychosocial well-being. PROCEDURE: . 2. Established resident with new onset of adverse behaviors: . f) The Interdisciplinary Care team will update the care plan to include problem behavior, goals and approaches . RI #1's Minimum Data Set (MDS) assessment with an Annual Reference Date (ARD) of 01/21/2025 indicated RI #1 had a Brief Interview for Mental Status (BIMS) of 11 of 15 which indicated that RI #1 had intact cognition. RI #2 was admitted to the facility on [DATE] with diagnosis to include Dementia without Behaviors, Alzheimer's Disease with late onset, Adjustment Disorder with Anxiety, and Mood Disorder due to Physiological Condition with Depressive Features. RI #2's Quarterly MDS assessment with an ARD of 08/21/2024 indicated RI #2 had a BIMS of 2 of 15 which indicated that RI #2 had severely impaired cognition. A review of RI #2's care plan documented Focus Resident has behavior wandering into other resident's room . Date Initiated: 09/17/2024 . Goal The resident's safety will be maintained through the review date. Date Initiated: 09/17/2024 . Interventions . Monitor resident behavior and document. Date Initiated: 09/17/2024 . The facility's signed investigative summary dated 11/06/2024 documented, (CNA (Certified Nursing Assistant) #4) stated (RI #1) was yelling. She entered the room and noted (RI #2) standing to the right side and near the head of (RI #1)'s bed. (RI #1) stated that (RI #2) had entered (his/her) room from the bathroom. (RI #1) stated (he/she) had been yelling at (RI #2) to go back the other way and that (RI #2) had slapped (him/her) on the forehead. (RI #2 and RI #1's room) share a bathroom. (RI #2) had entered (RI #1)'s room after using the bathroom. (RI #2) immediately did not remember the incident. (RI #1) stated (he/she) yelled and pushed against (RI #2) to prevent (RI #2) from getting in (his/her) bed. (RI #1) also stated that (he/she) did not think (RI #2) meant to hit (him/her) forehead, that (RI #2) might have stumbled as (RI #1) pushed (his/her) hand away. A review of Investigative File, included a witness statement from RI #1. The statement was dated for 10/31/2024 at 10:05 AM. The statement documented, Q: can you tell me what happened last night? A: yes, . did not mean any harm. (He/she) came out of the bathroom the wrong way and tried to get in bed with me. I tried to push (him/her) away and (he/she) slapped me. (He/she) did not mean any harm though. On 03/24/2025 at 4:10 PM, an interview was conducted with RI #1. RI #1 stated he/she never had a problem with another resident while at the facility and if he/she did, RI #1 would tell the Administrator. RI #1 said he/she had never been hit by another resident. An interview was conducted with Licensed Practical Nurse (LPN) #5 on 03/25/2025 at 3:06 PM. LPN #5 stated she recalled RI #2 had two episodes of wandering into other residents' room. The one incident with RI #1 and another one about six weeks before that one. LPN #5 stated the night RI #2 wandered into RI #1's room, she was called to assist. LPN #5 stated she separated the two and conducted an assessment. LPN #5 said RI #2 was confused wandered into RI #1's room thinking that was his/her bed and tried to get in the bed. LPN #5 stated interventions implemented after the incident were observing resident more frequently and taking resident to the bathroom. An interview was conducted with CNA #4 on 03/25/2025 at 4:25 PM. CNA #4 stated RI #2 got confused a lot. CNA #4 stated the bathroom doors confused him/her. CNA #4 stated RI #2 would go in one door and go out the other door. CNA #4 stated when she got in the room RI #2 was standing over RI #1. CNA #4 stated she explained to RI #2 that he/she walked into the wrong room and took RI #2 back into his/her room and put to bed. CNA #4 stated the incident was reported to charge nurse then Administrator. On 03/26/2025 at 10:01 AM an interview was conducted with the Administrator regarding the incident. The Administrator said that RI #2 had entered the room and RI #1 told RI #2 to get out. The Administrator said staff heard the yelling and the residents were separated and assessed no injury noted. The Administrator stated RI #2 had previous wandering behaviors and had to be redirected back to his/her room. The last incident of wandering was documented on 09/17/2024. When asked if the interventions implemented on 09/17/2024 were effective, the Administrator stated not necessarily, that was why the facility had a Plan Do Study Act (PDSA). When asked how was the facility was monitoring RI #2, the Administrator stated staff just keeping a closer eye on RI #2 and watching where he/she was going. The Administrator stated, it was a concern when residents with behaviors that had a potential to harm to other residents were not monitored which could lead to incidents of abuse. *************************** The facility implemented the following corrective actions: 10/30/2024 - Residents immediately separated. RI #2 assisted back to his/her room. One-on-One supervision provided until assessed by Integrated Behavioral Health (IBH) assessed on 10/31/2024. 10/30/2024 - Body Audits conducted revealed no injuries. 10/30/2024 - MD notified. RI #1 assessed, and he/she felt safe. 10/31/2024 -Investigation started 10/31/2024- Stop sign place on RI #1's door and RI #2's name placed on their door (inside bathroom). 10/31/2024 -Trauma assessment for RI #2 10/31/2024-Behavior meeting regarding RI #2 with care plan updates. Labs completed. RI #2 positive for Urinary Tract Infection; treatment started. 10/31/2024- QAPI reviewed incident and response. Plan Do Study Act. Behavior Monitoring and Intervention Report Audit by Social Services/ADM/Nurse Management 5 times per week for 2 weeks, 3 times a week for 2 weeks, and then weekly. ADM monitor audits. Any behaviors noted on the audit to have the potential to harm ither resident will be reported to the ADM and Interdisciplinary team to determine interventions needed. QAPI will review November, December, and January 2025 for monitoring. 11/10/2024 - Education completed with all staff on Behavior Policy to include that all behaviors were potentially harmful to other residents should have immediate intervention. 11/10/2024- Education completed with all staff on Abuse Policy ************************ Upon review of the facility's corrective actions, it was determined the facility had implemented corrective actions from 10/30/2024 through 11/10/2024 with newly developed and ongoing monitoring to effectively prevent re-occurrence. The facility is in compliance with F740.

Based on observations, interviews, and resident record review, the facility failed to ensure Resident Identifier (RI) #26's nebulizer mask was in a storage bag and dated. This affected RI #26, one of two residents sampled for Respiratory Care. Findings include: RI #26 was admitted to the facility on [DATE] with diagnoses to include: Chronic Obstructive Pulmonary Disease. RI #26's June 2024 Electronic Medication Record documented Albuterol 2.5 mg (milligrams)0.5 ml (milliliters) could be given every six hours as needed. On 06/23/2024 at 3:40 PM RI #26 was observed with the nebulizer at the bedside not covered, and no date on the tubing. On 06/24/2024 at 11:12 AM RI #26's nebulizer was observed at the bedside uncovered and no date on the tubing. On 06/24/2024 at 5:40 PM Licensed Practical Nurse (LPN) #3 was asked about nebulizer masks and tubing. LPN #3 said, there was no date on the nebulizer tubing, it should be changed and dated on Wednesday on the 11 to 7 shift. LPN #3 said, the facility could verify the tubing was changed by dating a piece of tape and putting it around the tubing, it was to be done weekly. LPN #3 said, the mask should be covered when not in use and the cover should be dated. LPN #3 said, the concern of not dating the nebulizer tubing or storage bag was the growth of bacteria. On 06/24/2024 at 5:50 PM the Director of Nursing (DON) was asked about nebulizers and masks. The DON said, there was no date on the nebulizer tubing, and it should be changed and dated weekly every Wednesday. The DON said, the facility verified the tubing was changed by the QA (Quality Assurance) nurse checking it. The DON said, the nebulizer mask should be covered when not in use and the cover should be dated. The DON stated, the concern with the nebulizer tubing not dated was not knowing when it was last changed and the concern with the nebulizer mask not covered was germs and bacteria.

Based on interviews, record review, review of the of facility policies ABUSE PREVENTION, and HUMAN RESOURCES MANAGEMENT POLICY AND PROCEDURES and the Alabama Department of Public health's (ADPH) Online Reporting System, the facility failed to ensure Resident Identifier (RI) #1 was free from misappropriation of funds from his/her personal funds. On 05/28/2024 the facility administrator was informed by the Business Office Manager (BOM) that RI #1 reported he/she had loaned Certified Nursing Assistant (CNA) #1 $250.00, and he/she had not been paid back as intended on 05/24/2024 and that today CNA #1 had told him/her it would be June 7, 2024 before she could repay the loan. This was cited as a result of investigation of complaint/report number AL00048072, and affected one of three residents reviewed for misappropriation of resident property. Findings Include: Review of an undated facility policy ABUSE PREVENTION, documented POLICY: . The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff .DEFINITIONS: g) Misappropriation of Resident Property: The deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. Review of a facility policy HUMAN RESOURCES MANAGEMENT POLICY AND PROCEDURES with an effective date of July 1, 2003, documented POLICY: The company forbids acceptance of tips, gifts or loans from our residents or family members. Gifts are to be returned with an explanation that our policy does not permit their acceptance .Procedures .C. Employees may not purchase, offer to purchase or borrow belongings of residents or family members .E. Soliciting money from . residents . may result in disciplinary action up to and including termination. The ADPH Online Facility Report Incident dated 05/28/2024, identified . Incident Type .Other Facility Incidents . Narrative summary of Incident: . 05/28/2024 during a phone conversation with the Business Office Manager, RI #1 mentioned that he/she had loaned CNA # 1, $250.00 and that she had not paid him/her back as intended on May 24, 2004 and that today she told him/her it would be June 7, 2024 before she could repay the loan. RI #1 was admitted to the facility on [DATE] with diagnoses of Sarcopenia. RI #1 was discharged from the facility on 05/22/2024. A review of Resident #1's five (5) day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/08/2024, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14 of 15, indicating the resident was cognitively intact. On 06/10/24 at 3:40 PM during an interview with RI #1, the resident confirmed he/she lent CNA # 1 $250.00. The resident said he/she called the Business office manager on 5/28/24 and reported the incident. The resident said he/she gave a statement and received the $250.00 back on 5/28/24. The resident said he/she was trying to help the CNA out by loaning her the money and did not feel threatened when she asked him/her to borrow the money. The resident said he/she was satisfied with the outcome of the matter and was happy to have received the money back. On 06/10/24 at 4:55 PM during an interview with CNA #1, the CNA confirmed she borrowed $250.00 from RI #1. CNA #1 said the resident had asked if he/she could do anything for her so she requested to borrow $250.00. The CNA said she gave the facility $250.00 on 05/28/24 and it was returned to the resident. The CNA said she was aware borrowing money from a resident was against the facility policy and she had been trained on the policy prior to borrowing the money from RI #1. The CNA confirmed as a result of the incident she was terminated from her position at the facility effective 05/28/24. On 06/10/24 at 4:45 PM during an interview with the administrator, the administrator said she became aware of the incident involving CNA # 1 and RI # 1 on 05/28/2024. The administrator said that an investigation was started, and the incident was reported to ADPH. The administrator said the investigation revealed that CNA # 1 borrowed $250.00 from RI #1, and CNA # 1 was terminated from her position due to the incident. On 06/13/24 at 1:00PM, during an interview with the BOM, it was mentioned that the BOM had received a call from RI # 1 on 5/28/24 to discuss insurance changes following his/her discharge on 5/22/24. The BOM stated that at the conclusion of the call, RI # 1 informed her that a CNA had borrowed $250.00 and had not repaid it. The BOM reported the incident, leading to an investigation. The BOM confirmed that the facility received the $250.00 from CNA #1, and she personally visited RI # 1's residence on 05/28/24 to deliver the money, obtaining a signed receipt. The BOM noted that upon delivering the money to RI # 1, he/she appeared calm, appreciative, and satisfied with the outcome. This deficiency was cited as a result of complaint/report number AL00047985 ************************* The facility took immediate actions to correct the non-compliance and prevent reoccurrence by: - On 05/28/2024, RI # 1, a former resident who had discharged on [DATE], called the BOM to discuss his/her insurance. During the conversation, he/she mentioned that he/she had loaned CNA #1 money on 05/10/2024 and she had not paid it back on 05/24/2024. CNA # 1 told RI # 1 that it would be 06/07/2024 before it would be paid back. - A report was made to the Alabama Department of Public Health (ADPH) on 05/28/2024. - 5-day report completed and submitted to ADPH on 05/28/2024. - An A-HOC QAPI meeting was held on 05/28/2024. - Repayment of the loan was completed on 05/28/2024. - CNA #1 was terminated effective 05/28/2024. - Education for all staff, all departments was started on 05/28/24 on Tips, Gifts, Loans, and Abuse (Misappropriation). Completed 06/04/2024. - Education for residents and discussion at the next two resident council meetings (June, July) on Tips, Gifts, and Loans. (Determine if any further events have occurred). Interview residents who do not attend council meetings on 6/4, 6/13, 6/20, and after July council meeting. ongoing. - Report findings of 6/4 resident council meeting to monthly QAPI. Completed 6/7/24. - Report findings of July resident council meeting to monthly QAPI in July. Dates to be determined, Ongoing. - Compliance has been met no further concerns identified. ************************* After review of documentation supporting the above corrective actions, including the facility's investigation file, and in-service/education records, the surveyor verified the facility implemented corrective actions including monitoring that began 05/28/2024, thus F602 was cited at past non-compliance.

Based on observations, interviews, residents' record review, the Center for Disease Control (CDC) Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, and facility policies titled, Standard Precautions and ENTERAL TUBE MEDICATION ADMINISTRATION PROCEDURES the facility failed to ensure: 1) a Registered Nurse (RN) used technique to prevent contamination while preparing and administering medications to Resident Identifier (RI) #24 and RI #44; 2) an RN followed Standard Precautions when she picked up an alcohol swab with blood on it without wearing gloves; 3) a Licensed Practical Nurse (LPN) did not create the potential for cross-contamination during medication pass when she did not perform hand hygiene after removing gloves, after assisting a resident to remove their shoes and before putting on new gloves to administer medication through RI #61's gastric tube, after providing resident care including the administration of medication through RI #61's gastric tube, and before preparing and administering medication for RI #82; 4) an LPN did not remove gloves from her uniform pocket, put on the gloves, and then provide resident care; 5) an LPN cleaned her stethoscope after wearing it on her neck and before using the stethoscope to verify placement of RI #61's gastric tube; the LPN did not clean the stethoscope after use and before putting back on her neck, and 6) an LPN disposed of a Personal Protective Equipment (PPE) gown before exiting RI #61's room after she wore the gown while administering medication through RI #61's gastric tube. These deficient practices were observed on two of two facility units and had the potential to affect residents who received medication from two of five medication carts in the facility. Findings Include: The facility policy titled, Standard Precautions, dated 09/2019 documented: POLICY: Standard Precautions will be utilized to provide a primary strategy for the prevention of healthcare-associated infections (HAI) agents among patients and healthcare personnel.DEFINITION: Standard Precautions applies to all persons regardless of their diagnosis or presumed infectious status. Standard Precautions applies to blood . PROCEDURE: . 2. Wash hands when visibly soiled, after contact with . body fluids, secretions, excretions, patient's intact skin . and contaminated items immediately after removing gloves and between patient contacts . Wear gloves when touching blood, body fluids, secretions, excretions, contaminated items with mucus membranes and non-intact skin. If hands move from a contaminated site to a clean body site during care, wash hands .or alcohol based hand rub. Wash hands before direct contact with patients . 5. Handle soiled patient care equipment in a manner that prevents transfer of microorganisms to others and to the environment; wear gloves if visibly contaminated; perform hand hygiene . The CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings with a revised date of 11/29/2022 documented: Introduction Adherence to infection prevention and control practices is essential to providing safe and high quality patient care across all settings where healthcare is delivered . Scope The core practices in this document should be implemented in all setting where healthcare is delivered. These venues include . long-term care . Core Practice Category . Standard Precautions . Core Practices . Use Standard Precautions to care for all patients in all settings. Standard Precautions include: . 5a . Hand Hygiene . 5c . Medication Safety . 5d. Risk Assessment with Appropriate Use of Personal Protective Equipment . Comments . Standard Precautions are the basic practices that apply to all patient care, regardless of the patient's suspected or confirmed infectious state, and apply to all settings where care is delivered. These practices protect healthcare personnel and prevent healthcare personnel or the environment from transmitting infections to other residents . Core Practice Category . 5a . Hand Hygiene . Core Practices . 1. Require healthcare personnel to perform hand hygiene in accordance with Centers for Disease Control and Prevention (CDC) recommendations. 2. Use an alcohol-based hand rub or wash with soap and water for the following clinical conditions: a. Immediately before touching a patient . d. After touching a patient or the patient's immediate environment . f. Immediately after glove removal . . Core Practice Category . 5c . Medication Safety . Core Practices . 2. Use aseptic technique when preparing and administering medications . . Core Practice Category . 5d. Risk Assessment with Appropriate Use of Personal Protective Equipment . Core Practices . d. Remove and discard PPE, other than respirators, upon completing a task before leaving the patient's room or care area. e. Remove and discard disposable gloves upon completion of a task . The facility policy titled ENTERAL TUBE MEDICATION ADMINISTRATION PROCEDURES dated 06/2023 documented: POLICY: To safely and accurately administer oral medications through an enteral tube. PROCEDURE: . 3. Prepare medications for administration . 5. Wash hands and apply gloves . 6. Verify placement . 8. Administer each medication . 15. Wash hands as per facility policy. RI #24 was admitted to the facility 11/18/2013 and readmitted [DATE]. RI #44 was admitted to the facility 12/05/2017. On 01/24/2024 at 10:47 AM during a medication pass observation RN #3 was observed entering RI #24's room with blood glucose assessement equipment on a plastic medication tray. RN #3 placed the medication tray on RI #24's bedside table. While checking RI #24's blood glucose, RN #3 used a lancet to prick RI #24's little finger and then used an alcohol pad to wipe blood from RI #24's little finger. RN #3 put the blood-tinged alcohol swab on the plastic medication tray. On 01/24/2024 at 10:50 AM, RN #3 exited RI #24's room with the plastic tray with the blood-tinged alcohol pad on the tray. RN #3 put the medication tray on top of the medication cart without using a barrier to prevent cross-contamination. RN #3 used her bare hand to discard the blood-tinged alcohol pad. RN #3 did not clean the medication cart. RN #3 performed hand hygiene and began using the medication cart to prepare medications for RI #44. On 10/24/2024 at 10:55 AM RN #3 administered the prepared medications to RI #44. On 01/24/2024 at 10:57 AM an interview was conducted with RN #3. The RN said that she did not use a barrier between the contaminated medication tray and medication cart. RN #3 stated that she did not wear gloves when she picked up the bloody alcohol pad because she just did not think about it. RN #3 stated that she did not clean the medication cart top before pulling the medications for RI #44. RN #3 said there was risk for contamination when she placed the contaminated medication tray on the medication cart and did not clean the medication cart before preparing the next resident's medications. RN #3 stated that there was risk for blood exposure when she did not use gloves to handle the used alcohol pad. On 01/25/2024 at 8:45 AM an interview was conducted with LPN #2, the Infection Preventionist (IP). The IP stated there should have been a barrier placed on top of the medication cart before placing the contaminated items on it. The IP said the top of the cart should have been cleaned after a contaminated item was placed on the cart. The IP said that RN #3 should have donned (put on) gloves before picking up the blood-tinged alcohol pad. The IP said not using gloves to handle the blood-tinged alcohol pad created a potential for cross-contamination. RI #61 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Gastrostomy Status. RI #61's Physician Orders for the month of January 2024 documented an order for enhanced barrier precautions due to feeding tube. RI #82 was admitted to the facility 04/13/2021. On 01/24/2024 at 4:57 PM, LPN #6 was observed during medication pass. LPN #6 put on gloves, retrieved the medication, and then removed her gloves. LPN #6 did not perform hand hygiene after removing her gloves. LPN #6 entered RI #61's room and without performing hand hygiene, she assisted RI #61 to the bed and removed RI #61's jacket and shoes. LPN #6 pulled gloves from her uniform pocket and put on the gloves. LPN #6 removed her stethoscope from around her neck and then checked placement of the tube. LPN #6 added water to the medication with same gloves, adjusted her Personal Protective Equipment (PPE) gown, and then administered the medication through the resident's tube. LPN #6 removed her gloves, and did not perform hand hygiene. LPN #6 discarded the trash, placed the stethoscope back around her neck (without cleaning it), attached the call light, placed the wheelchair beside the bed, and exited the room while wearing the PPE gown. LPN #6 went to the medication cart, removed the PPE gown, and held the gown under her arm. LPN #6 took gown to the nurses' station and discarded the gown in the trash. LPN #6 documented the medications as administered on the Medication Administration Record (MAR). At 5:21 PM LPN #6 began preparing RI #82's medication without performing hand hygiene. LPN #6 handled the mouse for the computer, prepared the medication for RI #82, locked the medication cart, entered RI #82's room, and administered the medication to RI #82. On 01/24/2024 at 5:26 PM an interview was conducted with LPN #6. LPN #6 said she should have washed her hands before and after every resident and between some tasks. LPN #6 said she did not change gloves or wash her hands when she gave medication to RI #61. LPN #6 said she should have washed her hands when she first started and each time she removed her gloves. LPN #6 said when she did put on gloves, she took the gloves from her pocket and her pockets were not clean. LPN #6 said the concern in her not washing her hands between tasks was contamination, and the spread of infection. LPN #6 said the concern in not washing her hands between residents was contamination. LPN #6 said she should have cleaned the stethoscope after each use, and she did not clean it. LPN #6 said she used the stethoscope, laid it the on the bed, and then put it back around her neck. LPN #6 said not cleaning the stethoscope was possible contamination if used on another resident. LPN #6 said she should have removed the PPE gown in the resident's room and then washed her hands. LPN #6 said she did not wash her hands after removing the PPE gown and gloves. LPN #6 said she did not perform hand hygiene before preparing RI #82's medication. LPN #6 said going from one resident to another during the medication pass without washing or sanitizing her hands was contamination and possibly spreading infection. On 01/25/2024 at 8:35 AM during an interview with the IP, she said staff/nurse should wash or sanitize their hands before and after each resident. The IP nurse said if the nurse touched something other than the medication while on the medication pass, they should wash or sanitize again before administering the medication. She said they should wash or sanitize their hands before signing off the medication on the MAR. The IP nurse said when giving medications by tube the nurse should wash their hands before preparing the medication and before administering the medication. The IP said the nurse should have performed hand hygiene before putting on gloves. The IP said if the nurse touched something other than the medication, they would need to remove their gloves, perform hand hygiene, and put on new gloves. The IP said the nurse should have removed the gown before exiting the resident's room, discarded it in the trash in the room, and then washed her hands. The IP nurse said LPN #6 should have put on gloves once she was in the room and could have placed some gloves on the barrier. The IP said LPN #6 should have assisted the resident, washed her hands, and put on the gloves. The IP nurse said nurses should never use gloves from their uniform pockets, because pockets were dirty. The IP nurse said LPN #6 should have cleaned the stethoscope after each use to prevent cross-contamination. The IP nurse said the concern with LPN #6 not washing her hands between the tasks and residents was cross-contamination. The IP nurse said LPN #6 should have washed or sanitized her hands after finishing with RI #61 medication administration and before starting RI #82's medication administration. She said the concern with going from one resident to another without washing or sanitizing her hands was cross-contamination. 33739

Based on observations, interviews, record review and review of RESIDENT BILL OF RIGHTS, the facility failed to accommodate the needs of Resident Identifier (RI) #103 by failing to ensure the call light was accessible on three of four days of the survey. This affected RI #103, one of 25 sampled residents. Findings Include: Review of RESIDENT BILL OF RIGHTS, dated 01/2023, documented: . Facility residents shall have the right to: . 10. Reside and receive services in the facility with reasonable accommodation of resident needs and preferences . RI #103 was admitted to the facility on [DATE] with a diagnosis to include Spastic Quadriplegic Cerebral Palsy. On 01/22/2024 at 3:47 PM, during initial tour surveyor observed RI #103 sitting in a Geri-chair (Geriatric Chair) while the call light was behind RI #103 on the side of the bed. The call light was not in reach. On 01/23/2024 at 5:01 PM, surveyor observed RI #103 sitting up in the bed while the call light was laying across the nightstand in the corner of the room. The call light was not in reach. On 01/24/2024 at 12:21 PM, surveyor observed RI #103 sitting in the Geri-chair, watching television while the call light was behind RI #103 on the nightstand. The call light was not in reach. On 01/24/2024 at 3:56 PM, an interview was conducted with Registered Nurse (RN) #3. RN #3 accompanied the surveyor to RI #103's room. RN #3 was asked where was RI #103's call light located. RN #3 stated it was on RI #103's nightstand. RN #3 said the call light should have been within RI #103's reach. On 01/25/2024 at 8:06 AM, an interview was conducted with the Director of Nursing (DON). The DON stated RI #103's call light should have been in reach. The DON said that all nursing staff were responsible for making sure call lights were within reach of residents.

Based on observations, interviews, record review, and the facility policy titled FINGERNAILS/TOENAILS CARE the facility failed to provide assistance with activities of daily living (ADLs) to ensure good grooming for a dependent resident, Resident Identifier (RI) #73. Specifically, the facility failed to ensure RI #73's fingernails were clean. This affected one of 25 sampled residents. Findings include: The facility's policy titled FINGERNAILS/TOENAILS CARE dated 10/2009 documented: . The purpose of this procedure is to clean the nail bed, to keep nails trimmed and to prevent infections . Nails can be partially cleaned during bath care . Nail care includes daily cleaning and regular trimming . The condition of the resident's nails and nail bed is to be reported to the charge nurse . RI #73 was readmitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease and Type Two Diabetes Mellitus. A review of RI #73's most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/05/2023 documented a Brief Interview of Mental Status (BIMS) score of seven of 15, which indicated the resident had severe cognitive impairment. According to the MDS RI #73 required substantial/maximal assistance with personal hygiene. A review of RI # 73's care plan documented .Resident requires setup to total assistance with ADL's .Nail care on shower days . On 01/23/2024 at 9:53 AM, RI #73 was observed lying in bed. The condition of his/her fingernails was discolored and unclean. On 01/24/2024 2:35 PM, RI #73 was observed lying in bed. His/her fingernails appeared discolored and unclean, with a brown substance observed underneath the nails. On 01/25/2024 10:59 AM, RI #73 was observed in bed. His/her fingernails appeared discolored and unclean, with an unknown brown substance observed underneath the nails. On 01/24/2024 at 2:48 PM, an interview was conducted with Licensed Practical Nurse (LPN) #7. During the interview, LPN #7 was asked about RI #73's ability to perform his/her own nail care. LPN #7 said he/she was unable due to advanced dementia. LPN #7 was uncertain of the last time nail care was performed for RI #73. Upon observing RI #73's nails, LPN #7 said it looked like nail care had not been recently performed. LPN #7 described RI #73's nails as long, broken, and appearing unclean. LPN #7 said that neglecting nail care for dependent residents could result in unclean nails. On 01/25/2024 at 10:42 AM, an interview was conducted with the Director of Nursing (DON). During the interview, the DON said that nail care for residents should be performed as needed. When questioned about RI # 73, the DON said he/she refused to allow nurses to cut his/her nails. Additionally, the DON said that if a resident refused nail care, their nails should still be maintained clean by washing their hands and cleaning underneath the nails to the extent the resident allowed.

Based on observations, interviews, resident record review, and the facility policy titled Oxygen Therapy, the facility failed to ensure Resident Identifier (RI) #11 received oxygen (O2) at the physician prescribed rate of two liters per minute (2 l/m). On 01/22/2024 and 01/23/2024, RI #11 was observed receiving O2 at a rate of four (4) l/m. This affected one of one resident sampled for respiratory care. Findings Include: Review of facility policy titled Oxygen Therapy dated 08/2014, documented: Policy: Oxygen (O2) is administered to promote adequate oxygenation and provide relief of symptoms of respiratory distress . PROCEDURE: 1. Oxygen therapy is to be provided under the direction of a written physicians order. 4. Adjust delivery rate as ordered. RI #11 was admitted to the facility 08/14/2014 and readmitted on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Review of RI #11's Physician Orders for January 2024 documented an as needed oxygen order dated 05/31/2023 . O2 AT 2 LITERS/MIN (minute) VIA (by) NASAL CANNULA AS NEEDED FOR SHORTNESS OF BREATH . On 01/22/2024 at 4:48 PM, the surveyor observed RI #11's oxygen infusing by nasal cannula at a rate of four liters per minute. On 01/23/2024 at 8:18 AM, the surveyor observed RI #11's oxygen (O2) infusing per nasal cannula at a rate of four liters per minute. On 01/23/2024 at 3:35 PM, the surveyor observed RI #11's O2 infusing per nasal cannula at four liters per minute. LPN #4 entered the room and the surveyor asked her if RI #11 was receiving O2. LPN #4 said yes. On 01/23/2024 at 3:36 PM, LPN #4 was asked to observe RI #11's oxygen. LPN #4 said it was infusing per nasal cannula at four liters per minute. LPN #4 reviewed the January 2024 physician orders and told the surveyor the oxygen orders indicated the rate of flow should be two liters per minute. On 01/23/2024 at 3:40 PM, LPN #5, the Unit Manager entered RI #11's room. LPN #5 checked the rate of flow and said it almost four liters per minute by nasal cannula. On 01/23/2024 at 3:47 PM an interview was conducted with LPN #5. She said RI #11's oxygen should be infusing at two liters per minute. LPN #5 said it was not infusing at the two liters per minute. LPN #5 said it was the responsibility of the nurse working the hall to verify, regulate, and make sure it was infusing at the ordered rate. LPN #5 said the concern with the oxygen not infusing at the physician ordered rate was the resident could be getting too much oxygen. LPN #5 said the policy for oxygen administration each shift should check to ensure the oxygen was on, the machine was functioning properly, and check if it was infusing at the prescribed rate.

