Every finding on record at Cedar Creek Post Acute

Based on the policy review, observation, interview, and product information sheets, the facility failed to provide an environment free of accident hazards for 1of 4 common hallways (200 hall) when the facility left a bleach germicidal spray cleaner and a disinfectant spray easily accessible to residents on the 200 hall, and when unsecured sharps were observed in 5 of 52 (Resident #2, #75, #76, #88, and 90) resident rooms observed for accident hazards. There were 5 residents with wandering behaviors in the facility. The findings include: 1. Review of the undated facility policy titled, Resident Environmental Quality, revealed .It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for resident, staff and the public . Review of the facility policy titled, Sharps Disposal, dated January 2025, revealed .Whoever uses contaminated sharps will discard them immediately . into designated containers .sharps will be discarded into containers that are .closable .puncture resistant .impermeable [not allowing fluids to pass through] and capable of maintaining impermeability through final waste disposal .Whoever observes incorrect disposal or handling .should report the information to the infection preventionist (or designee) . Review of the [named] bleach germicidal spray cleaner technical information sheet revealed, . Caution: Causes moderate eye irritation. Avoid contact with eyes or clothing. Review of the [named] disinfectant spray material safety data sheet revealed, .Causes irreversible eye damage. Do not get in eyes or on clothing. 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including End Stage Renal Disease, Renal Dialysis, and Anxiety. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident # 2 was cognitively intact. Observation in the Resident's room on 7/29/2025 at 7:46 AM, revealed scissors were observed on the bedside table in Resident #2's bath basin. Observation and interview in Resident #2's room on 7/29/2025 at 7:48 AM, LPN A was asked if scissors should be in the resident's room. LPN A confirmed residents should not have scissors in their room. During an interview on 7/30/2025 at 5:05 PM, the Assistant Director of Nursing (ADON) confirmed residents should not have scissors at the bedside. 3. Review of the medical record revealed Resident #75 was readmitted to the facility on [DATE], with diagnoses including Stage 2 Pressure Ulcer, Hypertension, Depression, Anxiety, and Methicillin Resistant Staphylococcus Aureus (MRSA a type of bacteria that is difficult to treat). Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #75 was cognitively intact. Resident required moderate assistance with bathing. Observations in Resident #75's bathroom on 7/29/2025 at 7:51 AM and 3:56 PM, revealed a disposable razor in a plastic bag on the back of the toilet. During an observation and interview on 7/29/2025 at 4:12 PM, LPN G confirmed that the razor should not be in Resident #75's bathroom unsecured. 4. Review of the medical record revealed Resident #76 was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure, Diabetes, and Anxiety. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #76 was cognitively intact. Resident #76 required partial to moderate assistance for personal care. 5.Review of the medical record revealed Resident #90 was admitted to the facility on [DATE], with diagnoses including Depression and Dementia. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 5, which indicated Resident #90 was significantly cognitively impaired. Resident #90 required maximum assist for ADLs. Observation in Resident #76 and #90's shared bathroom on 7/28/2025 at 12:35 PM, revealed a gray disposable razor left on the back of the toilet. During an observation and interview in Residents #76 and #90's shared bathroom on 7/28/2025 at 5:42 PM, CNA F confirmed that razors should not be left unsecured in resident bathrooms. 5. Review of the medical record revealed Resident #88 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Dementia, and Diabetes. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 14, which indicated Resident #88 was cognitively intact. Resident required partial to moderate staff assistance with bathing and personal care. Observations in Resident #88's bathroom on 7/28/2025 at 10:11 AM and 3:46 PM, revealed a blue disposable razor on the bathroom sink behind the faucet. During an observation and interview in Resident #88's bathroom on 7/28/2025 at 5:43 PM, the DON confirmed the blue disposable razor should not be in the resident's bathroom. Observation in Resident #88's room on 7/29/2025 at 10:20 AM, revealed a blue disposable razor was on the Resident's nightstand. During an observation and interview in Resident's #88's on 7/29/2025 at 10:25 AM, the DON confirmed the razor should not be on the nightstand in the Resident's room. 6. A random observation on the 200 hall on 7/28/2025 at 11:11 AM, 11:27 AM, and 3:46 PM, revealed a bottle of (Named) bleach germicidal spray cleaner and a bottle of (Named) disinfectant spray was left unattended and out of sight of the housekeeper on the left outer side of the cleaning cart. During an interview on 7/28/2025 at 3:56 PM, Housekeeper E was asked about the cleaning chemicals left on the outer side of the cleaning cart. The housekeeper stated, .I thought as long as I was using it I could have it on the side of the cart, but the activity lady told me it had to be locked away . During an interview on 7/30/2025 at 2:42 PM, the Housekeeping Manager was asked where housekeepers should keep (Named) bleach germicidal spray and (Named) disinfectant spray when staff are inside Resident rooms cleaning. The Housekeeping Manager stated .in the cart, locked up . The Housekeeping Manager was asked if chemical cleaning supplies should be left in the hall on the side of cart while the housekeeper is in the Resident rooms cleaning. The Housekeeping Manager stated, Not at all .the resident could pick it up, drink it and harm themselves.

Based on policy review, resident fund statement review, medical record review, and interview, the facility failed to notify the resident and/or resident representative when the amount in the residents' account exceeded the eligibility limit for 4 of 37 residents (Resident #45, #59, #86, and #87) and when the facility failed to refund the resident's funds within 30 days of death or discharge for 1 of 1 sampled residents (Resident #103) reviewed for personal fund account statements. The findings include: 1. Review of the undated facility policy titled, Resident Trust Fund revealed, .Excess resources.Medicaid eligible residents will be notified when the amount in the resident's account reaches $200 less than the Medicaid resource limit for one person. If the amount in the account in addition to the value of the resident's other nonexempt eligibility for Medicaid or SSI [Supplemental Security Income].the resident will also be notified when this situation arises.Refunds.Upon death or discharge of a resident with a personal fund account, the facility will convey within 30 days the resident's funds and a final accounting of those funds to the individual or probate jurisdiction administering the resident's estate . 2. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Diabetes, Malnutrition, and Bipolar Disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicated Resident #45 was moderately cognitively impaired. Review of Resident #45's Resident Fund Statement dated 4/1/2025 through 6/30/2025, revealed an ending balance of $5,880.89. 3. Review of the medical record revealed Resident #59 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Depression, and Anxiety. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #59 was cognitively intact. Review of Resident #59's Resident Fund Statement dated 4/1/2025 through 6/30/2025, revealed an ending balance of $3,781.32. 4. Review of the medical record revealed Resident #86 was admitted to the facility on [DATE], with diagnoses including Metabolic Encephalopathy, Chronic Obstructive Pulmonary Disease, Dementia, and Bipolar Disorder. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 6, which indicated Resident #86 was severely cognitively impaired. Review of Resident #86's Resident Fund Statement dated 4/1/2025 through 6/30/2025, revealed an ending balance of $7,766.99. 5. Review of the medical record revealed Resident #87 was admitted to the facility on [DATE], with diagnoses including Hypertension, Depression, Anxiety, and Glaucoma. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 14, which indicated Resident #87 was cognitively intact. Review of Resident #87's Resident Fund Statement dated 4/1/2025 through 6/30/2025, revealed an ending balance of $5,488.81. The facility failed to notify resident(s) and/or representative of residents' fund account balances over the eligibility limit. 6. Review of the medical record revealed Resident #103 was admitted to the facility on [DATE], with diagnoses including Heart Failure, Malnutrition, Dementia, Pseudobulbar Disorder. Review of the nurses note dated 2/4/2025, revealed .resident pronounced dead at 1755 [5:55 PM] . Review of the facility's refund check dated 3/31/2025, revealed a check in the amount of $279.26 was mailed to the funeral home. The facility failed to issue a refund of resident's account within 30 days of discharge. During an interview on 7/30/2025 at 11:42 AM, the Business Office Manager confirmed that the refund for Resident #103's account balance was not sent to the funeral home until 3/31/2025. The Business Office Manager confirmed that documentation could not be provided that residents and/or representatives were informed of account balances over the eligibility limit.

Based on policy review, medical record review, and interview the facility failed to follow physician orders to meet professional standards of practice for 7 of 21 (Resident #3, #6, #7, #11, #12, #14 and #45) sampled residents. The findings included: 1. Review of the facility policy titled, Administering Medications, dated March 2025, revealed .Medications are administered in a safe and timely manner, as prescribed.Medications are administered in accordance with prescriber orders, including any required time frame.the following information is checked/verified for each resident prior to administering medications.vital signs, if necessary.if a drug is withheld, refused or given at a time other than the scheduled time, the individual administering medication shall initial and circle the MAR [Medication Administration Record] space provided for that drug dose.the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next one.the individual administering the medication records in the resident's medical record: the date, the dosage, the signature and title of the person administering the drug.staff follows established facility infection control procedures.(handwashing, antiseptic technique, gloves, isolation precautions) for the administration of medications. 2. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses including Schizoaffective Disorder, Bipolar Type, Diabetes, Dementia, and Anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 2, which indicated Resident #3 was severely cognitively impaired. Resident #3 was taking Insulin, Antipsychotic, Antidepressant, Diuretic, Hypoglycemic, and Anticonvulsant medications. Review of the Physician Orders dated 7/29/2025, revealed the following medications: a. Insulin Aspart (for increased blood sugar) b. Tradjenta (for increased blood sugar) c. Furosemide (to decrease fluid) d. Lamotrigine (for bipolar disease) e. Clozapine (for bipolar disease) f. Allopurinol (for gout) g. Amlodipine (for Heart Failure) h. Bisacodyl for (for constipation) i. Famotidine (for reflux) j. Fluoxetine (for Bipolar) k. Insulin Glargine (for increased blood sugar) l. Lamotrigine (for Bipolar disease) Review of the Medication Administration Record (MAR) dated July 2025, revealed no medications were administered for July 8, 2025 from 7:30 AM to 12:00 PM. During an interview on 7/30/2025 at 12:57 PM, the Director of Nursing (DON) confirmed that a blank indicated medications were not administered. The DON confirmed that medications should be signed out when they are administered. 3. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses including Depression, Anxiety, and Insomnia. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 13 which indicated Resident #6 was cognitively intact. Resident #6 was taking antidepressant, anticoagulant, and opioid medications. Review of the Physician Orders dated 7/29/2025, revealed .Midodrine HCI [Hydrochloride-used to increase blood pressure] Oral Tablet 2.5 MG [milligrams] Take one tab by mouth before meals for hypotension, Hold if SBP [systolic blood pressure] > [greater than]110 . Review of the MAR dated July 2025, revealed Midodrine was administered when the blood pressure was outside the parameters on: a. 7/1/2025 at 6:30 AM with a blood pressure (BP) of 112/78. b. 7/2/2025 at 6:30 AM with a BP of 118/70. c. 7/4/2025 at 6:30 AM with a BP of 122/78 and 11:30 AM with a BP of 112/64. d. 7/5/2025 at 6:30 AM with a BP of 124/78 and 4:30 PM with a BP of 112/64. e. 7/6/2025 at 6:30 AM with a BP of 124/68. f. 7/10/2025 with a BP of 118/50. g. 7/11/2025 at 11:30 AM with a BP of 113/70. h. 7/17/2025 at 6:30 AM with BP of 119/52 and 11:30 AM with a BP of 119/52. i. 7/19/2025 at 6:30 AM with BP of 112/88. j. 7/26/2025 a 6:30 AM with a BP of 123/64. k. 7/25/2025 at 4:30 PM with a BP of 114/59. l. 7/30/2025 at 11:30 AM with a BP of 120/62. During an interview on 7/30/2025 at 1:00 PM, the DON confirmed that the medication should have been held and not administered according to the physician orders. 4. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses including Paraplegia, Neuromuscular Dysfunction of Bladder, Diabetes, Anxiety, and Depression. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 15 which indicated Resident #7 was cognitively intact. Resident #7 was taking hypoglycemic medications. Review of the Physician's Order dated 7/3/2025, revealed .Notify physician if blood sugar greater than 400 . Review of the MAR dated 7/2025, revealed Resident #7's blood glucose level was above 400 on the following dates. a. 7/10/2025 at 7:30 AM, glucose level was 403 b. 7/12/2025 at 9:00 PM, glucose level was 408 c. 7/14/2025 at 7:30 AM, glucose level was 462 d. 7/22/2025 at 11:30 AM, glucose level was 428 e. 7/25/2025 at 9:00 PM, glucose level was 408 The facility failed to notify the physician of Resident #7's glucose levels greater than 400. During an interview on 7/30/2025 at 12:30 PM, the DON confirmed that a resident's glucose level greater than 400 should be reported to the physician. 5. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE], with diagnoses including Paraplegia, Neuromuscular Dysfunction of Bladder, Diabetes, Anxiety, and Depression. Review of the Physician Orders dated 7/3/2025, revealed .Mirtazapine .for DEPRESSION .VERBALIZATION OF FEELING SADNESS .FOR (MIRTAZIPINE) USE: MONITOR # [number] OF EPISODES OF (VERBALIZATION OF FEELING SADNESS) every shift .FOR (TRAZODONE) [medication for depression] USE: MONITOR # OF EPISODES OF (VERBALIZATION OF DIFFICULTY OF SLEEPING) every shift FOR (DULOXETINE)[medication for depression] USE: MONITOR # OF EPISODES OF (VERBALIZATION OF DIFFICULTY OF SLEEPING) every shift . Review of the admission MDS assessment completed 7/7/2025, revealed a BIMS score of 15, which indicated Resident #11 was cognitively intact. Resident required moderate assistance with toileting. Resident was taking antidepressant, antianxiety, anticoagulant, antibiotic, opioid, and hypoglycemic medications. Review of MAR dated 7/2025, revealed .FOR (MIRTAZIPINE) USE:MONITOR # OF EPISODES OF (VERBALIZATION OF FEELING SADNESS) and FOR (DULOXETINE) USE: MONITOR # OF EPISODES OF (VERBALIZATION OF DIFFICULTY OF SLEEPING) every shift -Start Date 7/3/2025 1900 [7:00 PM] .FOR (TRAZODONE) USE:MONITOR # OF EPISODES OF (VERBALIZATION OF DIFFICULTY OF SLEEPING)every shift-Start Date 7/3/2025 1900 . Shift monitoring was not documented as performed on the following dated: a. 7/8/2025 from 7:00 PM to 7:00 AM b. 7/9/2025 from 7:00 AM to 7:00 PM c. 7/10/2025 from 7:00 AM to 7:00 PM d. 7/11/2025 from 7:00 AM to 7:00 PM e. 7/14/2025 from 7:00 PM to 7:00 AM f. 7/15/2025 from 7:00 PM to 7:00 AM g. 7/16/2025 from 7:00 PM to 7:00 AM h. 7/17/2025 from 7:00 AM to 7:00 PM and from 7:00 PM to 7:00 AM. During an interview on 7/30/2025 at 12:30 PM, the DON confirmed that blanks on the MAR indicates medication or monitoring was not performed. The DON confirmed the MAR should be completed if the medication or monitoring was performed. 6. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnoses including Diabetes, Spinal Stenosis, Anxiety, Depression, and Legal Blindness. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #12 was cognitively intact. Resident was taking an insulin, antianxiety, antidepressants, diuretics, and opioid medications. Review of the Physician Orders dated 7/30/2025, revealed the following medications: a. Amitriptyline (for depression) b. Baclofen (for muscle spasms) c. Brimonidine (for vision loss) d. Dorzolamide/Timilol (for vision loss) e. Lantus (for high blood glucose) f. Levothyroxine (thyroid hormone) g. Lubiprostone (for constipation) h. Rosuvastatin (for heart disease) i. Travoprost (for glaucoma and ocular hypertension) j. Vitamin D3 (for anemia) k. Melatonin (for insomnia) l. Lispro (for high blood glucose) m. Gabapentin (for nerve pain) n. Humalog (for high blood glucose) o. Cetirizine (for allergies) p. Citalopram (for depression) q. Docusate (for stool softener) r. Low-Ogestrol (for abnormal uterine bleeding) s. Torsemide (for heart failure) t. Aspirin (for heart disease) u. Calcium (for low calcium) v. Ferrous Sulfate (for anemia) w. Miralax (for constipation) x. Aripiprazole (atypical antipsychotic for depression) Review of the MAR dated July 2025, revealed no medications were administered for July 3, 2025, and July 6, 2025, from 7:00 PM to 7:00 AM, and July 8, 2025, from 7:00 AM to 7:00 PM. 7. Review of medical record revealed Resident #14 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Hypothyroidism, and Tracheostomy Status. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #14 was cognitively intact. Resident #14 was taking Diuretics and Anticonvulsant medications. Resident required suctioning and tracheostomy care. Review of the Physician Orders dated 7/29/2025, revealed: a. Trach [Tracheostomy] Care b. Change Disposable Inner Cannula c. Monitor tolerance of Trach Care d. Clean Trach Stoma with Normal Saline Review of Physician Orders dated 7/29/2025, revealed .Enhanced Barrier Precautions (12/19/2024) .Clean with Normal Saline every evening shift trach stoma (1/29/2025).Monitor tolerance for Trach Care every evening shift .Clean with Normal Saline every evening shift trach stoma .Change Disposable inner cannula .with trach care every evening . Review of the Treatment Administration Record (TAR) dated July 2025, revealed the facility failed to document the change of the Disposable Inner Cannula on the following dates: a. 7/11/2025 (7:00 PM-7:00 AM) b. 7/14/2025 (7:00 PM-7:00 AM) c. 7/19/2025 (7:00 PM-7:00 AM) d. 7/26/2025 (7:00 PM-7:00 AM) Review of the TAR dated July 2025, revealed tracheostomy care was not documented as performed on the following dates: a. 7/11/2025 (7:00 PM-7:00 AM) b. 7/14/2025 (7:00 PM-7:00 AM) c. 7/26/2025 (7:00 PM-7:00 AM) Review of the TAR dated July 2025, revealed .Monitoring tolerance of Trach Care every evening shift . was not documented for the following dates. a. 7/11/2025 (7:00 PM-7:00 AM) b. 7/14/2025 (7:00 PM-7:00 AM) c. 7/26/2025 (7:00 PM-7:00 AM) During an interview on 7/30/2025 at 12:47 PM, the DON confirmed there were days when the tracheostomy care was blank which indicated the treatment was not done. 8. Review of medical record revealed Resident #45 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Memory Deficit, Diabetes, Bipolar Disorder, and Dysphagia. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 9, which indicated Resident #45 was moderately cognitively intact. Resident #45 was taking an antidepressant, diuretic, hypoglycemic (including insulin) and an anticonvulsant medication. Review of the Physician Orders dated 7/29/2025, revealed .Carvedilol Tab [tablet] 25MG [Milligram] Give 1 tablet orally two times a day for HTN [Hypertension] Hold for HR [Heart Rate] <60 [less than 60]. Notify NP [Nurse Practitioner] if dose is held . Review of the MAR dated July 2025, revealed Carvedilol Tab 25MG was administered to Resident #45 as follows: a. 7/13/2025 at 9:00 PM and the Resident's heart rate was 56. b. 7/18/2025 at 9:00 PM and the Resident's heart rate was 57. c. 7/26/2025 at 9:00 PM and the Resident's heart rate was 56. d. 7/27/2025 at 9:00 AM and the Resident's heart rate was 59. During an interview on 7/30/2025 at 12:47, the DON confirmed the medication should have been held if the heart rate was less than 60.