Based on observation, interview, the facility policies for Menu Planning and Requirements and Menu Substitutions or Changes and Approval, and the facility menus and production sheets for Spring/Summer (S/S) 2023 Menu, Week 1, Day 2 and Day 3; the following menu discrepancies were observed: Four ounces of Chicken & Dumplings instead of six ounces were served to residents on Regular diets for Supper on Monday, 08/14/2023. The Puree Diet menu for the Supper meal on Monday, 08/14/2023 for the S/S 2023 Menu, Week 1, Day 2 listed Seasoned Spinach for the vegetable, not Pureed Spinach. The production sheet for that meal also listed Seasoned Spinach, not Pureed Spinach, Capri Vegetables were served instead of Green Beans for Lunch on Tuesday, 08/15/2023 for residents on Regular, Mechanical Soft, and Puree diets. The production sheet for that meal did not match the S/S 2023 Menu for Week 1, Day 3 and, instead of Green Beans, it listed Capri Vegetables to be prepared for the Regular, Mechanical Soft, and Puree diets. Sweet Potato Tots/Puffs were not prepared to be served to residents on the Finger Food diet for Lunch on Tuesday, 08/15/2023 as listed on the S/S 2023 Menu for Week 1, Day 3, although they were in the facility's freezer. This had the potential to affect 122 of 122 residents receiving meals from the facility's kitchen. Findings Include: The facility policy for Menu Planning and Requirements dated 2016, documented the following: Guideline: Menus are planned to provide nourishing, palatable, attractive meals that meet the nutritional needs of residents served, (based on age, size, gender, physical activity and state of health), in accordance with the Dietary Reference Intakes/Recommended Dietary Allowances as issued by the Food and Nutrition Board of the National Research Council, of the National Academy of Sciences, unless otherwise contraindicated by medical conditions and needs. Procedure: . 2. Menus are planned in . (advance) . The facility policy for Menu Substitutions or Changes and Approval dated 2016, documented the following: Guideline: Substitutions, whether a one-time substitution or a permanent menu change are recorded using a facility specific document. The registered dietitian (RD) periodically reviews the documented menu substitutions or menu changes for nutritional equivalency and appropriateness. Procedure: . 4. b. When making permanent changes to the menu, the appropriate spreadsheets are also modified or new spread sheets are created and approved by the registered dietitian for those days reflecting the permanent menu changes. The S/S 2023 Menu, Week 1, Day 2 was identified as the menu for Monday, 08/14/2023. The following observations were made of the Supper trayline on Monday, 08/14/2023, from 5:24 PM to 5:59 PM: At 5:24 PM, trayline was ongoing with four staff members performing the assembly of resident trays and loading the third of seven delivery carts. One aide set-up the trays with beverages and cold food at the start of the trayline. Employee Identifier (EI) #11, the PM Cook, and EI #12, the Dietary Manager, were serving hot food items from the steamtable onto plates. Another aide loaded trays onto the delivery carts. A fifth staff member, EI #7, the Dietary Supervisor, acted as a runner to replenish and assist the trayline. At 5:37 PM, Chicken and Dumplings was being served as the main entree with a 4-ounce spoodle. Also on the steamtable was an empty pan the steamed spinach had been served from, which EI #12 said, was empty because they ran out of spinach. At 5:59 PM, the last of seven delivery carts left the kitchen with resident supper trays. At 6:03 PM, the sizes of the serving utensils being used on the trayline for supper were verified with EI #12, the Dietary Manager. On 08/14/2023 at 6:30 PM, EI #11, the PM Cook, was interviewed. EI #11 said he knew what to prepare and how much to serve by looking at the Menu Book. When asked what happened with the spinach; EI #11 said there were only five bags in the freezer and he usually needs 10 to 12 bags, so it was not enough. EI #11 said a 4-ounce or a 6-ounce spoodle would be the correct serving size for Chicken and Dumplings. Upon being asked how he would know which spoodle size to use, EI #11 said it was in the book (Menu Book). EI #11 opened the Menu Book that was located in the trayline area. EI #11's review of the Menu Book revealed the serving size for Chicken and Dumplings was a 6-ounce spoodle. EI #11 said when they were low, they go down a size. EI #11 further said they did not have enough Chicken & Dumplings, so he used a 4-ounce spoodle so everybody could have some. The Menu Book for Monday Supper, S/S 2023 Menu, Week 1, Day 2 also revealed that the extended menu listed Seasoned Spinach, not Pureed Seasoned Spinach, on the Pureed Diet. Also the production sheet called for Seasoned Spinach, but not for any Pureed Seasoned Spinach. EI #11 said normally the Pureed Diet vegetable would be spinach, but pureed broccoli was used because there was not enough spinach. The S/S 2023 Menu, Week 1, Day 3 was identified as the menu for Tuesday, 08/15/2023. The Regular Diet for Lunch on the S/S 2023 Menu, Week 1, Day 3 listed the following: Roasted Turkey Breast, Gravy, Baked Fresh Sweet Potato, Green Beans. Fruit Crisp, and Cornbread. The Alternate Regular Diet for Lunch on the S/S 2023 Menu, Week 1, Day 3 listed the following: Baked Pork Chop, Loaded Mashed Potatoes, and Green Beans. The Finger Food Diet for Lunch on the S/S 2023 Menu, Week 1, Day 3 listed the following: Roast Turkey Strips, Sweet Potato Tots, Green Beans, Seasonal Fresh Fruit, and Cornbread. The Production Sheet for Lunch on Tuesday, 08/15/2023 included the following: Sweet Potato Tots (finger food), Capri Vegetables, Pureed Capri Vegetables, Sliced Potatoes (alternate finger food), Green Beans (alternate), Pureed Green Beans (alternate). The following observations were made of the Lunch trayline on Tuesday, 08/15/2023, from 12:23 PM to 12:46 PM: At 12:23 PM, trayline was ongoing. The items on the steamtable included Sliced Turkey, Capri Vegetables, Baked Sweet Potatoes, Cornbread, Ground Turkey, Pureed Turkey, Loaded Mashed Potatoes, and Pureed Capri Vegetables. At 12:46 PM, the items on the steamtable were verified with EI #11, the AM Cook, Additional modified and alternate menu items in the trayline area included: Turkey Strips, Pork Chop Strips, Green Beans, Mashed Sweet Potatoes, and Wedge Potato Fries. In addition, the Steamer contained a pan of Pork Chops. At 12:55 PM, EI #11 said no Pureed String Beans were prepared for lunch. At 12:56 PM, EI #7, the Dietary Supervisor, verified that the Wedge Potato Fries in were not made from Sweet Potatoes. EI #7 went into the Walk-in Freezer and pointed out the box of Sweet Potato Puffs. On 08/16/2023 at 9:33 AM, EI #12, the Dietary Manager, was interviewed. EI #12 said, she had only worked at the facility for three weeks. EI #12 said, she assumed the RD for the facility prepared the Spring/Summer 2023 Menu and the corresponding Production Sheet for the menu. EI #12 further said, the information was printed from a computer program. When asked how the facility ensured the diet served to the residents was nutritionally adequate, EI #12 said, by following the diet orders and reading the meal tickets for the residents. EI #12 said, six ounces of Chicken & Dumplings should have been served to the Regular diets at supper on Monday, 08/14/2023 for the S/S 2023 Menu, Week 1, Day 2. EI #12 said, four ounces was not the correct portion size. EI #12 further stated, if the residents did not get the accurate amount of nutrients, they could lose weight. Upon being asked the concern for Pureed Spinach not being listed on either the Pureed Diet menu or on the production sheet for Monday Supper, S/S 2023 Menu, Week 1, Day 2 on 08/14/2023; EI #12 said, the residents might not get the correct texture modification for spinach. When asked the concern for Sweet Potato Tots/Puffs not being served on the Finger Food diets at Tuesday Lunch, S/S 2023 Menu, Week 1, Day 3 on 08/15/2023; EI #12 said, if they offered something on the menu, they should get it. EI #12 did not know why Capri Vegetables were listed on the Production Sheet for the Regular, Mechanical Soft, and Pureed diets when the Tuesday Lunch, S/S 2023 Menu, Week 1, Day 3 for 08/15/2023 identified Green Beans for the Regular, Mechanical Soft, and Pureed diets. EI #12 said, communication was the problem when items on the Production Sheet did not match the items on the approved menu. EI #12 further stated, the staff prepared and cooked something else, other than what was on the menu. On 08/16/2023 at 9:56 AM, EI #7, the Dietary Supervisor, was interviewed. EI #7 said, she had worked at the facility for about five months. When asked who prepared the Spring/Summer 2023 Menu for the facility, EI #7 said, they got those menus from (name of EI #9), the training/regional RD for the facility's corporation. EI #7 further stated, EI #10 was the new RD consultant. It was EI #7's understanding that the production sheets and menus all came from the facility's corporation. When asked how the facility ensured the diet served to the residents was nutritionally adequate, EI #7 said, they had people on different diets and textures; they follow the menu. EI #7 said, a 6-ounce spoodle of Chicken & Dumplings should have been served for the Regular diets at supper on Monday, 08/14/2023 for the S/S 2023 Menu, Week 1, Day 2. EI #7 said, a 4-ounce spoodle being used to serve the Chicken and Dumplings was a problem, the person was not getting the proper serving size. Upon being asked the concern for Pureed Spinach not being listed on either the Pureed Diet menu or on the production sheet for Monday Supper, S/S 2023 Menu, Week 1, Day 2 on 08/14/2023; EI #7 said, if staff were following the menu as they should, Seasoned Spinach would be served to the Pureed diets and pureed spinach would not be prepared. EI #7 further stated, a resident could choke. When asked why Sweet Potato Tots/Puffs were not prepared for the Finger Food diets at Tuesday Lunch, S/S 2023 Menu, Week 1, Day 3 on 08/15/2023, although they were in the freezer; EI #7 said, it should have been done, the cook did not follow the menu. When asked the concern for Sweet Potato Tots/Puffs not being served on the Finger Food diets at Tuesday Lunch, S/S 2023 Menu, Week 1, Day 3 on 08/15/2023; EI #7 said, not following the menu, because it was there. Upon being asked the problem with Capri Vegetables being listed on the Production Sheet for the Regular, Mechanical Soft, and Pureed diets on 08/15/2023 when the Tuesday Lunch, S/S 2023 Menu, Week 1, Day 3 identified Green Beans for the Regular, Mechanical Soft, and Pureed diets; EI #7 said, that was conflicting information between the production sheet and the extended menu. EI #7 further said, it could affect ordering, would result in not following the menu, and residents would get upset if the menu was not followed as posted. On 08/16/2023 at 10:25 AM, EI #1, the Administrator, said the menus were from Dining RD, not the facility's corporation. EI #1 further stated, the menus were approved by an RD. During a telephone interview on 08/16/2023 at 11:23 AM, EI #10, the facility's Registered Dietitian, said the Dining RD website prepared the Spring/Summer 2023 Menu for the facility. When asked how the facility ensured the diet served to the residents was nutritionally adequate; EI #10 said the diets were RD approved, the facility ordered from approved vendors, the staff was trained on approved cooking techniques to conserve nutrients, and the staff were trained to handle and store food properly. EI #10 did not know who prepared the Production Sheet for the Spring/Summer 2023 Menu. When asked the problem with a 4-ounce portion of Chicken and Dumplings being served for the Regular diets at supper on 08/14/2023, instead of a 6-ounce serving as listed on the S/S 2023 Menu, Week 1, Day 2; EI #10 said, the menu spread sheet was not being followed and the residents were not getting what was planned for the meal. EI #10 further stated, monitoring of the trayline and weekly weights could help catch any continuation of a problem like that. Upon being asked the concern for Pureed Spinach not being listed on either the Pureed Diet menu or on the production sheet for Monday Supper, S/S 2023 Menu, Week 1, Day 2 on 08/14/2023; EI #10 said, he thought they would still puree it. EI #10 further stated, active managerial control should be in place to assure that puree food is pureed, but it should be listed as pureed on the menu and the production sheets. When asked the problem with the items on the Production Sheet not matching the items on the approved menus; EI #10 said, that was not following the planned menus.

Based on observation, interview, the 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code, and the facility's policies for Dishwashing: Machine Operation, Proper Handwashing and Glove Use, and Handwashing; the facility failed to prevent the potential for cross contamination on 08/13/2023 when Employee Identifier (EI) #8, a PM Aide, failed to wash hands during dishwashing when going from handling dirty dishes to clean ones. This had the potential to affect 122 of 122 residents receiving meals from the facility's kitchen. Findings Include: The facility's policy for Dishwashing: Machine Operation dated 2016, documented the following: Guideline: The Food and Nutrition Services staff shall maintain the operation of the dishwashing machine according to established procedure . to ensure effective cleaning and sanitizing of all tableware and equipment used in the preparation and service of food. Procedure: . 7. Follow the procedure for proper preparation and loading of dishes into the dishwashing machine. The standard sequence is as follows: a. Scrape all dishes and remove food debris. c. Stack dishes in racks . e. Monitor that the dishwashing machine is maintaining operating guidelines for wash, rinse, and final rinse temperatures. f. Use clean, washed hands to pull out clean racks . The facility's policy for Proper Hand Washing and Glove Use dated 2016, documented the following: Guideline: All employees will use proper handwashing procedures . Procedure: . 2. The proper procedure for washing hands is as follows: a. Turn on water as hot as comfortable. b. Wet hands and apply soap. c. Scrub 15 to 20 seconds or more: getting under nails, between fingers, and all exposed areas, such as back of hands and forearms. d. Rinse hands thoroughly. e. Dry hands with paper towel or air dyer (dryer). f. Turn off faucet with paper towel. 3. All employees will wash hands . between tasks. The facility's policy for Handwashing, dated September 2019, included the following: Policy: Staff will use proper handwashing technique to prevent the spread of infection. The 2022 U.S. FDA Food Code included the following: . 1-201.10 Statement of Application and Listing of Terms. (A) The following definitions shall apply in the interpretation and application of this Code. (B) Terms Defined. Handwashing Sink. (1) Handwashing sink means a lavatory, a basin or vessel for washing, a wash basin, or a plumbing fixture especially placed for use in personal hygiene and designed for the washing of the hands. Warewashing means the cleaning and SANITIZING of UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT. 2-301.11 Clean Condition. FOOD EMPLOYEES shall keep their hands and exposed portions of their arms clean. 2-301.12 Cleaning Procedure. (A) . FOOD EMPLOYEES shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a HANDWASHING SINK . 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES . and: . (E) After handling soiled EQUIPMENT or UTENSILS; . (I) After engaging in other activities that contaminate the hands. 2-301.15 Where to Wash. FOOD EMPLOYEES shall clean their hands in a HANDWASHING SINK or APPROVED automatic handwashing facility and may not clean their hands in a sink used for FOOD preparation or WAREWASHING, or in a service sink . 4-501.16 Warewashing Sinks, Use Limitation. (A) A WAREWASHING sink may not be used for handwashing . During the initial kitchen observation on 08/13/2023 at 4:15 PM, EI #8, a PM Aide, was seen breaking down returned resident trays from a transport cart and then washing the dishes by using the dishwashing machine. EI #8 was observed loading dirty dishes onto a rack and pushing it into the dishmachine. Then shortly, EI #8 was observed walking from the dirty side of the dishmachine to the clean side of the dishmachine. EI #8 then began unloading washed trays and glasses from racks on the clean side. EI #8 was asked if there was a handwashing sink he was using around the corner. EI #8 showed how he used the sprayer, which hung over the scraping sink, to rinse off his hands. EI #8 was interviewed on 08/13/2023 at 4:38 PM. When asked if he had been instructed on the importance of washing his hands between going from the dirty side of the dishmachine to the clean side; EI #8 said, Yes. EI #8 said, germs could get on the clean dishes. Upon being asked if he had been told it was okay to use the sprayer to wash his hands, EI #8 walked over to the hand sink in the kitchen and pointed to it. On 08/16/2023 at 9:33 AM, EI #12, the Dietary Manager, was interviewed. EI #12 was asked the problem with staff going from working on the dirty side of the dishmachine to the clean side of the dishmachine without washing their hands at a hand washing sink. EI #12 said, cross contamination. During an interview on 08/16/2023 at 9:56 AM, EI #7, the Dietary Supervisor, said cross contamination was the problem with staff going from working on the dirty side of the dishmachine to the clean side without washing their hands at a hand washing sink. EI #7 further stated, they have been trained, but sometimes people did not grasp the importance. During a telephone interview on 08/16/2023 at 11:23 AM, EI #10, the Registered Dietitian said, potential for cross contamination was the concern with staff going from the dirty side of the dishmachine to the clean side without washing their hands at a hand washing sink.

Based on observations, interviews and record review, the facility failed to ensure staff did not stand while feeding Resident Identifier (RI) #63 the breakfast and lunch meals on 08/14/2023. This deficient practice affected RI #63, one of one resident observed requiring assistance at meal time. Findings Include: RI #63 was admitted to the facility on [DATE], with diagnoses to include Vascular Dementia and Alzheimer's Disease. RI #63's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/26/2023, assessed RI #63 with a Brief Interview for Mental Status (BIMS) score of three which indicated RI #63 had severely impaired cognitive skills for daily decision making; and RI #63 required one person assist with eating. On 08/14/2023 at 8:33 AM, RI #63 was observed being fed the breakfast meal by Employee Identifier (EI) #5, a Certified Nursing Assistant (CNA). EI #5 was standing while feeding RI #63 the breakfast meal. On 08/14/2023 at 12:40 PM, during lunch time, EI #5 was again observed standing while feeding RI #63. On 08/16/2023 at 10:46 AM, an interview was conducted with EI #5. The surveyor asked EI #5, when she was observed feeding RI #63 the breakfast and lunch meals on 08/14/2023, what position was she in. EI #5 said, standing. EI #5 said, she should have been sitting but there was no chair in RI #63's room. On 08/16/2023 at 12:05 PM, the surveyor conducted an interview with EI #2, the Director of Nursing (DON). When asked how staff should be positioned when feeding a resident, EI #2 said, sitting in a chair at eye level of the resident. The surveyor asked EI #2, when standing, what type concerns could that be. EI #2 said, it could be a dignity concern.

Based on interviews, review of a policy titled Quality Improvement Program, review of the facility's QAPI (Quality Assurance Process Improvement) Plan and review of the facility's 03/26/2022 MONTHLY FACILITY QA & A (Quality Assessment and Assurance) MINUTES, the facility's Quality Assurance (QA) committee failed to thoroughly review all factors related to Resident Identifier (RI) #177's fire and injuries, to determine what corrective actions needed to be taken to prevent any further resident safety concerns. On 03/26/2022, RI #177, a resident with a documented history of smoking noncompliance, was in possession of his/her smoking materials and lighter, and subsequently ignited his/her bedding and body. After staff became aware, they extinguished the flames, rendered necessary aid, and RI #177 was sent to the hospital where he/she was found to have 3rd degree [CONDITION(S)] covering 10-19% of his/her body. This failure placed all remaining residents in the facility at risk for immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment, or death. The facility Form CMS-672 listed a facility census of 129 at the time of the survey. On 04/14/2022 at 7:05 PM, the facility's Administrator (Employee Identifier (EI) #1); the Vice President of the facility's management company/member of the Governing Body (EI #2); the facility's Director of Nursing (EI #5); and a Human Resources Representative (EI #43) were given a copy of the Immediate Jeopardy (IJ) template and were notified of the findings of IJ in the area of Quality Assurance and Process Improvement, F867. Findings include: Review of a policy titled Quality Improvement Program, dated 02/2018, revealed the following: POLICY: The Quality Improvement Committee will assess and monitor the quality of services provided to the residents in the facility in order to identify potential problems and/or opportunities for improvement. The committee will implement and systematically evaluate programs and processes to identified problems in order to proactively improve health care delivery. OBJECTIVE: . 4. Utilize data obtained from a variety of sources to identify quality problems, opportunities for improvement, and set priorities for action . 7. Perform root cause analysis, set targets; implement corrections to improve the process. Review of the undated Birmingham Nursing and Rehabilitation Center (BNRC) QAPI Plan revealed the following: .Purpose of BRNC's QAPI Plan BRNC's QAPI plan provides guidance for our overall quality improvement program and from principles to drive decisions which promote quality of person centered care. Focus areas will include all quality of care systems that affect resident well being . How QAPI plan will address key issues The quality of care and services provided by BNRC has a direct impact of the quality of life of our residents. Through collaboration of all departments with the QAPI activities we will strive to improve our services. Our plan included the policies and procedures used to identify systems and processes with opportunity for improvement, We will use data to monitor our performance, establish goals and measurements, and evaluate plans and processes. We will identify and prioritize problems and opportunities and develop process improvement plans as needed. We will use the process improvement plans to analyze underlying causes of systemic problems and adverse advents (events) . Performance improvement plans to improve processes, systems, outcomes, and satisfaction will be developed. Review of the Alabama Department of Public Health (ADPH) Online Incident Reporting System revealed Employee Identifier (EI) #1, the facility Administrator, reported a Fire / Smoke incident to ADPH on 03/26/2022 at 10:05 AM. This initial report indicated the incident occurred on 03/26/2022 at 7:20 AM. According to the initial report, RI #177 was found with active flames in his/her bed, and after the fire was extinguished, was transferred to a local hospital for evaluation. The facility's investigative summary related to this incident documented RI #177's roommate exited their room and yelled for a nurse, alerting staff there was a fire. EI #23, a Licensed Practical Nurse (LPN), ran to the room and found RI #177 in bed with his/her torso, groin and arms ablaze. After staff extinguished the resident and attended to his/her immediate needs, including cutting off smoldering clothing, RI #177 was transferred to a local hospital for evaluation and treatment. The facility's summary documented, Facility and fire department is in agreement that resident had smoked in bed and cigarette fell into bed causing linens and clothing to catch fire. The facility's investigative summary attributed the fire to RI #177's non-compliance with the smoking policy; further, the summary documented RI #177 had never been noncompliant with smoking rules since he was admitted to the facility on [DATE] .that (the) facility was made aware of . The summary did state that during the course of the investigation some staff made comments regarding prior suspicion of RI #177 smoking in his/her room; however, there were no interviews or statements contained in the facility's investigative file to support this statement. During the survey, concerns were identified related to incomplete and inaccurate SMOKING SAFETY EVALUATIONS, documented instances of resident noncompliance with smoking policies not communicated or addressed through care plan revisions, staff supervision of smoking residents, and systems for the storage of resident smoking materials. Cross reference F656, F689, F740, F835, F837, and F926. Review of the facility's MONTHLY QA & A MINUTES, dated 03/26/2022, revealed the following: . AD HOC QUALITY ASSURANCE MEETING Resident (RI #177) noted to have caused fire in bed by smoking. Resident alert and oriented with BIMS (Brief Interview for Mental Status) of 14 (cognitively intact) with independent smoking evaluation and care plan. Resident injury 2nd and 3rd degree [CONDITION(S)] on 20% of body. All residents who smoke had new smoking evaluations completed and updated plans of care . Smoking policy amended to include that all lights, matches and flame producing materials are to be kept secure by staff an no resident allowed to keep in their room. Resident council meeting with smokers to discuss new policy and smoking schedule . In-services began with staff on new policy to be completed by 04/01/2022 . There was no indication the facility had identified the documented incidents of smoking noncompliance with RI #177, or any other of the facility's smokers. There was also no documentation indicating the facility had identified or taken actions to address the facility's systems and processes for smoking evaluations, storage and monitoring of smoking materials, supervision, staff communication related to resident noncompliance with the smoking policy, and person centered safety interventions. EI #1, the Administrator, was interviewed on 04/13/2022 at 9:25 AM. EI #1 was asked if she has any concerns with resident SMOKING SAFETY EVALUATIONS not being complete or accurate. EI #1 stated the facility's evaluation forms are confusing, and acknowledged it was hard to tell at what point the forms were correct with multiple dates and signatures. EI #1 said the smoking evaluations were not meant to be a multi-use form, as it was being utilized by staff. EI #1 initially said the facility recognized the problem with the evaluation forms on 03/26/2022, but when questioned why the same forms had been being utilized since then, EI #1 said they originally intended to make it a single use form, but then later decided to do away with the evaluation tool they were utilizing. EI #1 indicated that decision had been made on 04/06/2022 but the facility's efforts to address it were not complete. EI #1 was then asked about concern with care plans being based on incomplete and inaccurate smoking evaluations. EI #1 said this resulted in a care plan that was not detailed enough for staff to know what to do or what to report. EI #1 said staff usually reported concerns to her during their morning meetings, and acknowledged she had been informed of three different smoking related incidents prior to the fire on 03/26/2022. EI #1 said she did not know why staff were not informing her of the smoking incidents. EI #1 further stated inconsistency with enforcing policy and reporting inconsistency resulted in inconsistent actions taken with each smoking incident. EI #1 said if staff did not report the concerns to her, she could not ensure appropriate actions were taken. When asked what had been done as a result of the 03/26/2022 fire, EI #1 said they had a QAPI meeting on 03/26/2022 and the facility's smoking policy was updated to reflect no residents should have possession of lighters or flame producing items. EI #1 said she did not know why there seemed to be a communication breakdown related to smoking incidents, because staff communicated with her regarding other things. During a follow-up interview with EI #1 on 04/13/2022 at 12:41 PM, EI #1 said the three smoking related incidents she had been made aware of prior to 03/26/2022 were not reviewed through QAPI. However, EI #1 said QAPI was reviewing to ensure smoking evaluations were being done. EI #1 was asked why smoking incidents that were documented in nurses notes were not recognized. EI #1 said she did not know. On 04/14/2022 at 8:55 AM, EI #1 was asked what was done to investigate how often residents may have been smoking in the building or their rooms. EI #1 said, if the resident was caught, there would be no need for an investigation because they were already caught. EI #1 indicated if a resident was caught smoking in the facility, social services should have completed a new smoking evaluation and updated the care plan per the facility's process. EI #1 was then asked what was done in regards to smoking residents who were allowed to keep cigarettes and lighters at all times. EI #1 said there was not a general investigation about this, but said each instance should have been handled through the care plan process for each individual case. EI #1 was asked how she had utilized the information she received as an opportunity for improvement or to identify problems that needed to be addressed. EI #1 acknowledged she was over QAPI at the facility and failed to use the information she did know about, but in hindsight agreed she should have done so. On 04/15/2022 at 3:35 PM EI #1, the Administrator, was asked what was done to address the 03/26/2022 incident involving RI #177 in QAPI . EI #1 explained what was on the QA documentation from the meetings on 03/26/2022. When asked why the facility had not recognized all the areas of concern the surveyors identified, EI #1 said, the QAPI meetings were done to ensure residents were safe at that time. When asked how the root cause was determined, EI #1 said, they used the five whys for root cause analysis, but it was not documented. On 04/15/2022 at 3:42 PM, EI #2, the Vice President of the facility's management company and member of the Governing Body, was asked what was done to address the 03/26/2022 incident involving RI #177 in QAPI . EI #2 said the Administrator and the team had a meeting on 03/26/2022 and 04/01/2022. When asked why they did not identify all the concerns identified by the surveyors, EI #2 said their focus was on ensuring the lighters were taken from residents. ********** The facility submitted an acceptable Removal Plan on 04/28/2022 for F867 that outlined the following: Birmingham Nursing and Rehabilitation Center,LLC IJ Removal F867 The president of Aurora Cares,LLC d/b/a [NAME] Cares,LLC (administrative service agreement provider for Birmingham Nursing and Rehabilitation Center,LLC) remotely assisted the executive director,the governing body, QAPI team, and the medical director to review and revise Birmingham Nursing and Rehabilitation Center, LLC's smoking policy on 4/16/22 and 4/18/22. The governing body and executive director were educated on implementing and enforcing the revised smoking policy. This education began and was completed on 4/18/22. Executive director was inserviced to present all incidents of smoking non-compliance to the quality assurance committee and to use root-cause analysis to identify casual factors to determine actions needed to prevent further resident safety concerns. Inservice completed by the governing body on 4/18/22. The president of Aurora Cares,LLC d/b/a [NAME] Cares,LLC (administrative service agreement provider for Birmingham Nursing and Rehabilitation Center,LLC.) remotely assisted the executive director and the governing body to review and develop Birmingham Nursing and Rehabilitation Center, LLC's revised smoking evaluation tool on 4/18/22. The revised smoking evaluation tool was approved by the QAPI committee and the medical director on 4/18/22. Quality Assurance Meetings were held on: 3/26/22, 4/01/22, 4/16/22, and 4/18/22. The executive director, the governing body, QAPI team, and the medical director (by telephone), discussed the removal plans and policy revisions. Contents will be completed and immediacy will be removed on 4/18/22. On 04/28/2022 at 8:15 PM, after review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 04/18/2022 and the scope and severity was lowered to an F level, to allow the facility time to further address and monitor the deficient practice in order to achieve compliance.