Based on policy review, observation, and interview, the facility failed to ensure infection control practices were followed to prevent the spread of infection when 2 of 4 (Licensed Practical Nurse (LPN) B and D) staff failed to perform hand hygiene for 3 of 9 (Resident #1, #18 and #75) residents, 2 of 4 (LPN B and Registered Nurse (RN) C) nurses failed to clean reusable equipment between residents for 2 of 9 (Resident #18 and #45) during medication administration. The findings include: 1. Review of the facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated 2019, revealed .Resident-care equipment, including reusable items .will be cleaned and disinfected according to current CDC [Center for Disease Control and Prevention] recommendations for disinfection .Reusable items are cleaned and disinfected between residents .stethoscopes, durable medical equipment .Reusable resident care equipment will be sanitized in between residents . Review of the undated facility policy titled, Handwashing/Hand Hygiene, revealed .This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections .All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors .Hand hygiene is indicated .after contact with blood, body fluids, or contaminated surfaces; after touching a resident .before moving from work on soiled body site to a clean body site on the same resident .and immediately after glove removal . Review of the facility policy titled, Isolation .Transmission Based Precautions, dated September 2022, revealed .Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection .or has a laboratory confirmed infection, and is at risk of transmitting the infection to other residents .Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces . 2. Observation during medication administration on 7/30/2025 at 8:08 AM, revealed LPN B failed to perform hand hygiene prior to donning and after doffing gloves when administering medications for Resident #1. Observation during medication administration on 7/30/2025 at 8:19 AM, revealed LPN B failed to perform hand hygiene prior to donning and after doffing gloves when administering medications for Resident #18. LPN B used the blood pressure machine to obtain vital signs, took the machine back into hallway and left it. LPN B failed to disinfect the blood pressure machine. Observation during medication administration on 7/30/2025 at 12:15 PM, revealed RN C failed to disinfect the stethoscope after use on Resident #45. During an interview on 7/30/2025 at 1:43 PM, the Director of Nursing (DON) confirmed that staff should wash hands between glove changes while passing medications and staff should clean reusable equipment between use on residents. 3. Review of the medical record revealed Resident #75 was readmitted to the facility on [DATE], with diagnoses including Pressure Ulcer, Hypertension, Depression, Anxiety, and Methicillin Resistant Staphylococcus Aureus (MRSA). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #75 was cognitively intact. Resident had a stage 2 and stage 3 pressure ulcer that were not present on admission. Review of a physician's order dated 7/16/2025, revealed, .Contact isolation due to MRSA [Methicillin-resistant Staphylococcus aureus] of wound x [times] 14 days every shift. Review of a physician's order dated 7/16/2025, revealed, TX: [Treatment] Cleanse area with wound cleanser and pat dry, Apply CALCIUM ALGINATE [promotes wound healing], cover w/ [with] silicone super absorbent DRESSING Location: right gluteus [large muscle of buttocks] every day shift for pressure injury AND as needed for pressure injury.TX: Cleanse area with wound cleanser and pat dry, Apply CALCIUM ALGINATE, cover w/ silicone super absorbent DRESSING Location: left gluteus every day shift for Altered Skin Integrity (Left Gluteus) - cleanse with normal saline, pat dry. apply calcium alginate with silver, cover with zinc and secure with foam border . Observation during wound care in the Resident's room on 7/30/2025 at 9:02 AM, LPN D failed to perform hand hygiene and don new gloves after removal of soiled dressings. LPN D moved the overbed table and wheelchair to resident's bedside with soiled gloves. During an interview on 7/30/2025 at 9:20 AM, LPN D stated I know that I messed up. I didn't sanitize after changing gloves. LPN D was asked if he should remove gloves and perform hand hygiene after removal of soiled dressing. LPN stated No, because one hand is clean and one hand is soiled. LPN confirmed that he should not touch objects in the room with soiled gloves. During an interview on 7/30/2025 at 9:31 AM, the DON confirmed staff should remove and change gloves during wound care and perform hand hygiene after the removal of gloves and confirmed that staff should not touch items in the resident's room with soiled gloves after performing wound for resident in contact precautions.

Based on policy review, observation and interview, the facility failed to ensure a safe, sanitary, and comfortable environment for 2 of 53 (Resident #5, #46, #55, and #93) shared resident bathrooms, and for 2 of 53 (Resident #64, #76, and #92) shared resident rooms observed. The findings include: 1. Review of the facility policy titled, Resident Environmental Quality, dated 2024, revealed .It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public .General Guidelines .Preventive maintenance schedules .for the maintenance of the building .should be followed to maintain a safe environment . 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses including Diabetes, Traumatic Brain Injury, and Chronic Kidney Disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 5, which indicated severe cognitive impairment. 3. Review of the medical record revealed Resident #93 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Bipolar, and Dementia. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 14, which indicated Resident #93 was cognitively intact. Observation in Residents #5 and #93's shared bathroom on 7/28/2025 at 10:25 AM, and on 7/29/2025 at 11:48 AM and 5:17 PM, a large patch of dried drywall mud was observed with a brown water stain measuring about 3 feet long above the baseboard on the wall behind the toilet. During an interview on 7/30/2025 at 5:17 PM, in Resident #5 and Resident #93's shared bathroom, the Maintenance Director confirmed that resident bathroom's sheetrock should be free from water stains and excessive sheetrock mud. 4. Review of the medical record revealed Resident #46 was admitted to the facility on [DATE], with diagnoses including Dementia, Anxiety, and Depression. Review of the quarterly MDS assessment dated [DATE], revealed Resident #46 was severely cognitively impaired. 5. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE] with diagnoses including Dementia, Chronic Obstructive Pulmonary Disease, and Anxiety. Review of the quarterly MDS assessment dated [DATE], revealed Resident #55's cognitive skills for decision making were severely impaired. Observation on 7/28/2025 at 11:15 AM, in Resident #46 and #55's shared bathroom revealed an approximate 3 inch x (by) 6 inch broken and caved-in area of drywall directly above the baseboard. During an interview on 7/30/2025 at 5:30PM, in Resident #46 and Resident #55's shared bathroom, the Maintenance Director confirmed that resident bathroom's sheetrock should be free from holes in the drywall. 4. Review of the medical record revealed Resident #64 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Dysphagia, Depression, Diabetes, and Gastrostomy. Review of the quarterly MDS assessment dated [DATE], revealed staff did not perform a BIMS due to Resident #64 was severely cognitively impaired. Resident was dependent on staff to perform Activities of Daily Living (ADLs). Observations in Resident #64's room on 7/28/2025 at 4:09 PM, and 7/29/2025 at 7:39 AM, 10:30 AM, and 3:54 PM, revealed thick dust and dirt build up on the air conditioner vents under the window and splattered dried brown substance on the resident's side rail of bed and on the infusion pole. During an observation and interview in Resident #63's room on 7/29/2025 at 4:32 PM, the Housekeeping Manager confirmed that the air conditioning vents, resident's side rail, and infusion pole were very soiled and should be cleaned daily. 5. Review of the medical record revealed Resident #76 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes, and Chronic Kidney Disease. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, which indicated Resident #76 was cognitively intact. Observations in Resident #76's room on 7/28/2025 at 12:33 PM and 7/29/2025 at 7:36 AM, revealed the privacy curtain had multiple brown splatters on the lower half of the curtain. During an interview on 7/30/2025 at 7:40 AM, the Director of Nursing confirmed that the privacy curtains should not be left soiled and stained. 6. Review of the medical record revealed Resident #92 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Anxiety, Depression, and Osteoarthritis. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 11, which indicated Resident #92 was moderately cognitively impaired. Observation in Resident #92's room on 7/29/2025 at 4:03 PM, revealed air conditioner vents with thick dust, dirt, and food crumbs. The wall behind the resident's bed had a large area of sheetrock peeled off with a hole. During an interview on 7/29/2025 at 5:09 PM, the Maintenance Director confirmed resident rooms should be clean, and free of dust build up and damaged sheetrock.

Based on facility policy review, www.hopkinsmedicine.org/health, Police Incident Report dated [DATE] review, facility investigation review, medical record review and interviews, the facility failed to ensure residents were free from abuse/sexual for 6 of 9 (Residents #3, #7, #9, #11, #14, and #15) sampled residents reviewed for abuse/neglect. On [DATE] during group activities Resident #11, who had a BIMS of 12, approached Resident #15, who had a BIMS of 4, began to rub across her shoulders and back, and then tried to kiss her. Resident #15 told Resident #11 to stop and pushed him away. Resident #11 then put some money on the table in front of Resident #15 and pushed it towards her while saying, If this isn't enough, let me know. On [DATE] Resident #11 approached Resident #15 during activities and pulled up his shirt and began rubbing his nipples. Resident #15 pushed him away from her. Resident #11 returned to his table and within a few minutes, stood up, pulled his pants down, and pointed to his penis saying, If any of you ladies want this come to room [ROOM NUMBER]. On [DATE], 5 days after Resident #11 began having inappropriate sexual behaviors, Resident #3, who had a BIMS score of 15, reported to staff that during the night before Resident #11 approached his bed and placed his genitals in his (Resident #3)'s hand. Resident #11 was transferred to a psychiatric facility on [DATE], 8 days after inappropriate sexual behaviors with Resident #15 were documented. On [DATE] during activities The facility failed to prevent Neglect when on [DATE] Resident #7 was found on the floor with his head under the bed. Staff failed to complete a post-fall assessment, an incident report, and notify the Physician/NP on [DATE], and there was no monitoring for adverse outcomes related to the fall. On [DATE] (3 days after the fall), Resident #7 experienced a change in mental status, and the physician/NP was not notified. On [DATE] (4 days after the fall) and 1 day after the change in mental status, the NP was notified and again not made aware of the fall with head injury. Nursing staff transferred Resident #7 to the emergency room (ER) without report of the recent fall with head injury. Resident #7 expired after arrival in the ER. The facility's failure to prevent sexual abuse for Resident #3, #11, and #15 and neglect for Resident #7 resulted in Immediate Jeopardy. The facility failed to ensure Resident #9 was free from physical abuse that resulted in actual HARM when Resident #14 was observed hitting and punching Resident #9's hand and bending her fingers back that resulted in pain, bruising and swelling of Resident #9's hand. The facility's failure to protect residents from abuse and neglect resulted in an Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:10 PM in the Administrator's office. The facility was cited at F-600 with a scope and severity of K, which is Substandard Quality of Care. The Immediate Jeopardy was effective [DATE] and is ongoing. A partial extended survey was conducted on [DATE] to [DATE]. The facility is required to submit a Plan of Correction (POC). The findings include: Review of the facility policy titled, Abuse Prohibition Plan, effective date [DATE], revealed, .The facility has a zero-tolerance policy for abuse .The facility shall attempt to identify and shall investigate any reported violation or allegation of abuse .'Sexual Abuse .' is non-consensual sexual contact of any type with a resident. It includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault ' Physical Abuse' includes, but not limited to hitting, slapping, pinching, and kicking .'Neglect' means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .The investigation shall begin immediately .It is the policy of this facility that Residents shall be protected from the alleged offender(s) .If the alleged offender is a facility Resident, the staff member shall immediately remove the perpetrator from the situation and another staff member shall stay with the alleged offender and wait for further instruction from the Administrator .Employees must always report any allegation of abuse or suspicion of abuse immediately to the supervisor . Review of an undated article titled, Frontotemporal Dementia [FTD], from www.hopkinsmedicine.org/health revealed, .Symptoms of FTD .common symptoms .Behavior and /or dramatic personality changes, such as swearing, increased interest in sex .Socially inappropriate, impulsive, or repetitive behaviors . Review of a Police Incident Report dated [DATE], revealed, .The caller, [Named Administrator], was notified today when she arrived back from vacation .I [Police Officer] was told [Named Resident #3] has a speech problem, and is very delayed when trying to speak .I was not able to speak with him [Resident #3] .[Named Resident #11] has been placed in the psychiatric ward .[Named Administrator] said [Named Resident #11] has these types of episodes when he does not take his medication as prescribed, which he is currently not doing . Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses which included Schizophrenia, Dysphagia, Dysarthria and Anarthria. Dysarthria is a less severe form of Anarthria and causes slurred or slowed speech. Anarthria is the loss of the ability to speak. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 revealed, a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Review of the undated current care plan for Resident #3 revealed there were no focus/problems or interventions on the care plan for risk related to actual abuse allegations. Review of the provider/Nurse Practitioner (NP) progress note dated [DATE] for Resident #3, revealed, .Patient being seen for follow-up on events this past weekend involving roommate .patient reports he does not want to discuss in detail w [with]/me what occurred over the weekend .does affirm allegation against roommate and that he [Resident #3] may be open to discussing w/local PD [Police Department] .Reports emotional and mental distress from prior roommate's actions . Review of the facility Clinical Notes for Resident #3 dated [DATE]- [DATE] frequently referenced Resident #3's desire to sit on the front porch, even referenced it as something he loves to do on a daily basis. The Clinical Notes referred to Resident #3 feeling safe and calm, in a good mood and smiling. During an interview on [DATE] at 3:08 PM, MDS Coordinator #1 and #2 confirmed there were no interventions related to actual risk associated with the allegation of nonconsensual sexual contact/sexual abuse Resident #3 reported on [DATE]. MDS Coordinator #1 and #2 agreed residents that experience alleged abuse should be monitored for risk of immediate and late onset of affects such as psychosocial harm. During an interview on [DATE] at 4:11 PM, Resident #3 agreed to interview in the presence of his roommate. Resident #3 was asked to recall the incident with his previous roommate, Resident #11, during the night of [DATE] - [DATE]. The surveyor provided support and patience during the interview as Resident #3 was very slow to answer and had difficulty expressing himself. Resident #3 stated, .[Named Resident #11] came to my bed and tried to push me on my side, 3 or 4 times .almost fell off the bed .he [Resident #11] stopped and looked right at me, took out his d k and put it in my hand .I yelled .he walked away laughing . Resident #3 was asked if he felt safe in the facility, Resident #3 replied, .I am safe with this roommate [pointing towards current roommate] but when he goes home, who will keep me safe .He [Resident #11] is still here, I see him out in the hall . Resident #3 became tearful and paused for several minutes. When asked if he reported the incident to staff after Resident #11 walked away, Resident #3 replied, .I tried but they wouldn't stand still long enough for me to talk, they think I can't talk . Resident #3 thanked the surveyor for standing still and listening to him. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses which included Bipolar Disorder, Schizoaffective Disorder, and Frontotemporal Neurocognitive Disorder. Common symptoms of Frontotemporal Neurocognitive Disorder include but are not limited to behavior such as socially inappropriate, impulsive, or repetitive behaviors, and increased interest in sex. Review of a Psychiatric Evaluation dated [DATE], for Resident #11 revealed, .recently admitted to the facility after being hospitalized at [Named psychiatric medical facility from Named Long term care facility] for verbal aggression, cussing, and threatening his staff .history of medication refusal/spitting medication .BIMS ,d+[DATE] . Review of the Admission MDS assessment dated [DATE] for Resident #11 revealed, a BIMS score of 12, which indicated moderately cognitively impaired. Continued review revealed Resident #11 required supervision to walk in corridor. Review of care plan for Resident #11 revealed, . [DATE] .Remind [Resident #11] that BEHAVIOR is not appropriate .Resident prefers to walk around facility constantly and enjoys sitting on front porch . [DATE] .displayed inappropriate sexual behaviors towards others .Redirect [Named Resident #11] and remind him of what is appropriate/not appropriate in social settings XXX[DATE] .rejects or resists care (history of refusing medications) . Resident #3, the victim of the alleged sexual assault enjoys sitting on the front porch. There were no care plan interventions for either resident to address psychosocial risk associated with repeated exposure in the facility. Review of the facility Clinical Notes for Resident #11 dated [DATE], revealed .Resident was down in the dining room rubbing up against a female resident the [then] gave her money and said if it isn't enough to let him know . Review of the facility Clinical Notes for Resident #11 dated [DATE], revealed .Resident was down in the dining room pulling his pants down and pointing to his penis telling the ladies to come to room [ROOM NUMBER] he had the room # written on a piece of paper. He also went over to another resident and tried to kiss her. Activities went and got the nurse . Review of the facility Clinical Notes for Resident #11 dated [DATE] at 8:45 AM, revealed .Resident was down in the dining room on [DATE] [2023] two different times this resident was making sexual comment's [comments] to the lady residents pulling his shirt up and rubbing his nipples and rubbing himself up on two female residents. Also [Also,] resident was rubbing his penis asking a female resident if she wanted some of that. Resident also had his room # written on a piece of paper telling the lady resident to come to his room. Activities reported this to the nurse . Review of the facility Clinical Notes for Resident #11 dated [DATE] at 1:53 PM, revealed .This resident was in the hallway raising up his shirt and playing with his nipples . Review of the facility Clinical Notes for Resident #11 dated [DATE] at 6:31 PM, revealed .Another resident family member notified Nurse Management this shift of sexual inappropriate behavior towards roommate/resident on last night. Roommate immediately moved out of room, placed in another room. Family [Resident #3's family] at bedside agreeable and aware. Review of the facility Clinical Notes for Resident #11 dated [DATE] at 1:29 PM, revealed, .Resident was down in the dining room cussing and giving the finger to other residents . Review of the NP progress note for Resident #11 dated [DATE] at 1:34 PM, revealed, .Received call from facility administrator yesterday evening regarding recent patient events/behaviors .exhibited sexually inappropriate behaviors on several occasions over the last week .unwanted sexual advances towards other residents and undressing, fondling himself, and exposing genitals in the presence of other residents in the dining/activities room, a common shared area for residents . event occurred over the weekend and prompted nurse to notify facility admin of behavior who in turn notified me .allegedly physically assaulted roommate . Review of the facility Clinical Notes for Resident #11 dated [DATE] at 9:23 AM, revealed, .Admin [Administrator] spoke to NP regarding Resident's behaviors and NP stated she would review his medications and a referral to psych was to be started by the building on Monday ,d+[DATE] [2023] .Nursing made aware . Review of the facility Clinical Notes for Resident #11 dated [DATE] at 9:35 AM, revealed .resident was observed being inappropriate in the dinning [dining] room. resident sent back to his room. spoke with [Named psychiatric facility] psych in [Named city] and sent a referral packet earlier today. waiting for a call back. resident is being observed for any other behaviors . Review of a signed written statement dated [DATE] revealed Registered Nurse (RN) JJJ stated, .was informed by the activities director that [Named Resident #15] was in the dining room and that she was visibly upset .[Named Resident #15] had made allegations that [Named Resident #11] had been trying to hug on her .given her money .After the activities director had informed me of the situation, we brought it to the DON's attention . Review of a signed written undated statement revealed LPN O stated, .This nurse was informed of Resident [Resident #11] playing with his genital area and Rubbing his nipples and this nurse informed staff that he should be sent to his Room for that behavior . Review of the facility Clinical Notes for Resident #11 dated [DATE] - [DATE] revealed multiple behaviors for Resident #11 which included spitting out medications, refusing medications, walking in the hallway with his shirt pulled up over his abdomen, and outburst of yelling and cursing staff. Interviews conducted during the survey revealed Administration and nursing staff denied abnormal behaviors for Resident #11 since his return from the psychiatric unit after the sexual allegations. Review of the (Named Psychiatric facility) Discharge Summary for Resident #11 dated [DATE], revealed, .Reason for Admission and Examination .Patient is admitted for sexually inappropriate behaviors where he put his genitalia in his roommate's hand, pulling his pants down showing his genitalia, pulling his shirt up rubbing his nipples . Review of the Psychiatric Evaluation (Amended) for Resident #11 dated [DATE], revealed, .currently readmitted to the facility after being hospitalized .for hypersexuality .While hospitalized , the resident was started on Provera [hormone] 5 mg [milligram] by mouth twice daily for hypersexuality .The residents ' medication, Provera, was being ordered this day from the pharmacy . Review of the NP Progress Note for Resident #11 dated [DATE] at 2:05 PM, revealed, .Assessment .Nymphomania [hypersexuality] (finding) .Oth [other] sexual dysfnct [dysfunction] .modified 13 Oct. [October] 2023 . During an interview on [DATE] at 2:10 PM, the Administrator stated Resident #11 had no sexual behavior prior to this incident on [DATE]. The Administrator stated Resident #11 had refused medications for a few days before and then had the inappropriate behaviors. When asked what were the effects of Resident #11 not taking his medications, the Administrator replied, .Resident #11 was in activities and pulled his shirt up .rubbed his nipples . [Named Resident #3] reported to his sister that [Named Resident #11] had tried to put his genitals in [Named Resident #3]'s hand . [Named Family member (FM) HH] reported the incident to the nurse, who reported to the Administrator . During an interview on [DATE] at 4:42 PM, the Activities Director stated Resident #11 was in activities when he pulled up his shirt and rubbed his nipples. She stated she removed Resident #11 from the activity room, escorted him to the nurse and reported what had happened in the dining room. During an interview on [DATE] at 9:32 AM, the DON stated, .I did a small investigation that involved [Named Resident #11] and his behavior in the dining room with other residents present .[Named Resident #11] was redirected and escorted from the dining room to his room .[Named Resident #11] was placed on 1 to 1 with the MDS [Minimum Data Set] Coordinator in his room .He [Resident #11] had been refusing his medications and this is why he was having behaviors . When asked what intervention had been initiated for Resident #11's inappropriate sexual behavior with Resident #15, the DON replied, .I spoke with [Named Resident #11] and told him he was not to hug anyone else without their permission . During an interview on [DATE] at 11:10 AM, Licensed Practical Nurse (LPN) O confirmed Resident #11 was sent to a psychiatric facility due to exposing himself to other residents. LPN O stated, .The day [[DATE]] [Named Resident #11] left going to [Named psychiatric facility] he was alone in his room. I walked him out to the car and he became agitated and hit the window of the car .He [Resident #11] had behaviors of spitting out his medications and cussing staff . During an interview on [DATE] at 11:47 AM, the Activity Director confirmed she had reported and documented Resident #11's inappropriate sexual behaviors multiple times beginning [DATE], and continuing on [DATE], and [DATE]. The Activity Director stated, .on the 18th [[DATE]] [Named Resident #11] was in activities and walked up to [Resident #15], put his hands on her shoulders and began to massage her .He [Resident #11] tried to kiss her while he was rubbing her and she pushed him away .He [Resident #11] put some money on the table in front of her [Resident #15] and pushed it towards her and said, ' .If that isn't enough, just let me know .' then he laughed and walked back to his table . I asked him to leave activities and reported it to the nurse, not sure which one, I think she was agency .On the 21st [[DATE]] he [Resident #11] was sitting at his table, stood up, and pulled his pants down then pointed to his penis and yelled, ' .if any of you ladies wants this come to room [ROOM NUMBER] .' he [Resident #11] had a piece of paper with the number 311 written on it He then walked over and tried to kiss [Named Resident #15] .I went and got the nurse [Named LPN H] .she [LPN H] came in and told him to go to his room .On the 22nd [[DATE]] he [Resident #11] he walked up to [Named Resident #15] rubbed up against her, and started rubbing his nipples and making sexual comments like ' .Do you want some of that .' then handing a piece of paper with his room number on it .I told him to leave activities and went to get a nurse .he [Resident #11] was walking down the hall outside of activities and pulled up his shirt and started rubbing his nipples . I went and told the nurse .may have been a different agency nurse .I told them he could not come back to activities . When asked if she had reported the inappropriate behaviors to anyone else, the Activity Director replied, .We talked about it in the morning meetings that week and [Named DON] said the psych nurse would see him . The Activity Director stated, .The Administrator and the DON have been upset about my documentation and said we would be in trouble if the State came in and seen it .I will not change my statements and say I heard that he [Resident #11] had done those things, I saw it happen . During an interview on [DATE] at 12:11 PM, the Social Services Director (SSD) confirmed there had been discussions about the inappropriate sexual behaviors reported by the Activity Director in the morning meetings. The SSD stated, .Either the Administrator or the DON keeps a record of the morning meetings .He [Resident #11] was to be seen by the NP .I think the Administrator spoke to the NP on the 26th [[DATE]] .He [Resident #11] would write letters to his girlfriend and bring them to me .the letters contained very explicit sexual content . During an interview on [DATE] at 12:50 PM, the DON reviewed a binder that contained the minutes for the morning meetings and confirmed there were no meeting minutes in the binder for [DATE] - [DATE]. The DON stated, .There were no interventions related to [Named Resident #11]'s sexual behaviors in activities because we did not know about them .I think the documentation by Activity was actually just hearsay .he [Resident #11] was sent out to psych .He [Resident #11] has had no continued behavior since returning to the facility . During an interview on [DATE] at 1:13 PM, LPN H confirmed the Activity Director notified her about Resident #11's inappropriate behavior. LPN H stated, .[Named Activity Director] told me he [Resident #11] was exposing himself to people in the dining room .I went down there and he [Resident #11] was sitting in his chair drinking coffee and smiling at me . When asked if she investigated or asked any of the residents present in the room about the behavior, LPN H replied, .There was nothing to investigate, he was sitting there drinking coffee . When asked if she had been trained on Abuse since being employed by the facility, LPN H replied, .Yes, many times . LPN H was asked if she had to actually see abuse in order to act on an allegation. LPN H replied, .Tell me if it was my responsibility to report the allegation, since the Activity Director was in management . During an interview on [DATE] at 3:08 PM, MDS Coordinator HHH and MDS Coordinator III confirmed neither one had performed 1 on 1 monitoring for Resident #11 prior to the resident being transferred to a psychiatric facility. MDS Coordinator HHH and III both confirmed Resident #11's inappropriate sexual behaviors on ,d+[DATE] - [DATE] had been presented by the Activity Director and discussed in the morning meetings. During an interview on [DATE] at 3:18 PM, the Administrator stated, .We were unable to substantiate the allegations of sexual abuse between [Named Resident #3] and [Named Resident #11] because it was not witnessed and both residents have an extensive history of psych behaviors, but no sexual behaviors .[Named Resident #3] has not been happy with living in the facility and does not want to be here .I think he [Resident #3] has been sexually inappropriate with staff .[Named Resident #11] had been refusing medication and spitting it out so his behavior increased and he was sent out .before that he was seen by the NP and had a medication change . When asked about the documentation of Resident #11's sexually inappropriate behaviors during activities reported by the Activity Director, the Administrator stated, .Well, after we got those notes cleaned up, we had to talk to [Named Activity Director] and explain why she could not document what someone tells her rather than what she actually sees. I think the behaviors was just what someone told her happened . When asked what she meant by getting the notes cleaned up, the Administrator replied, .We reviewed the notes and then asked staff if anything had been reported to them because [Named Activity Director] said she had reported to the nurse .We didn't find anyone she had reported the information to . The facility investigation contained signed written statements from 2 nurses confirming notification of Resident #11's sexual behaviors. During a telephone interview on [DATE] at 3:30 PM, former Assistant Director of Nursing (ADON) stated, .I conducted the morning meetings when the DON was unavailable .The minutes would be recorded and placed in the big binder in the DON ' s office .Yes, I was aware of the behaviors reported by [Named Activity Director] not sure what all the interventions were, I am sure a staff member had to be present in the dining room when he [Resident #11] was in there . When asked if having a staff member present would stop Resident #11's inappropriate behavior, the ADON replied, Of course. When asked about the behavior that occurred with Activity staff present in the dining room, the ADON replied, .There was staff in there and it happened anyway, well ain't that something . Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease with Early Onset, and Chronic Kidney Disease, Stage 3. Review of the Admission MDS assessment dated [DATE] for Resident #15 revealed, a BIMS score of 4 which indicated severe cognitive impairment. Resident #15 was independent with mobility/walking. Review of the Psychotherapy progress notes for Resident #15 dated [DATE] - [DATE], revealed no notes or evaluations related to nonconsensual sexual contact and inappropriate sexual behaviors toward Resident #15 from Resident #11. No Psychotherapy progress notes for [DATE] - [DATE] were provided by the facility. Review of undated care plan for Resident #15 revealed, .exhibits wandering behavior . Continued review revealed there was no problems/focus and interventions for risk related to victim of inappropriate sexual behavior and nonconsensual sexual contact by Resident #11 on [DATE] - [DATE]. Review of the facility Clinical Notes for Resident #15 dated [DATE]-[DATE], revealed there were no documentation of inappropriate sexual behaviors and nonconsensual sexual contact experienced by Resident #15 from Resident #11. During an interview on [DATE] at 3:08 PM, MDS Coordinator HHH and III confirmed there were no interventions related to actual risk associated with the nonconsensual sexual contact Resident #15 experienced from [DATE]-[DATE]. MDS Coordinator HHH and III agreed residents that experience alleged abuse should be monitored for risk of immediate and late onset of affects such as psychosocial harm. During an interview on [DATE] at 4:00 PM, Resident #15 was smiling, giggling, and very childlike in behavior (bouncing in chair during interview). Resident #15 was asked if she had a fun time in activity and if anyone ever bothered her or upset her during activity. Resident #15 replied, .I like to color and make pretty things . When asked if anyone had ever made her mad or touched her in a bad way. Resident #15 replied, .[Named (first name) Resident #11] kisses me here [pointed to her neck] and tells me how much he loves me .he just loves me all the time .but I tell him to get back .I don't want nobody kissing me . Resident #15 then got up from the table and walked away. During an interview on [DATE] at 4:27 PM, the Administrator was asked what the facility had done to protect Resident #15 from targeted nonconsensual sexual behavior from other residents. The Administrator stated, .[Named Resident #15] is young and pretty and puts herself in very social situations .She socializes, laughing and talking with everyone . The Administrator was asked if she thought Resident #15 caused the nonconsensual contact that occurred in [DATE]. The Administrator stated, No, I feel like she is so friendly and people take it wrong .[Named Resident #1) had been sent out to a psychiatric unit and I really don't know of any other interventions the facility could put in place . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses which included Unspecified Fracture of Third Lumbar Vertebra, Frontal Lobe and Executive Function Deficit, and Urinary Tract Infection. Resident #7 was discharged on [DATE] to Hospital #1. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #7 revealed, a BIMS score of 15 which indicated no cognitive impairment. Continued review revealed Resident #7 had an indwelling catheter. Review of the care plan for Resident #7 revealed, .Problem .[[DATE]] at risk for UTI (Urinary Tract Infection) .Interventions .Provide cues/assist [Named Resident #7] to drink fluids with medications and between meals .Monitor [Named Resident #7] for burning/painful urination .Obtain urine samples as ordered .Periwipes available to resident .Record I & O .Catheter care .Change catheter as needed for blockage or malfunction .Check catheter tubing for proper drainage and position .Keep drainage bag covered to promote dignity .Observe for discomfort, urine color, clarity, amount, odor, presence of blood; Notify MD of abnormal findings and follow up as indicated .Offer extra fluids throughout the day .Problem .At Risk For Falls R/T [related to] impaired mobility .Interventions .Keep area free of obstructions to reduce the risk of falls or injury .Place call bell/light within easy reach .Provide reminders to use ambulation and transfer assist devices .Remind [Resident #7] to call for assistance before moving from bed-to-chair and from chair-to-bed .[[DATE]] At risk for complications related to [Resident #7] has diagnosis of diabetes Interventions .Administer medications as ordered and monitor for adverse side effects .Diet as ordered .Labs as ordered, report abnormal findings to MD [Medical Doctor] with follow-up as indicated .Monitor blood sugar levels per MD order and notify MD of abnormal findings as indicated .Observe for excessive thirst, excessive eating, frequent voiding, change in level of consciousness, perspiration, fatigue, nausea/vomiting, tremors, provide interventions as per MD order; monitor for effectiveness and report to MD if ineffective .Monitor for change in level of consciousness .Problem .At risk for complications of renal failure .Observe for edema, warmth and color of extremities, shortness of breath, and vital signs daily. Report abnormalities to MD with follow-up as indicated .Problem .At risk for infection R/T indwelling catheter. [Resident #7] needs catheter related to bladder-neck obstruction .Interventions .Clean around catheter with soap and water .Keep tubing below level of bladder and free of kinks or twists .Report any sign of infection (temperature, pain, urine that looks cloudy, dark, or with blood) . [[DATE]] Footwear will fit properly and have non-skid soles . Review of the facility document (Incident Report) dated [DATE], LPN G documented, Observed resident on the floor between both beds and his head under his bed. Resident did not have non-skid footwear on. While assisting resident up from the floor, raised his head and bumped it on the bottom of the bed. Resident mental status was at his normal. Resident was resting comfortably in bed when writer [LPN G] exited room. Continued review revealed a bruise to Resident #7's forehead. Review of the facility Clinical Note dated [DATE] but entered on ,d+[DATE] [TRUNCATED]