Based on observations, interviews, resident record reviews, and review of facility policies titled SUBJECT: SMOKING and COMPREHENSIVE PERSON CENTERED CARE PLANS, the facility failed to ensure: A) the information obtained through the facility's Smoking Safety Evaluations was utilized in a manner to allow staff to develop and implement person-centered safety interventions for Resident Identifier (RI) #s 177, 10, 82, 48, 58, and 59. These six of six sampled residents reviewed for smoking safety have documented episodes of noncompliance with the facility's Smoking Policy, including smoking inside the facility unsupervised in resident rooms and/or bathroom areas. The staff members who documented the noncompliant actions of the residents failed to communicate all incidents to management as directed by the residents' smoking care plans. The facility did not ensure additional actions were taken to ensure proper safety interventions were in place, including supervision and monitoring, as well as systems to ensure noncompliant residents did not have access to lighters inside the facility. On 3/26/2022, RI #177, a resident with a history of smoking noncompliance was in possession of his/her smoking materials and lighter, and subsequently ignited his/her bedding and body. After staff became aware, they extinguished the flames, rendered necessary aid, and the facility sent RI #177 to the hospital where he/she was found to have 3rd degree [CONDITION(S)] covering 10-19% of his/her body. Further, during the survey, RI #10, a resident with right sided [CONDITION(S)] who was assessed as requiring minimal supervision and required the use of a smoking apron, was observed outside smoking on multiple occasions. During these observations, RI #10 did not wear a smoking apron and was observed to drop ashes from a lit cigarette onto his/her clothing. The staff present at the time of these observations did not acknowledge or intervene. These failures affected RI #s 177, 10, 82, 48, 58, and 59, six of six sampled residents reviewed for smoking safety and had the potential to affect all 36 smokers in the facility. In addition, these failures placed all 129 residents residing in the facility at risk for immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment, or death. On 04/14/2022 at 7:05 PM, the facility's Administrator (Employee Identifier (EI) #1); the Vice President of the facility's management company/member of the Governing Body (EI #2); the facility's Director of Nursing (EI #5); and a Human Resources Representative (EI #43) were given a copy of the Immediate Jeopardy (IJ) template and were notified of the findings of IJ in the area of Comprehensive Resident Centered Care Plan, F656. B) Further, the facility failed to ensure a comprehensive plan of care was developed to address RI #49's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] These deficient practices affected RI #s 177, 48, 10, 82, 58, 59, and 49, but had the potential to affect all 129 residents residing in the facility at the time of the survey. Findings include: A) Review of the facility's policy titled SUBJECT: SMOKING, last reviewed 11/2017, revealed the following: POLICY: This is a smoke-free facility. No smoking or use of smoking materials will be allowed inside the building . Smoking is to occur only in designated areas and in accordance with each smoking resident's individualized plan of care based on the Smoking Safety Evaluation. POLICY STATEMENT: It is not the intention of this facility to deprive residents of the pleasure of smoking, but rather to offer a safe and comfortable environment to all residents living in the facility. Both smoking and non-smoking residents will be considered in the development of smoking locations and designated times. RESPONSIBILITY: All staff, monitored by management. PROCEDURE: 1. All residents who smoke will be assessed for his or her ability to smoke safely, the ability to handle smoking material and the need for supervision while smoking. The Smoking Safety Evaluation will be completed upon admission, readmission, quarterly, annually, and as needed. Residents that are evaluated as independent with smoking: (and/or without history of smoking incidents; needing no interventions) will be permitted to keep and maintain their own smoking materials (i.e. cigarettes, e-cigarettes), and may smoke in designated areas without limitations. The resident may be permitted to keep fire materials on his/her person during waking hours if deemed appropriate per the smoking evaluation. Smoking materials not kept or maintained by resident will be maintained by Licensed Nurse. Residents found to have modified independence with smoking: may be subject to smoking limitations. Limitations may include, but are not limited to: facility storage of tobacco products and/or fire materials, designated smoking times, assistance with lighting tobacco products, assistance to hold cigarette, supervised smoking by staff, and/or other protective/safety measures as determined appropriate by the individualized plan of care based on the smoking evaluation . A review of the facility's policy titled, COMPREHENSIVE PERSON CENTERED CARE PLANS with a last review date of March, 2018, revealed, . POLICY: Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that identify how the interdisciplinary team will provide care. Comprehensive Person Centered Care Plan(CCP) - contains services provided, preference, ability, goals for admission and desired outcomes, and care level guidelines. PROCEDURE: . 4. will identify resident problems, needs, strengths, life-history, preferences, and goals 5. For each problem, need, or strength a resident--centered goal is developed. During the survey, document review revealed concerns related to the accuracy and completeness of the SMOKING SAFETY EVALUATIONS for RI #177, RI #10, RI #82, RI 48, RI #58 and RI #59. Further it was noted that after each documented episode of noncompliance with the facility's smoking policy, staff were not reevaluating the residents for smoking safety so that care plans could be updated with safety interventions. In addition, RI #10, who was assessed as requiring minimal supervision and a smoking apron was observed on multiple occasions without a smoking apron dropping ashes onto his/her body. Cross reference F689, F835, F837, F867, F740, and F926. 1. RI #177 was originally admitted to the facility on [DATE] with diagnoses including [MEDICAL RECORD OR PHYSICIAN ORDER] . During admission, RI #177's SMOKING SAFETY EVALUATION was completed on 05/18/2021. The section of this evaluation for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The evaluation did not capture RI #177's diagnoses of [CONDITION(S)] or [CONDITION(S)], although the evaluation has a section for Neurological diagnoses. The evaluation indicated RI #177 was independent with cognitive skills for decision making, had no indicators of [CONDITION(S)], and had clear speech. The following questions were not answered: Is the resident able to communicate the need for help if lit material falls on them? and Is resident able to move without assistance to/from designated smoking area? The section of the evaluation titled HISTORY indicated RI #177 could self-extinguish cigarettes and was able to manage ashes. The Fire Safety section indicated RI #177 attempted to obtain lighters or matches and lighter/matches had been obtained from an outside source. History of Smoking Related Incidents was marked as No. Staff assessed RI #177 as an independent smoker that required no assistive devices. The question for Care Plan Concern? was marked Yes. This evaluation was signed on 05/18/2021 by EI #26, Licensed Practical Nurse (LPN), and the following day by EI #44, the facility's prior Social Worker (SW). Review of RI #177's comprehensive care plans revealed a care plan for .Problem Onset: 05/18/2021 I enjoy smoking and has been assessed to be a smoker. Approaches listed included the following: - complete smoking assessment as needed - educate resident/family regarding facility smoking policy - show resident where appropriate smoking area is located - observe resident for unsafe smoking habits. If unsafe smoking habits are observed, notify mgmt (management) immediately - educate resident to extinguish smoking materials in appropriate container before leaving smoking area RI #177's medical records were reviewed. The Departmental Notes revealed the following documentation related to noncompliance with the facility's smoking policy: - 05/19/2021: smoking in room - 05/31/2021: suspected of smoking in staff bathroom - 06/09/2021: found outside smoking with other residents unsupervised at 2:45 AM (non-designated smoking time) - 08/04/2021: smoking in room Facility staff reviewed RI #177's smoking care plan on 08/23/2021, 11/16/2021, and 02/15/2022. The facility made no revisions to RI #177's smoking care plan, despite the above documented smoking related incidents. During an interview with EI #12, LPN, on 04/01/2022 at 8:08 AM, EI #12 explained a resident with [CONDITION(S)] and a history of [CONDITION(S)] would not be safe to have cigarettes and lighters unsupervised. EI #12 then confirmed RI #177 had both of these diagnoses and said RI #177 should not have been deemed an independent smoker or had cigarettes and lighters in his/her room unsupervised. During a follow-up interview with EI #12 on 04/02/2022 at 9:53 AM, EI #12 was asked who had seen her documentation related to RI #177's history of smoking in his/her room. EI #12 said she guessed everyone should have seen it. EI #12 further stated she did not know she was supposed to conduct another Smoking Safety Evaluation after this occurrence. EI #12 acknowledged RI #177's smoking care plan did not address the storage of the resident's cigarettes, lighters, or other smoking materials, but said in her opinion residents should not be allowed to have them, but it depended upon the facility. When asked how often the smoking care plan should be updated, EI #12 said after every incident. EI #12 was asked who she had reported the incident of finding RI #177 smoking in his/her room to. EI #12 said she had reported this incident to EI #6, the facility's prior Director of Nursing (DON). EI #6 was interviewed on 04/02/2022 at 2:42 PM. When asked what she could recall about RI #177, EI #6 stated she had spoken with the resident numerous times, regarding different cases of noncompliance. EI #6 stated she did recall being informed of RI #177 smoking in his/her room, but could not recall who told her. She only recalled one incident when RI #177 had OVID (01/31-02/09/2022) and staff informed her he/she was smoking in his/her room. When asked what staff should do when they find a resident to be smoking in their room, EI #6 stated the staff should retrieve the smoking materials from the resident, educate the resident, and notify management so that the incident can be addressed on the care plan and rounds can be made. EI #6 stated residents that were noncompliant with the facility's smoking policy should have their smoking materials kept on the nurse's cart. EI #6 also stated RI #177's care plan should have been updated after staff suspected he/she was smoking in the room to reflect the suspicion of the resident smoking in the room with an intervention added to keep the smoking materials on the cart. In addition, EI #6 said Social Services should have been made aware so they could reassess the resident for smoking safety. EI #6 confirmed that any resident suspected of smoking in their room should not be allowed to keep a lighter. EI #6 also stated a resident with [CONDITION(S)] and diabetes would be unsafe to smoke independently. 2. RI #10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of [CONDITION(S)] affecting right dominant side, Peripheral Vascular Disease, Type 2 Diabetes Mellitus, Chronic Systolic (congestive) Heart, Vascular Dementia, Pseudobulbar Affect, and Chronic Obstructive Pulmonary Disease ([CONDITION(S)]). RI #10's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 01/20/2022, documented RI #10 was cognitively intact and had upper and lower extremity range of motion impairment to one side. RI #10's 03/26/2022 SMOKING SAFETY EVALUATION was first completed and signed by EI #7, SW. EI #10, Registered Nurse (RN), also reviewed, revised and signed off on RI #10's 03/26/2022 smoking evaluation. The section of this evaluation for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Range of Motion was originally marked No Limitation but was marked out by EI #10 who indicated RI #10 did have [CONDITION(S)] with right sided weakness. History of Smoking Related Incidents was marked as 'Yes, and the following areas were marked: Burned Clothing, Drops Ashes on Self, and Other : non-compliant with smoking apron. The following INTERVENTIONS were marked for RI #10: Smokes Safely with Minimal Supervision, Smokers Apron, Facility Storage of Fire Materials Only, and Assistance with Lighting Tobacco Products Only. Review of RI #10's comprehensive care plans revealed a care plan for .Problem Onset: 11/10/2010 I am a smoker and have been assessed to be a smoker, noncompliance (noncompliant) wearing smoking apron, hx (history) [CONDITION(S)] clothes, drop ashes on (him/her)self. Approaches listed included the following: - Complete smoking assessment - Explain smoking policy to resident - Show resident appropriate place to smoke - Observe resident for safe smoking practices-if unsafe practices are observed, notified nursing and social services - Educate resident to check that all smoking material are extinguished in proper container - Smoker apron to be worn when smoking. - (resident's name) is allowed smoking materials on person - smokes safely minimum supervision - facility storage of fire materials RI #10 had a care plan for the following: .Problem Onset: 11/10/2010 I am a smoker and have been assessed to be modified independence with smoking, non-compliance (compliance) wearing smoking apron, hx [CONDITION(S)] clothes, drop ashes on (him/her)self. This care plan was revised on 04/01/2022 and 04/13/2022. Approaches listed included the following: - Show resident appropriate place to smoke - Facility to store fire materials only - staff to offer smoking apron with each smoking break - assistance with lighting tobacco products only - Complete smoking assessment - Reeducate on smoking policy - Staff to observe every smoke break for smoking materials extinguished in proper containers - stand closely to directly observe for unsafe smoking habits dropping ashes on self - offer ash tray to prevent dropping ashes on self -supervised smoking by staff - Notify nursing and social services for any observed for any safety hazards during smoking breaks - reeducate safety of compliance (compliance) with smoking policy There were no interventions that directed staff as to what to do should RI #10 refuse to use the smoking apron. On 03/30/2022 at 8:04 AM, an observation of the smoking area was made with six residents present, including RI #10. None of the six residents had on smoking aprons, and all six residents were flicking ashes onto the ground. EI #28, Certified Nursing Assistant (CNA), was the staff member present, but was noted to frequently have her back to the smokers as she was having to open the door to let other residents in and out of the facility. On 03/30/2022 at 8:18 AM, RI #10 was noted to have ashes on his/her sweatpants and radio. RI #10 was then observed sweeping the ashes off onto the ground using his/her left hand, which had a lit cigarette in between the middle and index fingers. At 8:22 AM, RI #10 was observed lighting a new cigarette with his/her previous cigarette, before throwing the butt into the proper container. At 8:25 AM, another resident asked RI #10 for his/her lit cigarette to light theirs, and once it was lit, returned the cigarette to RI #10. At 8:26 AM, RI #10 was observed dropping a long strand of ashes off the end of his/her lit cigarette held in the left hand onto his/her lap. At 8:28 AM. RI #10 again lit a new cigarette with the one he/she already had lit and threw the old one into the proper container. Two minutes later, RI #10 put out the lit cigarette on the wheelchair, kept the extinguished cigarette in his/her hand, and then entered the building. EI #28, the CNA, was interviewed on 04/14/2022 at 8:14 AM. When asked how she was trained to supervise the smokers while they were smoking, EI #28 said she was not really trained, but she knows to observe while they are smoking. She indicated she should be watching to make sure ashes are not falling on their laps and the cigarettes are being placed in the appropriate containers/ashtrays. When asked how she is able to watch everyone to make sure they are not dropping ashes on themselves, EI #28 said she could not watch all of them but does tell them to put their cigarettes in the ashtrays. When asked what she tells residents about the smoking aprons, she said she should put the aprons on the ones that really need them. However, EI #28 did not know which residents required the use of the smoking aprons. EI #28 was asked if she had offered RI #10 a smoking apron on 03/30/2022 when she was supervising the smoke break. EI #28 admitted she did not offer RI #10 a smoking apron EI #28 also admitted she did see RI #10 drop ashes onto his/her lap while she was outside supervising the smokers. During an interview on 04/03/2022 at 6:15 PM, RI #10 said that prior to the fire on 03/26/2022, he/she could go out to smoke whenever he/she wanted. RI #10 stated he/she was unaware he/she needed a smoking apron, when smoking. During an interview with RI #10's assigned CNA, EI #21, on 04/07/2022 at 11:28 AM, EI #21 admitted that before the fire on 03/26/2022, the facility was not taking up cigarettes and lighters, and the residents were allowed to keep them on them. EI#21 stated she did not assist RI #10 in getting ready for smoke breaks because RI #10 gets him/herself ready and takes him/herself down to the smoking area when he/she is ready. During an observation on 04/07/2022 at 12:03 PM, a business office employee, EI #16, opened the door to the smoking area for residents and used a lighter to light five residents' cigarettes. EI #16 lit RI #10's cigarette, without saying anything or offering a smoking apron. At 1:14 PM, EI #16 placed an ashtray for RI #10 on the rail of the gazebo. RI #10 was not wearing a smoking apron. During this observation, the surveyor observed smoking aprons hanging on a hook in the gazebo. During an interview on 04/13/2022 at 12:15 PM, EI #16, business office employee, stated she had not offered RI #10 a smoking apron on 04/07/2022 because she did not know RI #10 needed one. On 04/11/2022 at 3:59 PM, EI #47, a CNA, was observed in the smoking area lighting a cigarette for RI #10. RI #10 did not have a smoking apron on. At 4:00 PM, EI #47 was observed sitting down smoking a cigarette herself. EI #8, SW, was also present in the smoking area. There was a total of 16 residents present in the smoking area. While EI #47 was smoking a cigarette, EI #8 was observed running from one side of the smoking area to the other to get the door for residents in wheelchairs. At 4:03 PM, RI #10 was observed with ashes on his/her pants. At 4:06 PM, RI #10 lit a new cigarette using his/her old lit cigarette, prior to discarding the butt in the container. At 4:13 PM, RI #10 was again observed lighting a new cigarette from his/her pack using the old lit cigarette, before discarding it in the container. At 4:15 PM RI #10 again dropped cigarette ashes onto his/her pants while scratching his/her head with the left hand that contained the lit cigarette. On 4/13/22 at 11:56 AM an interview was conducted with EI #8, SW. EI #8 was asked what supervision meant on the smoking evaluation. EI #8 explained minimal supervision and supervision were the same thing and meant someone would watch them. EI #8 was asked when she went outside to supervise residents smoking what was her focus. EI #8 replied, watching for unsafe smoking habits, such as ashes falling on clothes. EI #8 was asked how she did that when there were several people out in the smoking area. EI #8 replied, she tried to have someone else out there with her to make it a little easier. EI #8 was asked, how many staff members go out during smoke breaks. EI #8 said it depended on how many people were out there, there was no set number. EI #8 indicated there were usually around 15 or so residents out at a time for smoke breaks. EI #8 was asked had she ever seen RI #10 drop ashes on him/herself. EI #8 replied, she had never seen RI #10 drop ashes. EI #8 was asked if she'd seen when RI #10 dropped ashes on him/herself on 04/11/2022. EI #8 said she had not seen that. When asked why not, EI #8 said there was a lot of people out there and she must have been looking at someone else. 3. RI #82 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of [CONDITION(S)], Other Muscle Spasm, Nicotine Dependence, Panic Disorder, Primary [CONDITION(S)], and [CONDITION(S)] II Disorder. RI #82's admission MDS assessment, with an ARD of 06/04/2021, documented RI #82 was cognitively intact. RI #82's admission SMOKING SAFETY EVALUATION was completed on 05/28/2021, and was signed by EI #32, LPN, and EI #44, the facility's prior SW. This assessment indicated RI #82 had no diagnoses impacting his/her ability to smoke. The sections to indicate Devices & Restraints and Manual Dexterity were not completed. This smoking evaluation assessed RI #82 as an independent smoker, that required no supervision, assistance, or storage of smoking materials. Review of RI #82's comprehensive care plans revealed a care plan for .Problem onset: 05/28/2021 I enjoy vaping and smoking and has been assessed to be an independent vapor and smoker and have behavior non compliance with smoking policy/schedule . Approaches listed included the following: - Complete smoking assessment as needed - Educate resident/family regarding facility smoking policy - Show resident where appropriate smoking area is located - Observe resident for unsafe smoking habits. If unsafe smoking habits are observed, notify mgmt immediately - Educate resident to extinguish smoking materials in appropriate container before leaving smoking area RI #82's Departmental Notes revealed incidents of noncompliance with the SMOKING policy. Documented was as follows: 08/03/2021: smell of smoke and perfume in resident's room, suspected smoking in room 12/20/2021: found outside smoking with other residents unsupervised at approximately 5:45 AM (non-designated smoking time) EI #32, LPN, was interviewed on 04/08/2022 at 1:50 PM. When asked what guidance or training the facility had provided her on completing the smoking evaluations, EI #32 said none, but Social Services does the evaluations, and the nurses just answer the questions and check the boxes. EI #32 said it was up to Social Services to review for accuracy. After reviewing RI #82's admission smoking evaluation, EI #32 said there were some areas that were not answered because she may not have seen all the questions that needed to be answered. When asked why it would be important for the smoking evaluation to be accurate and complete, EI #32 said it was necessary to make sure residents remain safe. EI #32 further indicated this was the first place she had ever worked that residents were allowed to keep cigarettes and lighters on their person. EI #32 said even after the facility took up lighters from residents after the 3/26/2022 fire, there were still residents that had them and were going out to smoke unsupervised. During an interview on 04/09/2022 at 6:50 AM, EI #49, the LPN who noted RI #82's December incident, stated in the past residents would just go out to smoke whenever they wanted because they kept their cigarettes and lighters with them. EI #49 stated she did not report the incident from December to management, because she did not know the care plan instructed staff to do that 4. RI #48 was admitted to the facility on [DATE] and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] RI #48's admission MDS with an ARD of 06/03/2021 documented a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition for daily decision making, and current tobacco use. RI #48's admission SMOKING SAFETY EVALUATION was completed on 05/27/2021. The section of this evaluation for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The section of the evaluation titled HISTORY indicated RI #48 could self-extinguish cigarettes and was able to manage ashes. The Fire Safety section indicated RI #48 attempted to obtain lighters or matches. History of Smoking Related Incidents was marked as No. Staff assessed RI #48 as an independent smoker, that required no supervision, assistance, or storage of smoking materials. The question for Care Plan Concern? was marked Yes. This evaluation was signed on 05/27/2021 by EI #26, LPN, and the following day by EI #44, the facility's prior Social Worker (SW). Review of RI #48's comprehensive care plans revealed a care plan for .Problem Onset: 05/27/2021 I enjoy smoking and has been assessed to be an independent smoker . Approaches listed included the following: - complete smoking assessment as needed - educate resident/family regarding facility smoking policy - show resident where appropriate smoking area is located - observe resident for unsafe smoking habits. If unsafe smoking habits are observed, notify mgmt (management) immediately - educate resident to extinguish smoking materials in appropriate container before leaving smoking area RI #48's Departmental Notes documented the following: - 07/25/2021: roommate complaining of RI #48 smoking in the bathroom - 03/13/2022: resident room smelled strongly of smoke; resident found in bathroom on toilet smoking a cigarette RI #48's admission SMOKING SAFETY EVALUATION was reviewed on 08/31/2021 and signed by EI #44, the facility's prior SW. The section for History Of Smoking Related Incidents remained marked No. This same smoking evaluation was also reviewed on 12/02/2021 and 02/14/2022 and signed by EI #7, SW. The section for History Of Smoking Related Incidents remained marked No. Staff completed a new SMOKING SAFETY EVALUATION for RI #48 on 03/14/2022. This evaluation documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The section of the evaluation titled Cognitive Skills for Decision Making indicated RI #48 had Modified Independence. The section of the evaluation titled HISTORY indicated RI #48 could self-extinguish cigarettes and was able to manage ashes. The Fire Safety section indicated RI #48 did not attempt to obtain lighters or matches despite having been found smoking in his/her bathroom. History of Smoking Related Incidents was marked as Yes and listed a History of smoking in bathroom in (his/her) room. Staff assessed RI #48 as an independent smoker that required no assistive devices. The question for Care Plan Concern? was marked No. This evaluation was signed on 03/14/2022 by EI #7, SW, and on 3/26/22 by EI #8, SW, and EI #10, RN Unit Manager. RI #48's care plan for smoking was marked as reviewed on 08/30/2021 but no revisions were made following the above documented incidents of smoking noncompliance. This care plan was also reviewed on 03/14/2022 and 03/26/2022 and an approach was added for the facility to store tobacco products and fire materials. On 04/08/2022 at 4:10 PM EI #7, SW, stated she was not aware of any smoking incidents involving RI #48 until 03/14/2022. EI #7 was asked if RI #48 had an incident in July 2021 what should be reflected on the smoking evaluation. EI #7 replied, whatever the incident was, it should have been on the smoking evaluation and the care plan. When asked what incidents were documented on the care plan, EI #7 said, smoking in bathroom on 03/14/2022. When asked what other incidents were documented on the care plan for smoking, EI #7 said, nothing else. When asked what the concern was with the smoking evaluation and care plan not reflecting smoking incidents for the resident, EI #7 said if it was not listed on the smoking evaluation and care plan, they would not know RI #48 needed other interventions. EI #7 said the purpose of the smoking evaluation and care plan were to make sure they were able to smoke safely and any interventions needed would be reflected on the care plan. EI #7 said if it was not done the resident could continue to have incidents and were at risk of more incidents that could result in harm to self or others. On 04/03/2022 at 6:40 PM RI #48 was asked about rules for smoking at the facility. RI #48 said there were smoke times and no smoking was allowed in rooms. When asked if he/she had smoked in his/her room, RI #48 said, yes. When asked prior to 03/26/2022 where were cigarettes and lighters kept, RI #48 said, he/she kept them. When asked when he/she could smoke prior to 03/26/2022, RI #48 said, anytime. When asked what staff members went with him/her to smoke prior to 3/26/2022, RI #48 said, no one. 5. RI #58 was admitted to the facility on [DATE] and readmitted [DATE] and had diagnoses to include [CONDITION(S)], Left Side Affected, [CONDITION(S)], [CONDITION(S)], Adjustment Disorder with Depressed Mood, Mood Disorder, and Nicotine Dependence, Cigarettes. Review of RI #58's comprehensive care plans revealed a care plan for .Problem Onset: 03/24/2020 . for being a smoker with behavior of noncompliance with smoking policy and schedule, suspicious for smoking in room and saving cigarette butts in room. Approaches listed included the following: -Inform resident/sponsor of changes in POC (Plan of Care) -Reeducate smoking policy as needed -Reeducate safety of compliance with smoking policy -Refer to psychiatry as needed -Nurse to keep resident's cigarettes and lighter on cart until time for resident to smoke -Complete smoking assessment as needed -Educate resident on appropriate smoking area and have resident show/tell you the appropriate smoking area -Observe resident for safe smoking practices if resident displays unsafe smoking practices notify Social Services and nursing -Supervise smoking by staff -Staff to keep all smoking materials This care plan was last revised on 04/02/2021 and was reviewed on 05/14/2021, 08/04/2021, 11/04/2021, 02/24/2022, and 03/26/2022 without further revision or new approaches to address smoking incidents that occurred during that time. RI #58's Departmental Notes documented the following: 04/20/2021: room smelled of cigarette smoke; when questioned, RI #58 placed his/her cigarettes into their jacket pocket and told staff they did not see any cigarettes 04/28/2021: staff found medicine cup in room with water and ashes in it 05/20/2021: resident found outside at the gazebo at 1:54 AM (non-designated smoking time) 06/11/2021: staff found small bowl with water and cigarette ashes in resident's room at the bedside 08/20/2021: staff found medicine cup on bedside table containing cigarette ashes 09/04/2021: RI #58 found smoking in room again; note indicates resident found multiple times and warned of the danger, but resident stated he/she was grown and could do what they wanted 09/05/2021: evidence found in RI #58's room of smoking, resident denied 09/28/2021: EI #27 removed RI #58's cigarette lighter from the table in the room and replaced RI #58's nasal cannula that had been removed 03/30/2022: Social Services notified resident was out to smoke and seen by a CNA with a lighter. Res [TRUNCATED]