Based on facility policy review, (Named Glucometer- a device used to check blood sugar levels with the use of a blood sample) User's Guide review, Guidelines for General Use of (Named germicidal cloth) wipes used by the facility review, DME (Durable Medical Equipment) supplier recommendation letter review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when a multi-use blood glucose meter was not cleaned and disinfected with facility required cleansing wipes to prevent cross-contamination of bloodborne pathogens for 2 of 11 (Residents #17 and Resident #18) sampled residents reviewed for blood glucose monitoring. Observations on 4/2/2024 revealed Licensed Practical Nurse (LPN) P failed to clean and disinfect the multi-use blood glucose meter before and after use on each resident in accordance with recommendations and facility policy, failed to perform hand hygiene, and failed to don gloves when performing point of care testing for Resident #18. Observations on 4/3/2024 revealed LPN E, LPN O, and Registered Nurse (RN) A failed to clean and disinfect the blood glucose meters that are used for multiple residents, in accordance with manufacturer recommendations and facility policy. The facility's failure to ensure staff properly disinfected the blood glucose meter that was used for multiple residents, in accordance with recommendations and the facility ' s policy, placed the residents at risk for potential contamination with bloodborne pathogens and the likelihood to cause serious injury, harm, impairment, and/or death resulted in Immediate Jeopardy. The facility had 7 residents receiving blood glucose monitoring with a multi-use blood glucose meter and the facility's failure had the potential to affect the 11 residents receiving blood glucose monitoring with a multi-use blood glucose meter. Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility ' s failure to appropriately clean and disinfect a multi-use blood glucose meter during medication administration. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy for F-880 on 4/4/2024 at 4:45 PM, in the Director of Nursing (DON)'s office. The facility was cited Immediate Jeopardy at F-880 at a scope/severity of K. The Immediate Jeopardy began on 4/2/2024 and is ongoing. A partial extended survey was conducted 4/4/2024 to 4/11/2024. The facility is required to submit a Plan of Correction (POC). The findings include: Review of the facility's policy titled, Cleaning and Disinfecting Glucometer, revised 10/9/2023, revealed, .Policy: To minimize the risk of transmitting blood-borne diseases .device shall be cleaned and disinfected after each use .Protocol: The facility shall ensure blood glucometers are cleaned and disinfected after each use and according to manufacturer's instructions for multiple-resident use . Review of the (Named Glucometer) User's Guide dated 2/10/2020 revealed, .Healthcare Professional Information .Healthcare professionals performing blood glucose (BG) test with this system on multiple patients must always wear gloves .Important Safety Instructions .Adhere to standard precautions when handling or using this device. All parts of the glucose monitoring system should be considered potentially infectious and are capable of transmitting blood-borne pathogens between patients and healthcare professionals .The meter should be disinfected after use on each patient .This blood glucose monitoring system may only be used for testing multiple patients when standard precautions and the manufacturer's disinfection procedures are followed .Cleaning Instructions: Cleaning is the removal of visible dirt and debris .The cleaning process does not reduce the risk for transmission of infectious diseases .wash hands with soap and water .put on single-use [disposable] medical protective gloves .Wipe the glucometer thoroughly including the front, back and sides .Remove gloves .Disinfection Instruction: The meter must be disinfected between patient uses .Before disinfecting clean the meter .Wash hands with soap and water and put on single-use medical protective gloves .Wipe the glucose meter thoroughly including the front, back and sides .allow to remain wet for two minutes .take off gloves and wash hands .before proceeding to the next patient . Review of the General Guidelines For Use, dated 2021, revealed, .[Named germicidal wipes] .If present, use a wipe to remove visible soil prior to disinfecting .Unfold a clean wipe and thoroughly wet surface .Allow treated surface to remain wet for two (2) minutes. Let air dry . Review of a letter of recommendation from DME supplier dated 4/4/2022, revealed, .As referenced in the manual for the [Named glucometer], the meter may be cleaned and disinfected using [Named disinfecting wipes] or any other EPA [Environmental Protection Agency]-registered disinfecting wipe .important note to consider when using an alternative EPA-registered disinfecting wipe is that the [Named glucometer] has been shown safe in disinfecting via [by way of] testing validation with [Named disinfecting wipes], but additional testing has not been conducted on other EPA-registered wipes .For this reason, customers are encouraged to follow the disinfectant's instructions for use carefully to ensure disinfection . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was admitted to the facility on [DATE]. Resident #17 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated moderate cognitive impairment. Resident #17's active diagnoses included Diabetes Mellitus. Resident #17 received insulin 6 of 7 days of the look-back period. Review of the medical record revealed Resident #17 received Lispro [short acting] insulin before meals per sliding scale [based on pre-defined BG ranges requiring a finger stick blood test]. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses which included Acute and Chronic Respiratory Failure, Acute on Chronic Diastolic (Congestive) Heart Failure, and Type 1 Diabetes Mellitus. Continued review revealed Resident #18 had a diagnosis of Methicillin Resistant Staphylococcus Aureus infection (MRSA). Review of the Quarterly MDS assessment dated [DATE] revealed Resident #18 had a BIMS score of 15, which indicated no cognitive impairment. Active Diagnoses included Diabetes Mellitus with hyperglycemia. Review of the Physician Order Sheet dated March 2024 revealed Resident #18 had orders which included .11/21/2023 .lispro [short acting insulin] .administer SQ [subcutaneous-under the skin] ACHS [before meals and at bedtime] per sliding scale. Review of the Medication Administration Record (MAR) dated 4/2/2024 revealed Resident #18 received insulin ACHS per sliding scale. Documentation on Resident #18's MAR revealed BG levels were checked at 8:00 AM and 12:00 PM, on the day of the surveyor's onsite observation. Review of the undated Care Plan Report for Resident #18 revealed, .At Risk for Infection .assessed for signs and symptoms of infection .STATUS: Active .GOAL DATE: 5/29/2024 .Metabolic-Diabetes Status .Administer a finger stick blood test per order .STATUS: Active . Observation and interview on the 200 Hall on 4/2/2024 at 11:24 AM, revealed Licensed Practical Nurse (LPN) P walked out of the dining room holding a used blood glucose test strip wrapped in a blood soiled alcohol pad and used lancet (device used to prick the finger to obtain a blood sample) in her right hand. LPN P carried a glucometer in her left hand. LPN P did not have gloves on either hand. LPN P placed the used glucometer on top of the medication cart and threw away the BG test strip and alcohol pad in the trash and the lancet in the biohazard container. LPN P documented Resident #18's BG on the Electronic Health Record (EHR) and picked up the dirty glucometer and placed it back in the medication cart. When asked if LPN P completed a BG fingerstick for Resident #18 in the dining room without donning gloves, LPN P replied, Yes. When asked if not following infection control protocol during a BG fingerstick was safe, LPN P replied, No. LPN P confirmed the glucometer was used for multiple residents' point of care finger sticks. Observation and interview on 200 Hall on 4/2/2024 at 11:34 AM, revealed, LPN P took a BG test strip, an alcohol pad, a lancet, and the dirty glucometer out of the cart and placed the test strip, alcohol pad, and the lancet in a plastic cup. LPN P took a pair of gloves, the dirty glucometer, and plastic cup into Resident #17's room. LPN P informed Resident #17 she was going to perform a fingerstick for a BG level before lunch. LPN P placed the dirty glucometer on the bedside table and inserted the BG test strip into it, then proceeded to wipe Resident #17's finger off with the alcohol pad and started to place the lancet in position to prick the resident's finger. The surveyor requested LPN P stop and step into the hallway for a private conversation. The surveyor advised LPN to not continue with the BG fingerstick without properly disinfecting the dirty glucometer. LPN P agreed and walked to the medication cart and placed the glucometer on top of the cart. LPN P used an alcohol pad and wiped the glucometer off then placed it back on top of the medication cart. LPN P was asked if the alcohol pad was approved to disinfect the glucometer with and she replied, I think so. LPN P was asked how long the surface of the glucometer had to remain wet for disinfection, she replied, 30 seconds. The surveyor asked LPN P to read the information for properly disinfecting the glucometer before using the glucometer on any other residents. LPN P locked the medication cart and walked away. During an interview in the DON's office on 4/2/2024 at 11:41 AM, the DON stated she expected the multi-use glucometers to be cleaned and disinfected after every finger stick BG test. The DON stated the nurse should use the (Named germicidal cleaning cloth). The DON was made aware of LPN P's deficient practice during observation. The DON stated she would go and correct LPN P right away. The DON stated LPN P was an agency nurse and asked the surveyor if she wanted to follow a facility nurse for a glucometer BG finger stick observation. Observation and interview on 4/3/2024 at 12:05 PM, revealed LPN E stated she had completed the afternoon BG finger sticks. LPN E was asked to demonstrate cleaning and disinfection of the multi-use glucometer on the 300 Hall medication cart. LPN E provided a verbal step by step tutorial which included using one alcohol pad to clean and disinfect the glucometer. When asked what the required length of time the glucometer had to stay wet, LPN E replied, 30 seconds to 1 minute. When asked if the alcohol wipe was an approved wipe for disinfecting the glucometer, LPN E replied, Yes, I think so. LPN E asked the surveyor if the alcohol wipe was okay to use on the glucometer. The surveyor replied, The appropriate method and supplies would depend on the manufacturer's recommendations and the facility policy. Observation and interview on 4/3/2024 at 12:14 PM, revealed LPN O performed a BG finger stick in the dining room, placed the used test strip, alcohol pad, and lancet in a plastic cup and walked back down the hall to the 200 Hall medication cart wearing the gloves she wore during the fingerstick procedure. Without changing gloves, LPN O took a germicidal cloth out of the medication cart, wiped the glucometer off, then placed the glucometer in a plastic cup to dry. The surveyor asked LPN O how long the glucometer was required to stay wet for disinfection, LPN O replied, 5 minutes. LPN O was asked if the glucometer should be cleaned off with a germicidal cloth, then disinfected with a second cloth, she replied, No. Observation and interview on 4/3/2024 1:16 PM, revealed Registered Nurse (RN) A was asked to demonstrate how to clean and disinfect the multi-use glucometer on the 400 Hall medication cart. RN A took the glucometer out of the cart along with a barrier paper and a germicidal cloth wipe. RN A gave a verbal tutorial which did not include the use of 1 germicidal wipe to clean the glucometer and then 1 germicidal wipe to disinfect the glucometer. RN A was asked how long the surface of the glucometer was required to remain wet for disinfection, she replied. Maybe 1 minute until it is dry. It doesn't take long. Observation of the nurse station and interview with the Administrator in Training (AIT) on 4/3/2024 at 1:19 PM, revealed a laminated copy of the General Guidelines For Use noted above was posted at the nurse station with the following handwritten notes printed on the document.*FOR MULTI-RESIDENT/SHARED EQUIPMENT* .Wet for 2 minutes! .Use between Residents . The surveyor requested a copy of the posted guidelines and stated the 3 nurses that were observed and interviewed had not correctly demonstrated the use of the germicidal cloth to clean and disinfect the multi-use glucometers.