Based on interviews, review of the facility's QAPI (Quality Assurance Process Improvement) Plan and review of the facility Administrator's job description, facility administration failed to ensure staff were consistently implementing the facility's smoking policy. Further, the Administrator admitted prior knowledge of resident noncompliance with the facility's smoking policy, but failed to present the incidents to the facility's Quality Assurance (QA) Committee for review/investigation in order to identify systemic breakdowns, so that actions could be taken to ensure facility systems did not contribute to further noncompliance with the facility's smoking policy. Further, the Administrator failed to provide oversight to ensure staff were implementing policies related to Behavior Management. These deficient practices placed all residents in the facility at risk for immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment, or death. The facility Form CMS-672 listed a facility census of 129 at the time of the survey. On 04/14/2022 at 7:05 PM, the facility's Administrator (Employee Identifier (EI) #1); the Vice President of the facility's management company/member of the Governing Body (EI #2); the facility's Director of Nursing (EI #5); and a Human Resources Representative (EI #43) were given a copy of the Immediate Jeopardy (IJ) template and were notified of the findings of IJ in the area of Administration, F835. Findings include: Cross Reference F656, F689, F740, F837, F867, and F926. Review of the facility's undated QAPI Plan revealed the following: .Guideline for Governance and Leadership The Executive Director (Administrator) has responsibility for ensuring that QAPI is implemented throughout our organization. QAPI meetings will be held monthly and all activities discussed as needed . Review of a Job Description for the facility's Administrator revealed the following: . General Description The Executive Director (administrator) leads and directs the overall operation of the Facility in accordance with resident needs, government regulations, and Facility policies so as to maintain quality care for the residents . Essential Duties 1 . Monitors each department's activities, communicates policies, evaluates performance, provides feedback and assists, coaches, and disciplines as needed. . 5. Maintains a working knowledge and monitors for compliance with all governmental regulations and Facility Quality Assurance standards . This job description was signed by EI #1, the facility Administrator, on 04/03/2020. EI #1, the Administrator was interviewed on 04/13/2022 at 9:25 AM. Upon reviewing the portion of the facility's smoking policy that states, Smoking is to occur only in designated areas and in accordance with each smoking resident's individualized plan of care based on the Smoking Safety Evaluation, EI #1 was asked what was the concern with resident's SMOKING SAFETY EVALUATIONS. EI #1 stated the facility's evaluation forms are confusing and acknowledged it was hard to tell at what point the forms were correct with multiple dates and signatures. EI #1 said the smoking evaluations was not meant to be a multi-use form, as it was being utilized by staff. EI #1 initially said the facility recognized the problem with the evaluation forms on 03/26/2022. EI #1 stated they originally intended to make it a single use form, but then later decided to do away with the evaluation tool they were utilizing. EI #1 indicated that decision had been made on 04/06/2022, but the facility's efforts to address it were not complete. EI #1 was asked what was the concern with care plans being based on incomplete and inaccurate smoking evaluations. EI #1 said this resulted in a care plan that was not detailed enough for staff to know what to do or what to report. EI #1 said staff usually reported concerns to her during their morning meetings, and acknowledged she had been informed of three different smoking related incidents prior to the fire on 03/26/2022. EI #1 said she did not know why staff were not informing her of the smoking incidents. EI #1 further stated inconsistency with enforcing policy and reporting inconsistency resulted in inconsistent actions taken with each smoking incident. EI #1 said if staff did not report the concerns to her, she could not ensure appropriate actions were taken. When asked what had been done as a result of the 03/26/2022 fire. EI #1 said they had a QAPI meeting on 03/26/2022 and the facility's smoking policy was updated to reflect no residents should have possession of lighters or flame producing items. EI #1 said she did not know why there seemed to be a communication breakdown related to smoking incidents, because according to EI #1, staff communicated with her regarding other things. During a follow-up interview with EI #1 on 04/13/2022 at 12:41 PM, EI #1 said the three smoking related incidents she had been made aware of prior to 03/26/2022, were not reviewed through QAPI. However, EI #1 said QAPI was reviewing to ensure smoking evaluations were being done. When asked why the extent of smoking related incidents documented in the nurses notes was not recognized, EI #1 said she did not know. On 04/14/2022 at 8:55 AM, EI #1 was asked what was done to investigate how often residents may have been smoking in the building or their rooms. EI #1 said, if the resident was caught, there would be no need for an investigation because they were already caught. EI #1 indicated if a resident was caught smoking in the facility, social services should have completed a new smoking evaluation and updated the care plan per the facility's process. EI #1 was then asked what was done in regards to smoking residents who were allowed to keep cigarettes and lighters at all times. EI #1 said there was not a general investigation about this, but said each instance should have been handled through the care plan process for each individual case. EI #1 was asked how she had utilized the information she was made aware of as an opportunity for improvement or to identify problems needing to be addressed. EI #1 acknowledged she was over QAPI at the facility and failed to use the information she did know about, but in hindsight agreed she should have done so. On 04/19/2022 at 11:55 AM, EI #1, Administrator, was asked what oversight she provided to the facility's Behavior Management Committee. EI #1 stated she attended weekly meetings and also attended at other times when asked. EI #1 indicated Social Services was responsible for the facility's Behavior Management Program. When asked what oversight she provided to Social Services regarding their responsibility of the Behavior Management Program, EI #1 said she reviewed the behavior management meeting sign in sheets and attended meetings at times. EI #1 further stated she would make suggestions or answers questions, if she was asked. EI #1 explained that what should occur is that Social Services, Unit Managers and the Director of Nursing should review the Interdisciplinary progress notes, with any behaviors discussed in the morning meetings, and the behaviors added to a monthly flow record (monitoring tool), if warranted. ********** The facility submitted an acceptable removal plan on 04/28/2022 for F835 that outlined the following: Birmingham Nursing and Rehabilitation Center, LLC IJ Removal F835 The president of Aurora Cares, LLC d/b/a [NAME] Cares, LLC (administrative service agreement provider for Birmingham Nursing and Rehabilitation Center, LLC) remotely assisted the executive director, the governing body, QAPI team, and the medical director to review and revise Birmingham Nursing and Rehabilitation Center, LLC's smoking policy. The governing body and executive director were educated on implementing and enforcing the revised smoking policy. This education began and was completed on 4/18/22. The governing body was inserviced by the president of Aurora Cares, LLC d/b/a [NAME] Cares, LLC (administrative service agreement provider for Birmingham Nursing and Rehabilitation Center, LLC.): 1. To provide oversight to facility and be an active-engaged quality assurance member to ensure appropriate actions are taken with smoking non-compliance and to identify any systemic changes needed to prevent any further injury to residents as a result of smoking non-compliance and fire hazards. This was completed 4/18/22. The executive director was inserviced by the governing body on 4/18/22: 1. Ensuring staff consistently implements the facility's revised smoking policy by reviewing all concerns with smoking non-compliance brought forth from the director of nursing's oversight monitoring. 2. The importance of presenting smoking incidents to the quality assurance committee for review and investigation in order to identify system break downs. 3. To present all incidents of smoking non-compliance to the quality assurance committee and to use root-cause analysis to identify casual factors to determine actions needed to prevent further resident safety concerns. 4. Weekly the executive director will notify the governing body of any instance that was referred to the quality assurance committee meeting concerning smoking non-compliance. The governing body will ensure proper quality assurance processes have been followed with each instance. The president of Aurora Cares, LLC d/b/a [NAME] Cares, LLC (administrative service agreement provider for Birmingham Nursing and Rehabilitation Center,LLC.) remotely assisted the executive director and the governing body, the medical director, and the QAPI team on 4/20/22 to review and add an addendum to Birmingham Nursing and Rehabilitation Center, LLC's Behavior Management and Psycho-pharmacological Medication Monitoring Protocol. The executive director has been inserviced on 4/20/22 by the governing body, to provide oversight to ensure staff are implementing the amended policy of Behavior Management and Psycho-pharmacological Medication Monitoring Protocol. The executive director will provide oversight by presenting all incidents of new or worsening behaviors to the quality assurance committee and to use root-cause analysis to identify casual factors to ensure appropriate actions needed to prevent further resident behaviors. Contents will be completed and immediacy will be removed on 4/20/22. On 04/28/2022 at 8:15 PM, after review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 04/20/2022 and the scope and severity was lowered to an F level, to allow the facility time to further address and monitor the deficient practice in order to achieve compliance.

Based on record review, interviews, review of the Social Worker (SW) Job Description, and review of a facility policy titled, Behavior Management and Psycho-pharmacological Medication Monitoring Protocol, the facility failed to ensure Resident Identifier (RI) #s 177, 10, 48, 82, 58, and 59 were placed on a behavior management program. RI #s 177, 10, 48, 82, 58, and 59 were all found to have Nurses' Notes describing unsafe behaviors related to noncompliance with the facility's Smoking Policy. Despite, Social Service involvement in resident evaluations and reviews, Social Services was unaware of resident's behaviors, due to staff failing to notify them of the behaviors. This deficient practice affected RI #s 177, 10, 82, 48, 58, and 59, six of six sampled residents reviewed for noncompliance with smoking policies, and had the potential to affect all 36 smokers in the facility. In addition, these failures placed all 129 residents residing in the facility at risk for immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment, or death. On 04/19/2022 at 1:37 PM, the facility's Administrator (Employee Identifier (EI) #1); the Director of Nursing (EI #4); and a Clinical Operations Consultant (EI #3) were given a copy of the Immediate Jeopardy (IJ) template and were notified of the findings of IJ in the area of Behavioral Health Services, F740. Findings include: Review of Job Descriptions signed by EI #7 and EI #8, SWs, revealed the following: .Essential Duties . 14. Reviews behavior charting so that an appropriate Care Plan is developed . Review of the facility's policy titled SUBJECT: Behavior Management and Psycho-pharmacological Medication Monitoring Protocol, dated 03/2018, revealed the following: .POLICY: . There will be an established Behavior Management Committee that will meet routinely to review .others as the Committee deems appropriate. PURPOSE: Residents with behaviors that are displayed routinely, that effect (affect) the resident's psychosocial well-being or that of other residents, or behaviors that can have potential for harm to self or others will be assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . During the survey, RI #s 177, 10, 48, 82, 58, and 59, were reviewed and found to have documented behaviors related to noncompliance with the facility's smoking policy, that placed them and others at risk. It was determined the facility had not taken actions or implemented additional safety interventions after each of these incidents to prevent further resident safety concerns. Cross reference F656, F689, F835, F837, F867, and F926. On 04/18/2022 at 3:00 PM, EI #7, one of the facility's SWs, was asked about the smoking related behaviors of RI #177, RI #48, RI #10, RI #82, RI #58, and RI #59. When asked how behavior management had been addressed for these smokers with noncompliance, EI #7 said when she first started working at the facility, she was told to address behaviors pertained to medication and had not previously addressed smokers noncompliance as a behavior. EI #7 could not remember who told her that because it was a long time ago. When asked how behavior management and the Psychopharmacological Medication Monitoring Protocol had been utilized for noncompliant smokers, EI #7 said, it was not until recently (last week), when she was informed it should be by EI #3, the Clinical Nurse Consultant, EI #1, the Administrator, and EI #2, the Governing Body. EI #7 said she was told all behavior needed to be indicated on the behavior monitoring forms. EI #7 was asked what system was in place to monitor smoking noncompliance. EI #7 said there had not been a system. EI #7 said there were some care plans but no monthly monitors. When asked what policy, procedure, or protocol there was that directed the staff in how to monitor behaviors, in an effort to implement interventions for prevention of behaviors. EI #7 replied she was only aware of the policy Behavior Management and Psychopharmacological Medication Monitoring Protocol, that did not address monitoring of behaviors. When asked how thoroughly her reviews were conducted of the nurses' notes, EI #7 said it was not thorough enough. EI #7 was asked what could have been done differently if she had reviewed the smoking noncompliance in the nurses notes more thoroughly. EI #7 said the behaviors and incidents would have been addressed more effectively. In review of EI #7's Job Description, EI #7 was asked what was her job responsiblity. EI #7 said she should review behavior charting so appropriate care plan can be developed. When asked how often did she conduct her review. EI #7 said daily and now she was communicating with nursing better. When asked where behavior charting was found. EI #7 said on the monthly behavior flow record and the behavior monitoring summary. EI #7 said she and EI #8, another SW, completed the monitoring summary and prepared the monthly logs. On 04/19/2022 at 9:20 AM, EI #7 was interviewed for follow up questions. EI #7 was asked who was a part of the Behavior Management Committee. EI #7 said the Medical Director, the Nurse Practitioner with the facility's Behavioral Health Company, the Director of Nursing, Social Services, the Administrator, and Unit Managers. EI #7 further stated they met weekly to discuss new admissions and readmissions who are taking [CONDITION(S)] medications, residents with quarterly and annual assessments, and any new behaviors. When asked how new behaviors that need to be addressed are identified, EI #7 said if a nurse does not tell her and she did not see it in the notes, she would not know about the behavior. When asked what system was in place to ensure the Behavior Management Committee is aware of all resident behaviors, EI #7 said she did not see anything in the policy about a system for the team or committee being made aware of all behaviors to include new behaviors. On 04/18/2022 at 4:00 PM, EI #8, the other SW was asked what her understanding was of behavior management with smokers noncompliance. EI #8 said, any noncompliance had to be reported. When asked why the behavior of noncompliant smokers was not addressed through behavior monitoring. EI #8 said she did not know why it was not addressed and she assumed the monthly flow record and monitoring summary were for behaviors addressed by [CONDITION(S)] medications. A follow-up interview was conducted with EI #8 on 04/19/2022 at 11:00 AM. EI #8 stated the Behavior Management Committee consisted of herself , Social Services, Nurses, Dietary, and Treatment Nurses. When asked how often the committee met, EI #8 said ideally every week on Thursday. EI #8 explained the committee met to discuss residents receiving psychoactive medications to discuss their medications and what should be done. EI #8 said other resident behaviors would be discussed as needed. When asked how the committee would know which other resident behaviors to discuss, EI #8 said another department would tell the committee or someone on the committee saw the behavior. EI #8 said she did not review nurses documentation everyday, that usually the nurses tell Social Services about behaviors. On 04/19/2022 at 11:55 AM EI #1, the Administrator, said Social Services, Unit Managers, and the Director of Nursing should review the interdisciplinary progress notes, with any new behaviors discussed in morning meetings, with the Behavior Management Committee and add them to a monthly flow sheet (monitoring tool) if warranted. *********** The facility submitted an acceptable Removal Plan on 04/28/2022 for F740 that outlined the following: Birmingham Nursing and Rehabilitation Center,LLC IJ Removal F740 The president of Aurora Cares,LLC d/b/a [NAME] Cares,LLC (administrative service agreement provider for Birmingham Nursing and Rehabilitation Center, LLC.) remotely assisted the executive director and the governing body, the medical director, and the QAPI team on 4/20/22 to review and add an addendum to Birmingham Nursing and Rehabilitation Center, LLC's Behavior Management and Psycho-pharmacological Medication Monitoring Protocol. The addendum includes: 1. The Behavior Management Committee is comprised of Social Services, Director of Activities, Charge Nurse,Director of Nursing or designee, Consultant Pharmacist, Physician and Mental Health Professional when available. Of those Committee members, the charge nurse is the position that will identify and communicate new or established residents with any new onset or worsening of behaviors. Although the charge nurse is the position that will identify and communicate behaviors, all facility staff are responsible for noting any instances that could potentially be deemed as a new or worsening behavior to be brought to the charge nurse's attention. This will include non-compliance with, but not limited to, smoking, or any other factors that indicate new or worsening stressors of a resident whereas the resident's environment does not promote their individualized emotional and psychosocial well-being. After each identification of new behaviors, communication will be shared from the charge nurse to Social Services through,a communication tool which is the Behavior/Intervention Monthly Flow Record. Social Services will bring every new or worsening identified behavior to review with the behavior management committee weekly. The committee will then address each instance of new or worsening behavior accordingly to develop and implement person-centered care plans that include and support the behavioral health care needs and to develop individualized interventions related to the resident's diagnosed conditions, such as assuring residents have access to community substance use services. The committee will then also address new or worsening behaviors by reviewing and revising behavioral health care plans that have not been effective and/or when the resident has a change in condition. The goal of the committee is to achieve expected improvements or maintain expected stable rate of decline based on the progression of the resident's diagnosed condition. The Behavior Management Committee will utilize the Behavior/Intervention Monthly Flow Record to ensure effective completion of each instance of new or worsening behaviors. 2. In addition to the communication that the Charge Nurse will complete to Social Services through the Stop and Watch Tool, the Charge Nurse will also communicate to the executive director and/or director of nursing via phone or in person after each episode prior to the end of the shift. The director of nursing will review the Stop and Watch Tool, interdisciplinary note, care plan,and the Behavior/Intervention Monthly Flow Record with Social Services to ensure appropriate interventions have been put in place. 3. Further Monitoring will be conducted by the Executive Director monthly upon review of the Behavior Management Committee's findings to ensure any actions needed are being conducted. The Executive Director will ensure that the Behavior Management Committee's findings are thorough, accurate and effective by evaluating that they have addressed each instance of new or worsening behavior accordingly to develop and implement person-centered care plans that include and support the behavioral health care needs and to develop individualized interventions related to the resident's diagnosed conditions, such as assuring residents have access to community substance use services. The Executive Director will also ensure the committee will also address new or worsening behaviors by reviewing behavioral health care plans that have not been effective and/or when the resident has a change in condition. The Executive Director will be responsible for further monitoring each individualized action needed to be taken as a result of each resident behavior. The Executive Director will look for achievement in expected improvements or the maintaining of expected stable rate of decline based on the progression of the resident's diagnosed condition. The executive director has been inserviced on 4/20/22 by the governing body, to provide oversight to ensure staff are implementing the amended policy of Behavior Management and Psycho-pharmacological Medication Monitoring Protocol. The executive director will provide oversight by presenting all incidents of new or worsening behaviors to the quality assurance committee and to use root-cause analysis to identify casual factors to ensure appropriate actions needed to prevent further resident behaviors. The behavior management committee has been inserviced on 4/20/22 by the executive director, on the addendum to the Behavior Management and Psycho-pharmacological Medication Monitoring Protocol. This will ensure behavior monitoring is implemented and effective management of residents with new or worsening behaviors. All staff inserviced by director of nursing and unit managers to reflect that charge nurse is the position that will identify and communicate new or established residents with any new onset or worsening of behaviors. Although the charge nurse is the position that will identify and communicate behaviors, all facility staff are responsible for noting any instances that could potentially be deemed as a new or worsening behavior to be brought to the charge nurse's attention by completing the Stop and Watch Tool. This will include non-compliance with, but not limited to, smoking, or any other factors that indicate new or worsening stressors of a resident whereas the resident's environment does not promote their individualized emotional and psychosocial well-being. This will be completed by 4/21/22. Any employee that fails to be educated by 4/21/22 will be suspended from work until education has been completed. Residents who smoke have been reviewed to ensure each resident with non-compliance was placed on the Behavior/Intervention Monthly Flow Record by social services and completed 4/21/22. Contents will be completed and immediacy will be removed on 4/21/22. On 04/28/2022 at 8:15 PM, after review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 04/21/2022 and the scope and severity was lowered to an F level, to allow the facility time to further address and monitor the deficient practice in order to achieve compliance.

Based on interview and review of Employee Identifier (EI) #2's (Vice President of the facility's management company and member of the governing body) job description, the governing body failed to provide oversight to facility staff to ensure appropriate actions were taken following a fire on 03/26/2022 in which Resident Identifier (RI) #177 ignited his/her bedding and body while smoking in bed. While an investigation was done at the facility level, the facility failed to review and consider all pertinent resident records and facility systems related to resident smoking policies. As a result, the facility did not identify all actions and/or systemic changes needed to prevent any further injuries to residents as a result of smoking noncompliance and fire hazards. This deficient practice placed all residents in the facility at risk for immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment, or death. The facility Form CMS-672 listed a facility census of 129 at the time of the survey. On 04/14/2022 at 7:05 PM, the facility's Administrator (Employee Identifier (EI) #1); the Vice President of the facility's management company/member of the Governing Body (EI #2); the facility's Director of Nursing (EI #5); and a Human Resources Representative (EI #43) were given a copy of the Immediate Jeopardy (IJ) template and were notified of the findings of IJ in the area of Governing Body, F837. Findings include: Cross Reference F656, F689, F740, F835, F867 and F926. Review of EI #2's Job Description revealed the following: . Job Title: Vice President . Standard Requirements . 3. Supports and participates in common teamwork . d. follows up as appropriate with supervisor, co-workers, and/or staff regarding reported complaints, problems, and concerns . EI #2 was interviewed on 04/13/2022 at 1:00 PM. EI #2 identified her role as the Vice President of the facility's management company, and indicated governing body was part of the agreement. EI #2 indicated they provide consulting to the facility and do mock surveys. When asked what concerns she was aware of in regards to the facility's smoking policy and systems, EI #2 said the only problem she knew about was that residents were noncompliant. When asked what she had instructed or advised the facility to do regarding their smokers over the last year, EI #2 said she had not instructed the facility in any way, and said her assistance was not requested until 03/26/2022. EI #2 stated she had reviewed QAPI to ensure they were having meetings, reviewed to ensure appropriate attendees were present for the QAPI meetings. During a follow-up interview with EI #2 on 04/14/2022 at 10:32 AM, EI #2 was asked for all individuals that comprised the governing body for the facility. EI #2 stated she was the only member of the governing body for the facility. EI #2 was then asked, as the governing body of the facility, what oversight she provides to the facility and staff. EI #2 said as the governing body, she checks to ensure the facility has systems in place to run the facility and assists with any issues, if asked to assist. EI #2 denied being made aware of any issues, other than the fire on 03/26/2022. EI #2 further stated she was aware the facility had a large number of smokers, but said she expected the facility to enforce the smoking policy. When asked about the facility's practices regarding smoking materials and lighters, EI #2 said she was not aware the facility was not taking those items up after waking hours, as the policy specified. EI #2 further explained that she knows the facility was not handling it as the policy said, and indicated each resident should be evaluated individually to determine their independence level. When asked when she had become aware of these concerns, EI #2 said she did not know. When questioned regarding the facility's SMOKING SAFETY EVALUATION tool, EI #2 said she had no concerns with the tool. EI #2 was then asked what training the staff had been provided regarding use of the smoking evaluation tool. EI #2 said the evaluation was self-explanatory if staff read the assessment. When discussing missing answers on the evaluations, and history not being captured, EI #2 agreed the evaluations should be complete and accurate. EI #2 agreed residents should be re-evaluated for smoking abilities following any smoking-related incident, because the evaluations help in the development of the residents' care plans. When asked how often she visited the facility, EI #2 said she was usually at the facility one time per month, but said she has no involvement in their Quality Assurance and Process Improvement Committee. On 04/15/2022 at 3:42 PM EI #2 was asked what was addressed during the 03/26/2022 QAPI meeting, regarding the fire involving Resident Identifier (RI) #177. EI #2 said the administrator and the team had a meeting on 03/26/2022 and 04/01/2022. EI #2 said their focus was on ensuring the lighters were taken from residents. When asked what involvement she had with the facility's post-incident actions, EI #2 said EI #1, the Administrator, had called her the morning of the fire. EI #2 said she came to assist the facility. EI #2 said her assistance consisted of reviewing video footage to ensure timely response to the fire. *********** The facility submitted an acceptable removal plan addressing F837 on 04/28/2022 that outlined the following: Birmingham Nursing and Rehabilitation Center, LLC IJ Removal F837 The president of Aurora Cares,LLC d/b/a [NAME] Cares,LLC (administrative service agreement provider for Birmingham Nursing and Rehabilitation Center, LLC) remotely assisted the executive director, the governing body, QAPI team, and the medical director to review and revise Birmingham Nursing and Rehabilitation Center, LLC's smoking policy on 4/16/22 and 4/18/22. The governing body and executive director were educated on implementing and enforcing the revised smoking policy. This education began and was completed on 4/18/22. The governing body was inserviced by the president of Aurora Cares, LLC d/b/a [NAME] Cares, LLC (administrative service agreement provider for Birmingham Nursing and Rehabilitation Center,LLC.): 1. To provide oversight to facility and be an active-engaged quality assurance member to ensure appropriate actions are taken with smoking non-compliance and to identify any systemic changes needed to prevent any further injury to residents as a result of smoking non-compliance and fire hazards. This was completed 4/18/22. 2. Weekly the executive director will notify the governing body of any instance that was referred to the quality assurance committee meeting concerning smoking non-compliance. The governing body will ensure proper quality assurance processes have been followed with each instance. The executive director was inserviced by the governing body on 4/18/22: 1. Ensuring staff consistently implements the facility's revised smoking policy by reviewing all concerns with smoking non-compliance brought forth from the director of nursing's oversight monitoring. 2. The importance of presenting smoking incidents to the quality assurance committee for review and investigation in order to identify system break downs. 3. To present all incidents of smoking non-compliance to the quality assurance committee and to use root-cause analysis to identify casual factors to determine actions needed to prevent further resident safety concerns. Contents will be completed and immediacy will be removed on 4/18/22. On 04/28/2022 at 8:15 PM, after review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 04/18/2022 and the scope and severity was lowered to an F level, to allow the facility time to further address and monitor the deficient practice in order to achieve compliance.