Based on facility policy review, medical record review, facility investigation review, hospital record review, and interview, the facility failed to provide an environment that is free from accident hazards for 1 of 6 (Resident #7) sampled residents reviewed for falls. On [DATE] at 5:30 PM, Resident #7, known to have a history of falls with injury, was found on the floor following an unwitnessed fall from bed. LPN G documented staff (CNA AA and CNA CC) assisted Resident #7 off the floor and Resident #7 hit his head on the bed. CNA AA and CNA CC then placed Resident #7 back in bed. There was no documentation to show a post-fall assessment was completed prior to moving Resident #7 from the floor to the bed. There was no documentation to show neuro checks were conducted. There was no incident report or investigation documented following the unwitnessed fall to determine the root cause. There were no immediate interventions documented following the fall and no notification to the Physician/Nurse Practitioner (NP) on [DATE]. On [DATE] (4 days after the unwitnessed fall) Resident #7 was transferred to the hospital on [DATE] for a change in mental status. There was no documentation that facility staff reported Resident #7's unwitnessed fall on [DATE] to the Emergency Department (ED). The facility's failure to provide an environment that was free from accident hazards resulted in an Immediate Jeopardy (IJ), a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:10 PM in the Administrator's office. The facility was cited at F-689 with a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective [DATE] and is ongoing. A partial extended survey was conducted [DATE] to [DATE]. The facility is required to submit a Plan of Correction (POC). The findings include: Review of the facility policy titled, Accidents and Supervision, revised [DATE] revealed, .The facility shall establish and utilize a systemic approach to address resident risk and environmental hazards to minimize the likelihood of accidents .1. Identification of Hazards and Risks .a. Communicating the interventions to all relevant staff .Providing training as needed .d. Documenting interventions .e. Ensuring that the interventions are put into action . Review of the facility policy titled, Fall Risk-Fall Prevention, revised [DATE] revealed, .1. The fall risk assessment shall be completed by a licensed nurse .b. After a fall .c. Upon a significant change in medical status . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses which included Unspecified Fracture of Third Lumbar Vertebra, Frontal Lobe and Executive Function Deficit, and Urinary Tract Infection. Resident #7 was discharged on [DATE] to Hospital #1. Review of the care plan for Resident #7 revealed, .[[DATE]] At Risk For Falls R/T [related to] impaired mobility .Interventions .Keep area free of obstructions to reduce the risk of falls or injury .Place call bell/light within easy reach .Provide reminders to use ambulation and transfer assist devices .Remind [Resident #7] to call for assistance before moving from bed-to-chair and from chair-to-bed .[[DATE]] Footwear will fit properly and have non-skid soles . Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #7 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Review of the facility document (Incident Report) dated [DATE], revealed LPN G documented, Observed resident on the floor between both beds and his head under his bed. Resident did not have non-skid footwear on. While assisting resident up from the floor, raised his head and bumped it on the bottom of the bed. Resident mental status was at his normal. Resident was resting comfortably in bed when writer [LPN G] exited room. Continued review revealed a bruise to Resident #7's forehead. Review of the facility Clinical Note dated [DATE] but not entered into the Electronic Health Record (EHR) until [DATE], revealed LPN G documented Resident #7 was found on the floor with his head under the bed. Continued review revealed that while staff were assisting him out from under the bed, he raised his head and hit it on the bottom of the bed. LPN G documented there were no injuries. The Clinical Note was not documented as a late entry. Review of the facility Clinical Note dated [DATE] revealed LPN F documented Resident #7 experienced a change in condition. The provider was not notified of Resident #7's change in condition until [DATE], the following day. Review of the facility Fall Risk assessment dated [DATE] revealed Resident #7 had a history of multiple falls in the last 90 days, had an unsteady gait and was at moderate risk for falls. Review of the facility Hospital Transfer Form dated [DATE] but completed on [DATE] revealed .Mental Disorders/Neurological/Psychiatric Issues .Change in Mental Status . There was no documentation by LPN G of the unwitnessed fall on [DATE]. Review of the hospital record dated [DATE] at 10:05 AM revealed, .PT [patient] was found unresponsive in bed .[nursing home] staff reports patient is normally talking and oriented, BG [blood glucose] was 517 .Bruising on forehead purple and yellow in color . Resident #7 expired at the hospital on [DATE]. Septic shock was documented as the cause of death. During an interview on [DATE] at 11:25 AM, the DON verified the unwitnessed fall on [DATE] for Resident #7 was not charted until [DATE]. The DON stated she became aware of Resident #7's unwitnessed fall after he was sent to Hospital #1 emergency room (ER) for a change in mental status when someone reported to her Resident #7 had a knot and a bruise on his head. She stated she followed-up with LPN G, who said Resident #7 had a fall and hit his head pretty hard on [DATE]. After the DON received report on the fall from [DATE], she initiated an investigation and requested LPN G complete an incident report on [DATE]. The DON stated she educated LPN G when he stated he was unaware he needed to document on the fall. Continued interview revealed, the DON was asked what her expectations were when a resident experienced a fall. She replied, .I expect a head-to-toe assessment, neuro checks, notification to the NP, family, DON, Administrator and implement any new orders received . The DON verified no neuro checks were initiated. The DON was then asked what her expectations for a resident for a change in mental status were. She replied, .To reach out to the NP, obtain, and implement any new orders received . The DON looked at the progress note documented by LPN F and stated .[LPN F] should have contacted the NP herself .The NP should have been notified as soon as the change in mental status was noticed .with any change in condition, there should be follow-up charting for 72 hours . During a telephone interview on [DATE] at 3:57 PM, LPN G stated Resident #7 experienced an unwitnessed fall on Thursday, [DATE] .[LPN K] found him [Resident #7] .we went in and assessed him [LPN G, CNA AA, CNA CC] .everything seemed fine .he was being belligerent when we got him up off the floor .[LPN G] did not do an incident report .I was off Friday [[DATE]], Saturday [[DATE]], Sunday [[DATE]] .Monday [[DATE]], the night nurse [LPN F] informed me [Resident #7] needed a urine .when I got to his room between 9 AM and 10 AM to give meds .he was totally different .I went to call the NP .got order to send Resident #7 out .found out later Resident #7 had passed .a few days later, CNA AA and CNA CC said Resident #7 had multiple falls over the weekend [after the fall on [DATE]] .Resident #7 was between his and his roommate's bed .lying on his back .Resident #7 said he slid out of bed and landed on his bottom .Resident #7 bumped his head on the frame of the bed when we got him up .Resident #7 had scooted under the bed .head was under the bed .No visible injuries noted at that time .I did neuro checks but did not chart it .I was not trained well on that system .on that Monday, he had a bruise to the forehead or temporal area . Continued interview revealed LPN G stated .I did not report the fall because I was unfamiliar with the computer system and the Unit Manager was there and saw him on the floor . LPN G was asked if he reported the fall when Resident #7 was transferred out to the hospital. LPN G replied, No. I just told them about the change in mental status . During a telephone interview on [DATE] at 5:00 PM, the facility NP was asked what her expectations were to report a change in mental status. She replied, .I would expect to be notified immediately after the patients immediate needs were met, no matter the time .On call is available for the night shift .If emergent or unstable, I would expect staff to call 911 and then notify me immediately after . Continued interview revealed, the NP was not notified about Resident #7's fall on [DATE] and was contacted on [DATE] about a change in mental status for Resident #7. During an interview on [DATE] at 12:45 PM, LPN K, the Unit Manager, recalled she was about to leave for the day and went to tell the nurse something when she observed LPN #4 with 2-3 unnamed CNAs in Resident #7's room. Resident #7 was positioned on the floor, toward the foot of the bed, sitting up with his back against the bed. LPN K stated Resident #7 was not cooperating, so she backed out of the room and let staff finish with Resident #7. When asked her expectations for staff when a fall occurred, LPN K stated she would expect the nurse on duty to complete an event note, progress note, and 72-hour charting. When asked if LPN K followed-up on Resident #7's fall the next day, LPN K stated No, the ADON [Assistant Director of Nursing] dealt with the falls in the facility. Continued interview revealed LPN K admitted she did not notify the NP, DON, ADON, or family about Resident #7's fall and should have followed-up the next day on the fall from [DATE]. During a telephone interview on [DATE] at 5:57 PM, CNA DD was asked if Resident #7 had experienced any fall, CNA DD responded, Which one, because he had several. CNA DD could not recall any dates of the falls. During an interview on [DATE] at 11:17 PM, Family Member (FM) KK stated she had not been notified of a fall on [DATE] nor of a change in mental status on [DATE]. During an interview on [DATE] at 9:06 AM, Family Member (FM) LL stated she had not been notified of a fall on [DATE] nor of a change in mental status on [DATE]. During an interview on [DATE] at 3:07 PM, CNA GG stated Resident #7 did fall and was found on the floor face down, beside the bed and the bedside table. CNA GG stated he did not observe the fall but did notify the unnamed nurse and helped get Resident #7 up off the floor into the bed. When asked if Resident #7 had experienced any change in mental status, CNA GG stated Resident #7 would typically curse and yell, but he actually became calm and quiet after the unwitnessed fall. Continued interview revealed, CNA GG felt there was something different with Resident #7 and asked the unnamed nurse if she felt Resident #7 looked okay, the unnamed nurse replied, Yes. Refer to F-580, F-600, and F-726.

Based on policy review, medical record review, and interview, the facility failed to notify and consult the Physician/Nurse Practitioner (NP) of a change in condition related to falls 1 of 6 (Resident #7) sampled residents reviewed for change in condition. On [DATE], Resident #7 had an unwitnessed fall and was found on the floor with his head under the bed. Resident #7 hit his head while being placed back in bed by staff. The Physician/NP was not notified of Resident #7's unwitnessed fall on [DATE], and on [DATE], Resident #7 experienced a change in mental status. The NP was notified on [DATE] (1 day after the change in mental status and 4 days after the unwitnessed fall) of Resident #7's change in condition and again, was not notified of the unwitnessed fall the resident sustained on [DATE]. The facility's failure to immediately notify the Physician/NP of Resident #7's fall with injury resulted in Immediate Jeopardy (IJ), a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death, when Resident #7 had an unwitnessed fall and remained in the facility for 4 days following the fall and after experiencing mental status change the night before being transferred to the hospital where he expired in the emergency room (ER). The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:10 PM, in the Administrator's office. The facility was cited at F-580 at a scope and severity of J. The Immediate Jeopardy was effective [DATE] and is ongoing. A partial extended survey was conducted [DATE] to [DATE]. The facility is required to submit a Plan of Correction (POC). The findings include: Review of the facility policy titled Notification of Change, revised on [DATE], revealed .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies the resident's representative .when there is a change requiring notification .The facility shall inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification .Circumstances requiring notification include: 1. Accidents .b. potential to require physician intervention .2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses which included Unspecified Fracture of Third Lumbar Vertebra, Frontal Lobe and Executive Function Deficit, and Urinary Tract Infection. Resident #7 was discharged on [DATE] to Hospital #1. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #7 revealed, a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Review of the facility Clinical Note dated [DATE] but entered into the Electronic Health Record (EHR) on [DATE], revealed, .Resident was found on the floor with his head under the bed .While sliding the resident to get his head clear of the bed the resident raised his head and hit it on the underneath of the bed . The Clinical Note documented on [DATE] and dated [DATE] was not documented as a late entry. Review of the facility Clinical Note dated [DATE], revealed, .Res [resident] appears to be more confused, not understanding simple tasks . During an interview on [DATE] at 11:25 AM, the Director of Nursing (DON) verified the unwitnessed fall on [DATE] for Resident #7 was not charted until [DATE]. The DON stated she became aware of Resident #7's unwitnessed fall after he was sent to Hospital #1 emergency room (ER) for a change in mental status when someone reported to her Resident #7 had a knot and a bruise on his head. She stated she followed-up with LPN G, who said Resident #7 had a fall and hit his head pretty hard on [DATE]. After the DON received report on the fall from [DATE], she initiated an investigation and requested LPN G complete an incident report on [DATE]. The DON stated she educated LPN G when he stated he was unaware he needed to document on the fall. Continued interview revealed, the DON was asked what her expectations were when a resident experienced a fall. She replied, .I expect a head-to-toe assessment, neuro checks, notification to the NP, family, DON, Administrator and implement any new orders received . The DON verified no neuro checks were initiated. The DON was then asked what her expectations for a resident for a change in mental status were. She replied, .To reach out to the NP, obtain, and implement any new orders received . The DON looked at the progress note documented by LPN F and stated .[LPN F] should have contacted the NP herself .The NP should have been notified as soon as the change in mental status was noticed .with any change in condition, there should be follow-up charting for 72 hours . During a telephone interview on [DATE] at 3:57 PM, Licensed Practical Nurse (LPN) G stated .I did not report the fall because I was unfamiliar with the computer system .the Unit Manager was there and saw him on the floor . During a telephone interview on [DATE] at 5:00 PM, the NP stated she was not notified about Resident #7's unwitnessed fall on [DATE]. During an interview on [DATE] at 12:45 PM, LPN K, who was the Unit Manager, confirmed she observed Resident #7 on the floor and did not notify the NP, Director of Nursing (DON), Assistant Director of Nursing (ADON), or resident representative about Resident #7's unwitnessed fall on [DATE]. When asked if she followed-up on Resident #7's fall the next day, LPN K stated No, the ADON deals with the falls in the facility. Continued interview revealed LPN K admitted she did not notify the NP, DON, ADON, or family about Resident #7's fall and should have followed-up the next day on the fall from [DATE]. During an interview on [DATE] at 11:17 PM, Family Member (FM) KK, the conservator for Resident #7, stated she had not been notified of a fall on [DATE] nor of a change in mental status on [DATE]. During a telephone interview on [DATE] at 9:06 AM, FM LL, who could also make decisions for Resident #7, confirmed she had not been notified about a fall on [DATE] nor a change in mental status on [DATE]. During a telephone interview on [DATE] at 10:25 AM, the NP stated she was not notified of Resident #7's change in mental status on [DATE] but would expect the facility to notify her of any change in condition for any resident.

Based on facility policy review, medical record review, facility investigation review, hospital record review, and interview, the facility failed to assess after a fall, care for a resident after a fall, and monitor after a fall for 1 of 6 (Resident #7) sampled residents reviewed for falls. On [DATE] at 5:30 PM, Resident #7, known to have a history of falls with injury, was found on the floor following an unwitnessed fall from bed. There was no documentation to show a post-fall assessment was completed prior to moving Resident #7 from the floor to the bed. There was no documentation to show neuro checks were conducted. There was no incident report or investigation documented following the unwitnessed fall to determine the root cause. There were no immediate interventions documented following the fall. On [DATE] (4 days after the unwitnessed fall) Resident #7 was transferred to the hospital on [DATE] for a change in mental status. The findings include: Review of the facility policy titled, Accidents and Supervision, revised [DATE] revealed, .The facility shall establish and utilize a systemic approach to address resident risk and environmental hazards to minimize the likelihood of accidents .1. Identification of Hazards and Risks .a. Communicating the interventions to all relevant staff .Providing training as needed .d. Documenting interventions .e. Ensuring that the interventions are put into action . Review of the facility policy titled, Fall Risk-Fall Prevention, revised [DATE] revealed, .1. The fall risk assessment shall be completed by a licensed nurse .b. After a fall .c. Upon a significant change in medical status . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses which included Unspecified Fracture of Third Lumbar Vertebra, Frontal Lobe and Executive Function Deficit, and Urinary Tract Infection. Resident #7 was discharged on [DATE] to Hospital #1. Review of the care plan for Resident #7 revealed, .[[DATE]] At Risk For Falls R/T [related to] impaired mobility .Interventions .Keep area free of obstructions to reduce the risk of falls or injury .Place call bell/light within easy reach .Provide reminders to use ambulation and transfer assist devices .Remind [Resident #7] to call for assistance before moving from bed-to-chair and from chair-to-bed .[[DATE]] Footwear will fit properly and have non-skid soles . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #7 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Review of the facility document (Incident Report) dated [DATE], revealed LPN G documented, Observed resident on the floor between both beds and his head under his bed. Resident did not have non-skid footwear on. While assisting resident up from the floor, raised his head and bumped it on the bottom of the bed. Resident mental status was at his normal. Resident was resting comfortably in bed when writer [LPN G] exited room. Continued review revealed a bruise to Resident #7's forehead. Review of the facility Clinical Note dated [DATE] but not entered into the Electronic Health Record (EHR) until [DATE], revealed LPN G documented Resident #7 was found on the floor with his head under the bed. Continued review revealed that while staff were assisting him out from under the bed, he raised his head and hit it on the bottom of the bed. LPN G documented there were no injuries. The Clinical Note was not documented as a late entry. Review of the facility Clinical Note dated [DATE] revealed LPN F documented Resident #7 experienced a change in condition. The provider was not notified of Resident #7's change in condition until [DATE], the following day. Review of the facility Fall Risk assessment dated [DATE] revealed Resident #7 had a history of multiple falls in the last 90 days, had an unsteady gait and was at moderate risk for falls. Review of the hospital record dated [DATE] at 10:05 AM revealed, .PT [patient] was found unresponsive in bed .[nursing home] staff reports patient is normally talking and oriented, BG [blood glucose] was 517 .Bruising on forehead purple and yellow in color . Resident #7 expired at the hospital on [DATE]. Septic shock was documented as the cause of death. During an interview on [DATE] at 11:25 AM, the DON verified the unwitnessed fall on [DATE] for Resident #7 was not charted until [DATE]. The DON stated she became aware of Resident #7's unwitnessed fall after he was sent to Hospital #1 emergency room (ER) for a change in mental status when someone reported to her Resident #7 had a knot and a bruise on his head. She stated she followed-up with LPN G, who said Resident #7 had a fall and hit his head pretty hard on [DATE]. After the DON received report on the fall from [DATE], she initiated an investigation and requested LPN G complete an incident report on [DATE]. The DON stated she educated LPN G when he stated he was unaware he needed to document on the fall. Continued interview revealed, the DON was asked what her expectations were when a resident experienced a fall. She replied, .I expect a head-to-toe assessment, neuro checks, notification to the NP, family, DON, Administrator and implement any new orders received . The DON looked at the progress note documented by LPN F and stated .[LPN F] should have contacted the NP herself .The NP should have been notified as soon as the change in mental status was noticed .with any change in condition, there should be follow-up charting for 72 hours . During a telephone interview on [DATE] at 3:57 PM, LPN G stated Resident #7 experienced an unwitnessed fall on Thursday, [DATE] .[LPN K] found him [Resident #7] .we went in and assessed him [LPN G, CNA AA, CNA CC] .everything seemed fine .he was being belligerent when we got him up off the floor .[LPN G] did not do an incident report .I was off Friday [[DATE]], Saturday [[DATE]], Sunday [[DATE]] .Monday [[DATE]], the night nurse [LPN F] informed me [Resident #7] needed a urine .when I got to his room between 9 AM and 10 AM to give meds .he was totally different .I went to call the NP .got order to send Resident #7 out .found out later Resident #7 had passed .a few days later, CNA AA and CNA CC said Resident #7 had multiple falls over the weekend [after the fall on [DATE]] .Resident #7 was between his and his roommate's bed .lying on his back .Resident #7 said he slid out of bed and landed on his bottom .Resident #7 bumped his head on the frame of the bed when we got him up .Resident #7 had scooted under the bed .head was under the bed .No visible injuries noted at that time .I did neuro checks but did not chart it .I was not trained well on that system .on that Monday, he had a bruise to the forehead or temporal area . Continued interview revealed LPN G stated .I did not report the fall because I was unfamiliar with the computer system and the Unit Manager was there and saw him on the floor . LPN G was asked if he reported the fall when Resident #7 was transferred out to the hospital. LPN G replied, No. I just told them about the change in mental status . During a telephone interview on [DATE] at 5:00 PM, the facility NP was asked what her expectations were to report a change in mental status. She replied, .I would expect to be notified immediately after the patients immediate needs were met, no matter the time .On call is available for the night shift .If emergent or unstable, I would expect staff to call 911 and then notify me immediately after . Continued interview revealed, the NP was not notified about Resident #7's fall on [DATE] and was contacted on [DATE] about a change in mental status for Resident #7. During an interview on [DATE] at 12:45 PM, LPN K, the Unit Manager, recalled she was about to leave for the day and went to tell the nurse something when she observed LPN #4 with ,d+[DATE] unnamed CNAs in Resident #7's room. Resident #7 was positioned on the floor, toward the foot of the bed, sitting up with his back against the bed. When asked her expectations for staff when a fall occurred, LPN K stated she would expect the nurse on duty to complete an event note, progress note, and 72-hour charting. When asked if LPN K followed-up on Resident #7's fall the next day, LPN K stated No, the ADON [Assistant Director of Nursing] dealt with the falls in the facility. Continued interview revealed LPN K admitted she did not notify the NP, DON, ADON, or family about Resident #7's fall and should have followed-up the next day on the fall from [DATE]. During an interview on [DATE] at 3:07 PM, CNA GG stated Resident #7 did fall and was found on the floor face down, beside the bed and the bedside table. CNA GG stated he did not observe the fall but did notify the unnamed nurse and helped get Resident #7 up off the floor into the bed. When asked if Resident #7 had experienced any change in mental status, CNA GG stated Resident #7 would typically curse and yell, but he actually became calm and quiet after the unwitnessed fall. Continued interview revealed, CNA GG felt there was something different with Resident #7 and asked the unnamed nurse if she felt Resident #7 looked okay, the unnamed nurse replied, Yes.

Based on facility policy review, medical record review, and interview, the facility failed to implement a comprehensive person-centered care plan for 3 (Resident #3, Resident #10, and Resident #15) of 20 residents reviewed. The findings include: Review of the facility's policy titled Comprehensive Care plan dated 11/30/2026 revised 10/24/2022 effective 11/9/2023, revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .that include measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs .'Person Centered' means to focus on the resident as the locus [focus] of control and support the resident in making their own choices and having control over their daily lives .at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses which included Schizophrenia, Dysphagia, Dysarthria and Anarthria. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 revealed, a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Review of the undated current care plan for Resident #3 revealed there were no focus/problems or interventions on the care plan for risk related to actual abuse allegations. Review of the provider/Nurse Practitioner (NP) progress note dated 9/26/2023 for Resident #3, revealed, .Patient being seen for follow-up on events this past weekend involving roommate .patient reports he does not want to discuss in detail w [with]/me what occurred over the weekend .does affirm allegation against roommate and that he [Resident #3] may be open to discussing w/local PD [Police Department] .Reports emotional and mental distress from prior roommate's actions . Review of the facility Clinical Notes for Resident #3 dated 9/26/2023- 9/29/2023 frequently referenced Resident #3's desire to sit on the front porch, even referenced it as something he loves to do on a daily basis. The Clinical Notes referred to Resident #3 feeling safe and calm, in a good mood and smiling. During an interview on 4/2/2024 at 3:08 PM, MDS Coordinator #1 and #2 confirmed there were no interventions related to actual risk associated with the allegation of nonconsensual sexual contact/sexual abuse Resident #3 reported on 9/24/2023. MDS Coordinator #1 and #2 agreed residents that experience alleged abuse should be monitored for risk of immediate and late onset of affects such as psychosocial harm. During an interview on 4/2/2024 at 4:11 PM, Resident #3 agreed to interview in the presence of his roommate. Resident #3 was asked to recall the incident with his previous roommate, Resident #11, during the night of 9/23/2023 - 9/24/2023. The surveyor provided support and patience during the interview as Resident #3 was very slow to answer and had difficulty expressing himself. Resident #3 stated, .[Named Resident #11] came to my bed and tried to push me on my side, 3 or 4 times .almost fell off the bed .he [Resident #11] stopped and looked right at me, took out his d k and put it in my hand .I yelled .he walked away laughing . Resident #3 was asked if he felt safe in the facility, Resident #3 replied, .I am safe with this roommate [pointing towards current roommate] but when he goes home, who will keep me safe .He [Resident #11] is still here, I see him out in the hall . Resident #3 became tearful and paused for several minutes. When asked if he reported the incident to staff after Resident #11 walked away, Resident #3 replied, .I tried but they wouldn't stand still long enough for me to talk, they think I can't talk . Resident #3 thanked the surveyor for standing still and listening to him. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Atrial Fibrillation and Dementia. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #10 revealed, a BIMS score of 14 which indicated no cognitive impairment. Review of Comprehensive Care Plan for Resident #10 dated 1/5/2024 revealed, .1/5/2024 risk for falls r/t (related to) impaired mobility .transfers-Assist .to desired location with assistance .Hoyer lift X [times] 2 person assist with transfer . Review of the Clinical Note documented late on 1/25/2024 at 3:29 PM for effective date 1/24/2024 at 12:30 PM, the DON documented Pt [patient]stated she was having knee pain from transfer. AIT (Administrator in training) and myself entered room to speak with pt[patient] regarding the transfer pain. PT [patient] states she was transferred by 2 people and her knee began to hurt once she was back in bed. Stated that she did not want any pain medication. AIT asked her if she would like any heat or ice. Pt stated she did not want those either. NP [Nurse Practitioner] made aware of concerns. Xray ordered. Review of Physical Therapy Treatment Encounter Note dated 1/25/2024, revealed PTA [Physical Therapist Assistant] documented Entered patient's room pt [patient] reported increase pain in R knee due to tech twisted and broke her leg when they were transferring her back to bed and she is unable to move her legs this session. Assist can [Certified Nursing Assistant] with toilet hygiene rolling R <> L [right to left] with max [maximum] A [assist] .spoke with nursing with patient's concerns and comments .Pt responded poorly with PT [physical therapy] interventions . On 1/23/2024 Resident #10 was transferred from the wheelchair to bed by CNA EE and CNA FF without using a mechanical lift. During an interview on 4/2/2024 at 1:00 PM, CNA EE had been working at the facility for 7 years. She stated she had just taken over the group and was asked by Resident #10 to put her in the bed because her leg was hurting. Therapy had gotten Resident #10 up that morning and had been working with her. CNA EE requested the assistance of CNA FF to transfer the resident. CNA EE stated she used a gait belt and did an underarm 2-person lift to transfer the resident to the bed. The resident requested her legs be straightened out and was clean and dry. CNA EE stated she had not cared for Resident 10 often previously other than to do her weekly weights. When asked how the weights were done, she stated by named mechanical lift. When asked where she would check to see how to get the resident up, CNA EE stated she would check the Kiosk/care plan to find out how to transfer the resident. During an interview on 4/2/2024 at 330 PM, revealed CNA FF had been working at the facility for approximately 7 years. CNA FF stated she was asked to assist in putting Resident #10 to bed. Resident #10 was in a wheelchair and complained of pain. CNA FF stated they used a gait belt and stood her up with the assistance of CNA EE. CNA FF stated, she had never worked with this resident before. CNA FF stated the resident complained of pain prior to the transfer as well as during the transfer. During an interview on 4/10/2024 at 9:15 AM, the Doctor of Physical Therapy [DPT] stated that Resident #10 was added to their case load on 1/5/2024 and evaluated on 1/8/2024. The transfer recommendation for nursing staff was for them to transfer Resident #10 with a mechanical lift and therapy transferred the resident with a sliding board. This plan of care continues to be in place at present. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses which included Bipolar Disorder, Schizoaffective Disorder, and Frontotemporal Neurocognitive Disorder. Common symptoms of Frontotemporal Neurocognitive Disorder include but are not limited to behavior such as socially inappropriate, impulsive, or repetitive behaviors, and increased interest in sex. Review of the Admission MDS assessment dated [DATE] for Resident #11 revealed, a BIMS score of 12, which indicated moderately cognitively impaired. Continued review revealed Resident #11 required supervision to walk in corridor. Review of care plan for Resident #11 revealed, . 8/22/2023 .Remind [Resident #11] that BEHAVIOR is not appropriate .Resident prefers to walk around facility constantly and enjoys sitting on front porch . 9/26/2023 .displayed inappropriate sexual behaviors towards others .Redirect [Named Resident #11] and remind him of what is appropriate/not appropriate in social settings .10/3/2023 .rejects or resists care (history of refusing medications) . Resident #3, the victim of the alleged sexual assault enjoyed sitting on the front porch. There were no care plan interventions for either resident to address psychosocial risk associated with repeated exposure in the facility. Review of the facility Clinical Notes for Resident #11 dated 9/22/2023 at 8:45 AM, revealed .Resident was down in the dining room on 09/21/23 [2023] two different times this resident was making sexual comment's [comments] to the lady residents pulling his shirt up and rubbing his nipples and rubbing himself up on two female residents. Also [Also,] resident was rubbing his penis asking a female resident if she wanted some of that. Resident also had his room # written on a piece of paper telling the lady resident to come to his room. Activities reported this to the nurse . Review of the facility Clinical Notes for Resident #11 dated 9/24/2023 at 6:31 PM, revealed .Another resident family member notified Nurse Management this shift of sexual inappropriate behavior towards roommate/resident on last night. Roommate immediately moved out of room, placed in another room. Family [Resident #3's family] at bedside agreeable and aware. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease with Early Onset, and Chronic Kidney Disease, Stage 3. Review of the Admission MDS assessment dated [DATE] for Resident #15 revealed, a BIMS score of 4 which indicated severe cognitive impairment. Resident #15 was independent with mobility/walking. Review of undated care plan for Resident #15 revealed, .exhibits wandering behavior . Continued review revealed there was no problems/focus and interventions for risk related to victim of inappropriate sexual behavior and nonconsensual sexual contact by Resident #11 on 9/18/2023-9/22/2023, and Resident #19 on 2/21/2024. Review of the facility Clinical Notes for Resident #15 dated 2/22/2024, revealed, .Presented to DON office with activities director and 100 hall nurse. Stated that resident CC [Resident #19] kissed her on her cheek and she was only letting someone know about it because she did not want him to kiss her anymore . During an interview on 4/2/2024 at 11:47 AM, the Activity Director confirmed she had reported and documented Resident #11's inappropriate sexual behaviors multiple times beginning 9/18/2023, and continuing on 9/21/2023, and 9/22/2023. The Activity Director stated, .on the 18th [9/18/2023] [Named Resident #11] was in activities and walked up to [Resident #15], put his hands on her shoulders and began to massage her .He [Resident #11] tried to kiss her while he was rubbing her and she pushed him away .He [Resident #11] put some money on the table in front of her [Resident #15] and pushed it towards her and said, ' .If that isn't enough, just let me know .' then he laughed and walked back to his table . I asked him to leave activities and reported it to the nurse, not sure which one, I think she was agency .On the 21st [9/21/2023] he [Resident #11] was sitting at his table, stood up, and pulled his pants down then pointed to his penis and yelled, ' .if any of you ladies wants this come to room [ROOM NUMBER] .' he [Resident #11] had a piece of paper with the number 311 written on it He then walked over and tried to kiss [Named Resident #15] .I went and got the nurse [Named LPN H] .she [LPN H] came in and told him to go to his room .On the 22nd [9/22/2023] he [Resident #11] walked up to [Named Resident #15] rubbed up against her, and started rubbing his nipples and making sexual comments like ' .Do you want some of that .' then handing a piece of paper with his room number on it . During an interview on 4/2/2024 at 1:13 PM, LPN H stated, .[Named Resident #19] is obsessed with [Named Resident #15], always trying to give her candy and bring her things, but she doesn't return the feelings .she pushes him away .One day in activities he [Resident #19] was beside her [Resident #15] and she pushed him away, had to tell both of them to go to their room and cool off . During an interview on 4/2/2024 at 3:08 PM, MDS Coordinator HHH and III confirmed there were no interventions related to actual risk associated with the nonconsensual sexual contact Resident #15 experienced from 9/18/2023-2/21/2024. MDS Coordinator HHH and III agreed residents that experience alleged abuse should be monitored for risk of immediate and late onset of affects such as psychosocial harm. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE], with diagnoses which included Catatonic Disorder due to known Physiological Condition, Chronic Obstructive Pulmonary Disorder (COPD) and Schizophrenia. Other diagnoses included Other Sexual Dysfnct. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #19 had a BIMS score of 5, which indicated severely cognitively impaired. Resident #19 was independent with mobility/walking. Review of the undated current care plan for Resident #19 revealed, .Resident practices sexual expression daily on his bed with roommate in room .Dx [Diagnosis] Hypersexuality . Review of the facility Clinical Notes for Resident #19 dated 3/6/2024 at 4:43 PM, revealed, .Resident observed attempting to be affectionate towards another resident .redirected to room . During an interview on 4/2/2024 at 11:47 AM, the Activity Director stated, .[Named Resident #19] frequently tried to get next to [Named Resident #15] .[Resident 19] got mad at [Named Resident #11] because he said [Named Resident #11] told him he was going to rape [Named Resident #15] and said he [Resident #11] had [NAME] coming out of his chest .I reported it to all the nurses .

Based on facility policy review, medical record review, and interview, the facility failed to ensure the appropriate information for transfer or discharge was communicated to the receiving healthcare facility or provider for 1 of 3 residents (Resident #7) sampled residents reviewed. Resident #7 was transferred to Hospital #1 Emergency Department (ED) on 1/29/2024 for evaluation of a change in mental status. Facility nursing staff failed to communicate information related to Resident #7's unwitnessed fall on 1/25/2024 on the written report to Hospital #1. The findings include: Review of the facility policy titled, Transfer and Discharge, revised 10/24/2022 and effective 11/20/2023 revealed, .For a transfer to another provider, the following information must be provided to the receiving provider . Other necessary information, including a copy of the resident's discharge summary, as applicable, to ensure a safe and effective transition of care .Emergency Transfers/Discharges-for medical reasons, or for the immediate safety and welfare of a resident, initiated by the facility (nursing responsibilities unless otherwise specified) . Any other documentation, as applicable, to ensure a safe and effective transition of care . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses which included Unspecified Fracture of Third Lumbar Vertebra, Frontal Lobe and Executive Function Deficit, and Urinary Tract Infection. Resident #7 was discharged on [DATE] to Hospital #1. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #7 revealed, a BIMS score of 15 which indicated no cognitive impairment. Review of the facility clinical note dated 1/25/2024 but entered on 1/29/2024, revealed LPN G documented .Resident was found on the floor with his head under the bed. Staff was assisting to get resident off the floor. While sliding the resident to get his head clear of the bed the resident raised his head and hit it on the underneath of the bed . Review of the facility clinical note dated 1/28/2024, revealed LPN F documented .Res [Resident] appears to be more confused, not understanding simple tasks . Review of the facility Hospital Transfer Form dated 1/29/2024 but completed on 1/30/2024, revealed .Mental Disorders/Neurological/Psychiatric Issues .Change in Mental Status . There was no documentation to show LPN G reported the unwitnessed fall on 1/25/2024 or the change in mental status that started on 1/28/2024 on the Hospital Transfer Form. During a telephone interview on 3/27/2024 at 3:57 PM, LPN G was asked if he reported the 1/25/2024 unwitnessed fall when Resident #7 was transferred out to the hospital. LPN G replied, .No. I just told them about the change in mental status . The facility failed to ensure Hospital #1 received accurate and appropriate information related to Resident #7's 1/25/2024 fall that could have likely resulted in a delay of treatment in the ED.

Based on facility policy review, observation, and interview, the facility failed to keep a clean and sanitary environment for 2 of 14 (306 and 314) rooms observed. The findings include: Review of the facility policy titled, Housekeeping-Cleaning and Disinfecting, revised 5/15/2023, revealed, .It is the policy of this facility to ensure the provision of routine cleaning and disinfecting in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. The facility requires the use cycle cleaning schedules to outline the frequencies and maintain regularly scheduled environmental service task . Observation in room [ROOM NUMBER] on 7/11/2023 at 11:13 AM, revealed the wall air conditioner had build-up debris in the vents. The wall on the left side near the door was covered with dried debris. Observation in room [ROOM NUMBER] on 7/11/2023 at 11:14 AM, revealed trash was on the floor near the A-bed, and a water basin was on the floor near the B-side. Dry debris was on the floor. During an interview on 7/11/2023 at 2:21 PM, the Director of Housekeeping stated that the housekeepers were to pull the trash, wipe down the tables, sweep. and mop the floors. The Director of Housekeeping acknowledged the issues with the cleanliness of the residents' rooms. Observation and interview in room [ROOM NUMBER], on 7/11/2023 at 2:24 PM, the Director of Housekeeping, confirmed the wall air conditioner had build-up debris in the vents. The wall on the left side near the door was covered with dried debris. Observation and interview in room [ROOM NUMBER], on 7/11/2023 at 2:26 PM, with the Director of Housekeeping confirmed trash and dried debris was on the floor. During an interview on 7/11/2023 at 4:12 PM, the Administrator stated she expected the residents' rooms to be clean.

Based on facility policy review, medical record review, hospital medical record review, and interview, the facility failed to ensure nursing staff applied a bilevel positive airway pressure (BiPAP) mask to a resident, assessed and documented oxygen saturation levels, and notified the medical doctor/nurse practitioner (MD/NP) when a resident was found unresponsive and went into cardiac arrest for 1 of 4 sampled residents (Resident #1) reviewed who required oxygen therapy. The findings include: Review of the facility's policy titled, Notification of Change dated 11/30/2017 revealed .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies the resident's representative, consistent with his or her authority, when there is a change requiring notification .Life Threatening Conditions .Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status .circumstances that require a need to alter treatment. This may include: new treatment .acute condition . Review of the facility's policy titled, Dyspnea dated 10/19/2020 revealed .Shortness of breath; .oxygen Saturation of 92% or Less; or, change from baseline with decline in respiratory status .Interventions: Administer supplemental Oxygen, 2-4L [liters] per Nasal Cannula .Titrate oxygen to maintain O2 [oxygen] saturation Greater than 90%, unless Resident has end stage COPD [chronic obstructive pulmonary disease] or CO2 [carbon dioxide] retention (Target O2 Saturation 88-90%); .if Resident has COPD leaning over a pillow on a bedside table while sitting on the side of the bed can be helpful. Duoneb treatment stat; Administer Dexamethasone 4mg [milligrams] IM [intramuscular}, Chest Xray .Notify MD/NP [medical doctor/nurse practitioner], Vital Signs and O2 Saturation every 4 hours for 24 hours then every shift for 3 days . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Acute and Chronic Respiratory Failure with Hypoxia, Bacterial Pneumonia, Obstructive Sleep Apnea, Chronic Bronchiectasis Asthma, and Mental Retardation (Intellectual Disability). Review of the physician's orders dated 2/8/2023 revealed Resident #1 was to have 4L/minute per nasal cannula and BiPAP with inspiratory PAP of 10 and expiratory PAP of 5 to be applied at hour of sleep and removed in the morning. Review of the admission Minimum Data Set [MDS] dated 2/12/2023 revealed Resident #1 has a Brief Interview for Mental Status [BIMS] score of 7 which indicated a severe cognitive impairment. Continued review revealed Resident #1 required oxygen therapy. Review of the Admission/Baseline Care Plan revealed Resident #1 had respiratory compromise and had physician orders for BiPAP and supplemental oxygen. Review of the Occupational Therapy Treatment Encounter Notes dated 2/13/2023 at 4:13 PM revealed, Caregiver training provided focusing on proper positioning for the patient to increase lung capacity due to desaturation noted with lethargy. Nurse is aware. Patient was seen 3 times this day .Response to Session Interventions. Patient with lethargy noted but was able to respond to question better in the afternoon. Nurse notified . Review of the vital signs for Resident #1 revealed there was no documentation of O2 saturation level from 2/13/2023-2/14/2023. Review of the Treatment Notes dated February 2023 revealed, .2/13/2023 11p [PM]-7a [AM] .Not Completed (Resident Unavailable) .Author .[LPN #2] . Review of Clinical Notes dated 2/14/2023 at 2:03 AM revealed Resident #1 was found unresponsive during walking rounds. LPN #2 documented Resident #1 was pale, lips were blue, and the chest did not appear to rise and fall. Resident #1 did not respond to a sternal rub. Staff began cardiopulmonary resuscitation and notified emergency medical services (EMS). Resident #1 was transported to Hospital #1 Emergency Department (ED). There was no documentation regarding O2 saturation level or notification of the MD/NP. Review of Hospital #1 medical record revealed EMS reported Resident #1 was found by EMS in cardiac arrest. Resident #1 was pronounced dead at Hospital #1 on 2/20/2023 at 5:18 PM. During a phone interview on 4/5/2023 at 9:57 AM, Licensed Practical Nurse (LPN) #2 stated she was informed by Certified Nursing Assistant (CNA) #8 on the night of 3/13/2023 that she found Resident #1 unresponsive when making rounds. When asked whether she had placed the BiPAP on Resident #1, LPN #2 stated, No. I did not put it on him. LPN #2 stated she did put mask on Resident #1 the night prior (3/12/2023) and noticed the mask had a bad seal. When asked whether she reported it to the Director of Nursing (DON), she stated no. During an interview on 4/5/2023 at 4:00 PM, the DON stated she was made aware of the incident regarding Resident #1 by LPN #2. Further interview revealed there no incident report or investigation for Resident #1 being sent to Hospital #1 ED for cardiac arrest. When asked if she was aware Resident #1 did not have BiPAP in place at the time of cardiac arrest, the DON responded, no. The DON stated When a resident goes to the hospital/ER [emergency room ], a Hospital Transfer Form is completed .there was an agency nurse on duty at the time of the incident, and the form was not completed at that time, but I completed it later that morning . During a phone interview on 4/5/2023 at 4:41 PM, the Nurse Practitioner stated she would expect to be called if a resident experienced desaturation and went into cardiac arrest. The Nurse Practitioner confirmed she was not notified Resident #1 went into cardiac arrest on 2/14/2023 and was sent to Hospital #1 ED. During a phone interview on 4/6/2023 at 9:23 AM, the Medical Director stated he was not familiar with the care of Resident #1 and was made aware later that Resident #1 had been sent to Hospital #1 ED.