Based on interviews and review of the facility's policy titled Subject: Smoking, the facility failed to develop and implement a smoking policy that defined smoking times, identified designated smoking areas, outlined a system for smoking material storage, addressed noncompliance, provided instructions for the use of the facility's Smoking Evaluation tool, and the development of related person-centered care plans. This failure placed all residents in the facility at risk for immediate jeopardy, as these failures were likely to result in serious injury, serious harm, serious impairment, or death. The facility Form CMS-672 listed a facility census of 129 at the time of the survey. On 04/22/2022 at 12:03 PM, the facility's Administrator (Employee Identifier (EI) #1); the Vice President of the facility's management company/member of the Governing Body (EI #2); and a Clinical Operations Nurse Consultant (EI #3) were given a copy of the Immediate Jeopardy (IJ) template and were notified of the findings of IJ in the area of Smoking Policies, F926. Findings include: Review of the facility's policy titled SUBJECT: SMOKING, last reviewed 11/2017, revealed the following: POLICY: This is a smoke-free facility. No smoking or use of smoking materials will be allowed inside the building . Smoking is to occur only in designated areas and in accordance with each smoking resident's individualized plan of care based on the Smoking Safety Evaluation. POLICY STATEMENT: It is not the intention of this facility to deprive residents of the pleasure of smoking, but rather to offer a safe and comfortable environment to all residents living in the facility. Both smoking and non-smoking residents will be considered in the development of smoking locations and designated times. RESPONSIBILITY: All staff, monitored by management. PROCEDURE: 1. All residents who smoke will be assessed for his or her ability to smoke safely, the ability to handle smoking material and the need for supervision while smoking. The Smoking Safety Evaluation will be completed upon admission, readmission, quarterly, annually, and as needed. Residents that are evaluated as independent with smoking: (and/or without history of smoking incidents; needing no interventions) will be permitted to keep and maintain their own smoking materials (i.e. cigarettes, e-cigarettes), and may smoke in designated areas without limitations. The resident may be permitted to keep fire materials on his/her person during waking hours if deemed appropriate per the smoking evaluation. Smoking materials not kept or maintained by resident will be maintained by Licensed Nurse. Residents found to have modified independence with smoking: may be subject to smoking limitations. Limitations may include, but are not limited to: facility storage of tobacco products and/or fire materials, designated smoking times, assistance with lighting tobacco products, assistance to hold cigarette, supervised smoking by staff, and/or other protective/safety measures as determined appropriate by the individualized plan of care based on the smoking evaluation . 3. Smoking is only permitted in designated smoking areas with reasonable smoking times to be designated by the facility. .b. No smoking material will be disposed of in waste cans, floors, or any other inappropriate area. .f. Smoking areas are to be maintained in such a manner that minimizes risk for fire hazards. . 5. Violation of the smoking policy may result in discharge from the facility . The Smoking Policy also included an Addendum: Smoking Policy E8, dated 03/26/2022, the date of the fire, that listed the following: No resident will be allowed to keep a lighter, matches, or any other flame producing product used to light a cigarette in the room. Igniting materials will be secured at the nurses station. Smoking times will be enforced for all residents from 8am until 10pm on the even hours. Violation of this policy may result in discharge from the facility. Neither the facility policy or the addendum identified where the designated smoking areas were or how staff should utilize the Smoking Safety Evaluations to develop individualized care plan interventions. Further, the policy did not specify what actions staff should take upon identification of a resident who is noncompliant with the facility's smoking policy; nor did it indicate who was responsible for securing the residents' lighters and/or any other flame producing materials or a system for monitoring to ensure residents did not have access to their lighters while inside the facility. Cross Reference F656, F689, F740, F835, F837, and F867. ********** The facility submitted an acceptable Removal Plan for F926 on 04/28/2022 that outlined the following: Birmingham Nursing and Rehabilitation, LLC IJ Removal F926 The president of Aurora Cares, LLC d/b/a [NAME] Cares, LLC (administrative service agreement provider for Birmingham Nursing and Rehabilitation Center, LLC.) remotely assisted the executive director and the governing body, the medical director, and the QAPI team on 4/16/22 and 4/18/22 to review and develop Birmingham Nursing and Rehabilitation Center, LLC's revised smoking policy. All revisions that were made to the smoking policy are listed below: 1. All residents who smoke will be assessed for his/her ability to smoke safely, the ability to handle smoking materials, and the need for supervision while smoking. The revised smoking evaluation tool will be completed upon admission, re-admission, quarterly, annually, and on any instances of smoking non-compliance. 2. Signs that prohibit smoking in the facility will be prominently placed at all building entrances that are used by residents, staff and visitors. a. Staff will be informed of this policy at the time of hire. Current staff are being inserviced on the revisions of the smoking policy. Inservices will be completed on 4/19/22. Residents who smoke were informed of the revisions to the smoking policy in a resident council meeting held on 4/18/22 by the executive director, social services, and director of nursing. Resident responsible party (of residents who smoke) will be notified by letter mailed on 4/19/22. b. Residents or their appointed representatives, as appropriate, will be informed of this policy upon admission to the facility. c. This policy will be continuously communicated to visitors found smoking or using smoking materials in the building or in non-designated areas. 3. Smoking is only permitted in the enclosed courtyard. Resident smoking times are daily beginning at 8:00 AM, 10:00 AM, 12:00 Noon, 2:00 PM, 4:00 PM, 6:00 PM, 8:00 PM, and ending at 10:00 PM. a. The enclosed courtyard will be provided with a fireproof ashtray in which all smoking material will be disposed. b. No smoking material will be disposed of in waste cans, floors or any other inappropriate area. c. Ashtrays can only be emptied by staff into a fireproof metal container. d. No flammable liquid or combustible gases may be taken into the smoking areas. e. Use of oxygen in smoking areas and while smoking is not permitted. f. Smoking areas are to be maintained in such a manner that minimizes risk for fire hazards. 4. Tobacco/e-cigarettes are the only smoking product that is permitted at the facility. No illegal substances are permitted. If any resident is found in possession of any illegal substances, the charge nurse will immediately confiscate the illegal substance and notify the Birmingham Police Department. 5. The facility assumes no responsibility for any incidents relating to smoking that may occur while the resident is out on pass. 6. All residents who smoke will be supervised by an assigned and trained staff member. It will be no less than one trained staff member in the enclosed courtyard at all designated smoking times. There will be one trained staff member in the enclosed courtyard for every twelve smoking residents. There will be one additional trained staff member in the enclosed courtyard at the designated smoking times for each resident that requires assistance of one. 7. Residents will not be allowed to keep any smoking materials. 8. Any suspected non-compliance or non-compliance with the smoking policy will be reported to the charge nurse by any staff member immediately. The charge nurse will ensure the safety of residents when non-compliance occurs by removing all smoking materials. 9. The charge nurse will document and record non-compliance or suspected non-compliance in the medical record and on the 24 hour report sheet. The charge nurse will notify the executive director and/or director of nursing via phone or in person after each episode prior to the end of the shift to inform of suspected non-compliance or non-compliance of smoking policy. The director of nursing will make a referral to the behavior management committee. 10. Resident will be re-evaluated for the ability to smoke safely via revised smoking evaluation tool. The care plan will be reviewed and revised to reflect resident safety needs at the time of the occurrence by the charge nurse. 11. All episodes of non-compliance will be reviewed by the quality assurance committee using root¿ cause analysis to identify casual factors to determine actions needed to prevent further safety concerns. 12. Consequences of non-compliance will result in revocation of smoking privileges until the quality assurance team has determined an individualized intervention. 13. The facility will secure all smoking materials in a locked box kept at the nurse's station. Residents who smoke will be provided smoking materials at the designated smoking times by the assigned trained staff member. Smoking materials will only be lit by the staff member. Residents who refuse to comply with individualized-smoking-safety interventions will not be allowed to smoke. The resident responsible party and the medical director will be notified. Residents who smoke will be checked every shift by the charge nurse for possession of any smoking materials, including flame producing items. The governing body and executive director were educated on implementing and enforcing the smoking policy by the president of Aurora Cares, LLC d/b/a [NAME] Cares, LLC (administrative service agreement provider for Birmingham Nursing and Rehabilitation Center, LLC.). This education began and was completed on 4/16/22. The governing body and executive director were educated on implementing and enforcing the revisions to the smoking policy by the president of Aurora Cares, LLC d/b/a [NAME] Cares, LLC (administrative service agreement provider for Birmingham Nursing and Rehabilitation Center, LLC.). This education began and was completed on 4/18/22. The director of nursing and unit mangers were inserviced by the executive director on the smoking policy. This education began and was completed on 4/16/22. The director of nursing and unit mangers were inserviced by the executive director on the revised smoking policy. This education began and was completed on 4/18/22. All staff will be educated on Birmingham Nursing and Rehabilitation Center, LLC's revised smoking policy and to include: all residents must be supervised, when staff is supervising smoking, they will ensure resident safety by observing dropping of ashes, lighting resident smoking material, and ensuring smoking materials are extinguished in the correct receptacle, distributing and collecting all smoking products, how to identify and manage suspected or observed non-compliance with the smoking policy by the executive director, director of nursing, and unit managers. This education was completed on 4/17/22 and on 4/19/22. The facility has 121 employees. All employees will receive education and will be completed by 4/19/22. Any employee that fails to be educated by 4/19/22 will be suspended from work until education has been completed. The president of Aurora Cares, LLC d/b/a [NAME] Cares, LLC (administrative service agreement provider for Birmingham Nursing and Rehabilitation Center, LLC.) remotely assisted the executive director and the governing body to review and develop Birmingham Nursing and Rehabilitation Center, LLC's revised smoking evaluation tool on 4/18/22. The revised smoking evaluation tool was approved by the QAPI committee and the medical director on 4/18/22. The governing body and executive director were inserviced by the president of Aurora Cares, LLC d/b/a [NAME] Cares, LLC (administrative service agreement provider for Birmingham Nursing and Rehabilitation Center, LLC.) 1. How to accurately complete the revised smoking evaluation tool to include where to obtain the information needed to complete the form accurately. This was started and completed on 4/18/22. 2. How to utilize the revised smoking evaluation tool to ensure the information obtained through the revised smoking evaluation tool is utilized in a manner to allow staff to develop and implement person-centered safety interventions for residents who smoke. The executive director has inserviced the director of nursing and unit managers: 1. How to accurately complete the revised smoking evaluation tool to include where to obtain the information needed to complete the form accurately. This was started and completed 4/18/22. 2. How to utilize the revised smoking evaluation tool to ensure the information obtained through the revised smoking evaluation tool is utilized in a manner to allow staff to develop and implement person-centered safety interventions for residents who smoke. This was started and completed 4/18/22. All licensed nurses and social services will be inserviced by the director of nursing and/or unit managers to include where to obtain the information needed to complete the revised smoking evaluation tool accurately. This education started on and was completed on 4/18/22. 1. How to accurately complete the revised smoking evaluation tool with instruction form. 2. How to utilize the revised smoking evaluation tool to ensure the information obtained through the revised smoking evaluation tool is utilized in a manner to allow staff to develop and implement person-centered safety interventions for residents who smoke. a. The licensed nurse is to complete the revised smoking evaluation tool on admission, re¿ admission, quarterly, annually, and for non-compliance with the revised smoking policy. The charge nurse will use the information from the revised smoking evaluation tool to update the care plan with any necessary interventions. b. By the next business day, a member of the interdisciplinary team will review the completed revised smoking evaluation tool for accuracy. 3. Licensed nurses will be trained to document all instances of suspected smoking non-compliance or non-compliance in the nurse's notes and 24 hour report to be communicated to the executive director and/or director of nursing by phone or in-person after each episode prior to the end of the shift. The director of nursing will make a referral to the behavior management committee. Licensed nurses will be trained to ensure residents do not have any smoking materials. Residents will be checked each shift for smoking materials and will be documented on the medication administration record. If residents are found to have smoking materials or are non-compliant with smoking, the nurse will remove all smoking products and notify the director of nursing and/or executive director by phone or in-person after each episode prior to the end of the shift and document in the nurse's notes and 24 hour report. The director of nursing will make a referral to the behavior management committee. As a systemic change, the director of nursing will provide oversight to ensure the revised smoking policy is followed, for accuracy of the revised smoking evaluation tool and implementation of care plans on admission, quarterly, annually, and suspected non-compliance or non-compliance and will report findings to the executive director via phone or in person after each episode prior to the end of the shift. The director of nursing will make a referral to the behavior management committee. The director nursing and/or assistant director of nursing will monitor by reviewing the nurse's note for residents who smoke and 24 hour reports five times per week and revise smoking evaluation and care plan as necessary to prevent further resident safety concerns. Each Monday, the director of nursing and/or assistant director of nursing will review nurse's notes for residents who smoke and 24 hour report for Saturday and Sunday. The revised smoking evaluation tool was completed on 100% of all residents who smoke and the care plan was reviewed and revised with any changes on 4/18/22. Contents will be completed and immediacy will be removed on 4/19/22. On 04/28/2022 at 8:15 PM, after review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 04/19/2022 and the scope and severity was lowered to an F level, to allow the facility time to further address and monitor the deficient practice in order to achieve compliance.

Based on observation, record review, interviews, review of the facility's investigative file related to a fire involving Resident Identifier (RI) #177, and review of the facility's policy titled SUBJECT: SMOKING, the facility failed to accurately and completely conduct SMOKING SAFETY EVALUATION(s) in accordance with facility policy. Further, the facility failed to ensure the information obtained through the SMOKING SAFETY EVALUATION(s) was utilized in a manner to allow staff to develop, implement and revise person-centered safety interventions for RI #s 177, 10, 82, 48, 58, and 59, six of six sampled residents reviewed for smoking safety. All six of these residents were found to have documented episodes of noncompliance with the facility's smoking policy, including smoking inside the facility unsupervised in the hallway, residents' rooms and/or bathrooms or going to the smoking area unsupervised at non-designated smoking times. The staff members who documented the noncompliant actions of the residents failed to communicate all incidents to management as directed by the residents' smoking care plans; nor did the facility ensure additional actions were taken to ensure proper safety interventions and policies to promote resident safety were in place, including supervision and monitoring, as well as systems to ensure noncompliant residents did not have access to lighters inside the facility structure. On 03/26/2022, RI #177, a resident with a documented history of smoking noncompliance, was in possession of his/her smoking materials and lighter, and subsequently ignited his/her bedding and body. After staff became aware, they extinguished the flames, rendered necessary aid, and RI #177 was sent to the hospital where he/she was found to have third degree [CONDITION(S)] covering 10-19% of his/her body. Further, during the survey, RI #10, a resident with right sided [CONDITION(S)], who was assessed as requiring minimal supervision and the use of a smoking apron, was observed outside smoking on multiple occasions. During these observations, RI #10 did not have a smoking apron on and was observed to drop ashes from a lit cigarette onto his/her clothing. The staff present at the time of these observations did not acknowledge or intervene. RI #82's documentation reflected staff suspicion of RI #82 smoking inside the resident's room, as well as going outside to smoke unsupervised at non-designated times. RI #48's documentation reflected a history of smoking inside his/her room and in the bathroom. RI #58's documentation reflected staff suspicion of RI #58 smoking in his/her room, finding medicine cups with water and ashes on multiple occasions at RI #58's bedside, finding a lighter at the bedside with oxygen in the room and going outside to smoke unsupervised at non-designated times. RI #59's documentation reflected RI #59 had a history of going out to smoke at non-designated times and walking in the hallway or other areas inside the facility with a lit cigarette or cigar. These failures placed RI #s 177, 10, 82, 48, 58, and 59, as well as all remaining residents in the facility at risk for immediate jeopardy, as these failures were likely to result in serious injury, serious harm, serious impairment, or death. The facility Form CMS-672 listed a facility census of 129 at the time of the survey. On 04/14/2022 at 7:05 PM, the facility's Administrator (Employee Identifier (EI) #1); the Vice President of the facility's management company/member of the Governing Body (EI #2); the facility's Director of Nursing (EI #5); and a Human Resources Representative (EI #43) were given a copy of the Immediate Jeopardy (IJ) template and were notified of the findings of IJ in the area of Accident Hazards/Supervision/Devices, F689. Findings include: Cross reference F656, F740, F835, F837, F867, and F926. Review of the Alabama Department of Public Health (ADPH) Online Incident Reporting System revealed EI #1, the facility Administrator, reported a Fire / Smoke incident to ADPH on 03/26/2022 at 10:05 AM. This initial report indicated the incident occurred on 03/26/2022 at 7:20 AM. According to the initial report, RI #177 was found with active flames in his/her bed, and after the fire was extinguished, was transferred to a local hospital for evaluation. The facility's investigative summary related to this incident documented RI #177's roommate, RI #108, exited their room and yelled for a nurse, alerting staff there was a fire. EI #23, a Licensed Practical Nurse (LPN), ran to the room and found RI #177 in bed with his/her torso, groin and arms ablaze. After staff extinguished the resident and attended to his/her immediate needs, including cutting off smoldering clothing, RI #177 was transferred to a local hospital for evaluation and treatment. The facility's summary documented, Facility and fire department is in agreement that resident had smoked in bed and cigarette fell into bed causing linens and clothing to catch fire. The facility's investigative summary attributed the fire to RI #177's non-compliance with the smoking policy; further, the summary documented RI #177 had never been noncompliant with smoking rules since he was admitted to the facility on [DATE] .that (the) facility was made aware of . The summary did state that during the course of the investigation some staff made comments regarding prior suspicion of RI #177 smoking in his/her room; however, there were no interviews or statements contained in the facility's investigative file to support this statement. Review of the facility's policy titled SUBJECT: SMOKING, last reviewed 11/2017, revealed the following: POLICY: This is a smoke-free facility. No smoking or use of smoking materials will be allowed inside the building . Smoking is to occur only in designated areas and in accordance with each smoking resident's individualized plan of care based on the Smoking Safety Evaluation. POLICY STATEMENT: It is not the intention of this facility to deprive residents of the pleasure of smoking, but rather to offer a safe and comfortable environment to all residents living in the facility. Both smoking and non-smoking residents will be considered in the development of smoking locations and designated times. RESPONSIBILITY: All staff, monitored by management. PROCEDURE: 1. All residents who smoke will be assessed for his or her ability to smoke safely, the ability to handle smoking material and the need for supervision while smoking. The Smoking Safety Evaluation will be completed upon admission, readmission, quarterly, annually, and as needed. Residents that are evaluated as independent with smoking: (and/or without history of smoking incidents; needing no interventions) will be permitted to keep and maintain their own smoking materials (i.e. cigarettes, e-cigarettes), and may smoke in designated areas without limitations. The resident may be permitted to keep fire materials on his/her person during waking hours if deemed appropriate per the smoking evaluation. Smoking materials not kept or maintained by resident will be maintained by Licensed Nurse. Residents found to have modified independence with smoking: may be subject to smoking limitations. Limitations may include, but are not limited to: facility storage of tobacco products and/or fire materials, designated smoking times, assistance with lighting tobacco products, assistance to hold cigarette, supervised smoking by staff, and/or other protective/safety measures as determined appropriate by the individualized plan of care based on the smoking evaluation . 3. Smoking is only permitted in designated smoking areas with reasonable smoking times to be designated by the facility. .b. No smoking material will be disposed of in waste cans, floors, or any other inappropriate area. .f. Smoking areas are to be maintained in such a manner that minimizes risk for fire hazards. . 5. Violation of the smoking policy may result in discharge from the facility . The Smoking Policy also included an Addendum: Smoking Policy E8, dated 03/26/2022, the date of the fire, that listed the following: No resident will be allowed to keep a lighter, matches, or any other flame producing product used to light a cigarette in the room. Igniting materials will be secured at the nurses station. Smoking times will be enforced for all residents from 8am until 10pm on the even hours. Violation of this policy may result in discharge from the facility. Neither the facility policy or the 03/26/2022 addendum identified where the designated smoking areas were or how staff should utilize the Smoking Safety Evaluations to develop individualized care plan interventions. Further, the policy did not specify what actions staff should take upon identification of a resident who is noncompliant with the facility's smoking policy; nor did it indicate who was responsible for securing the residents' lighters and/or any other flame producing materials or a system for monitoring to ensure residents did not have access to their lighters while inside the facility. 1. RI #177 was originally admitted to the facility on [DATE] with diagnoses including [CONDITION(S)], Diabetes Mellitus Type 2, [CONDITION(S)], Cerebral Infarction, Dysphasia, and [CONDITION(S)]. RI #177's admission SMOKING SAFETY EVALUATION was completed on 05/18/2021. The section of this evaluation for Diagnosis Impacting Ability to Smoke was marked as None. The evaluation did not capture RI #177's diagnoses of [CONDITION(S)] or [CONDITION(S)], despite having a section for Neurological diagnoses. The evaluation indicated RI #177 was independent with cognitive skills for decision making, had no indicators of [CONDITION(S)], and had clear speech. The following questions were not answered: Is the resident able to communicate the need for help if lit material falls on them? and Is resident able to move without assistance to/from designated smoking area? The section of the evaluation titled HISTORY indicated RI #177 could self-extinguish cigarettes and was able to manage ashes. The Fire Safety section indicated RI #177 attempted to obtain lighters or matches and lighter/matches had been obtained from an outside source. History of Smoking Related Incidents was marked as No. Staff assessed RI #177 as an independent smoker, that required no supervision, assistance, or storage of smoking materials. The question for Care Plan Concern? was marked Yes. This evaluation was signed on 05/18/2021 by EI #26, LPN, and the following day by EI #44, the facility's prior Social Worker (SW). Review of RI #177's comprehensive care plans revealed a care plan for .Problem Onset: 05/18/2021 I enjoy smoking and has been assessed to be a smoker. Approaches listed included the following: - complete smoking assessment as needed - educate resident/family regarding facility smoking policy - show resident where appropriate smoking area is located - observe resident for unsafe smoking habits. If unsafe smoking habits are observed, notify mgmt (management) immediately - educate resident to extinguish smoking materials in appropriate container before leaving smoking area. On 05/19/2021 RI #177's Departmental Notes documented the following: . 8:21 AM . Resident alert to person at times responds slowly to commands. inquired to this nurse of smoke assignment times at 3 am 4am smelled smoke resident had smoked while in room inbed (in bed). Asked resident to let me keep cigarettes until assigned times . This note was made by EI #12, LPN. Review of RI #177's SMOKING SAFETY EVALUATIONS and comprehensive care plans revealed no new smoking evaluation or care plan updates or revisions were made following this documented incident of smoking non-compliance. EI #12 was interviewed on 04/01/2022 at 8:08 AM. When asked when she had seen RI #177 smoking in his/her room, EI #12 said it had happened shortly after admission in May 2021. EI #12 said she never saw a cigarette in RI #177's hand but there was smoke in the room EI #12 indicated she took his/her cigarettes and lighter. When asked how RI #177 got his/her cigarettes and lighter back, EI #12 said she did not know, and she assumed another nurse must have given them back to RI #177. EI #12 stated she documented this incident in the nurse's notes and notified the oncoming shift. When asked about diagnoses impacting residents' ability to safely smoke, EI #12 explained a resident with [CONDITION(S)] and a history of [CONDITION(S)] would not be safe to have cigarettes and lighters unsupervised. EI #12 then confirmed RI #177 had both of these diagnoses and said RI #177 should not have been deemed an independent smoker or had cigarettes and lighters in his/her room unsupervised. During a follow-up interview with EI #12 on 04/02/2022 at 9:53 AM, EI #12 was asked who had seen her documentation related to RI #177 smoking in his/her room. EI #12 said she guessed everyone should have seen it. EI #12 further stated she did not know she was supposed to conduct another Smoking Safety Evaluation after this occurrence. EI #12 acknowledged RI #177's smoking care plan did not address the storage of the resident's cigarettes, lighters, or other smoking materials, but said in her opinion residents should not be allowed to have them, but it depended upon the facility. When asked how often the smoking care plan should be updated, EI #12 said after every incident. EI #12 was asked who she had reported the incident of finding RI #177 smoking in his/her room to. EI #12 said she had reported this incident to EI #6, the facility's prior Director of Nursing (DON). EI #6 was interviewed on 04/02/2022 at 2:42 PM. When asked what she could recall about RI #177, EI #6 stated she had spoken with the resident numerous times, regarding different cases of noncompliance. EI #6 stated she did recall being informed of RI #177 smoking in his/her room, but could not recall who told her. She only recalled one incident when RI #177 had COVID (01/31-02/09/2022) and staff informed her he/she was smoking in his/her room. When asked what staff should do when they find a resident to be smoking in their room, EI #6 stated the staff should retrieve the smoking materials from the resident, educate the resident, and notify management so that the incident can be addressed on the care plan and rounds can be made. EI #6 stated residents that were noncompliant with the facility's smoking policy should have their smoking materials kept on the nurse's cart. EI #6 also stated RI #177's care plan should have been updated after staff suspected he/she was smoking in the room to reflect the suspicion of the resident smoking in the room with an intervention added to keep the smoking materials on the cart. In addition, EI #6 said Social Services should have been made aware so they could reassess the resident for smoking safety. EI #6 confirmed that any resident suspected of smoking in their room should not be allowed to keep a lighter. EI #6 also stated a resident with [CONDITION(S)] and diabetes would be unsafe to smoke independently. A follow-up interview was conducted on 04/06/2022 at 7:53 AM with EI #12, the LPN who noted RI #177 smoking in his/her room on 05/19/2021. When asked what she did when she realized RI #177 had somehow obtained his cigarettes and lighter again, EI #12 said nothing, because she knew to keep an eye on him. When asked if she had questioned anyone about RI #177 having these items in his/her possession again, EI #12 said she asked another nurse why they had been returned to the resident and was informed it was the residents' right to have their cigarettes and lighters. EI #12 said she thought someone in management may have okayed RI #177 to have his cigarettes and lighter again, but said she had not questioned them about it to find out for sure. On 05/31/2021 RI #177's Departmental Notes documented the following: . 4:17 AM . At approx (approximately) 0400 am resident was suspected of smoking cigarettes in staff bathroom . This note was made by EI #15, Registered Nurse (RN). Review of RI #177's SMOKING SAFETY EVALUATIONS and comprehensive care plans revealed no new smoking evaluation or care plan updates or revisions were made following this documented incident of smoking non-compliance. EI #15 was interviewed on 04/10/2022 at 7:08 AM. EI #15 was asked what unsafe smoking habits on the care plan referred to, and EI #15 stated smoking in their room, carrying a lit cigarette down the hall, smoking in the bathroom, playing with lighters and/or matches and smoking around oxygen would all be considered examples of unsafe smoking habits. When asked what should be done if she witnesses unsafe smoking habits, EI #15 said if the resident had a lit cigarette, she would approach and ask them to put it out, educate them on the smoking policy, and ask the resident to surrender their cigarettes and lighter. When asked if she had ever seen or suspected a resident of smoking inside the facility, EI #15 said yes, RI #177. EI #15 was asked what the facility's smoking times were prior to the fire on 3/26/2022, and EI #15 said she was not sure because the Certified Nursing Assistants (CNAs) handled that. EI #15 further stated that prior to 03/26/2022 the residents were allowed to keep their lighters, because no one took them up. EI #15 was asked about the note she made on 05/31/2021 regarding RI #177 smoking in the employee bathroom. EI #15 said RI #177 denied smoking in the employee bathroom, but she requested his/her lighter anyway. EI #15 stated RI #177 refused to comply with surrendering the lighter. When asked what management she reported this to and what their response was, EI #15 said she did not remember. When asked if RI #177's Smoking Safety Evaluation had been updated following this incident, EI #15 said she did not update it, because Social Services is responsible for that. However, EI #15 said she did not report this to Social Services because after she documented it and reported to someone (who she could not recall), her part was over. Further, when asked about care plan revisions or updates following this incident, EI #15 again stated that would be Social Services responsibility. EI #15 was then asked what concerns she would have with a resident smoking inside the facility. EI #15 said they could injure themselves, set the place on fire, or blow the place up with oxygen. On 06/09/2021 RI #177's Departmental Notes documented the following: . 2:45 AM . Resident outside smoking with other residents aware of resident's behavior and inability to comply with BNRC (Birmingham Nursing and Rehabilitation Center) policies and residents rights . This note was made by EI #12, LPN. Review of RI #177's SMOKING SAFETY EVALUATIONS and comprehensive care plans revealed no new smoking evaluation or care plan updates or revisions were made following this documented incident of smoking non-compliance. EI #12 was interviewed regarding her 06/09/2021 note on 04/06/2022 at 7:53 AM. EI #12 confirmed she had found RI #177 going outside to smoke at non-designated times. EI #12 said staff would tell RI #177 not to go outside at non-designated times without staff knowing, but he would do it anyway. EI #12 stated RI #177 was noncompliant with smoking times, and was also known to smoke in his/her room. EI #12 stated she felt RI #177 was just following the same pattern he/she saw other smoking residents doing. EI #12 said she was not even sure who all of the smokers were. When discussing RI #177's care plan, EI #12 said there was an intervention to notify management of unsafe smoking habits immediately but she had not done so because she was caring for other residents. EI #12 further stated RI #177 should have been identified as an unsafe smoker, the first time he/she was caught smoking in his/her room, especially considering RI #177's diagnoses. On 08/04/2021 RI #177's Departmental Notes documented the following: . 1:40 PM . Resident .was noted smoking cigarettes in (his/her) room, this writer and (EI #10, RN) asked resident if (he/she) was smoking and (he/she) said yes, cigarettes were turned over to these two nurses 2 (two) small butts in a pack, resident given smoking rules again . This note was made by EI #29, RN. Review of RI #177's SMOKING SAFETY EVALUATIONS and comprehensive care plans revealed no new smoking evaluation or care plan updates or revisions were made following this documented incident of smoking non-compliance. EI #29 was interviewed on 04/06/2022 at 9:21 AM regarding her 08/04/2021 note. EI #29 said she did not see RI #177 actually smoking a cigarette that day but the smell was very strong and he/she had admitted to her and EI #10 that he/she was smoking in the room. EI #29 said they did confiscate RI #177's lighter and a pack with two cigarette butts in it at that time. When questioned about RI #177's care plan intervention to report unsafe smoking habits to management, EI #29 stated she did not know how anyone would know what that meant or what to look for. EI #29 said she did not write RI #177's care plan, but it should be more specific. She further indicated RI #177's smoking care plan was not complete and should have included more information. EI #29 said the care plan should identify the resident's problems and include steps staff should take for the resident. EI #29 said the care plan was important for staff to know what is expected of them. EI #29 said she had reported this incident to management because she did report it to EI #10, who was part of management. EI #29 said EI #10 did go into RI #177's room with her on 08/04/2021. When asked if there had been any changes made to RI #177's care plan as a result of this smoking noncompliance incident, and EI #29 said she did not know if any changes were made to the care plan, but they did still have a policy that said residents were not to smoke in their rooms. EI #29 further stated that according to the facility policy, smoking violations may result in facility discharge. When asked if RI #177's Smoking Safety Evaluation had been updated following the incident on 08/04/2021, EI #29 said she did not know, because she did not know who would be responsible for doing a new evaluation after an incident occurred. EI #29 said the concern with a resident smoking inside the facility would be resident safety, including fire, injuries, and with oxygen in the building, stated it could be disastrous for safety overall. EI #10, RN Unit Manager, was interviewed on 04/06/2022 at 9:55 AM. When asked about the smoking incident involving RI #177 on 08/04/2021, EI #10 said she and EI #29 did not actually observe RI #177 smoking in the room, but said EI #29 had informed her because she suspected RI #177 was smoking in the room. EI #10 confirmed EI #29 requested RI #177 provide her with his cigarettes and lighter, but EI #10 did not recall RI #177 admitting anything or stating anything to them at the time. EI #10 was asked why the note did not reference taking up RI #177's lighter, and EI #10 said the smoking materials were taken up, but she did not know what was in it. When questioned what would be considered unsafe smoking habits, EI #10 stated smoking in the room would be considered unsafe. EI #10 said if unsafe smoking habits are observed, staff should remove the smoking materials and reassess the resident for smoking safety. When asked what management she had reported this incident to, EI #10 said she had not, she thought the EI #29 had. When asked what changes had been made to RI #177's care plan as a result of this incident, EI #10 said she did not know, she was just a witness. When asked what the facility's policy stated regarding smoking incidents, EI #10 said the policy indicated smoking violations could result in discharge from the facility. EI #10 was then questioned as to the facility's system for taking up lighters from residents. She indicated she was not aware of a documented process or system for that, and she did not know how that was handled. EI #10 said if residents are smoking inside the facility it could result in the building catching fire, and the residents could get burned. Further review of RI #177's SMOKING SAFETY EVALUATIONS revealed RI #177's admission SMOKING SAFETY EVALUATION, dated 05/18/2021, had been signed as reviewed on a quarterly basis. EI #44, the facility's prior SW, signed it off as reviewed on 08/31/2021, and EI #7, SW, signed it off as reviewed on 11/18/2021 and 02/08/2022. However, there were no new smoking evaluations done at those times, and there were no apparent changes made to the original evaluation at the time of reviews. The assessment still indicated RI #177 was an independent smoker, that required no supervision, assistance, or storage of smoking materials. The section for History of Smoking Related Incidents was still marked No, despite having a section that should have identified a history of Smoking in Bed. A new SMOKING SAFETY EVALUATION was completed for RI #177 on 03/14/2022, following a readmission from a hospital stay. The section of this evaluation for Diagnosis Impacting Ability to Smoke was marked as None. The evaluation did not capture RI #177's diagnoses of [CONDITION(S)] or [CONDITION(S)], despite having a section for Neurological diagnoses. The evaluation indicated RI #177 was independent with cognitive skills for decision making, had no indicators of [CONDITION(S)], and had clear speech. The section of the evaluation titled HISTORY indicated RI #177 could self-extinguish cigarettes and was able to manage ashes. The Fire Safety section indicated RI #177 attempted to obtain lighters or matches. History of Smoking Related Incidents was marked as No, despite having a section to specifically identify a history of Smoking in Bed. Staff assessed RI #177 as an independent smoker, that required no supervision, assistance, or storage of smoking materials. The question for Care Plan Concern? was marked Yes. This evaluation was signed on 03/14/2022 by EI #7, SW. During an interview with EI #7 on 03/31/2022 at 1:32 PM, EI #7 denied any prior knowledge of RI #177 having ever smoked in his/her room. During another interview with EI #7, Social Worker on 04/05/2022 at 1:55 PM, EI #7 said she was unaware of the noncompliant smoking incidents involving RI #177 when she signed off on the 11/18/2021 and the and 02/08/2022 SMOKING SAFETY EVALUATIONS, but acknowledged nursing staff had documented them in the notes. EI #7 said staff should have communicated these incidents to her. EI #7 further stated RI #177 should have been reevaluated for smoking safety and interventions following each incident, but he he/she had not been. When asked why this had not been done, EI #7 said she had not looked back through the record for any documentation, but said the information could have been communicated to her verbally as well, but it was not. EI #7 said she had not heard a word about any of RI #177's smoking noncompliance until during this survey. On 03/26/2022, RI #177's Departmental Notes documented the following: . 8:01 AM . At approx 0725, the fire alarm went off, Writer started down the hall looking for the cause of the alarm . (RI #177's roommate) stepped out into the hall and yelled for help (his/her) roommate needed help. Writer saw smoke coming from the room . Resident was sitting across the bed with (his/her) back against the wall and (his/her) feet towards the floor. Writer screamed for help and for staff to call 911. Writer then attempted to put the fire out by beating/smothering it, Resident's lap/groin, chest, and bilateral arms were burning, Resident was screaming for help as Writer beat the flames . (fire department) arrived at approximately 0735 with the paramedics . Resident was transferred by paramedics to ER . This note was made by EI #23, LPN. On 03/26/2022 another Departmental Note revealed: . 6:19 PM . Resident admitted to (local hospital) burn unit . RI #177's former roommate was interviewed on 03/29/2022 at 5:24 PM and described the events of 03/26/2022 as he/she recalled them. RI #177's roommate (a blind resident) stated he/she was asleep and the smell of the smoke woke him/her up. The roommate said he/she could feel the heat and RI #177 was yelling. The roommate further said, the night before RI #177 was talking to his/herself and playing with a lighter (roommate motioned with his hand and thumb as if demonstrating the flicking motion of a lighter). The roommate said he/she had shared a room with RI #177 for approximately a month and a half and had never known him/her to smoke in the room or play with lighters. The roommate ended the interview by stating he/she was now scared to be there because the residents were supposed to be safe in the facility. LPN, EI #23 was interviewed on 03/30/2022 at 6:48 AM. EI #23 said on 03/26/2022 around 7:25 AM, she heard a beeping sound she had never heard before and started walking toward the sound. She indicated about that time, RI #177's roommate came out of their room and said he/she thought his/her roommate needed help. EI #23 said when she looked up she could see that smoke was coming from the room. EI #23 said when she entered the room, she saw RI #177 on fire. She indicated she saw RI #177's arms, shirt, and groin area on fire. EI #23 said she then picked up a pillow and started beating the flames until she got the fire out. EI #23 said RI #177 was saying 'help me, help me put it out'. EI #23 said while other staff were attending to RI #177 she had to step out of the room for a few minutes because her eyes were burning from the smoke, but about five minutes later she returned and observed two other staff members cutting the smoldering mattress out from under RI #177. EI #23 said staff also had to cut RI #177's clothing off of him/her. EI #23 said during this time the fire department and paramedics arrived, and the paramedics took RI #177 to the hospital. When asked what she felt caused the fire, EI #23 said she believed it was caused by a cigarette or cigar of some sort. When asked about the facility's smoking policy, EI #23 said the residents on her hall seemed to go out to smoke whenever they wanted, even two or three in the morning, without supervision. When asked where the smoking materials were maintained, EI #23 said RI #177 had his/hers on the bedside table. EI #23 further stated everyone kept their cigarettes and lighters in their rooms. EI #23 stated she had not had any training related to smoking policies. She indicated that when she first started working at the facility, she asked about residents going out to smoke and having their cigarettes and lighters in their rooms because she had never seen a facility allow that, and a nurse (unknown which one) told her it was fine for the residents to do those things and not to worry about it. When asked if she had ever known RI #177 to smoke in his/her room before, EI #23 said there were a few times the prior year that she smelled smoke, but RI #177 denied having smoked in the room. On 3/31/2022 at 7:36 AM, during a follow-up interview, EI #23 recalled having seen a cigar on the residents bedside table, the day of the fire incident; however, EI #23 said she did not know where it went or what happened to it in all the ruckus. She described it as a brown cigar with a white tip. EI #23 said she did not see a lighter, but said RI #177 must have had one. On 04/04/2022 at 7:28 AM, EI #46, CNA, was interviewed. EI #46 said she responded to the smoke in RI #177's room on the morning of 03/26/2022. She said when she got to the room, EI #23 had already put the fire out. EI #46 said the skin on RI #177's left arm was burned off exposing pink skin, and indicated RI #177's clothing had melted to RI #177's skin. EI #46 said she also saw that the mattress was burned and noted a green pack of cigarettes on the right side of the bed and pieces of a green lighter on the floor beside the bed. EI #46 said she retrieved scissors for the nursing staff in the room and a new gown, and then the paramedics and fire department came into the room to transport RI #177 to the hospital. EI #46 said if the residents' cigarettes and lighters had been [NAME] [TRUNCATED]