Based on facility policy review, medical record review, and interviews, the facility failed to resume an anticoagulant medication after a surgical procedure for 1 of 3 residents (Resident #2) reviewed, which resulted in the resident suffering a Cerebrovascular Accident (CVA), causing irreversible Harm. The findings include: Review of the facility's policy titled, Medication Reconciliation, revised 11/23/2021, revealed, .Medication Reconciliation/Drug Regimen Review is an interdisciplinary process between Nursing, Medical Staff and Pharmacy that compares the resident's most current list of home medications against the physician's orders upon admission and discharge, addresses discrepancies/issues, and thereby decreases potential Adverse Drug Events (ADEs) and omissions of medication therapy .A clinically significant medication issue is a potential or actual issue that, in the clinician's professional judgment, warrants: Physician/practitioner communication, and Completion of prescribed/recommended actions before midnight of the next calendar day .Clinically significant means the effects, results, or consequences that materially affect or are likely to affect an individual's mental, physical, or psychosocial well-being .Negatively by exacerbating, causing, or contributing to a symptom, illness, or decline in status .Communication to the physician to convey an identified potential or actual clinically significant medication issue AND a response from the physician to convey prescribed/recommended actions in response to the medication issue .Residents will have all medications reconciled upon admission and at discharge. The nurse will review the medication list with the resident/representative. The physician/practitioner will review the resident's medication and any recommendations/orders will be completed before midnight of the next calendar day of receiving the recommendation/order. The final outcome of this process is to generate the most accurate medication list and to identify potential or actual clinically significant medication issues .Clinically significant medication issues include, but are not limited to: Presence of a medical condition that may warrant medication therapy .Omissions .Procedure: 1. Upon admission staff will obtain a list of current medications from the referral source i.e. hospital, resident/representative or another source .2. Upon admission the nurse and resident/representative will review and modify the medication list as indicated. 3. The Physician/Practitioner will review the medication orders and prescribe recommendations/orders, if indicated, which will be completed by the next calendar day . Review of the facility's policy titled, Anticoagulant Therapy, revised 6/27/2022, revealed, .To provide safe delivery of care to the resident receiving anticoagulant therapy through initiatives designed to achieve optimal anticoagulant-related health outcomes and minimize avoidable adverse events .Elderly patients are often prescribed anticoagulant therapy [a class of medication] for treatment or prophylactic reasons. Common conditions in which anticoagulants are prescribed include .Atrial Fibrillation .Anticoagulant therapy that is held for a medical procedure will be promptly reevaluated after the procedure and resumed as ordered by the physician or nurse practitioner .Anticoagulant refers to a class of medications that are used to prevent clot extension and formation .Examples include .Eliquis .The pharmacy consultant shall conduct a medication review upon admission, monthly, and as requested . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses which included Atrial Fibrillation, Occlusion and Stenosis of Unspecified Carotid Artery and Chronic Kidney Disease. Review of the admission Minimum Data Set (MDS) for Resident #3 revealed he scored Review of the Discharge Minimum Data Set (MDS) assessment for Resident #2 dated 9/30/2022, revealed a memory problem and severely impaired decision making. Review of the Physician's Orders for Resident #2 dated 4/27/2022 revealed, .Hold Eliquis 2 days prior to catheter removal . Review of the Clinical Notes Report for Resident #2 dated 5/2/2022 revealed, .Notified by [Named Dialysis Clinic] that resident is scheduled for dialysis catheter removal on Friday 5-6-2022 @ [at] 0845 [8:45 AM.] Transport arranged by dialysis. Order to hold Eliquis x [for] 3 days prior to procedure. NP [Nurse Practitioner] aware and agrees . Review of the Progress Notes signed by the Nurse Practitioner (NP) dated 5/11/2022 revealed, .5/11/2022 Weekly labs show creatinine and GFR [Glomerular Filtration Rate] continue to improve and patient has been cleared to stop dialysis and will have shunt removed tomorrow. Review of the Neurologist Progress Note for Resident #2, provided by the resident's daughter, dated 9/20/2022 revealed, XXX[AGE] year old man with Atrial Fibrillation, not on anticoagulation confirmed by ALF [SNF Skilled Nursing Facility] .Pt [patient] presents with soley subcortical syndrome, and therefore I suspect possible small vessel ideology. However, given his history of atrial fibrillation not on any anticoagulant currently, an embolic shower primarily affecting the right cerebral hemisphere is not entirely excluded .Will need to obtain records from PCP [Primary Care Physician] and Cardiologist before starting back on anticoagulant, determine if there is a reason why he was taken off the Eliquis . Review of a note by the Nurse Practitioner dated 9/30/2022, revealed .Patient was sent to ER [emergency room ] on 9/20/22 d/t [due to] AMS [Acute Mental Status.] He was taken to [Named Hospital.] H&P [History and Physical] from the ER/initial encounter not sent, so information from that is limited. Progress notes report that her [he] was found to have a mild right hemiparesis and TPA [Tissue Plasminogen Activator] was given and he was admitted to ICU [Intensive Care Unit] for further evaluation. Neurology consulted on 9/21 and recommended holding aspirin for another 24 hours and also restarting Eliquis in 7 days .He returned to the facility on ,d+[DATE], however after just a few hours had another change in mental status, with facial drooping, slurred speech, and unilateral weakness .CT (Computerized Tomography] of head showed acute occlusion of posterior left M2 and patient was readmitted .Repeat CT on 9/27 showed a large acute infarction of the left cerebral hemisphere involving the temporal and parietal lobes . Review of the Physician Order Sheet October 2022 for Resident #2 revealed, .9/30/2022 Eliquis 5 mg [milligram] tablet .one tab po [by mouth] BID [twice a day] Unspecified Atrial Fibrillation . Review of the Medication Administration Records (MARs) for Resident #2 revealed he was administered Eliquis 5 mg twice a day with a start date of 5/26/2021 in January, February, March, and April of 2022. Continued review revealed he was administered Eliquis 5 mg on 5/1/2022 at 9:00 AM, 9:00 PM and 5/2/2022 at 9:00 AM. The instructions on the MAR read, .4/28/2022 one tab [tablet] po bid x 4 days then hold x 3 days prior to dialysis catheter removal . Continued review of the May, June, July, and August MARs revealed no administration of Eliquis. Continued review of the September MAR revealed Eliquis 5 mg was administered once at 9:00 PM on 9/30/2022. During an interview on 10/25/2022 at 10:10 AM, the ADON stated Resident #2 was not put back on Eliquis when he returned from having his perma-cath removed, and he had a stroke. She stated, we missed it. When asked how the nursing staff is alerted to restart a medication that is held for a procedure and expected to be started back after the procedure, she stated, They are taught to do that. I don't do on-boarding, so I don't know how they keep up with it. They should just know. During a phone interview on 10/25/2022 at 10:53 AM, Family Member #3 stated her father, Resident #2, had his dialysis shunt removed on 5/12/2022 and came back to the facility the same day. She stated the removal of the shunt was originally scheduled for 5/4/2022, but there was a problem with transportation, so it was rescheduled for 5/12/2022. She stated the facility did not restart his Eliquis after the procedure, and on 9/20/2022 he had a stroke. She stated he had a diagnosis of Atrial Fibrillation and a pacemaker, and that is why he was on Eliquis. She stated he was discharged back to the nursing home on 9/25/2022. She stated when she arrived at the nursing home to check on him, he was very weak on one side, he could not speak and was very wobbly. She stated he was sent back to the hospital and was diagnosed with large acute infarction (injury) to his brain. She stated he is now paralyzed on one side, has a feeding tube, and cannot speak. She stated she called the Administrator and asked her why her father was not put back on Eliquis, and was told the dialysis center should have given them orders to resume the Eliquis. The daughter stated she called the dialysis center and was told it was not their place to reorder the medication. At that point, he was discharged from their care. She stated the neurologist at the hospital told her Resident #2 had the stroke because he was not on a blood thinner and had a diagnosis of Atrial Fibrillation. During an interview on 10/25/2022 at 1:10 PM, the ADON confirmed the MAR for Resident #2 contained an order to hold Eliquis 3 days prior to the surgical procedure. She stated it was supposed to be discontinued out of the computer, then put back on the MAR. During an interview on 10/25/2022 at 1:16 PM, the Regional Nurse Consultant stated there is no option in their electronic health record to hold a medication. She stated the nurses should discontinue it, and then reorder it with the date it is supposed to start back. She confirmed, Using nursing judgement, I would think it should have been restarted. There was a lack of communication. During a phone interview on 10/25/2022 at 1:41 PM, the Consultant Pharmacist stated she normally reviews resident's medical records on admission and monthly. She stated she gets the list of medications and compares them to the facility's computer orders. She stated on monthly reviews, she looks at medications and the diagnoses. When asked if she expected a resident with a diagnosis of Atrial Fibrillation and the presence of a pacemaker to be on an anticoagulant, she stated sometimes doctors write a note in the chart stating they are in normal sinus rhythm and do not order an anticoagulant. She stated if there is a note from the doctor regarding that, she would have written in her notes. She confirmed Resident #2 did not have a note from the doctor stating he did not want him on anticoagulants.

Based on facility policy review, medical record review, and interviews, the facility's Pharmacy Consultant failed to conduct a thorough Medication Record Review (MRR) for 1 of 3 residents (Resident #2) reviewed. An anticoagulant medication was held, and was not resumed after a surgical procedure, which resulted in the resident suffering a Cerebrovascular Accident (CVA), causing irreversible Harm. The findings include: Review of the facility's policy titled, Resident Rights and Resident Responsibilities, revised 10/24/2022, revealed, .The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility .The right to participate in the development and implementation of his or her person-centered plan of care . Review of the facility's policy titled, Medication Reconciliation, revised 11/23/2021, revealed, .Medication Reconciliation/Drug Regimen Review is an interdisciplinary process between Nursing, Medical Staff and Pharmacy that compares the resident's most current list of home medications against the physician's orders upon admission and discharge, addresses discrepancies/issues, and thereby decreases potential Adverse Drug Events (ADEs) and omissions of medication therapy .A clinically significant medication issue is a potential or actual issue that, in the clinician's professional judgment, warrants: Physician/practitioner communication, and Completion of prescribed/recommended actions before midnight of the next calendar day .Clinically significant means the effects, results, or consequences that materially affect or are likely to affect an individual's mental, physical, or psychosocial well-being .Negatively by exacerbating, causing, or contributing to a symptom, illness, or decline in status .Communication to the physician to convey an identified potential or actual clinically significant medication issue AND a response from the physician to convey prescribed/recommended actions in response to the medication issue .Residents will have all medications reconciled upon admission and at discharge. The nurse will review the medication list with the resident/representative. The physician/practitioner will review the resident's medication and any recommendations/orders will be completed before midnight of the next calendar day of receiving the recommendation/order. The final outcome of this process is to generate the most accurate medication list and to identify potential or actual clinically significant medication issues .Clinically significant medication issues include, but are not limited to: Presence of a medical condition that may warrant medication therapy .Omissions .Procedure: 1. Upon admission staff will obtain a list of current medications from the referral source i.e. hospital, resident/representative or another source .2. Upon admission the nurse and resident/representative will review and modify the medication list as indicated. 3. The Physician/Practitioner will review the medication orders and prescribe recommendations/orders, if indicated, which will be completed by the next calendar day . Review of the facility's policy titled, Anticoagulant Therapy, revised 6/27/2022, revealed, .To provide safe delivery of care to the resident receiving anticoagulant therapy through initiatives designed to achieve optimal anticoagulant-related health outcomes and minimize avoidable adverse events .Elderly patients are often prescribed anticoagulant therapy [a class of medication] for treatment or prophylactic reasons. Common conditions in which anticoagulants are prescribed include .Atrial Fibrillation .Anticoagulant therapy that is held for a medical procedure will be promptly reevaluated after the procedure and resumed as ordered by the physician or nurse practitioner .Anticoagulant refers to a class of medications that are used to prevent clot extension and formation .Examples include .Eliquis .The pharmacy consultant shall conduct a medication review upon admission, monthly, and as requested . Review of the facility's Grievance Log dated 5/2022 through 9/2022 revealed no issues related to the complaint. Review of the facility's Resident Council Meeting minutes dated 5/2022 through 10/2022 revealed no issues related to the complaint. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses which included Atrial Fibrillation, Occlusion and Stenosis of Unspecified Carotid Artery and Chronic Kidney Disease. Review of the Discharge Minimum Data Set (MDS) assessment for Resident #2 dated 9/30/2022, revealed a memory problem and severely impaired decision making. Review of the Care Plan Report for Resident #2 included problems/assessments for Diabetes, Risk for Bleeding r/t (related to) anticoagulant and antiplatelet use and Risk for Falls. Appropriate goals and interventions were implemented. Review of the Physician's Orders for Resident #2 dated 4/27/2022 revealed, .Hold Eliquis 2 days prior to catheter removal . Review of the Clinical Notes Report for Resident #2 dated 5/2/2022 revealed, .Notified by [Named Dialysis Clinic] that resident is scheduled for dialysis catheter removal on Friday 5-6-2022 @ [at] 0845 [8:45 AM.] Transport arranged by dialysis. Order to hold Eliquis x [for] 3 days prior to procedure. NP [Nurse Practitioner] aware and agrees . Review of the Medication Administration Records (MARs) for Resident #2 revealed he was administered Eliquis 5 mg twice a day with a start date of 5/26/2021 in January, February, March, and April of 2022. Continued review revealed he was administered Eliquis 5 mg on 5/1/2022 at 9:00 AM, 9:00 PM and 5/2/2022 at 9:00 AM. The instructions on the MAR read, .4/28/2022 one tab [tablet] po bid x 4 days then hold x 3 days prior to dialysis catheter removal . Review of the Progress Notes signed by Nurse Practitioner dated 5/11/2022 revealed, .5/11/2022 Weekly labs show creatinine and GFR [Glomerular Filtration Rate] continue to improve and patient has been cleared to stop dialysis and will have shunt removed tomorrow. Review of the Consultant Pharmacist's Medication Regimen Review (MRR) for Resident #2 revealed, . 1/1/2022 through 1/13/2022 Reviewed but did not require recommendations .2/21/2022 Admission MRR No recommendations at this time .3/7/2022 No recommendations at this time .3/19/2022 No recommendations at this time .4/21/2022 Reviewed but did not require any recommendations .5/16/2022 Reviewed but did not require any recommendations .6/13/2022 Reviewed but did not require any recommendations .7/23/2022 Reviewed but did not require any recommendations .8/12/2022 Please clarify [Named Resident's] re-admission order for LEVETIRACEMTAM. The discharge order states that the medication is the extended release tablet. The order entered in MyUnity does not indicate the extended release tablet . A note was in the Follow-Through column, Pt [patient] not on this med. Continued review revealed, .10/3/2022 Reviewed but did not require any recommendations . Review of the Neurologist Progress Note for Resident #2, provided by the resident's daughter, dated 9/20/2022 revealed, XXX[AGE] year old man with Atrial Fibrillation, not on anticoagulation confirmed by ALF [SNF Skilled Nursing Facility] .Pt [patient] presents with soley subcortical syndrome, and therefore I suspect possible small vessel ideology. However, given his history of atrial fibrillation not on any anticoagulant currently, an embolic shower primarily affecting the right cerebral hemisphere is not entirely excluded .Will need to obtain records from PCP [Primary Care Physician] and Cardiologist before starting back on anticoagulant, determine if there is a reason why he was taken off the Eliquis . Review of the Nurse Practitioner notes dated 10/3/2022 revealed . Patient was sent to ER [emergency room ] on 9/20/22 d/t [due to] AMS [Acute Mental Status.] He was taken to [Named Hospital.] H&P [History and Physical] from the ER/initial encounter not sent, so information from that is limited. Progress notes report that her [he] was found to have a mild right hemiparesis and TPA [Tissue Plasminogen Activator] was given and he was admitted to ICU [Intensive Care Unit] for further evaluation. Neurology consulted on 9/21 and recommended holding aspirin for another 24 hours and also restarting Eliquis in 7 days .He returned to the facility on ,d+[DATE], however after just a few hours had another change in mental status, with facial drooping, slurred speech, and unilateral weakness .CT (Computerized Tomography] of head showed acute occlusion of posterior left M2 and patient was readmitted .Repeat CT on 9/27 showed a large acute infarction of the left cerebral hemisphere involving the temporal and parietal lobes . Review of the Medication Administration Records (MARs) for Resident #2 revealed he was administered Eliquis 5 mg twice a day with a start date of 5/26/2021 in January, February, March, and April of 2022. Continued review revealed he was administered Eliquis 5 mg on 5/1/2022 at 9:00 AM, 9:00 PM and 5/2/2022 at 9:00 AM. The instructions on the MAR read, .4/28/2022 one tab [tablet] po bid x 4 days then hold x 3 days prior to dialysis catheter removal . Continued review of the May, June, July, and August MARs revealed no administration of Eliquis. Continued review of the September MAR revealed Eliquis 5 mg was administered once at 9:00 PM on 9/30/2022. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Cardiomyopathies, Thrombocytopenia, and Essential Hypertension. Review of the Discharge MDS assessment for Resident #1 dated 10/17/2022 revealed his memory was OK and he was moderately impaired in decision making. Continued review revealed he required extensive assistance for all Activities of Daily Living (ADLs) except eating, which he required supervision only. Continued review revealed he had 1 fall since admission that resulted in no injury. Review of the Care Plan Report for Resident #1 included problems/assessments for Covid-19, At Risk for Falls, Requires Dialysis, Fragile Skin and Risk for Urinary Tract Infections. Appropriate goals and interventions were in place. Review of the Hospital Discharge Summary for Resident #1 revealed, .Stop taking these medications .sacubitril-valsartan 24-26 mg tablet Commonly known as: ENTRESTO . Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses which included Guillain-Barre Syndrome, Dysphagia and Lymphedema. Review of the Quarterly MDS for Resident #3 dated 9/16/2022 revealed a BIMS score of 15, which indicated no cognitive impairment. During an interview on 10/25/2022 at 10:10 AM, the ADON stated Resident #2 was not put back on Eliquis when he returned from having his perma-cath removed, and he had a stroke. She stated, we dropped the ball. When asked how the nursing staff is alerted to restart a medication that is held for a procedure and expected to be started back after the procedure, she stated, They are taught to do that. I don't do on-boarding, so I don't know how they keep up with it. They should just know. During a phone interview on 10/25/2022 at 10:53 AM, Family Member #3 stated her father, Resident #2, had his dialysis shunt removed on 5/12/2022 and came back to the facility the same day. She stated the removal of the shunt was originally scheduled for 5/4/2022, but there was a problem with transportation, so it was rescheduled for 5/12/2022. She stated the facility did not restart his Eliquis after the procedure, and on 9/20/2022 he had a stroke. She stated he had a diagnosis of Atrial Fibrillation and a pacemaker, and that is why he was on Eliquis. She stated he was discharged back to the nursing home on 9/25/2022. She stated when she arrived at the nursing home to check on him, he was very weak on one side, he could not speak and was very wobbly. She stated he was sent back to the hospital and was diagnosed with large acute infarction (injury) to his brain. She stated he is now paralyzed on one side, has a feeding tube, and cannot speak. She stated she called the Administrator and asked her why her father was not put back on Eliquis, and was told the dialysis center should have given them orders to resume the Eliquis. The daughter stated she called the dialysis center and was told it was not their place to reorder the medication. At that point, he was discharged from their care. She stated the neurologist at the hospital told her Resident #2 had the stroke because he was not on a blood thinner and had a diagnosis of Atrial Fibrillation. During an interview on 10/25/2022 at 1:10 PM, the ADON confirmed the MAR for Resident #2 contained an order to hold Eliquis 3 days prior to the surgical procedure. She stated it was supposed to be discontinued out of the computer, then put back on the MAR. During an interview on 10/25/2022 at 1:16 PM, the Regional Nurse Consultant stated there is no option in their electronic health record to hold a medication. She stated the nurses should discontinue it, and then reorder it with the date it is supposed to start back. She confirmed, Using nursing judgement, I would think it should have been restarted. There was a lack of communication. During a phone interview on 10/25/2022 at 1:41 PM, the Consultant Pharmacist stated she normally reviews resident's medical records on admission and monthly. She stated she gets the list of medications and compares them to the facility's computer orders. She stated on monthly reviews, she looks at medications and the diagnoses. When asked if she expected a resident with a diagnosis of Atrial Fibrillation and the presence of a pacemaker to be on an anticoagulant, she stated sometimes doctors write a note in the chart stating they are in normal sinus rhythm and do not order an anticoagulant. She stated if there is a note from the doctor regarding that, she would have written in her notes. She confirmed Resident #2 did not have a note from the doctor stating he did not want him on anticoagulants.

Based on medical record review and interview the facility failed to notify a family representative in a timely manner for 1 of 7 sampled residents (Resident #2) reviewed. The findings include: Review of the medical record revealed that Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Review of the progress notes dated 8/3/2022, late entry for (8/1/2022), revealed .Resident appears to be extremely confused. Her sentences don't seem to go together. Stating that people are coming in her room and messing with her things. Everything appears to be in place. Also stated that her urine had blood in it 3 weeks ago and that it was gone now. NP [Nurse Practitioner] aware and ordered a UA [urinalysis] C&S [culture and sensitivity] . Review of the progress notes dated 8/3/2022 revealed .Resident presented to my office with the activities director. Resident stated she is afraid of a CNA [Certified Nure Assistant] because she ripped her flowers up. Activities coordinator stated the flowers were thrown away because they were dead. Explained this to the resident but she is adamant that it was purposely done to harm her. Resident again states that she had blood in her urine but now states that it was 3 or 4 days ago. I asked her did she have blood in her urine 3 weeks ago as well. She stated no and that her urine did not have blood in it now. UA shows moderate bacteria and nitrates. Awaiting culture . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress noted dated 8/17/2022 revealed .Spoke with resident's daughter regarding resident stating she did not receive a shower for 2 weeks and MDS Coordinator had an IDT [Interdisciplinary Team] meeting with her and she stated she was concerned. Daughter made aware of the care plan for [CONDITION(S)]. Requested that mom have a follow up UA to assure resident is free of infection . During a telephone interview on 9/12/2022 at 2:03 PM, the Complainant stated she had concerns regarding Resident #3 not receiving showers. The Complainant had spoken to the Nurse Supervisor and was told the issue was that the facility had agency CNAs in the building. The agency CNAs were not giving showers because they would report to the nurse that she had refused. The Complainant's concern was whether the nurses were validating the refusals or just listening to the CNAs. During the conversation, the Nurse Supervisor revealed Resident #3 had [CONDITION(S)] due to [CONDITION(S)]. It was treated with antibiotics and could explain why she said she was not getting a shower. The Complainant was not made aware by the nursing staff. Resident #1 had a [CONDITION(S)]. During an interview on 9/12/2022 at 3:35 PM, the Licensed Practical Nurse (LPN) #1, stated she got the antibiotic order from the NP. LPN #1 said she would tell the nurses on the floor to notify the family and the pharmacy and document the notifications. LPN #1 was trying to help the nurses out on the floor because they had so much to do, and many of them were not used to working on the type of EHR (electronic health record) system. During an interview on 9/12/2022 at 4:53 PM, the Director Of Nursing (DON) confirmed the nurses were supposed to contact the family. The DON was unsure if the nurses who worked on 8/1/2022 spoke to the family regarding the positive urinalysis and confirmed she did not have documentation stating the nurse did.