Based on interviews, review of Resident Identifier (RI) #7's medical record, RI #7's local hospital record and Mosby's MEDICAL DICTIONARY 7th EDITION, the facility's licensed staff failed to intervene in a timely manner when an acute change in medical condition was identified in RI #7. On 5/22/2019 at 4:45 PM, RI #7, with a medical history to include [MEDICAL CONDITION] of the lower extremity and [MEDICAL CONDITION], began to experience a change of condition. RI #7 displayed Altered Mental Status (AMS), [MEDICAL CONDITION](increased heart rate), and a decrease in blood pressure. The licensed staff member assigned to care for RI #7 during this time acknowledged that she only monitored (watched) RI #7 from the time she observed a change in the resident's condition at 4:45 PM until the physician was notified at 10:00 PM. At 10:00 PM, when RI #7 had an increase in temperature, Tylenol was administered, the physician was notified, Emergency Medical Services was called and RI #7 was transferred to a local hospital. According to RI #7's Attending Physician, the resident was critically ill and needed immediate evaluation at the onset of the acute change in medical condition that could only have been provided in the hospital setting. RI #7 History and Physical Reports indicated RI #7 was admitted to the hospital on [DATE] with Nausea/Vomiting,[MEDICAL CONDITION] and Left Lower Extremity [MEDICAL CONDITION]. This deficient practice placed RI #7, one of seven sampled residents reviewed for notification of change, in immediate jeopardy for serious injury, harm, impairment or death. On 6/21/2019 at 5:16 PM, the Interim Executive Director, Director of Nursing Services (DNS), Infection Control Prevention Officer, Human Resource Director, Corporate Clinical Nurse and Corporate Vice President were given a copy of the Immediate Jeopardy (IJ) template and notified of the finding of substandard quality of care at the immediate jeopardy level in the area of Quality of Care, F 684. Findings include: RI #7 was admitted to the facility on [DATE]. RI #7 has a medical history to include [DIAGNOSES REDACTED]. RI #7's Departmental (Nurse) Notes dated 5/23/2019 12:32 AM, written by Employee Identifier (EI) #6, a Registered Nurse (RN) documented Late Note for 5/22/19 3-11 shift. Resident sleeping in w/c (wheelchair) this pm approx (approximately) 4:45 pm difficult to awake, drowsey (drowsy) and slightly confused initialy (initially) orieted (oriented) however to person and place. PERRLA (pupils equal, round, reactive to light and accommodation) DNS notified to obtain more info . Reported that Resident had not had much sleep since last pm and to put (him/her) to bed and to continue to observe (him/her), initial BP (blood pressure) 154/64 P (pulse) 124 R (respiration) 16 after lying down in bed at 5pm vs (vital signs) (BP) 102/76 P 126 R 16 Resident continues to be drowsey (drowsy) but more alert. DNS and ED (Executive Director) both notified of same and again inst. (instructed) to observe resident. 7:30 PM PERRLA (BP) 103/53 P 114 R 16 color pale . Resident reports feeling very weak. 8:30 PM VS (vital signs) (BP) 108/60 P 118 R 16 Temp. (Temperature) 99.1 face flushed. No other changes noted. 10PM Temp. 101.1 P 116 R 16 BP 88/46 Tylenol 2 po (by mouth) given. Spo2 (oxygen saturation) 97 % on RA (room air) Dr. (EI #7) notified orders recied (received) to send Resident to (name of hospital) ER (emergency room ) via (by way of) 911 transfer . On 6/12/2019 at 12:32 AM, an interview was conducted with EI #6, the RN assigned to care for RI #7 during the 3:00 PM to 11:00 PM shift on 5/22/2019. When asked when she initially identified a change in RI #7's condition, EI #6 replied when RI #7 was hard to awake at 4:45 PM. EI #6 was asked what she did when she noticed the change in condition. EI #6 stated that she went to DNS (EI #2) and the Executive Director (EI #1) to get a second opinion about RI #7's mental status. When asked what was done when RI #7 experienced a change in condition, EI #6 stated she was instructed to watch the resident as the DNS thought RI #7 may have been awake most of night. When asked if she thought the resident was sleepy, EI #6 said no. EI #6 stated her concern was that RI #7 was septic again and getting critical. When asked if RI #7's vital signs improved from the time she noticed the change in the resident's condition (4:45 PM) until the physician was called at 10:00 PM, EI #6 replied no. When asked what RI #7's admitting [DIAGNOSES REDACTED].#6 replied,[MEDICAL CONDITION]. According to www.cdc.gov .[MEDICAL CONDITION] is the body's extreme response to an infection. It is a life-threatening medical emergency.[MEDICAL CONDITION] happens when an infection you already have - in your skin, lungs, urinary tract, or somewhere else - triggers a chain reaction throughout your body. Without timely treatment,[MEDICAL CONDITION] can rapidly lead to tissue damage, organ failure, and death . During a follow-up interview on 6/14/2019 at 3:17 PM, EI #6 acknowledged that she only monitored (watched) RI #7 from the time she observed a change in the resident's condition at 4:45 PM until the physician was notified at 10:00 PM. At 10:00 PM, when RI #7 had an increase in temperature, Tylenol was administered and the physician was notified. During a telephone interview on 6/12/2019 at 7:22 AM, EI #7, RI #7's Attending Physician, was asked when on 5/22/2019 was he notified of RI #7's change in condition. EI #7 replied, at 10:00 PM. In a follow-up telephone interview on 6/12/2019 at 1:20 PM, EI #7 was asked why was there a need for RI #7 to have immediate evaluation/intervention at a local hospital rather than the nursing facility. EI #7 replied that RI #7 was septic when he/she arrived at the hospital. EI #7 stated he spoke with the staff at the hospital, who kept him informed of RI #7's condition. EI #7 further explained that RI #7's increased heart rate could have been [MEDICAL CONDITION] Fibrillation and RI #7 did not need to wait around in the nursing facility. According to EI #7, when RI #7's blood pressure dropped, the resident required intensive care monitoring, as RI #7 was critically ill and required immediate evaluation and intervention that could have only been done in a hospital setting. EI #7 commented RI #7 should have been sent out when the resident displayed [MEDICAL CONDITION] had AMS. Page 1815 of Mosby's MEDICAL DICTIONARY 7th EDITION with a copyright date of 2006 indicated, [MEDICAL CONDITION] a condition in which the heart rate contracts at a rate greater than 100 beats per minute. During a follow-up telephone interview on 6/14/2019 at 1:29 PM, EI #7 was asked did the delay in physician notification cause a delay in treatment for [REDACTED]. EI #7 replied yes. EI #7 explained that evaluation was needed for why RI #7 was experiencing an elevated heart rate and AMS. EI #7 stated this evaluation had to be done before treatment what was delayed could even be determined. RI #7's local hospital History and Physical Reports indicated RI #7 was admitted to the hospital on [DATE]. The report indicated . Assessment/Plan: This is a (age) year old (male/female) with history of DM,[REDACATED], sacroid (sarcoid) who presents with nausea/vomiting. nausea/[MEDICAL CONDITION], present on admission LLE (left lower extremity) [MEDICAL CONDITION] . Patient will be admitted to inpatient status. I anticipate a 2 midnight stay secondary to the ongoing medical evaluation and management [MEDICAL CONDITION]. RI #7 was discharged from the hospital and transferred back to Birmingham Nursing and Rehabilitation Center on 5/31/2019. ************************* On 6/22/2019 at 9:26 PM, the facility submitted a Removal Plan which documented: This is a plan for removal of Immediate Jeopardy (IJ) which was called on 6/21/19 at 5:16 p.m. F-684 An in-service on notification of a change in a resident's status (Policy A.16) began on 6/21/19 by LPN, Staff Development Coordinator, for Licensed Nurses and was completed on 6/22/19 at 5:13 p.m. Any nurse not receiving the in-service will not be allowed to work until in-service is complete. We have 38 licensed nurses on staff. As of 5:13 p.m. 6/22/19, 18 licensed nurses have been in-serviced. 20 licensed nurses remain to receive the in-service prior to their next shift. This in-service included changes in resident condition to include significant change in vital signs, emesis/diarrhea, onset of pressure sores, A&I's (accidents and incidents) (per Regulations), symptoms of infectious process, abnormal lab findings, 5% wt. (weight) gain or loss in 30 days, repeated refusals to take medications (for 2 days), change in level of consciousness, abnormal complaints of pain or ineffective relief of pain, unusual behavior, missing resident, glucometer ranges using specific parameters that are given by physician for reporting. Director of Nurses and RN-charge nurse received a disciplinary action on 6/22/19 related to not reporting a change in a resident's condition to the physician which resulted in a delay in treatment. A 1:1 in-service on notification of a change in resident status (Policy A.16) was provided to RN, Director of Nursing on 6/21/19 at 8:00 p.m. by the Clinical Nurse Consultant. Infection Control Prevention Officer has reviewed 123 of 123 records, on 6/21/19 and 6/22/19, for changes of condition. This was accomplished through review of interdisciplinary notes, MD (Medical Doctor) orders, incident reports, and 24 hour reports. There was no change of condition that was not reported to the physician. Through observations and interviews with staff there have been no residents that were affected by failure of the staff to follow and implement policy A.16 and physician orders. Observations and interviews were completed by the Director of Nurses on 6/22/19 at 5:13 p.m. RI #7 remains in the facility with no negative outcomes and has not been re-hospitalized . An in-service on Interact Clinical Care Paths and Identifying the Signs and Symptoms [MEDICAL CONDITION]-CDC (Centers for Disease Control and Prevention) which included the signs of [MEDICAL CONDITION] was started for Licensed Nurses on 6/21/19 @ 8 pm by LPN, Staff Development Coordinator and will be completed by 6/22/19 at 5:13 p.m. We have 38 licensed nurses on staff. As of 5:13 p.m. 6/22/19 23 licensed nurses have been in-serviced on signs and symptoms [MEDICAL CONDITION]-CDC, 15 licensed nurses remain to receive the in-service. There have been 24 out of 38 licensed nurses in-serviced on Interact Clinical Pathways, 14 licensed nurses remain to receive the in-service prior to their next shift. A statement of acknowledgment was added to ensure Licensed Nurses will follow established policy A.16. This in-service will include signs [MEDICAL CONDITION]; confusion or disorientation, shortness of breath, high heart rate, fever, or shivering, or feeling very cold, extreme pain or discomfort, and clammy or sweaty skin and to notify the physician as soon as the change in condition is identified. Birmingham Nursing and Rehabilitation is requesting immediacy of jeopardy to be removed today (6/22/19). ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F 684 was lowered to a D level on 6/22/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 298.

Based on interviews, review of a complaint received by the State Survey Agency and the Director of Nursing Service's and the Executive Director's job description, the Executive Director (ED) and Director of Nursing Services (DNS) failed to ensure the facility's policy titled NOTIFICATION OF A CHANGE IN A RESIDENT'S STATUS was implemented when they instructed Employee Identifier (EI) #6, a Registered Nurse to place Resident Identifier (RI) #7 in bed and monitor the resident instead of notifying the physician when RI #7 experienced a change in medical condition on 5/22/2019. On 5/22/2019 at 4:45 PM, RI #7, with a medical history to include [MEDICAL CONDITION] of the lower extremity and [MEDICAL CONDITION], began to experience a change of condition. RI #7 displayed Altered Mental Status (AMS), [MEDICAL CONDITION](increased heart rate), and a decrease in blood pressure. EI #6, the Registered Nurse assigned to care for RI #7 during this time acknowledged that the DNS and ED had instructed her to place the resident in bed and monitor his/her condition. EI #6 stated she only monitored (watched) RI #7 from the time she observed a change in the resident's medical condition at 4:45 PM until the physician was notified at 10:00 PM. At 10:00 PM, when RI #7 had an increase in temperature, Tylenol was administered, the physician was notified, Emergency Medical Services was called and RI #7 was transferred to a local hospital. According to RI #7's Attending Physician, the resident was critically ill and needed immediate evaluation at the onset of the acute change in medical condition that could only have been provided in the hospital setting. RI #7 History and Physical Reports indicated RI #7 was admitted to the hospital on [DATE] with Nausea/Vomiting,[MEDICAL CONDITION] and Left Lower Extremity [MEDICAL CONDITION]. This deficient practice placed RI #7, one of seven sampled residents reviewed for notification of change, in immediate jeopardy for serious injury, harm, impairment or death. On 6/21/2019 at 5:16 PM, the Interim Executive Director, Director of Nursing Services (DNS), Infection Control Prevention Officer, Human Resource Director, Corporate Clinical Nurse and Corporate Vice President were given a copy of the Immediate Jeopardy (IJ) template and notified of the finding of immediate jeopardy in the area of Administration, F 835. Findings include: On 6/6/2019, the State Survey Agency received a complaint which alleged Resident Identifier (RI) #7's attending physician was not notified when the resident experienced a change in condition on 5/22/2019. According to the complaint, RI #7 experienced a change in condition at 3:00 PM on 5/22/2019; however, the physician was not notified until 10:00 PM. Once the physician was notified, the physician gave an order to send the resident out to the hospital. The complainant stated the nurse, later identified as Employee Identifier (EI) #6, wanted to notify the physician; however, the Executive Director told the nurse not to. RI #7 was transferred and admitted to a local hospital for [MEDICAL CONDITION] of the left leg [MEDICAL CONDITION]. Refer to F 580 and F 684 The Job Description for the job titled Director of Nursing Services dated 1/1/2017, documented . General Description Responsible for the overall management of resident care 24 hours a day, seven days per week. Functions include: performing a variety of duties to provide quality nursing care to residents and to coordinate total nursing care for residents; implementing specific procedures and programs . complying with operating policies and procedures, state requirements, Department of Health regulations, . On 6/12/2019 at 12:32 AM, an interview was conducted with EI #6, the RN assigned to care for RI #7 during the 3:00 PM to 11:00 PM shift on 5/22/2019. When asked when she initially identified a change in RI #7's condition, EI #6 replied when RI #7 was hard to awake at 4:45 PM. EI #6 was asked what she did when she noticed the change in condition. EI #6 stated that she went to DNS (EI #2) and the Executive Director (EI #1) to get a second opinion about RI #7's mental status. When asked what was done when RI #7 experienced a change in condition, EI #6 stated she was instructed to watch the resident as the DNS thought RI #7 may have been awake most of the night. EI #6 stated after she notified EI #1 and EI #2 of RI #7's elevated heart rate, she was still instructed to continue to observe the resident. EI #6 was asked when the physician should have been called and she replied, when she first found RI #7 with altered mental status. When asked if the physician was called, EI #6 answered no. EI #6 was asked what reason she was given for not notifying the doctor. EI #6 replied that she was never told by EI #1 or EI #2 to not call the doctor. EI #6 explained that it was clear that if she called the doctor, the doctor would send the resident out to the emergency room but EI #1 and EI #2 felt the resident should be just watched (observed/monitored). In an interview on 6/12/2019 at 2:44 PM, EI #2, the DNS was asked what instructions had she given EI #6 regarding RI #7 after being informed the resident had altered mental status and an increased heart rate, EI #2 stated she instructed the nurse, EI #6, to put RI #7 in the bed. EI #2 was asked what were her last instructions to EI #6 regarding RI #7. EI #2 answered that she and EI #1 were in her office when she told EI #6 to continue to monitor the resident. When asked why did she instruct the nurse the continue to monitor the resident when the policy indicated the physician should be called, EI #2 replied that she never told EI #6 to not call the physician but that she truly didn't think RI #7 was in any distress. When asked what the facility's policy was on a resident's change in condition, EI #2 answered notify the physician. When asked why the policy was not followed, EI #2 replied that she couldn't answer and that she never told EI #6 to not call the physician. During a follow-up interview on 6/13/2019 at 8:30 AM, EI #2, the DNS was asked what her role was once she became aware RI #7 had experienced a change in medical condition. EI #2 replied, to ensure the resident was assessed and the physician was notified. EI #2 explained that she probably should have found out if EI #6 had notified the physician. EI #2 stated she did not ask the nurse (EI #6) whether or not the physician had been notified but she should have. In a follow-up interview on 6/14/2019 at 4:48 PM, EI #2, the DNS was asked if she overheard EI #1 instruct EI #6 to place RI #7 in Trendelenburg to see if the resident's blood pressure would go up, recheck the resident in 20 minutes and if it was still low to call the physician. EI #2 answered that she did not hear or observe that. When asked who directed resident's medical care, EI #2 answered the physician. EI #2 was asked if the physician directed the resident's medical care, why did she instruct EI #6 to lay the resident down in bed and monitor the resident's condition. EI #2 replied, that did not mean for the nurse to not call the physician. When asked why she didn't ensure the physician had been notified, EI #2 replied that she had never done that before. EI #2 explained that she didn't realize that she needed to go behind a nurse to make sure the physician was notified. The Job Description for the job titled Executive Director dated 8/1/2012, documented . General Description The Executive Director leads and directs the overall operation of the Facility in accordance with resident needs, government regulations and Facility policies so as to maintain quality care for the residents while achieving the Facility's business objectives . In an interview on 6/12/2019 at 4:11 PM, EI #1, the Executive Director (ED) was asked what she based her decision on to have EI #6 (a RN) continue to monitor RI #7, a resident with a history [MEDICAL CONDITIONS], who had been assessed to have abnormal vital signs and altered mental status, EI #1 stated she was trying to back off and let the DNS (EI #2) take the lead. EI #1 was asked what the facility's policy indicated should be done when a resident experienced a change in condition. EI #1 answered, assess the condition, obtain vital signs and notify the physician or physician extender and resident's sponsor. When asked why EI #6 was told to continue to monitor the resident, EI #1 replied that if she would have been the Charge Nurse, she would have called the physician and not monitored. During a follow-up interview on 6/13/2019 at 11:55 AM, EI #1 was asked as the Executive Director what she should have done after being made aware RI #7 had experienced a change in condition. EI #1 replied, to make sure the nursing staff followed the policies and procedures. RI #7's local hospital History and Physical Reports indicated RI #7 was admitted to the hospital on [DATE]. The report indicated . Assessment/Plan: This is a (age) year old (male/female) with history of DM (Diabetes Mellitus),[REDACATED], sacroid (sarcoid) who presents with nausea/vomiting. nausea/[MEDICAL CONDITION], present on admission LLE (left lower extremity) [MEDICAL CONDITION] . Patient will be admitted to inpatient status. I anticipate a 2 midnight stay secondary to the ongoing medical evaluation and management [MEDICAL CONDITION]. RI #7 was discharged from the hospital and transferred back to Birmingham Nursing and Rehabilitation Center on 5/31/2019. ************************* On 6/22/2019 at 9:26 PM, the facility submitted a Removal Plan which documented: This is a plan for removal of Immediate Jeopardy (IJ) which was called on 6/21/19 at 5:16 p.m. F-835 Executive Director was suspended on 6/20/19 at 2:30 PM by the Regional Vice President pending investigation. Interim Executive Director was designated 6/20/19 at 2:30 pm. A 1:1 In-service was provided to (the) Interim Executive Director and Director of Nursing on 6/21/19 @ 8pm on Notification of Change in Condition (Policy A.16) including care paths by the Clinical Nurse Consultant. Notification of Change in resident Status includes significant change in vital signs, emesis/diarrhea, onset of pressure sores, A&I's (accidents and incidents) (per Regulations), symptoms of infectious process, abnormal lab findings, 5% wt. (weight) gain or loss in 30 days, repeated refusals to take medications (for 2 days), change in level of consciousness, abnormal complaints of pain or ineffective relief of pain, unusual behavior, missing resident, glucometer ranges using specific parameters that are given by physician for reporting. Both the Director of Nursing and Interim Executive Director signed an acknowledgment to follow and provide oversight of the established policies. RI #7 remains in the facility with no negative outcomes and has not been re-hospitalized . The Interim Executive Director and the Director of Nursing will ensure implementation of established policy and procedures (A.16) as well as care paths. Birmingham Nursing and Rehabilitation is requesting immediacy of jeopardy to be removed today (6/22/19). ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F 835 was lowered to a D level on 6/22/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 298.