Based on policy review, documentation review, and interview, the facility failed to provide a nourishing snack at bedtime between the evening and breakfast meal which was 15 hours affecting 84 of the 90 resident census. The findings include: Review of facility's policy titled, Frequency of Meals and Snacks, dated 9/1/2019, revealed, .The resident will receive adequate and frequent meals .There will be no more that 14 hours between an evening meal and breakfast the following day, unless a nourishing snack is served at bedtime; then up to 16 hours may elapse between an evening meal and breakfast the following day if the resident council agrees to this mealtime span . Review of the facility documentation, Scheduled Meal Times, dated 12/6/2021, revealed 15 hours between the dinner meal at 5:00 PM and the breakfast meal at 8:00 AM. During and interview on 12/13/2021 at 11:40 AM, the Registered Dietitian stated she was aware of the 15 hour requirement between meals and that the resident council must approve the meal times. She confirmed a resident council meeting had not taken place for approval of meal times. During an interview on 12/13/2021 at 11:40 AM, the Activities Director stated she was not aware of the 15 hour time span between dinner and breakfast meal. She stated meal times were not discussed in a resident council meeting until 12/10/2021.

Based on facility policy review, observations and interview, the facility failed to maintain dietary equipment in a sanitary manner for 2 of 2 observations in the dietary department. The findings include: Review of the facility's policy titled, Infection Prevention and Control Program, dated 6/9/2021, revealed, .All reusable items and equipment requiring special cleaning or disinfection shall be cleaned in accordance with our current procedures governing the cleaning and disinfection of soiled or contaminated equipment . Observations in the kitchen on 12/6/2021 at 9:30 AM and at 11:55 AM, revealed the can opener blade and the base slot had a very heavy accumulation of blackened sticky debris. Further observation revealed a moderate amount of dried debris on the shelves under the steam table, the convection oven and the prep tables. Further observation revealed a moderate amount of blackened sticky debris on the side surfaces and back splash plate on the stove. Further observation revealed a deep fryer with a moderate amount of food crumbs floating in the used oil and sticky tan debris on the side surfaces. Further observations revealed 2 fry baskets with a moderate amount of dried food particles present in the bottom. The fry baskets were sitting on a towel that was soiled with brown specks. Further observation revealed moderate amount of dried tan debris on the plate dome rack. Observation during the tray line preparation at the noon meal on 12/6/2021, revealed the clean plate stack in the plate warmer had a plate with a dried brown circle in the center of the plate. During an interview on 12/6/2021 at 12:10 PM, the Certified Dietary Manager (CDM) confirmed the clean plate stack in the plate warmer had a plate with a dried brown circle in the center of the plate, the can opener blade and the base slot had a very heavy accumulation of blackened sticky debris, a deep fryer with a moderate amount of food crumbs floating in the used oil, sticky tan debris on the fryer side surfaces and 2 fry baskets with a moderate amount of dried food particles present in the bottom sitting on a towel that was soiled with brown specks. During an interview on 12/6/2021 at 12:15 PM, the Registered Dietician (RD) confirmed a moderate amount of dried debris on the shelves under the steam table, the convection oven and the prep tables, a moderate amount of blackened sticky debris on the side surfaces and back splash plate on the stove, and a moderate amount of dried tan debris on the plate dome rack. She stated the dietary department had a cleaning schedule to follow. She stated she did not know when the kitchen was last cleaned.

Based on facility policy review, medical record review, observation, and interview, the facility failed to handle soiled Transmission Based Precaution linen in a manner to prevent spread of infection and the facility failed to ensure oxygen tubing was kept off the floor for Residents #70 and #79. The findings include: Review of the facility's policy titled, Infection Prevention and Control Program, revised on 6/9/2021, revealed, .Laundry and direct care staff shall handle, store, process, and transport linens so as to prevent spread of infection . Observation of the laundry staff on 12/6/2021 at 11:52 AM revealed she removed soiled linens from the laundry bin on the observation hall (residents on transmission based precautions). She was wearing a face shield, a mask, and gloves but did not have a gown on. She stated when isolation linens are handled, a gown, gloves, goggles, and a mask were to be worn. She confirmed she was not wearing a gown. She stated, I should have a gown on, but I don't. During an interview on 12/8/2021 at 5:50 PM, the Laundry/Housekeeping supervisor stated isolation linens are obtained from the dirty linen cart on the hall and placed in a barrel with a lid for transport to the laundry room. He stated the staff who picked up the isolation laundry were required to wear the appropriate PPE (Personal Protective Equipment) which included a gown, gloves, an N95 mask, and a face shield. He stated the laundry staff should not handle isolation linens without wearing all the required PPE. Review of the medical record revealed Resident #70 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #70 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated Resident #70 had severe cognitive impairment. Continued review revealed Resident #70 required oxygen therapy. Review of the Care Plan Report for Resident #70 dated 11/10/2021, revealed, .At risk for shortness of breath related to [named Resident #70] has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] 2.5 mg [milligram]/3 ml [milliliter] (0.083%) solution for nebulization (VIAL, NEBULIZER (ML)) Notes: 3 ml via nebulization q6hrs [every 6 hours] PRN [as needed] for SOB [shortness of breath] . Observation in Resident #70's room on 12/6/2021 at 10:43 AM, revealed an undated nasal cannula lying on the floor. Observation and interview in Resident #70's room on 12/6/2021 at 11:08 AM, Registered Nurse (RN) #1 confirmed the nasal cannula was not dated and was on the floor. Review of the medical record revealed Resident #79 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Admission MDS assessment for Resident #79 dated 11/29/2021, revealed the resident received oxygen therapy. Review of the Care Plan Report for Resident #79 dated 11/20/2021, revealed, .Oxygen as ordered via [CONDITION(S)] . Observation and interview in Resident #79's room on 12/7/2021 at 9:40 AM, revealed the resident had oxygen in use via [CONDITION(S)]. Continued observation revealed the resident's oxygen tubing was in the floor and LPN #2 stepped on it. During an interview LPN #2 confirmed the oxygen tubing was in the floor. She stated, It shouldn't be on the floor. During an interview on 12/13/2021 at 2:14 PM, the Director of Nursing (DON) confirmed all oxygen tubing found on the floor was to be replaced immediately, and dated.