Based on interviews, review of Resident Identifier (RI) #7's medical record, RI #7's hospital record, the facility's policy titled, NOTIFICATION OF A CHANGE IN A RESIDENT'S STATUS, Mosby's MEDICAL DICTIONARY, and a complaint received by the State Survey Agency, the facility failed to ensure Employee Identifier (EI) #6, a Registered Nurse timely notified RI #7's Attending Physician when the resident experienced a change in medical condition. On 5/22/2019 at 4:45 PM, RI #7, with a medical history to include [MEDICAL CONDITION] of the lower extremity and [MEDICAL CONDITION], began to experience a change of condition. RI #7 displayed Altered Mental Status (AMS) and [MEDICAL CONDITION](increased heart rate); the resident was difficult to awake, drowsy, pale, weak, and had a decrease in blood pressure. RI #7's Attending Physician stated he should have been immediately notified when the resident had Altered Mental Status and [MEDICAL CONDITION] at 4:45 PM. At 10:00 PM, when RI #7 had an increase in temperature, Tylenol was administered, the physician was notified, Emergency Medical Services was called and RI #7 was transferred to a local hospital. According to RI #7's Attending Physician, the resident was critically ill and needed immediate evaluation at the onset of the acute change in medical condition that could only have been provided in the hospital setting. RI #7 History and Physical Reports indicated RI #7 was admitted to the hospital on [DATE] with Nausea/Vomiting,[MEDICAL CONDITION] and Left Lower Extremity [MEDICAL CONDITION]. This deficient practice placed RI #7, one of seven sampled residents reviewed for notification of change, in immediate jeopardy for serious injury, harm, impairment or death. On 6/21/2019 at 5:16 PM, the Interim Executive Director, Director of Nursing Services (DNS), Infection Control Prevention Officer, Human Resource Director, Corporate Clinical Nurse and Corporate Vice President were given a copy of the Immediate Jeopardy (IJ) template and notified of the finding of immediate jeopardy in the area of Resident Rights / Notify of Changes, F 580. Findings include: On 6/6/2019, the State Survey Agency received a complaint which alleged Resident Identifier (RI) #7's attending physician was not notified when the resident experienced a change in condition on 5/22/2019. According to the complaint, RI #7 experienced a change in condition at 3:00 PM on 5/22/2019; however, the physician was not notified until 10:00 PM. Once the physician was notified, the physician gave an order to send the resident out to the hospital. RI #7 was transferred and admitted to a local hospital for [MEDICAL CONDITION] of the left leg [MEDICAL CONDITION]. According to www.cdc.gov .[MEDICAL CONDITION] is the body's extreme response to an infection. It is a life-threatening medical emergency.[MEDICAL CONDITION] happens when an infection you already have - in your skin, lungs, urinary tract, or somewhere else - triggers a chain reaction throughout your body. Without timely treatment,[MEDICAL CONDITION] can rapidly lead to tissue damage, organ failure, and death . The facility's policy titled NOTIFICATION OF A CHANGE IN A RESIDENT'S STATUS dated (MONTH) (YEAR), documented POLICY: The attending physician/physician extender (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist) and the resident representative will be notified of a change in a resident's condition, per standards of practice and Federal and/or State regulations. RESPONSIBILITY: All Licensed Nursing Personnel. PR[NAME]EDURE: 1. Guideline for notification of physician / responsible party (not all inclusive): a. Significant change in / or unstable vital signs (Temperature, B/P (blood pressure), Pulse, Respiration) . i. Change in level of consciousness . RI #7 was admitted to the facility on [DATE]. RI #7 has a medical history to include [DIAGNOSES REDACTED]. RI #7's Departmental (Nurse) Notes dated 5/23/2019 12:32 AM, written by Employee Identifier (EI) #6, a Registered Nurse (RN) documented Late Note for 5/22/19 3-11 shift. Resident sleeping in w/c (wheelchair) this pm approx (approximately) 4:45 pm difficult to awake, drowsey (drowsy) and slightly confused initialy (initially) orieted (oriented) however to person and place. PERRLA (pupils equal, round, reactive to light and accommodation) DNS notified to obtain more info . Reported that Resident had not had much sleep since last pm and to put (him/her) to bed and to continue to observe (him/her), initial BP (blood pressure) 154/64 P (pulse) 124 R (respiration) 16 after lying down in bed at 5pm vs (vital signs) (BP) 102/76 P 126 R 16 Resident continues to be drowsey (drowsy) but more alert. DNS and ED (Executive Director) both notified of same and again inst. (instructed) to observe resident. 7:30 PM PERRLA (BP) 103/53 P 114 R 16 color pale . Resident reports feeling very weak. 8:30 PM VS (vital signs) (BP) 108/60 P 118 R 16 Temp. (Temperature) 99.1 face flushed. No other changes noted. 10PM Temp. 101.1 P 116 R 16 BP 88/46 Tylenol 2 po (by mouth) given. Spo2 (oxygen saturation) 97 % on RA (room air) Dr. (EI #7) notified orders recied (received) to send Resident to (name of hospital) ER (emergency room ) via (by way of) 911 transfer . In an interview on 6/11/2019 at 4:02 PM, EI #9, a Certified Nursing Assistant (CNA) was asked if she was familiar with RI #7. EI #9 replied yes. When asked about the change in condition RI #7 experienced on 5/22/2019, EI #9 stated she noticed RI #7 was weaker, really drowsy, sleeping a lot, not his/her normal self and RI #7 didn't eat dinner, which he/she normally did. EI #9 stated she reported this change in RI #7's condition to EI #6, the RN. According to EI #9, after she reported the change in RI #7's condition to EI #6, the RN assessed the resident, checked RI #7's vital signs and requested EI #9 get some assistance to lay RI #7 down in the bed. On 6/12/2019 at 12:32 AM, an interview was conducted with EI #6, the RN assigned to care for RI #7 during the 3:00 PM to 11:00 PM shift on 5/22/2019. When asked when she initially identified a change in RI #7's condition, EI #6 replied when RI #7 was hard to awake at 4:45 PM. EI #6 was asked what she did when she noticed the change in condition. EI #6 stated that she went to DNS (EI #2) and the Executive Director (EI #1) to get a second opinion about RI #7's mental status. When asked what was done when RI #7 experienced a change in condition, EI #6 stated she was instructed to watch the resident as the DNS thought RI #7 may have been awake most of the night. When asked if she thought the resident was sleepy, EI #6 said no. EI #6 stated her concern was that RI #7 was septic again and getting critical. EI #6 was asked what factors were involved in identifying RI #7's change of condition. EI #6 answered the resident's level of consciousness and increased heart rate. EI #6 explained that when RI #7 was laid down, the resident's blood pressure dropped but his/her heart rate was still elevated. EI #6 stated after she notified EI #1 and EI #2 of RI #7's elevated heart rate, she was still instructed to continue to observe the resident. When asked if RI #7's vital signs improved from the time she noticed the change in the resident's condition (4:45 PM) until the physician was called at 10:00 PM, EI #6 replied no. EI #6 was asked when should the physician have been called and she replied, when she first found RI #7 with altered mental status. When asked if the physician was called, EI #6 answered no. EI #6 was asked what reason she was given for not notifying the doctor. EI #6 replied that she was never told by EI #1 or EI #2 to not call the doctor. EI #6 explained that it was clear that if she called the doctor, the doctor would send the resident out to the emergency room but EI #1 and EI #2 felt the resident should be just watched (observed/monitored). When asked what RI #7's admitting [DIAGNOSES REDACTED].#6 replied,[MEDICAL CONDITION]. In a telephone interview on 6/12/2019 at 7:22 AM, EI #7, RI #7's Attending Physician, was asked when on 5/22/2019 was he notified of RI #7's change in condition. EI #7 replied, at 10:00 PM. When asked what he was told by the nurse, EI #7 stated when the nurse got to work the resident had Altered Mental Status (AMS), a heart rate in the 120s and that she had closely monitored the resident. Page 1815 of Mosby's MEDICAL DICTIONARY 7th EDITION with a copyright date of 2006 indicated, [MEDICAL CONDITION] a condition in which the heart rate contracts at a rate greater than 100 beats per minute. In a follow-up interview on 6/14/2019 at 3:17 PM, EI #6, the RN assigned to care for RI #7 during the 3:00 PM to 11:00 PM shift on 5/22/2019, stated she informed the physician, EI #7, that when she first saw RI #7 that the resident had AMS and an increased heart rate. EI #6 commented that she didn't give the physician a time that he (EI #7) must have assumed it was 3:00 PM because that was when her shift started. On 6/12/2019 at 9:19 AM, an interview was conducted with EI #11, the Licensed Practical Nurse (LPN) assigned to care for RI #7 during the 7:00 AM to 3:00 PM shift on 5/22/2019. When asked how RI #7's condition was at the beginning of her shift on 5/22/2019, EI #11 stated RI #7 was fine. EI #11 was asked, how RI #7's condition was at the end of her shift on 5/22/2019. EI #11 answered, RI #7 was normal. When asked if she had observed a change in RI #7's condition during her shift on 5/22/2019, EI #11 replied no. In an interview on 6/12/2019 at 2:44 PM, EI #2, the DNS acknowledged that there was nothing documented in RI #7's medical record to indicate the physician had been notified prior to 10:00 PM on 5/22/2019. When asked what instructions had she given EI #6 regarding RI #7 after being informed the resident had altered mental status and an increased heart rate, EI #2 stated she instructed the nurse, EI #6, to put RI #7 in the bed. EI #2 was asked what were her last instructions to EI #6 regarding RI #7. EI #2 answered that she and EI #1 were in her office when she told EI #6 to continue to monitor the resident. When asked why did she instruct the nurse the continue to monitor the resident when the policy indicated the physician should be called, EI #2 replied that she never told EI #6 to not call the physician but that she truly didn't think RI #7 was in any distress. When asked what the facility's policy was on a resident's change in condition, EI #2 answered notify the physician. When asked why the policy was not followed, EI #2 replied that she couldn't answer and that she never told EI #6 to not call the physician. In an interview on 6/12/2019 at 4:11 PM, EI #1, the Executive Director (ED) acknowledged that there was nothing documented in RI #7's medical record to indicate the physician had been notified prior to 10:00 PM on 5/22/2019. When asked what she based her decision on to have EI #6 (a RN) continue to monitor RI #7, a resident with a history [MEDICAL CONDITIONS], who had been assessed to have abnormal vital signs and altered mental status, EI #1 stated she was trying to back off and let the DNS (EI #2) take the lead. EI #1 explained that she was there when EI #6 reported the resident had a low blood pressure. According to EI #1, she informed EI #6 to put the resident in Trendelenburg to see if the resident's blood pressure would go up, recheck the resident in 20 minutes and if it was still low to call the physician. When asked if there was a significant drop in RI #7's vital signs from 4:45 PM to 5:00 PM, EI #1 stated there was a significant drop from reading the nurse's notes. EI #1 was asked what the facility's policy indicated should be done when a resident experienced a change in condition. EI #1 answered, assess the condition, obtain vital signs and notify the physician or physician extender and resident's sponsor. When asked why EI #6 was told to continue to monitor the resident, EI #1 replied that if she would have been the Charge Nurse, she would have called the physician and not monitored. Page 1888 of Mosby's MEDICAL DICTIONARY 7th EDITION with a copyright date of 2006 indicated, Trendelenburg position is a position in which the head is low and the body and legs are on an inclined plane. It is sometimes used to increase the blood flow to the brain in [MEDICAL CONDITION] (low blood pressure) and shock. In a follow-up interview on 6/14/2019 at 3:17 PM, EI #6, the RN assigned to care for RI #7 during the 3:00 PM to 11:00 PM shift on 5/22/2019 was asked if the ED, EI #1, had instructed her to place RI #7 in Trendelenburg to see if the resident's blood pressure would go up, recheck the resident in 20 minutes and if it was still low to call the physician. EI #6 said no. When asked should the physician have been notified after her assessment and the first set of vital signs obtained, EI #6 replied yes. When asked why the physician was not notified at this time, EI #6 stated after she had identified RI #7's altered mental status, she was instructed by the DNS and ED to just monitor the resident because they thought the resident was just sleepy. EI #6 was asked if the resident presented as just needing to sleep. EI #6 replied, no RI #7 looked worse. When asked why she did not follow the policy, EI #6 stated that she was following what the DNS and ED had told her to do. In a follow-up interview on 6/14/2019 at 4:48 PM, EI #2, the DNS was asked if she overheard EI #1 instruct EI #6 to place RI #7 in Trendelenburg to see if the resident's blood pressure would go up, recheck the resident in 20 minutes and if it was still low to call the physician. EI #2 answered that she did not hear or observe that. When asked based on her observation of RI #7 on 5/22/2019 when should the physician have been called. EI #2 replied, when RI #7's elevated heart was identified. When asked who directed resident's medical care, EI #2 answered the physician. EI #2 was asked if the physician directed the resident's medical care, why did she instruct EI #6 to lay the resident down in bed and monitor the resident's condition. EI #2 replied, that did not mean for the nurse to not call the physician. When asked why she didn't ensure the physician had been notified, EI #2 replied that she had never done that before. EI #2 explained that she didn't realize that she needed to go behind a nurse to make sure the physician was notified. In a follow-up telephone interview with EI #7, RI #7's Attending Physician, on 6/13/2019 at 12:19 PM, was asked regarding the nurse not informing him until 10:00 PM after identifying RI #7 has a heart rate in the 120s at 4:45 PM, would he agree that this lack of timely notification created a reasonable expectation that an adverse outcome could have occurred such as serious injury, harm, impairment or death. EI #7 replied yes. EI #7 explained that RI #7 was hypotensive, febrile and given the resident's medical history it was very concerning. RI #7's local hospital History and Physical Reports indicated RI #7 was admitted to the hospital on [DATE]. The report indicated . Assessment/Plan: This is a (age) year old (male/female) with history of DM,[REDACATED], sacroid (sarcoid) who presents with nausea/vomiting. nausea/[MEDICAL CONDITION], present on admission LLE (left lower extremity) [MEDICAL CONDITION] . Patient will be admitted to inpatient status. I anticipate a 2 midnight stay secondary to the ongoing medical evaluation and management [MEDICAL CONDITION]. RI #7 was discharged from the hospital and transferred back to Birmingham Nursing and Rehabilitation Center on 5/31/2019. ************************* On 6/22/2019 at 9:26 PM, the facility submitted a Removal Plan which documented: This is (a) plan of removal to remove an Immediate Jeopardy (IJ) which was called on 6/21/19 at 5:16 p.m. F580 A 1:1 in-service was provided to RN, Director of Nursing on 6/21/19 at 8 p.m. by the Clinical Nurse Consultant. A 1:1 in-service was provided to RN-Charge Nurse on 6/22/19 by LPN, Staff Development Coordinator. An acknowledgment was signed by RN, Director of Nursing and, RN-Charge Nurse to confirm the expectation of the facility to follow the established policy A.16 Notification of a change in a resident's status. This in-service included notification of change in condition (policy A.16). Notification of Change in resident Status includes significant change in vital signs, emesis/diarrhea, onset of pressure sores, A&I's (accidents and incidents) (per Regulations), symptoms of infectious process, abnormal lab findings, 5% wt. (weight) Gain or loss in 30 days, repeated Refusals to take medications (for 2 days), change in level of consciousness, abnormal complaints of pain or ineffective relief of pain, unusual behavior, missing resident, glucometer ranges using specific parameters that are given by physician for reporting. We have 38 licensed nurses on staff. As of 5:13 p.m. 6/22/19, 18 licensed nurses has been in-serviced on policy (A.16). 20 licensed nurses must receive the in-service before their next shift. Infection Control Prevention Officer has reviewed 123 of 123 records, on 6/21/19 and 6/22/19, for changes of condition. This was accomplished through review of interdisciplinary notes, MD (Medical Doctor) orders, incident reports, and 24 hour reports. There was no change of condition that was not reported to the physician. Licensed staff are to notify physician for any change in resident condition. There was no change of condition that was not reported to the physician. Through observations and interviews with staff there have been no residents that were affected by failure of the staff to follow and implement policy A.16 and physician orders. Observations and interviews were completed by the Director of Nurses on 6/22/19 at 5:13 p.m. RI #7 remains in the facility with no negative outcomes and has not been re-hospitalized . RN, Director of Nurses and RN-Charge Nurse received a disciplinary action on 6/22/19 related to not reporting a change in a resident's condition to the physician which resulted in a delay in treatment. An in-service on Interact Care Paths was started on 6/21/19 @ 8pm by LPN, Staff Development Coordinator and will be completed by 6/22/19. We have 38 licensed nurses on staff and 23, and 15 licensed nurses must receive the in-service before their next shift. In-services will include signs [MEDICAL CONDITION]; confusion or disorientation, shortness of breath, high heart rate, fever, or shivering, or feeling very cold, extreme pain or discomfort, and clammy or sweaty skin. A statement of acknowledgment was added to ensure nurses will follow established policy A.16. Birmingham Nursing and Rehabilitation is requesting immediacy of jeopardy to be removed today (6/22/19). ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F 580 was lowered to a D level on 6/22/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 298.

Based on a review of Resident Identifier (RI) #1's medical record, the facility's policy titled COMPREHENSIVE PERSON CENTERED CARE PLANS and staff interviews, the facility failed to ensure Employee Identifier (EI) #1 and EI #6, both Certified Nursing Assistants (CNAs) followed RI #1' s care plan on how to transfer the resident. On 7/25/2017, EI #1, a CNA, used a sit to stand lift, without the assistance of another staff member to transfer RI #1. During the transfer, RI #1 became weak, let go of the lift and slid to the floor. RI #1 did not sustain any injuries; however, on 9/14/2017, EI #6, a CNA attempted to transfer RI #1 from the bed to the wheelchair. EI #6 did not follow the care plan when she failed to utilize the lift with the assistance of another staff during this transfer. RI #1's knees became weak and the resident was lowered to the floor. RI #1 complained of bilateral knee pain. An X-ray was done which revealed RI #1 sustained a left femur (bone of the thigh) fracture. This affected RI #1, one of three sampled residents reviewed for falls. Findings include: The facility's policy titled COMPREHENSIVE PERSON CENTERED CARE PLANS documented POLICY: Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care . Pocket Care Guide - part of the Comprehensive Care Plan and used as the tool to make staff aware of the resident's daily care needs .PR(NAME)EDURE: . 6. Staff approaches are to be developed . Assigned disciplines will be identified to carry out the intervention . On 10/27/2017, the Alabama State Survey Agency received a complaint which alleged in September 2017, while being transferred from the Hoyer lift by the assistance of one CNA, RI #1 slipped from the Hoyer lift and was lowered the floor. An in-house X-ray was done which revealed RI #1 sustained a left femur fracture. RI #1 was readmitted to the facility on [DATE]. RI #1 has a medical history to include: Dementia and Muscle Weakness. RI #1's care plan titled (RI #1) at risk for falls r/t (related to) generalized weakness, dementia. (RI #1) has an hx (history) of falls. Transfers with lift and two person assist with a problem onset date of 5/13/2013 last reviewed 8/30/2017, had an approach of . * Transfer with standup lift and staff of two . RI #1's Daily Care Guide had an intervention of . * Transfers using Sit to Stand lift with 2 person assist (Role: CNA) . *Transfer with standup lift and staff of two (Role: CNA). The Resident Incident Report revealed on 7/25/2017 at 2:05 PM, RI #1 sustained a fall. The report documented . Called to room at 205pm noted resident sitting in floor with straps of sit to stand lift remaining around resident. CNA (Certified Nursing Assistant) stated that resident was up in the lift and started to get weak and let go of the lift and started sliding to the floor. Resident was then lowered the rest of the way to the floor by the lift. no injury noted . An interview was conducted with EI #1, a CNA, on 11/1/2017 at 8:45 a.m. EI #1 was asked to recall the circumstances surrounding the fall on 7/25/2017. EI #1 stated she used a sit to stand lift to transfer RI #1 from the wheelchair to the bed. EI #1 stated the resident's legs became weak and the resident was lowered to the floor. EI #1 was asked if she followed RI #1's care plan when she did not use two people while using the lift. EI #1 stated, no. EI #1 was asked why the facility required two people with the lift. EI #1 stated so an accident would not happen. EI #1 was asked what the potential harm of not using two people when using the lift. EI # 1 stated injury or broken bones could occur. In an interview on 11/1/2017 at 2:12 PM, EI #7, the Director of Nursing (DON) was asked about RI #1's fall on 7/25/2017. EI #7 stated, a CNA assisted RI #1 with the sit to stand lift. The CNA did not have the second person as the facility required. RI #1's knees became weak, buckled and the resident was lowered to the floor. According to EI #7, RI #1 did not sustain any injury from the incident. When asked if RI #1's care plan was followed, EI #7 said no. Contained within the facility's investigation of RI #1's fall on 7/25/2017 was a document titled 5 WHYS TOOL which indicated the root cause(s) as . CNA Did Not Follow Plan of Care . The Resident Incident Report revealed on 9/14/2017 at 11:00 AM, RI #1 sustained a fall. The report documented . Called to resident room to find resident in front of wheelchiar (wheelchair) on (his/her) knees. Resident was being transferred from bed to wheelchair with one person assist and (his/her) knees became weak and (he/she) was lowered to the floor . Resident complains of bilateral knee pain . The POST-INCIDENT ACTIONS for fall that occurred on 9/14/2017 documented . Immediate Post-Incident Action: Educate staff to review pocket care guides and to ask for assistance when needed . RI #1's Departmental Notes dated 9/14/2017 9:46 PM, documented . C/O (complained of) LEFT KNEE PAIN. LEFT KNEE SWOLLEN, TENDER TO TOUCH. DR. (name) NOTIFIED. NEW ORDER RECEIVED FOR X-RAY . X-RAY TO BE DONE 9/15/2017 . RI #1's RADIOLOGY (X-RAY) REPORT dated 9/15/2017 documented . Results: . There is a subtle . [MEDICAL CONDITION] femur . RI #1's Departmental Notes dated 9/15/2017 1:28 PM, documented . 1040 (10:40 AM) Xray reports obtained. Called to MD (Medical Doctor) xrays noted with left femoral fracture. Orders received to send resident to ER of family choice . RI #'1 X-ray report from the local hospital dated 9/15/2017, documented . Conclusion: . There is a minimally displaced . fracture . of the distal femur . An interview was conducted on 11/1/2017 at 9:30 AM, with EI #6, the CNA who transferred RI #1 on 9/14/2017. When asked if she recalled the incident, EI #6 said yes. According to EI #6, it was mid-morning and she attempted to transfer RI #1 from the bed to the wheelchair. RI #1's legs became weak and the resident was lowered to the floor. EI #6 was asked if she was supposed to use a lift when she transferred RI #1. EI # 6 stated she thought RI #1 had changed to standing on his/her own with assistance from staff. EI #6 was asked how did staff access the residents' care plan or care guide. EI #6 stated, it's at the nurses' desk. EI #6 was asked if she looked at RI # 1's care plan or care guide prior to transferring RI #1. EI # 6 stated no, but looking back she should have because it can change every day. In an interview on 11/1/2017 at 2:12 PM, EI #7, DON was asked about RI #1's fall on 9/14/2017. EI #7 stated she was notified that a CNA assisted RI #1 with a transfer and did not use the lift as care planned. This deficiency was cited as a result of the investigation of complaint/report number AL 393.

Based on review of Resident Identifier (RI) #1's medical record, the facility's policy titled Interdisciplinary Fall Reduction/Injury Prevention Protocolreview, review of facility policy titled, and staff interviews, the facility failed to ensure Employee Identifier (EI) #1 and EI #6, both Certified Nursing Assistants (CNAs) transferred RI #1 with the standup lift and assistance of two staff members. On 7/25/2017, EI #1, a CNA, used a sit to stand lift, without the assistance of another staff member to transfer RI #1. During the transfer, RI #1 became weak, let go of the lift and slid to the floor. RI #1 did not sustain any injuries; however, on 9/14/2017, EI #6, a CNA attempted to transfer RI #1 from the bed to the wheelchair. EI #6 did not follow the care plan when she failed to utilize the lift with the assistance of another staff during this transfer. RI #1's knees became weak and the resident was lowered to the floor. RI #1 complained of bilateral knee pain. An X-ray was done which revealed RI #1 sustained a left femur (bone of the thigh) fracture. This affected RI #1, one of three sampled residents reviewed for falls. Findings include: The facility's policy titled Interdisciplinary Fall Reduction/Injury Prevention Protocol dated 7/2012, documented Intent: An interdisciplinary approach at reducing falls, preventing injury and increasing safety awareness ultimately resulting in improved quality of care for our residents . On 10/27/2017, the Alabama State Survey Agency received a complaint which alleged in September 2017, while being transferred from the Hoyer lift by the assistance of one CNA, RI #1 slipped from the Hoyer lift and was lowered the floor. An in-house X-ray was done which revealed RI #1 sustained a left femur fracture. RI #1 was readmitted to the facility on [DATE]. RI #1 has a medical history to include: Dementia and Muscle Weakness. RI #1's Quarterly Minimum Data Set (MDS) with an assessment reference date of 7/28/2017, indicated RI #1 was severely impaired in cognitive skills for daily decision making, with a Brief Interview for Mental Status (BIMS) of 6. RI #1 was assessed as being totally dependent on staff for transfers, with two person physical assistance. The MDS further indicated RI #1 had one fall with no injury since the prior assessment. RI #1's care plan titled (RI #1) at risk for falls r/t (related to) generalized weakness, dementia. (RI #1) has an hx (history) of falls. Transfers with lift and two person assist with a problem onset date of 5/13/2013 last reviewed 8/30/2017, had an approach of . * Transfer with standup lift and staff of two . RI #1's Daily Care Guide had an intervention of . * Transfers using Sit to Stand lift with 2 person assist (Role: CNA) . *Transfer with standup lift and staff of two (Role: CNA). The Resident Incident Report revealed on 7/25/2017 at 2:05 PM, RI #1 sustained a fall. The report documented . Called to room at 205pm noted resident sitting in floor with straps of sit to stand lift remaining around resident. CNA stated that resident was up in the lift and started to get weak and let go of the lift and started sliding to the floor. Resident was then lowered the rest of the way to the floor by the lift. no injury noted . An interview was conducted with EI #1, a CNA, on 11/1/2017 at 8:45 a.m. EI #1 was asked to recall the circumstances surrounding the fall on 7/25/2017. EI #1 stated she used a sit to stand lift to transfer RI #1 from the wheelchair to the bed. EI #1 stated the resident's legs became weak and the resident was lowered to the floor. EI #1 was asked what the protocol of using the stand-up lift. EI #1 stated you are supposed to use two people. EI #1 stated she was written up for not using two people with the lift. EI #1 was asked why the facility required two people with the lift. EI #1 stated so an accident would not happen. EI #1 was asked what the potential harm of not using two people when using the lift. EI # 1 stated injury or broken bones could occur. In an interview on 11/1/2017 at 2:12 PM, EI #7, the Director of Nursing (DON) was asked about RI #1's fall on 7/25/2017. EI #7 stated, a CNA (EI #1) assisted RI #1 with the sit to stand lift. The CNA did not have the second person as the facility required. RI #1's knees became weak, buckled and the resident was lowered to the floor. According to EI #7, RI #1 did not sustain any injury from the incident. EI #7 stated a second person should have been in the room. EI #7 stated she did a counseling session with the CNA, EI#1, for not following safety rules. The Resident Incident Report revealed on 9/14/2017 at 11:00 AM, RI #1 sustained a fall. The report documented . Called to resident room to find resident in front of wheelchiar (wheelchair) on (his/her) knees. Resident was being transferred from bed to wheelchair with one person assist and (his/her) knees became weak and (he/she) was lowered to the floor . Resident complains of bilateral knee pain . The POST-INCIDENT ACTIONS for fall that occurred on 9/14/2017 documented . Immediate Post-Incident Action: Educate staff to review pocket care guides and to ask for assistance when needed . RI #1's Departmental Notes dated 9/14/2017 9:46 PM, documented . C/O (complained of) LEFT KNEE PAIN. LEFT KNEE SWOLLEN, TENDER TO TOUCH. DR. (name) NOTIFIED. NEW ORDER RECEIVED FOR X-RAY . X-RAY TO BE DONE 9/15/2017 . RI #1's RADIOLOGY (X-RAY) REPORT dated 9/15/2017 documented . Results: . There is a subtle . fracture of the distal femur . RI #1's Departmental Notes dated 9/15/2017 1:28 PM, documented . 1040 (10:40 AM) Xray reports obtained. Called to MD (Medical Doctor) xrays noted with left femoral fracture. Orders received to send resident to ER of family choice . RI #'1 X-ray report from the local hospital dated 9/15/2017, documented . Conclusion: . There is a minimally displaced . fracture . of the distal femur . An interview was conducted on 11/1/2017 at 9:30 AM, with EI #6, the CNA who transferred RI #1 on 9/14/2017. When asked if she recalled the incident, EI #6 said yes. According to EI #6, it was mid-morning and she attempted to transfer RI #1 from the bed to the wheelchair. RI #1's legs became weak and the resident was lowered to the floor. EI #6 was asked if she was supposed to use a lift when she transferred RI #1. EI # 6 stated she thought RI #1 had changed to standing on his/her own with assistance from staff. In an interview on 11/1/2017 at 2:12 PM, EI #7, DON was asked about RI #1's fall on 9/14/2017. EI #7 stated she was notified that a CNA assisted RI #1 with a transfer and did not use the lift or ask for assistance of another staff members. EI #7 stated RI #1 became weak again and was lowered to the floor. An x-ray was ordered and it showed RI #1 had a left femur fracture. This deficiency was cited as a result of the investigation of complaint/report number AL 393.

Based on interview and record review the facility failed to notify the Physician after a radiology report was received at the facility on 12/22/11 at 8:09 PM. RI (Resident Identifier) #1 fell on [DATE] around 11:00 AM, resulting in an acute left intertrochanteric fracture. As a result of the Physician not being notified of the fracture on 12/22/12, the resident was not sent to the local hospital emergency department until 12/23/11 at 12:53 PM. This affected one of four sampled residents identified with falls. Findings include: A review of the facility policy titled "X-RAY AND DIAGNOSTIC TESTS" with no review/revise date revealed: "...RESPONSIBILITY: All Licensed Nursing Personnel, monitored by Director of Nursing...5. Results of test will be reviewed by licensed nurse and acted upon as appropriate..." A review of the facilty policy titled, "NOTIFICATION OF A CHANGE IN A RESIDENT'S STATUS" with no review/revise date revealed: "POLICY: The attending physician/responsible party will be notified of a change in a resident's condition, per standards of practice and Federal and/or State Regulations...PROCEDURE: 1. Guideline for notification of physician /responsible part (not all inclusive)...a. Significant change in/ or unstable vital signs...d. Any accident or incident...f. Abnormal lab findings..." RI #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set with an Assessment Reference Date of 12/08/2011, assessed RI #1 as scoring a 15 on the BIMS (Brief Interview of Mental Status). A score of 13-15 suggests the resident is cognitively intact. RI #1 was also assessed as needing one person assist with bed mobility, transfer, dressing, toileting, personal hygiene and bathing. RI #1 was assessed as being occasionally incontinent of bladder and always continent of bowel. A review of the "Nurses Note" dated 12/22/11 at 11:00 AM, revealed, "Resident fell on ,[DATE] shift @ (at) 11:00 am..." A review of the "Physician's Telephone Orders" dated 12/22/11 at 3:00 PM, revealed, "Obtain x-ray of (L) (Left) shoulder, (L) humus, (L) Hip, (L) Mandible...Femur (L), (L) ribs..." Review of the local "Radiology Report" revealed the final report was sent to the facility on [DATE] at 20:09 (8:09 PM). A review of the report revealed, "...Exam HIP LEFT- 2V (views), LEFT..." The conclusion made by the local Radiologist revealed, "...Acute left intertrochanteric fracture... Electronically signed by...12/22/2011 8:07:25 PM EST (Eastern Standard Time)...Exam: FEMUR LEFT-2V, LEFT Results:...There is a fracture involving intertrochanteric femur without displacement..." At the bottom right hand side of the report EI #1 , LPN (Licensed Practical Nurse) handwrote "Faxed (initials.)" A review of the video surveillance time line of RI #1 timed the local X-ray company entered RI #1's room at 4:06 PM on 12/22/11, and exited the room at 4:26 PM. A review of the "24 HOUR NURSING REPORT" revealed the following information: "...(name of RI #1)...shift 3-11...x-Rays + (Positive) Fx (fracture)..." In an interview with EI #2, LPN, on 1/19/12 at 10:30 AM, she was asked how was RI #1 on 12/23/11. EI #2 responded, she went to find the results of the X-rays, but only found one X-ray of the skull. EI #2 called the X-ray company and requested they send the reports. The X-ray company explained they had already sent the reports last night, but sent a new copy to EI #2. EI #2 looked through the chart and found the reports sent on 12/22/11 at 8:09 PM. The reports showed RI #1 had a [MEDICAL CONDITION]. EI #2 showed EI #3, RN (Registered Nurse) Unit Manger the reports and called EI #4, the Physician. He instructed them to send RI #1 to the ED, (Emergency Department), for evaluation. An interview was conducted with EI #1, LPN on 1/19/12 at 11:30 AM. He was asked what time the X-ray result came into the facility for RI #1. EI #1 responded, he did not know what time but he put them on the chart. EI #1 was asked did he report the findings (fracture) to the Physician. He responded, he tried to call the doctor, but could not get through so he faxed them to the office. When asked what number he called, he replied the office number. When asked, if he could not get in touch with the physician what would he do. EI #1 responded, he could have called another doctor, but he faxed them to the office because he did not see a fracture. When asked if he spoke with a physician that night, EI #1 replied, no. In an interview with EI #4, the Physician, on 1/20/12 at 1:00 PM, he was asked what should the nurse have done once the results of the abnormal X-ray were received. EI #4 replied, when the results were received the nurse should have called him. When asked should the resident have received medical attention sooner, he replied, EI #1 should have been sent out.

Based on interview and record review the facility failed to relieve RI (Resident Identifier) #1's left hip pain during the 3-11 PM shift on 12/22/11. RI #1 only received the routine [MEDICATION NAME] (pain medication) during the 8 hour 3-11 PM shift, no other pain medication was given during that time. The left side pain was caused from a left [MEDICAL CONDITION] sustained from a fall in the bathroom around 11:00 AM on 12/22/11. RI #1 was not sent to the local hospital emergency department until 12/23/12 at 12:53 PM, where she received 2 mg (milligrams) [MEDICATION NAME] intravenously for pain relief. This affected one of four residents sampled with falls. Findings include: A review of the facility policy, "PAIN EVALUATION/MANAGEMENT" with no review/revise date revealed, "...Policy: all residents will be evaluated for pain at the time of admission, re-admission and as needed...Procedure:...5. If no relief or if the resident finds pain above acceptable levels notify the physician. 6. Notify physician if resident's response to their medication or treatment is not satisfactory to develop further interventions for relief of pain..." RI #1 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The most recent Minimum Data Set with an Assessment Reference Date of 12/8/2011 assessed RI #1 as scoring a 15 on the BIMS (Brief Interview of Mental Status). A score of 13-15 suggests the resident is cognitively intact. RI #1 was also assessed as needing one person assist with bed mobility, transfer, dressing, toileting, personal hygiene and bathing. RI #1 was assessed as being occasionally incontinent of bladder and always continent of bowel. RI #1 was also assessed as having occasional pain, being on a scheduled pain medication regimen and receiving as needed pain medication. A review of RI #1's care plan with a problem of, "Pain..." with a goal date of 3/11/12, revealed the following approaches: "* Assess for Pain intensity *Try non-pharmacy interventions *Administer Medication as ordered *Monitor for effectiveness * Report any unresolved pain to MD (Medical Doctor) promptly." A review of the "Nurses Note" dated 12/22/11 at 11:00 AM, revealed, "Resident fell on ,[DATE] shift @ (at) 11:00 am..." Review of the local "Radiology Report" revealed the final report was sent to the facility on [DATE] at 20:09 (8:09 PM). A review of the report revealed, "...Exam HIP LEFT- 2V (views), LEFT..." The conclusion made by the local Radiologist revealed, "...Acute left intertrochanteric fracture... Electronically signed by...12/22/2011 8:07:25 PM EST (Eastern Standard Time)...Exam: FEMUR LEFT-2V, LEFT Results:...There is a fracture involving intertrochanteric femur without displacement..." At the bottom right hand side of the report EI #1, LPN (Licensed Practical Nurse) handwrote, "Faxed (initials.)" Review of the 24 Hour Nursing Report dated 12/22/11 revealed, "...(name of RI #1)...shift 3-11...x-rays + (positive) Fx (fracture)...shift 11-7 c/o (complaint of) pain gave Tylenol and [MEDICATION NAME]" A review of the Nursing Notes for 12/22/11, revealed no notes were written during the 3-11 PM shift. Review of the "Physician's Orders" dated 12/01/11 through 12/31/11 revealed RI #1 had a prescription for, "[MEDICATION NAME] HCL ([MEDICATION NAME]) 50 mg (Milligram) tabl (tablet)... one (1) tablet by mouth at bedtime. DX (diagnosis): Pain not relieved by [MEDICATION NAME] HCL 50 mg tabl...one (1) tablet by mouth... every eight hours as [MEDICATION NAME] 325 mg ta (tablet)...two (2) tablets (650mg)...by mouth every six hours...as needed... " Review of the MAR (Medication Adminsitration Record) for the month of December 2011 revealed RI #1 received [MEDICATION NAME] 50 mg on 12/22/11 at 1:00 PM (as needed dose), Tylenol 325 mg two tablets at 3:00 PM and [MEDICATION NAME] 50 mg at 9:00 PM (routine dose). On 12/23/11, RI #1 received Tylenol 325 mg two tablets at 12:35 AM, [MEDICATION NAME] 50 mg at 3:05 AM, Tylenol 325 mg two tablets at 6:35 AM and Tylenol 325 mg two tablets plus [MEDICATION NAME] 50 mg at 11:00 AM. A review of the times on the December 2011, MAR indicated [REDACTED]. A review of the MAR indicated 0" pain on the 7-3 shift, 3-11 shift and 11-7 shift. It also documented RI #1 had no pain on 12/23/11 during the 7-3 shift. A review of the back of the December 2011 MAR indicated [REDACTED]. The only documentation made for 7-3 shift on 12/22/11 was left side pain, no numerical value was given to RI #1's pain. There was no documentation of any pain medication given or numerical pain scale written on the back of the December MAR indicated [REDACTED]. A review of the nursing departmental notes dated 12/23/11 at 7:21 AM, revealed, "...complained of pain during the night gave [MEDICATION NAME] 50 mg and Tylenol 650..." Further review of the nursing departmental notes dated 12/23/11 at 8:08 AM, revealed a note written for 12/22/11, "...Resident had a fall on 7-3 shift at 11:00 AM...Resident stated that she was hurting really bad to her Left side and her pain level was a 9 out of 10...Stat X-ray was ordered on resident for pain to her left...hip..." In an interview with RI #1 on 1/20/12 at 1:15 PM, she was asked if and when she was in pain. She answered she was in pain all afternoon and that evening after the fall. RI #1 further explained she cried during the evening and night. When asked if the pain medication helped with the pain, RI #1 responded, very little. In an interview with EI #6, 3-11 PM shift CNA (Certified Nurse Aide) on 1/20/12 at 2:45 PM, she was asked how EI #1 was acting the evening on 12/22/11. EI #6 responded, RI #1 was complaining of leg pain. When asked if RI #1 cried or yelled that evening, EI #6 replied, "Yes, She was crying. I tried to get her up to go to the bathroom, but she was crying in pain, so I had to put a diaper on her." In a later interview on 1/20/12 at 6:17 PM, with EI #6, she was asked if she remembered what time RI #1's leg was hurting. EI #6 replied when she first got there around 3:00 PM and then about 3:30 PM. When asked when RI #1 was crying. EI #6 replied, she was moaning at 3:00 PM but was crying at 3:30. When asked what she did after she saw RI #1 crying, EI #6 replied she tried to re-position her and then told the LPN (EI #1) who replied, Okay. When asked if RI #1 was her normal self, EI #6 answered, "No, she was fussing about him (EI #1). He wouldn't bring her her pain meds (medications)." When asked about her pain level, EI #6 replied RI #1 seemed to have the same level of pain during the night. EI #6 was asked if she told the LPN RI #1 was in pain and crying, she replied yes. In an interview with EI #1, 3-11 shift LPN (Licensed Practical Nurse) on 1/19/12 at 11:30 AM, he was asked did RI #1 ever complain of pain during his shift on 12/22/11. EI #1 responded, RI #1 said she was hurting on her left side. When asked if he gave RI #1 any pain medication during his shift, EI #1 responded he only gave her regular pain medication, [MEDICATION NAME]. He did not think she had anything else ordered. In a later interview on 1/21/11 at 12:04 PM, EI #1 was asked if RI #1 complained of pain during the 3-11 shift. He replied, no just when the CNAs would do care. In an interview with EI #4, the Physician, on 1/20/11 at 1:00 PM, he was asked if he had been notified of the resident's unresolved pain, what would he have done. EI #4 replied he would have called in something stronger. When asked with RI #1's current pain regime would it have relieved the bone pain, EI #4 replied probably not from a fracture.

This deficiency was written as a result of the investigation of complaint #AL 901. Based on interviews and record review, this facility failed to promptly notify the physician when RI #1 complained of pain. Employee Identifier (EI) #1 said that on 1/11/11, RI #1 was complaining of pain more than usual and that RI #1's pain was intractible and unrelieved. The LPN, (EI #2) assigned to the resident on the morning of 1/11/11, documented that the resident had numerous complaints of pain. This deficient practice affected 1 of 3 sampled residents identified with pain. On 2/25/11 at 6:50 p.m., the facility's Regional Vice President, Corporate Registered Nurse, Executive Director and Director of Nursing were notified of the findings of Immediate Jeopardy at F 157 which occurred on 1/11/11. The Immediate Jeopardy was relieved on 2/25/11, when the facility submitted their immediate corrective action plan and the surveyors verified that the facility had begun implementation of their immediate corrective actions. Findings include: On 1/11/11 at 2:50 a.m., nurse's notes document that RI #1 had made numerous complaints by yelling out that his indwelling foley catheter was hurting and that he will complain that his foot or ankle hurts. The note states that his feet are repositioned by staff members and that he is calling every 2 minutes for someone to straighten or stretch out his arm or reposition his extremities. The note also indicates that RI #1 is receiving pain medication on a routine basis and prn. In addition, an interview with a licensed nurse (EI #1) revealed that RI #1 was hollering out more than usual The facility policy related to "Notification of a Change in a Resident's Status " (10/09) specifies: "The attending physician/responsible party will be notified of a change in a resident's condition, per standards of practice and Federal and/or State Regulations (for) ... 1. J. Abnormal complaints of pain, ineffective relief of pain from current regimen. " RI #1 has resided in the facility since 04/29/05 with [DIAGNOSES REDACTED]. RI #1's annual Minimum (MDS) data set [DATE], documents this resident as cognitively intact with a mental status score of 15 correct responses out of a total possible 15 questions. Functionally, the resident was totally dependent upon staff for bed mobility, transfers, dressing, eating, toilet use and personal hygiene, experiencing frequent episodes of pain at an intensity level of 7 out of a maximum possible pain level of 10. On 01/08/11 at 12:59 AM, nursing staff documented the following: "Weekly Summary" in the Departmental Notes: "Resident is alert and oriented to time, place and situation, he is able to converse his needs to staff, and make decisions regarding his daily care. He has impaired mobility and is unable to assist staff with repositioning ... Resident is on a scheduled pain treatment, receives [MEDICATION NAME] 7.5 mg (milligrams) Q (every 8 hours and prn (as needed) Q 12 hrs ..." On 01/10/11 at 9:30 PM, nursing documented: "Resident alert c/o (complaints of) pain with foley cath(eter). 5 pm prn given, continue to c/o pain foley cath. Irrigated with 120 cc water. Water went in easy and came out easy. " On 01/11/11 at 2:50 PM nursing documents: "Resident has made numerous complaints, yelling out that his indwelling foley hurts him, and once this is taken care of, he will no longer c/o pain to catheter site, but will c/o his foot or ankle hurt, and bilateral feet has been repositioned numerous times, by several staff members, he is calling only about two minutes apart, to straighten/stretch out his arm, or to reposition his feet and knees, his arms are contractures with limited expansion. Resident is receiving pain medication on a routine basis and prn. " On 2/25/11 at 10:02 a.m., EI #1 stated she heard RI #1 holler all night on 1/11/11. EI #1 explained it was not unusual for RI #1 to holler some, but that night he hollered more than usual. EI #1 said that RI #1was in intractable pain that was unrelieved. EI #1 heard the resident call out, "Someone help me! Help me! Oh, oh, I'm in so much pain!" On 2/24/11 at 4:45 p.m., the surveyor interviewed RI #1 about his pain on 1/11/11. RI #1 described his pain as "very severe." On 2/25/11 at 2:45 p.m., RI #1 rated his pain at that time as 9 or 9.5 on a 1 (minimal) to 10 (maximum) pain scale. He explained the nurses gave him Tylenol, but it did not help much. The nursing staff would not give him additional pain medication because he had just taken some and said they would call the doctor and get him something else for pain. Employee Identifier (EI) #2, the Licensed Practical Nurse who wrote the nursing note of 01/11/11 at 2:50 AM, was interviewed by survey staff on 02/25/11 at 9:00 AM. EI #2 affirmed she had not called the physician . On 02/25/11 at 8:20 AM, the resident's physician (EI #4) was asked whether facility staff had notified him of RI #1's unrelieved pain on 1/11/11. EI #4 stated he was not notified of RI #1's pain until 01/13/11, when he ordered staff to send RI #1 to the hospital. EI #4 said that the facility did not call him during the time RI #1 was reported to be screaming. Nursing notes contained no evidence of the physician's notification of RI #1's pain until two days later (1/13/11). _____________________________ On 2/25/2011, the facility submitted an immediate plan for the removal of jeopardy cited at F 157. This plan included the following: Inservices for licensed nursing staff on the current shift (3-11) beginning at 7:14 p.m. on 2/25/11 to encompass remaining shifts until all licensed staff are educated in the following: "1. Policy and procedure on notification of Physician with changes in resident's status. 2. Policy and procedure for pain assessment/pain management. 3. Following residents plan of care related to pain as it pertains to location, frequency, duration and intensity and the use of the Instant Care Plan when a change in status occurs. All residents who receive pain medication will be added to the 24 hour report sheet to ensure adequate communication from shift to shift between nurses. The pain management flow sheet (RC-PP-D-011) has been added to all residents Medication Report (MAR) to monitor for new onset pain, administration of prn pain medication and the effectiveness. The unit managers or designee will bring to morning meeting the previous days' 24 hour report for review with nursing leadership. The Director of Nursing will ensure during morning meeting that the proper review of all prn pain medication documentation and physician notification has occurred. The Executive Director will receive report from the Director of Nursing during morning meeting of any pain occurrences from prior 24 hour. Executive director will review the report for compliance." Prior to exiting the facility on 2/25/11 at 10:00 p.m., the surveyors observed the immediate plan being put into place. Based on the acceptance of the immediate plan, the immediate jeopardy deficiency cited at F 309 = J level is lowered to a D to allow the facility time to fully evaluate and implement systems to correct the identified deficient practice.

This defienciency is written as a result of the investigation of complaint #AL 901. Based on record review and interviews with staff, the facility failed to follow interventions put into place for 1 of 3 sampled residents identified with pain, Resident Identifier (RI) #'s 1. On 2/25/11 at 6:50 p.m., the facility's Regional Vice President, Corporate Registered Nurse, Executive Director and Director of Nursing were notified of the findings of Immediate Jeopardy at F 282 which occurred on 1/11/11. The Immediate Jeopardy and was relieved on 2/25/11, when the facility submitted their immediate corrective action plan and the surveyors verified that the facility had begun implementation of their immediate corrective actions. Findings include: 1. RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of this resident's plan of care dated 11/23/10 revealed that the resident complains of pain to the lower legs/feet and extremities related to his [MEDICAL CONDITION]. The care plan also includes the resident has contractures to the upper extremities at times and complaints of pain to the upper extremities at times. Approaches included: Assess location, frequency, duration, and intensity of pain. Document assessment. Report increased pain trend to the physician and to administer pain medication as requested. The approaches also stated to document the effectiveness. LPN #2 documented the following note on 1/11/11 at 2:50 a.m.: "Resident has made numerous complaints yelling out that his indwelling foley hurts him, and once this is taken care of, he will no longer c/o (complain of) pain to catheter site, but will c/o his foot or ankle hurt, and bilateral feet has been repositioned numerous time, by several staff members, he is calling only about two minutes apart, to straighten/stretch out his arm or to reposition his feet and knees, his arms are contractures with limited expansion. Resident is receiving pain medication on a routine basis and prn." Review of the medication administration records revealed RI #1 received two [MEDICATION NAME] (Tylenol) 325 mg tablets by mouth on 1/10/11, 1/11/11 and 1/12/11. Although the nurse's notes on 1/10/11 state that the resident complained of pain with his foley catheter and a 5 p.m. prn was given, there was no documentation to include the intensity of the pain or if the pain medication was effective. On 1/11/11 at 8:52 p.m. nurse's notes document the resident complained of pain and that a prn was given. There was no documentation to show the location of the pain, an assessment for the intensity and duration of the pain nor was the effectiveness of the pain medication documented. The DON (EI #3) was interviewed on 02/25/11 at 12:15 PM. EI #3 said she went with EI #2 when EI #2 deflated the bulb and repositioned the catheter. EI #3 stated that the catheter as well as repositioning RI #1's feet. She said this was all she remembered. When asked if she assessed RI #1's pain level, she said that she did not. RI #1 stated that the nurse should have given the prn pain medication. She stated it was not signed out on the MAR but that he had a medication scheduled at 6 a.m., 2 p.m., 10 p.m. When asked if RI #1 could have received a prn [MEDICATION NAME], EI #3 stated that he could not have gotten another one until 5:00 a.m. When asked what was done to relieve RI #1's pain on 1/11/11 from 2:50 a.m. until 6:00 a.m., EI #3 stated that he was only repositioned and that no prns were given. From 2:30 a.m. until 6:00 a.m., EI #3 could not say whether RI #1's pain was relieved. When asked whether any staff called the physician to report the resident's pain, EI #3 said, she couldn't recall. When asked if anyone did a pain assessment on 1/11/11 to determine RI #1's pain level, EI #3 stated that she could not find documentation of a pain assessment being completed. _____________________________________ On 2/25/2011, the facility submitted an immediate plan for the removal of jeopardy cited at F 282. This plan included the following: Inservices for licensed nursing staff on the current shift (3-11) beginning at 7:14 p.m. on 2/25/11 to encompass remaining shifts until all licensed staff are educated in the following: "1. Policy and procedure on notification of Physician with changes in resident's status. 2. Policy and procedure for pain assessment/pain management. 3. Following residents plan of care related to pain as it pertains to location, frequency, duration and intensity and the use of the Instant Care Plan when a change in status occurs. All residents who receive pain medication will be added to the 24 hour report sheet to ensure adequate communication from shift to shift between nurses. The pain management flow sheet (RC-PP-D-011) has been added to all residents Medication Report (MAR) to monitor for new onset pain, administration of prn pain medication and the effectiveness. The unit managers or designee will bring to morning meeting the previous days' 24 hour report for review with nursing leadership. The Director of Nursing will ensure during morning meeting that the proper review of all prn pain medication documentation and physician notification has occurred. The Executive Director will receive report from the Director of Nursing during morning meeting of any pain occurrences from prior 24 hour. Executive director will review the report for compliance." Prior to exiting the facility on 2/25/11 at 10:00 p.m., the surveyors observed the immediate plan being put into place. Based on the acceptance of the immediate plan, the immediate jeopardy deficiency cited at F 282 = J level is lowered to a D to allow the facility time to fully evaluate and implement systems to correct the identified deficient practice.

Based on interviews, and review of the medical record, this facility failed to assess and effectively manage the pain experienced by Resident Identifier (RI #1) on 1/11/11. Documentation in the medical record and interviews with facility staff as well as the physician reveal that on 1/11/11 at 2:50 a.m., RI #1 was verbally complaining of pain by calling out for help due to the pain he was experiencing with his indwelling catheter as well as in his extremities. While staff state that the resident was calling out every 2 minutes with his pain, there was no information documented within the medical record of the level of pain RI #1 was experiencing nor was there contact made with the physician about RI #1's pain. On 1/11/11 at 2:50 a.m., RI #1 complained to the Licensed Practical Nurse (LPN), Employee Identifier (EI) #2, who documented that the resident (RI #1) was hollering out every 2 minutes related to pain in his extremities and pain related to his Foley catheter. An interview with the EI # 2 revealed she had asked for assistance from the Director of Nursing (DON), EI #3 at this time. Neither EI #2 or EI #3 called the physician to inform him of the resident's increase or accelerated pain. An interview was conducted with another LPN (EI #1) on 2/25/11 at 10:02 a.m. EI #1 said RI #1 was in intractable pain that was unrelieved. EI #1 said that the resident was hollering "Someone help, help me. Oh oh, I'm in so much pain." During an interview with the resident on 2/24/11 at 4:45 p.m., RI #1 said his pain was very severe. During an interview with the Physician on 2/24/11 at 11:10 a.m., the physician said he was not notified of RI #1's pain on 1/11/11 and that someone should have called him earlier. A subsequent interview with the EI #4 on 2/22/11 at 8:20 a.m. confirmed that he was not called until 1/13/11 when he sent RI #1 out. EI #4 also stated that they (the facility) did not call him the whole time RI #1 was screaming (with pain). This deficient practice affected RI #1, one of 63 residents identified by the facility's Resident Census and Condition on pain management. On 2/25/11 at 6:50 p.m., the facility's Regional Vice President, Corporate Registered Nurse, Executive Director and Director of Nursing were notified of the findings of Immediate Jeopardy at F 309 which occurred on 1/11/11. The Immediate Jeopardy and was relieved on 2/25/11, when the facility submitted their immediate corrective action plan and the surveyors verified that the facility had begun implementation of their immediate corrective actions. Findings include: RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) with an assessment date of 11/16/10 documents the resident can repeat three words on the first attempt, is able to report the correct year, month and day of the week. RI #1 is totally dependent on staff for assistance with Activities of Daily Living (ADLs), to include bed mobility, transfers, dressing, eating, toilet use and personal hygiene. The assessment identified the resident has an indwelling catheter and is always incontinent of bowel. In addition, the section of the assessment titled, " Pain Assessment Interview " indicates that RI #1 has frequent pain at an intensity level of 7 (on a 0 to 10 scale, with zero being no pain and ten being the worst pain you can imagine). The assessment indicates that RI #1's pain has made it hard for him to sleep at night and that the pain has limited his day to day activities. The assessment indicates that the resident has both scheduled pain medication and PRN (as needed) pain medication for pain management. A care plan devised for the resident with a date of 11/23/10, documents: " C/O (complains of) pain to lower legs/feet and extremities r/t (related to) [MEDICAL CONDITION] C1-C4; Contractures to upper extremities and c/o pain to upper extremities at times. Approaches: ...Assess location, frequency, duration, and intensity of pain. Document assessment. Report increased pain trend to physician...Administer pain medication as requested. Document effectiveness... " The "Pain Assessment/Management" dated 10/09, specifies: "Policy: All residents will be assessed for pain at the time of admission, readmission and as needed. Procedure: When to Assess: ...2. Upon all new complaints of pain/discomfort from resident or resident's family. 3. Upon a change in behavior of resident (e.g. Decreased appetite, depression, agitation, aggression, etc.). A. Completing Pain Management Assessment Tool: 3. The physician will be called and the results of the pain assessment reviewed in order to develop further interventions for relief of pain... 5. Update Care Plan..." Review of the "Departmental Notes" for Nursing state: 1/10/11 at 9:30 p.m.: "Resident alert c/o (complaint of) pain with foley cath. 5pm prn (as needed) given, continue to c/o pain foley cath. (catheter) irrigated with 120 cc water, water went in easy and came out easy. " 1/11/11 at 2:50 a.m., "Resident has made numerous complaints yelling out that his indwelling foley hurts him, and once this is taken care of, he will no longer c/o pain to catheter site, but will c/o his foot or ankle hurt, and bilateral feet has been repositioned numerous time, by several staff members, he is calling only about two minutes apart, to straighten/stretch out his arm or to reposition his feet and knees, his arms are contractures with limited expansion. Resident is receiving pain medication on a routine basis and prn." A review of the Medication Administration Orders (MAO) dated 1/1/11 through 1/31/11 document physician's orders [REDACTED]. The MAO for the month of January 2011 documented that RI #1 received his routine pain medication at 6 a.m., 2 p.m., and 10 p.m. every day. The first documented prn [MEDICATION NAME] on the "Controlled Drug Record" was given on 1/11/11 and 1/12/11, each at 5:00 p.m. The "Controlled Drug Record" for January 1/10/11 documented the routine [MEDICATION NAME] was given as ordered at 6:00 a.m., 2:00 p.m., and 10:00 p.m. Additionally one PRN [MEDICATION NAME] was given at 5:00 p.m. This documentation revealed that RI #1 was unable to receive any additional pain medication after the routine 10:00 p.m. dose, until 5:00 a.m., on 1/11/11, seven hours later. An interview was conducted with RI #1 on 2/24/11 at 4:45 p.m. regarding his pain. RI #1 described his pain as very severe on 1/11/11 during the night. He said he had received Tylenol earlier, but it did not help much. A subsequent interview with RI #1 on 2/25/11 at 2:45 p.m. revealed that he would rate his pain a 9 or 9.5 (on a scale of 0 to 10 with 10 being the worst), on the night of 01/11/11. RI #1 said the pain was in his lower stomach, a couple of days before hospitalization . The LPN (EI #2), working with RI #1 on the night of 1/11/11 was interviewed on 2/25/11 at 8:50 a.m. EI #2 stated that RI #1 had been yelling out the majority of the shift; that he was yelling for help for repositioning for his arms and legs and for a pillow between his legs. EI #2 stated that she deflated the bulb (on the foley catheter). EI #2 said she did not call the physician that night. She had requested help from the Director of Nursing (DON) and they together had assessed the resident. EI #2 said she did not document this in the medical record. EI #2 said she was instructed to give the resident another PRN pain medication when it was time, but she could not give it to him before 5:00 a.m. The surveyor asked EI #2 if the resident had suffered in pain from 2:50 a.m. until 6:00 a.m. EI #2 said he did. The DON (EI #3) was interviewed on 02/25/11 at 12:15 PM. EI #3 said she went with EI #2 when EI #2 deflated the bulb and repositioned the catheter. EI #3 stated that the catheter as well as RI #1's feet were repositioned and that was all she remembered. When asked if she assessed RI #1's pain level, she said that she did not. RI #1 stated that the nurse should have given the prn pain medication. She stated it was not signed out on the MAR but that he had a medication scheduled at 6 a.m., 2 p.m., 10 p.m. When asked if RI #1 could have received a prn [MEDICATION NAME], EI #3 stated that he could not have gotten another one until 5:00 a.m. When asked what was done to relieve RI #1 ' s pain on 1/11/11 from 2:50 a.m. until 6:00 a.m., EI #3 stated that he was only repositioned and that no prns were given. From 2:30 a.m. until 6:00 a.m., EI #3 could not say whether RI #1's pain was relieved. When asked whether any staff called the physician to report the resident's pain, EI #3 said, she couldn't recall. When asked if anyone did a pain assessment on 1/11/11 to determine RI #1's pain level, EI #3 stated that she could not find documentation of a pain assessment being completed. An interview was conducted on 2/25/11 at 11:15 a.m. with the LPN (EI #1) working the night of 1/11/11. During this interview, EI #1 stated it wasn't unusual for him (RI #1) to holler some and that his hollering was more than usual. She stated that this night, he was in intractable pain that was unrelieved. EI #1 stated that she heard RI #1 calling out, " Someone help me, help me! Oh oh! I'm in so much pain! "EI #1 also said that one of the nurse's names was called over the intercom and the resident in turn, began calling this nurse's name. He was hollering for anyone to help him. An interview was conducted with RI #1's physician (EI #4) on 2/24/11 at 11:00 a.m., and again on 2/25/11 at 8:20 a.m. about the pain RI #1 had experienced on the night of 1/11/11. EI #4 said that nursing staff called him on 1/13/11 (2 days later), the day RI #1 was sent out to the hospital. EI #4 said that the nursing staff told him that RI #1 had been screaming and he wanted to know why he had not been called earlier. EI #4 also said one of the nurses said the hollering was awful. After being admitted to the hopsital on 1/13/11, RI #1 was disgnosed with a scrotal abscess and underwent an incision and drainage of the abscess. ______________________________________ On 2/25/2011, the facility submitted an immediate plan for the removal of jeopardy cited at F 309. This plan included the following: Inservices for licensed nursing staff on the current shift (3-11) beginning at 7:14 p.m. on 2/25/11 to encompass remaining shifts until all licensed staff are educated in the following: "1. Policy and procedure on notification of Physician with changes in resident's status. 2. Policy and procedure for pain assessment/pain management. 3. Following residents plan of care related to pain as it pertains to location, frequency, duration and intensity and the use of the Instant Care Plan when a change in status occurs. All residents who receive pain medication will be added to the 24 hour report sheet to ensure adequate communication from shift to shift between nurses. The pain management flow sheet (RC-PP-D-011) has been added to all residents Medication Report (MAR) to monitor for new onset pain, administration of prn pain medication and the effectiveness. The unit managers or designee will bring to morning meeting the previous days' 24 hour report for review with nursing leadership. The Director of Nursing will ensure during morning meeting that the proper review of all prn pain medication documentation and physician notification has occurred. The Executive Director will receive report from the Director of Nursing during morning meeting of any pain occurrences from prior 24 hour. Executive director will review the report for compliance." Prior to exiting the facility on 2/25/11 at 10:00 p.m., the surveyors observed the immediate plan being put into place. Based on the acceptance of the immediate plan, the immediate jeopardy deficiency cited at F 309 = J level is lowered to a D to allow the facility time to fully evaluate and implement systems to correct the identified deficient practice.