Based on medical record review, observation, and interview the facility failed to ensure the prescribed tube feeding formula was available for 1 of 5 residents (Resident #77) reviewed for tube feedings when Resident #77's prescribed tube feeding was substituted with a tube feeding formula that required an increase in rate to equal the nutritional value. The increase in the tube feeding rate resulted in Resident #77's increased residuals, tube feedings held frequently, and rate had to be decreased, so the resident was not provided the required caloric intake to sustain him in his severely malnourished state, which resulted in unresponsiveness, [DIAGNOSES REDACTED], and emergent hospitalization . The Administrator, Director of Nursing (DON), and Regional Nurse Consultants were notified of the Immediate Jeopardy (IJ) on 3/3/2020 at 7:31 PM in the Administrator's office. The facility was cited Immediate Jeopardy at F-693. The facility was cited at F-693 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was removed onsite and was effective from 10/2/2019 through 3/5/2020. An Immediate Action Removal Plan, which removed the immediacy of the jeopardy was received on 3/6/2020 at 2:55 PM. The corrective actions were validated onsite by the surveyors on 3/6/2020. The facility's noncompliance at F-693 continues a a scope and severity of, D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: Medical record review revealed Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #77 was severely cognitively impaired. Continued review revealed Resident #77 required tube feeding for nutrition. Medical record review of the Care Plan dated 2/14/2020 revealed Resident #77 was at risk for compromised nutritional status related to tube feeding. Interventions included to calculate caloric needs/fluid requirements and adjust based on weight, tolerance, and hydration status. Continued interventions included check tube placement by aspiration before giving feeding/meds; elevate head of bed; monitor and document weight; and report diarrhea, decreased urine output, and dry mucous membranes to dietitian. Review of Physician's admission orders [REDACTED]. Review of the Progress Notes dated 2/19/2020, showed, .Unit Manager advised, currently out of [MEDICATION NAME] 1.5, using [MEDICATION NAME] 1.2. Unit Manager working with supply company to get [MEDICATION NAME] 1.5 as soon as possible . Review of a Dietary Note dated 2/19/2020, showed, .Unit Manager advised currently out of [MEDICATION NAME] 1.5, using [MEDICATION NAME] 1.2. Unit Manager working with supply company to get [MEDICATION NAME] 1.5 as soon as possible. Currently running [MEDICATION NAME] 1.2 @ 40 ml/hr x 24 hours with 30 ml water autoflush and 30 ml water flush before and after meds BID (twice daily) providing 1152 calories. Recommend increasing rate to 45 ml/hr x 24 hours. Increased rate along with flushes will provide 1286 calories. Once [MEDICATION NAME] 1.5 available recommend going back to previous TF orders . Review of the Physician order [REDACTED].Until [MEDICATION NAME] 1.5 available, run [MEDICATION NAME] 1.2 @ (at) 45 mL (milliliter) / hr (hour) x 24 hours w /(with) 30 mL H20 (water) autoflush. Once [MEDICATION NAME] 1.5 available, return to previous TF (tube feeding) order of [MEDICATION NAME] 1.5 @ 40 mL /hr x 24 w/ 30 mL H20 autoflush . Review of the medical record showed Resident #77 had significant amounts of residual with his feedings. The rate ordered was 40 ml/hr, but the rate was decreased as low as 25 ml/hr to compensate for the large residuals. The resident, with a history of malnutrition, failed to receive the necessary calories to sustain him and prevent low blood sugar as evidenced by [DIAGNOSES REDACTED], unresponsiveness, and emergent hospitalization on [DATE]. Medical record review of the Treatment Record dated 3/3/2020 revealed .[MEDICATION NAME] 1.5 @ (at) 40 mL (milliliter) / HR (hour) x 20 hours (off from 1 PM-5 PM) with 30 mL H20 (water) autoflush . Medical record review of Nursing Notes dated 3/4/2020 at 10:36 PM revealed .earlier today, approximately 1 pm (1:00 PM) resident's mother informed this nurse that the resident was having a birthday party around 3 pm (3:00 PM) and would like to turn his enteral feeding off around 3 pm instead of 1 pm. approximately 245 pm (2:45 PM) resident was disconnected from feeding, reported to oncoming nurse that feeding should be reconnected at approximately 7 pm (7:00 PM) instead of 5 pm (5:00 PM) . Observation on 3/4/2020 at 7:36 PM and 8:16 PM revealed Resident #77 was not receiving the tube feeding. Review of the medical record revealed no documentation the physician was notified for a one-time order to change the times the tube feeding was off. Interview with Licensed Practical Nurse (LPN) #6 on 3/4/2020 at 8:16 PM, revealed Resident #77's tube feeding had not been restarted since the beginning of the shift. Continued interview revealed Resident #77 did not receive tube feeding from 1:00 PM to 5:00 PM as ordered and LPN #6 stated she did not know why the tube feeding was not restarted at 5:00 PM as scheduled. Continued interview revealed LPN #6 stated she did not receive report from the previous nurse who cared for Resident #77. Interview with the Assistant Director of Nursing on 3/4/2020 at 8:25 PM, confirmed she was the nurse from 8:00 AM to 3:00 PM and another nurse took over care on that hall. Continued interview confirmed Resident #77's tube feeding was turned off at approximately 2:30 PM instead of 1:00 PM as ordered. During an interview with the Registered Dietician (RD) on 3/5/2020 at 10:19 AM, confirmed she was not notified until 2/19/2020 when the Unit Manger contacted her to inform her the facility supply of [MEDICATION NAME] 1.5 was depleted. During further interview confirmed she expected the formula to be overnighted to the facility at the latest, however Resident #77 was still receiving [MEDICATION NAME] 1.2 the day he was found unresponsive and was transferred to the hospital via ambulance. The Immediate Action Removal Plan was verified by the surveyors on 3/6/2020 by: 1. The surveyors verified through record review, observations and interviews Resident #77 received the correct tube feeding at the correct rate. 2. The surveyors verified through review of facility documentation dated 3/3/2020, 3/4/2020, and 3/5/2020 QAPI meetings were held regarding corrective action plans for Resident #77 to include auditing for correct feeding and rates as prescribed . 3. The surveyors verified through record review education provided to licensed nurses regarding administering enteral tube feedings per Physician orders. The facility's noncompliance at F-693 continues at a scope and severity of D for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on facility policy review, medical record review, and interview the facility failed to report an abuse allegation to the State Survey Agency for 1 of 38 residents (Resident #33) reviewed or abuse. The Administrator, Director of Nursing (DON), and Regional Nurse Consultants were notified of the Immediate Jeopardy (IJ) on 3/3/2020 at 7:31 PM in the Administrator's office. The facility was cited Immediate Jeopardy at F-609. The facility was cited at F-609 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was removed onsite and was effective from 10/2/2019 through 3/5/2020. An Immediate Action Removal Plan, which removed the immediacy of the jeopardy was received on 3/6/2020 at 2:55 PM. The corrective actions were validated onsite by the surveyors on 3/6/2020. The facility's noncompliance at F-609 continues a a scope and severity of, D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: Review of the facility policy titled, Abuse Prohibition Plan, revised 5/2019, showed, .It is the policy of this facility that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Regulations and Law .All alleged violations are reported immediately but not later than 2 hours after the allegation is made, if the events that caused the allegations involve or result in serious bodily injury . Review of the medical record showed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident was cognitively intact. Further review revealed the resident required 2 person total assist transfers. Review of the Comprehensive Care plan dated 9/25/2019, showed, .Transfers-(mechanical) lift assist . Review of the Radiology report dated 10/23/2019, showed, .Impacted nondisplaced left humeral fracture . During an interview on 3/2/2020 at 9:05 AM, Resident #33 stated about 4 months ago I was lying in bed when (named CNA #1) came in and was going to get me up for bingo. He didn't have a lift and I told him 'No!' I'm not going without the lift. I asked him to please get the lift, but he wouldn't go get it. During further interview she stated CNA #1 proceeded to lift the resident by her arms to transfer her to a chair from the bed. Resident #33 stated, When he pulled me up, I heard a loud pop and I started having pain in my left arm. I told him it hurt, but he just said, 'You didn't break your arm!' Then he picked up my arm and moved it around and said, 'see' It really hurt when he did that. During further interview she stated she informed the Director of Nursing (DON) the next day that CNA #1 did not use the lift when he attempted to transfer her and she insisted for him to use the lift, but he didn't and when he pulled her up by her arms she heard a pop and began to have pain in her left arm. During a telephone Interview on 3/3/2020 at 1:13 PM, Resident #33's family member stated Resident #33 told her CNA #1 attempted to get her up for Bingo without assistance. During further interview she stated he didn't use the lift and she thought her arm was broke during the attempted transfer. During further interview she stated Resident #33 told her CNA #1 took her arm and moved it up and down after she told him she heard a pop and she stated she had pain in her left arm. During further interview she stated, (named Resident #33) cries every time she talks about the situation with her arm. During an interview on 3/4/2020 at 4:51 PM with the Director of Nursing (DON) she stated she had 24 hours to report an abuse allegation to the state survey agency after she investigated and determined it was qualified as abuse. Further interview she stated, I don't know what the policy is. During an interview on 3/6/2020 at 5:16 PM with the Administrator she stated the incident involving Resident #33 and CNA #1 on 10/22/2019 was not reported to the state survey agency. An Immediate Action Removal Plan, which removed the immediacy of the Jeopardy, was received on 3/6/2020 at 2:55 PM and corrective actions were validated on site by the surveyors on 3/6/2020. The Immediate Action Removal Plan was verified by the surveyors on 3/6/2020 by: 1. The surveyors verified the facility's policy to report and investigate any events through review of staff education. Staff interviews on abuse allegation reporting and interview with the Administrator of events that occurred. Review of events reported on 3/4/2020. 2. The surveyors verified the facility's Incident Reporting System intake information regarding Resident #33 and CNA #1 was reported to the state agency on 3/4/2020. 3. The surveyors reviewed the facility's abuse policy and verified there were no changes made to the policy. The facility's noncompliance at F-609 continues at a scope and severity of D for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on facility policy review, medical record review, and interview, the facility failed to investigate an abuse allegation for 1 of 38 residents (Resident #33) reviewed for abuse. The facility was cited Immediate Jeopardy at F-610. The facility was cited at F-610 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was removed onsite and was effective from 10/2/2019 through 3/5/2020. An Immediate Action Removal Plan, which removed the immediacy of the jeopardy was received on 3/6/2020 at 2:55 PM. The corrective actions were validated onsite by the surveyors on 3/6/2020. The facility's noncompliance at F-610 continues a a scope and severity of, D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: Review of the facility policy, Abuse Prohibition Plan, revised 5/2019, showed, .The policy of this facility is that reports of abuse, neglect, exploitation, misappropriation of resident's property and injuries of unknown origin are promptly and thoroughly investigated. The Administrator will investigate or assign the investigation to designated facility personnel such as the Director of Nursing (DON). The investigation will begin immediately . Review of the medical record showed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] showed Resident #33 was cognitively intact. Further review revealed the resident required 2 person total assist with transfers. Review of the Radiology report dated 10/23/2019, showed, .Impacted nondisplaced left humeral (long bone that extends from the elbow to the shoulder) fracture . During an interview on 3/2/2020 at 9:05 AM, Resident #33 stated about 4 months ago I was lying in bed when (named CNA #1) came in and was going to get me up for bingo. He didn't have a lift and I told him 'No!' I'm not going without the lift. I asked him to please get the lift, but he wouldn't go get it. Further interview revealed CNA #1 proceeded to lift the resident by her arms to transfer her to a chair from the bed. Resident #33 stated, When he pulled me up, I heard a loud pop and I started having pain in my left arm. I told him it hurt, but he just said, 'You didn't break your arm!' Then he picked up my arm and moved it around and said, 'see' It really hurt when he did that. Further interview revealed Resident #33 informed the Director of Nursing (DON) the next day that CNA #1 did not use the lift when he attempted to transfer her and she insisted for him to use the lift, but he didn't and when he pulled her up by her arms she heard a pop and began to have pain in her left arm. During a telephone Interview on 3/3/2020 at 1:13 PM, Resident #33's family member stated Resident #33 told her CNA #1 attempted to get her up for Bingo without assistance. Further interview she stated he didn't use the lift and she thought her arm was broke during the attempted transfer. Further interview revealed Resident #33 told her CNA #1 took her arm and moved it up and down after she told him she heard a pop and she stated she had pain in her left arm. Further interview she stated, (named Resident #33) cries every time she talks about the situation with her arm. During an interview on 3/4/2020 at 4:51 PM with the Director of Nursing (DON) she stated an investigation involving Resident #33 on 10/22/2019 was not done. During an interview on 3/6/2020 at 5:16 PM with the Administrator confirmed the incident on 10/22/2019 involving Resident #33 was not investigated. An Immediate Action Removal Plan, which removed the immediacy of the Jeopardy, was received on 3/6/2020 at 2:55 PM and corrective actions were validated on site by the surveyors on 3/6/2020. The Immediate Action Removal Plan was verified by the surveyors on 3/6/2020 by: The surveyors verified an abuse investigation was conducted on 3/4/2020. The surveyors verified interviews with interviewable residents and skin assessments were conducted on non interviewable residents. 1. The surveyors reviewed the facility's abuse policy and verified there were no changes made to the policy. 2. The surveyors verified through review of facility documentation dated 3/3/2020, 3/4/2020, and 3/5/2020 QAPI meetings were held regarding Residents #33. 3. The surveyors verified through review education was provided to staff concerning the Abuse Prohibition Plan/Policy. The facility's noncompliance at F-610 continues at a scope and severity of D for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on facility policy review, medical record review and interview, the facility failed to develop and implement a person centered care plan with interventions related to blood sugar monitoring and tube feeding residual to prevent [DIAGNOSES REDACTED] for 1 of 38 residents (Resident #77) reviewed for implementation of care plans placing Resident #77 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) when Resident #77 became unresponsive, hypoglycemic, and required emergent hospitalization . The Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 3/5/2020 at 3:50 PM in the Administrators office. The facility was cited Immediate Jeopardy at F-656. The facility was cited F-656 at a scope and severity Level of J. The Immediate Jeopardy was effective from 10/2/2019 through 3/5/2020. The Immediate Jeopardy was removed onsite and was effective 10/2/2019 through 3/5/2020. An Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was received on 3/6/2020 at 2:55 PM. The corrective actions were validated onsite by the surveyors on 3/6/2020. The findings include: Review of the facility policy, Comprehensive Care Plan, revised 12/2019, showed .The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team or in accordance with the resident's preferences and potential for discharge, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record . Review of the medical record showed Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] showed Resident #77 was severely cognitively impaired. Continued review revealed Resident #77 required tube feeding for nutrition. Review of the hospital History of Present Illness dated 1/23/2020, showed .Today, the patient was altered and less interactive, and EMS (Emergency Medical Services) was called. EMS said they got a blood glucose of 12 at his home. He was brought to the emergency room where D5 was started and the patient's mental status recovered quickly to baseline .the patient's core temperature was also found to be 91 degrees . Review of the Comprehensive Care Plan dated 2/14/2020 showed Resident #77 had no care plan for [DIAGNOSES REDACTED] or for monitoring for signs and symptoms of [DIAGNOSES REDACTED]; length of time to hold tube feeding when residual was too high; and appropriate physician notification. Further review showed no new interventions were placed for monitoring signs and symptoms of [DIAGNOSES REDACTED] for Resident #77 after his return to the facility after his hospitalization on [DATE]. Review of the Nursing Notes dated 2/3/2020, showed, Resident #77 was receiving [MEDICATION NAME] 1.5 at 40 ml/hr (milliliters per hour). Review of the progress note dated 2/23/2020, showed, approximately 1435 (2:35 PM) resident became non responsive after having a second BM (bowel movement). Resident had been disconnected from tube feeding after checking residual and having > (greater than) 110 ml residual (replaced) x's 2. NP (Nurse Practitioner) notified and gave orders to send resident out for evaluation and treatment. Medical record review of the vital signs dated for 2/23/2020, revealed no documented blood sugar prior to transfer to the hospital by the facility. Review of the Emergency Patient Record dated 2/23/2020, showed .Per EMS (Emergency Medical Service) The initial call was for an unresponsive PT (patient). Nurses at this facility saw that he went unresponsive 40 minutes. Our glucometer read L0 for us. We gave him D10 ([MEDICATION NAME] 10%) infusion. He's had a low heart rate with 'us' and weak carotid pulses .Intraosseous special catheter (surgical steel IV (intravenous) catheter inserted directly into a patient's long bone in an emergency life threatening situation to provide rapid infusion of life saving medications/solutions) left tibia inserted at 1536 (3:36 PM) . Review of (Named Hospital) History of Present Illness dated 2/24/2020, showed, .TF had reportedly been temporarily stopped D/T (due to) high gastric residuals/apparent constipation. Ultimately staff found resident unresponsive and checked BS (blood sugar) which read low. He was also hypothermic -T-max 89 F (maximum temperature 89 degrees Fahrenheit). Had significant BM today however TF was never resumed . Review of Emergency Provider Report dated 2/24/2020 showed, .1. [DIAGNOSES REDACTED] 2. Hypothermia 3. Severe Protein-Calorie Malnutrition .Apparent difficulty tolerating TF which was ultimately held .Received multiple amps (unit dose vials) of D50 ([MEDICATION NAME] 50 % (used in an emergency to treat [DIAGNOSES REDACTED])) and started D5 drip ([MEDICATION NAME] 5 % (IV infusion to sustain normal blood glucose level)) .Emergency warming blanket .Patient critically ill due to Hypothermia/[DIAGNOSES REDACTED] . Review of Resident #77's Patient Medication Profile dated 2/29/2020, revealed, .[MEDICATION NAME] emergency kit 1 mg as needed for [DIAGNOSES REDACTED] . During an interview on 3/5/2020 at 11:12 AM with Licensed Practical Nurse (LPN) #4, confirmed Resident #77 had a residual of 200 mL at 12:00 PM on 2/23/2020 and she did not call the medical doctor or nurse practitioner to report the high residual. Continued interview LPN #4 stated when Resident #77 became unresponsive she did not think to check his blood sugar. During an interview on 3/5/2020 at 3:50 PM with the Director of Nursing (DON) she confirmed Resident #77 had a history of [REDACTED]. glucose level should have been monitored. During a telephone interview with the Medical Director on 3/5/2020 at 5:19 PM, confirmed the paramedics checked Resident #77's blood sugar when they arrived on 2/23/2020. He stated, They checked it for us. During continued interview he confirmed the blood sugar dropped from the resident not receiving his tube feeding. An Immediate Action Removal Plan, which removed the Immediacy of the Jeopardy, was received on 3/6/2020 at 3:50 PM and corrective actions were validated on site by the surveyor on 3/6/2020. The surveyors verified the Removal Plan by: 1). Verified the care plans with interventions were in place for 17 residents at risk for developing low blood sugar. 2). Reviewed and validated staff education on recognizing signs and symptoms of low blood sugar. 3). Interviewed staff for returned knowledge of signs and symptoms of low blood sugar. The facility's noncompliance at F-656 continues at a scope and severity level of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on facility policy review, medical record review, and interview the facility failed to ensure a resident's Advance Directive preference was accurately reflected in the medical record for 2 of 91 residents (Resident #49 and #6) reviewed for Advance Directives, placing the residents in an Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The facility's failure to follow their procedures for processing Advance Directives, had the potential for staff not intervening with life saving measures, (CPR (Cardiopulmonary Resuscitation)) for Resident #49 when Resident #49 wanted CPR and intervening with life saving measures (CPR) for Resident #6, when Resident #6 wanted to be a DNR (Do Not Resuscitate). The Administrator, Director of Nursing (DON), and Regional Nurse Consultants were notified of the Immediate jeopardy on [DATE] at 9:20 PM in the Administrator's office. The facility was cited Immediate Jeopardy at F-678. The facility was cited at F-678 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was removed onsite and was effective from [DATE] through [DATE]. An Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE] at 2:55 PM. The corrective actions were validated onsite by the surveyors on [DATE]. The facility's noncompliance at F-678 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: Review of the facility policy, Advance Directives, revised on ,[DATE], showed, .The facility representative will assist the resident as needed to communicate any changes in the resident's Advance Directive to the physician and/or responsible party .The facility representative will discuss and provide written information explaining the Advance Directive Program, upon admission to the facility .The facility representative will periodically discuss the resident's Advance Directive to ensure the resident's wishes concerning end of life treatment have not changed . Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #49 was cognitively intact. Review of the Physician Orders for Scope of Treatment (POST) for Resident #49 dated [DATE] located in the POST Form Book at the Nurses station showed the resident's code status was a DNR (Do not resuscitate). Review of Resident #49's EMR (Electronic Medical Record) showed the Code Status Ribbon (which displayed for quick reference at the top of the resident's EMR) was blank, which indicated the resident's code status was Full Code (Cardiopulmonary Resuscitation (CPR)). Review of Resident #49's Comprehensive Care Plan dated [DATE], showed a Code Status of Full Code. Review of Resident #49's Face Sheet, the Advance Directives section showed the directive was listed as Full Code. During an interview on [DATE] at 6:44 PM, with Licensed Practical Nurse (LPN) #6, who was assigned to Resident #49, she stated she would refer to the POST Form Book located at the nurses' station to determine a resident's code status. During an interview on [DATE] at 6:45 PM, LPN #7 stated she would refer the POST Form Book located at the nurses' station to determine for a resident's code status. During an interview on [DATE] at 7:40 PM, Resident #49 stated he wanted CPR if his heart stopped and his decision had not changed since admission to the facility. Review of the medical record showed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's Admission MDS assessment dated [DATE], showed the resident was cognitively intact. Review of Resident #6's POST dated [DATE] located in the Post Form book showed the resident code status was Full Code. Review of Resident #6's EMR showed the Code Status Ribbon displayed an Advance Directive status of Do Not Resuscitate (DNR). Review of Resident #6's Face Sheet, the Advance Directives section for showed the directive was listed as Do Not Resuscitate. Review of Resident #6's Care Plan dated [DATE] showed Resident #6's code status was DNR. During an interview on [DATE] at 5:43 PM with LPN #1, who was assigned to Resident #6, she stated she would look on the computer for a resident's code status. Further interview she stated, The code status is in bold right next to the resident's name on the computer. She then demonstrated this on the computer screen by opening the resident's EMR and pointing to the ribbon at the top of the screen where DNR was highlighted in yellow. During an interview on [DATE] at 6:27 PM with the Administrator confirmed code status on the POST forms for Resident #49 and Resident #6 conflicted with their code statuses in the EMR. During an interview with Registered Nurse (RN) #1 on [DATE] at 6:40 PM, who was assigned to Resident #6, he stated, If a resident coded (if the resident had no pulse and was not breathing) I would go to the computer and check the resident's code status. Further interview RN #1 stated, I can tell if a resident has a Full Code or DNR status by looking at the Code Status ribbon at the top of their EMR, it is in bold letters on the face sheet. Further interview RN #1 demonstrated obtaining Resident #6's code status by opening his computer and pointing to the ribbon at the top of the screen of Resident #6's EMR where DNR was highlighted in yellow. During an interview on [DATE] at 7:10 PM, with Admissions Clerk stated she was responsible to get the POST form signed by the resident and the doctor. Further interview revealed once the POST form was signed by the resident and the doctor, she would enter the code status selection in the computer. Further interview she stated if the resident was a full code the ribbon was blank and if the resident was a DNR it would display in yellow on the ribbon in the Resident's EMR. Further interview she stated she placed the original POST form in the POST form book at the nurses station. During an interview on [DATE] at 8:19 PM, the Administrator confirmed staff were not to rely on the computer, but refer to the POST Form book located at the nurses' station for a resident's code status. Further interview confirmed the staff had not been educated on referring to the POST Form book, not the computer, for a resident's code status. During an interview on [DATE] at 10:00 AM, the Administrator stated Admissions personnel were responsible for getting a POST form signed by the resident and the doctor, putting the code status in the Resident's EMR, and putting the POST form in the book at the nurses' station. Further interview she stated the MDS nurse was to go to the POST book at the nurses' station to get a resident's code status for implementation of an Advance Directive care plan. Further interview confirmed this process did not happen for Residents #49 and #6. During an interview on [DATE] at 11:52 AM, MDS Coordinator confirmed she looked in the computer for the POST form she did not refer to the book at the nurses' station when implementing a resident's Advance Directive Care Plan. Further interview confirmed the code statuses on the POST forms for Resident #49 and #6 conflicted with the code status on their care plans. She stated, There was a process failure. An Immediate Action Removal Plan which removed the immediacy of the Jeopardy was received on [DATE] at 2:55 PM and corrective actions were validated on site by the surveyors on [DATE]. The Immediate Action Removal Plan was verified by the surveyors on [DATE] by: 1. The surveyors verified through review of Resident #49 and #6's POST forms were accurately reflected in the electronic medical record. 2. The surveyors verified through review of all facility residents' POST forms and the EMR to ensure accuracy. No other resident was found to have a POST that was inaccurately reflected on the EMR. 3. The surveyors verified through review of the education completed on [DATE] to all on duty and off duty licensed nurses and certified nursing assistants regarding verifying a code status through the Disaster Readiness/POST form book located at the nurses' station. 4. The surveyors verified through review of the education completed on [DATE] and interviews with Social Services, Admissions, and Nursing Management regarding the process of updating a POST form and ensuring it was reflected in the electronic medical record. 5. The surveyors verified through review of the education completed on [DATE] and interviews with the Administrator and the Director of Nursing regarding the new process for auditing the POST form through the Code Status audit tool on new admissions/readmission and residents with annual, quarterly, or significant change assessments and to ensure their advanced directive preferences were accurate and reflected in the electronic medical record. Once the POST form is completed it is communicated with the staff and placed in the Disaster Readiness/POST form book located at the nurses' station. 6. The surveyors verified through review of the education completed on [DATE] to on duty and off duty licensed nurses and certified nursing assistants regarding verifying a code status no longer be entered in the ribbon or in the resident care needs (Customized Approach to Care for an individual resident's needs for Certified Nursing Assistants) and to utilize the signed POST form in the Disaster Readiness/POST form book located at the nurses' station to advise of residents' advanced directive preferences. Alerts placed at the nurses' station as a reminder to no longer reference the ribbon and/or resident care needs. 7. The surveyors verified through interviews with various licensed nurses and certified nursing assistants regarding verifying a resident's code status and the location of the Disaster Readiness/POST form book. The facility's noncompliance at F-678 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on facility policy review, medical record review, facility documentation review, and interview the facility failed to ensure 1 of 38 residents (Resident #33) was free from abuse placing the resident in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) when Resident #33 sustained a left humerus (long bone that extends from the shoulder to the elbow) fracture during an attempted transfer, without a mechanical lift, on 10/22/2019. The facility failed to ensure Resident #33 was free from Psychosocial harm as evidenced by Resident #33 had increased anxiousness, cried when she talked about the incident that occurred on 10/22/2019, was fearful of Certified Nursing Assistant (CNA) #1, and received psychosocial therapy and medication changes. The Administrator, Director of Nursing (DON), and Regional Nurse Consultants were notified of the Immediate Jeopardy (IJ) on 3/3/2020 at 7:31 PM in the Administrator's office. The facility was cited Immediate Jeopardy at F-600. The facility was cited at F-600 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was removed onsite and was effective from 10/2/2019 through 3/5/2020. An Immediate Action Removal Plan, which removed the immediacy of the jeopardy was received on 3/6/2020 at 2:55 PM. The corrective actions were validated onsite by the surveyors on 3/6/2020. The facility's noncompliance at F-600 continues a a scope and severity of, D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: Review of the facility policy, Abuse Prohibition Plan, revised 5/2019, revealed, .The facility has a zero-tolerance policy for abuse. Verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion is prohibited. The resident will not be subjected to mistreatment, neglect, exploitation or misappropriation of property. The facility will attempt to identify and will investigate any reported violation or allegation of abuse .Willful means the individual deliberately, not that the individual must have intended to, inflict injury or harm . Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #33 was cognitively intact. Further review revealed the resident required 2 person total assist with transfers. Review of the Comprehensive Care Plan dated 9/25/2019, showed, .Transfers-(Mechanical) Lift Assist . Review of Resident #33's Physician Visit note dated 10/23/2019 showed Resident #33 was having left shoulder pain and an X-ray was ordered. Review of Resident #33's Mobile Radiology report dated 10/23/2019, showed, .Impacted nondisplaced left humeral fracture .NP (Nurse Practitioner) made aware . Review of Resident #33's Physician Order Sheet dated September 13, 2019 showed, .[MEDICATION NAME] 25mcg (micrograms)/hr (hour) [MEDICATION NAME] 1 patch [MEDICATION NAME] every 72 hrs for pain .9/18/2019 [MEDICATION NAME] 10 mg (milligram) every 6 hrs for pain . Review of Resident #33's physician order dated 10/23/2020 showed, .Biofreeze (topical pain medication)4% topical gel to left shoulder prn (as needed) for pain . Review of Resident #33's Physician Visit note dated 10/25/2019, showed Resident #33 had a contusion to her left arm and the X-ray showed fracture. Further review showed, .Send to Ortho (Orthopedic) Urgent Care for further evaluation of L (Left) Shoulder pain to eval (evaluation) and fx(fracture)/treatment . Review of Resident #33's Orthopedic Consult Note (from the Orthopedic Urgent Care Center) dated 10/25/2020 showed, .10/22/2019 someone was attempting to transfer her and squeezed her too tightly. An xray performed at the facility reported a fracture. She has pain from her left shoulder radiating down into the left forearm. The pain has been worsening and is exacerbated by lifting, moving and exertion. There is associated bruising as well. Plan: Sling, Send to ER (emergency room ), discussed that the xrays to reveal evidence of a fracture at the humerus . Review of Resident #33's ER Note dated 10/25/2019 showed, .a tech was transferring her from her wheelchair to a bed 2 days ago. He tried to lift her under her arms. When this occurred she felt a pop in her left shoulder. She has had pain ever since then. It is sharp and throbbing, 10 out of 10 in severity, it is worse with movement. She has noticed some increased bruising, she denies any other injuries . Review of Resident #33's ER Radiology report of the left humerus dated 10/25/2019, showed, .Comminuted fractures proximal humerus . Review of Resident #33's Clinical Notes Report dated 10/25/2019, showed, .Resident returned from ER by ambulance/stretcher. Awake alert and oriented. Diagnosis: [REDACTED]. Sling to left arm in place . Review of Resident #33's Psychotherapy notes dated 10/28/2019, 11/4/2019, 11/18/2019, and 12/2/2019, showed she was receiving psychotherapy related to her increased anxieties, frustration, and concern over the incident that occurred 10/22/2019. Review of Resident #33's Physician Orders dated 11/11/2019, showed a new medication order as follows: .[MEDICATION NAME] (medication for anxiety) 1 milligram (mg) 1 PO (by mouth) BID (twice daily) PRN (as needed) in adjunction to (in addition to) scheduled dose . Continued review indicated she received 16 doses of the PRN [MEDICATION NAME] from 11/11/2019 through 12/4/2019 following the incident. Review of the facility's documentation titled, Activity Calendar, dated October 2019, showed, Bingo scheduled on 10/22/2019 at 3:00 PM. During an interview on 3/2/2020 at 9:05 AM, Resident #33 stated about 4 months ago I was lying in bed when (named CNA #1) came in and was going to get me up for bingo. He didn't have a lift and I told him 'No!' I'm not going without the lift. I asked him to please get the lift, but he wouldn't go get it. During further interview revealed CNA #1 proceeded to lift the resident by her arms to transfer her to a chair from the bed. Resident #33 stated, When he pulled me up, I heard a loud pop and I started having pain in my left arm. I told him it hurt, but he just said, 'You didn't break your arm!' Then he picked up my arm and moved it around and said, 'see' It really hurt when he did that. During further interview revealed Resident #33 informed the Director of Nursing (DON) the next day that CNA #1 did not use the lift when he attempted to transfer her and she insisted for him to use the lift, but he didn't and when he pulled her up by her arms she heard a pop and began to have pain in her left arm. Review of the medical record showed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Significant Change MDS dated [DATE], showed, Resident #13 was cognitively intact. During an interview on 3/2/2020 at 3:30 PM with Resident #13, Resident #33's roommate, she stated she had been Resident #33's roommate since 9/2019. Further interview she stated she was lying in her bed when CNA #1 attempted to transfer Resident #33. She stated, I heard (named Resident #33) tell (named CNA #1) 'No, No' but (named CNA #1) continued to get (named Resident #33) up. During further interview she stated they usually use a mechanical lift to get Resident #33 out of bed, but CNA #1 did not have one and additional staff assistance. During a telephone Interview on 3/3/2020 at 1:13 PM, Resident #33's family member stated Resident #33 told her CNA #1 attempted to get her up for Bingo without assistance. Further interview she stated he didn't use the lift and she thought her arm was broke during the attempted transfer. During further interview revealed Resident #33 told her CNA #1 took her arm and moved it up and down after she told him she heard a pop and she stated she had pain in her left arm. Further interview she stated, (named Resident #33) cries every time she talks about the situation with her arm. During an interview on 3/4/2020 at 2:00 PM with the Activities Director confirmed Resident #33 would attend Bingo 2 days a week, on Tuesday and Thursday, but did not attend on Tuesday, 10/22/2019. During an interview on 3/4/2020 at 4:19 PM with Nurse Practitioner #1 she stated the facility told her this injury was chronic. However on her 10/25/2019's assessment she found fresh bruising and contusions on her left arm. During further interview she stated when she talked to Resident #33's family member, she said Resident #33 had a fracture to her neck a couple of years ago, not her arm. That's when I ordered for (named Resident #33) to be sent to Orthopedic Urgent care for further evaluation of left shoulder pain and fracture. During an interview on 3/4/2020 at 4:30 PM with Licensed Practical Nurse #2 stated Resident #33 reported to her that her arm was hurting after CNA #1 had lifted her. During further interview revealed Resident #33 reported CNA #1 bear hugged her and she felt pain in her arm and the pain did not go away. During further interview she stated, I re-educated (named CNA #1) to use 2 person assist and mechanical lift with (named Resident #33). During further interview she stated she reported the incident to her supervisor and was informed they already knew about it. During an interview on 3/3/2020 at 4:51 PM with the Director of Nursing (DON) confirmed Resident #33 was a 2 person assist transfer with a mechanical lift, since admission. Further interview she stated Resident #33 felt CNA #1 was a little rough during the transfer when her arm was broken. During further interview she stated, If a resident reported a CNA was rough, I would report it to the administrator, go to the CNA, consider the resident's ability as a historian, would take all factors into consideration and investigate it to rule it out as abuse. During further interview the DON confirmed she was notified by Resident #33 on 10/25/2019 that CNA #1 was rough with her during the attempted transfer on 10/22/2019. During an interview on 3/6/2020 at 5:16 PM with the Administrator confirmed the incident involving Resident #33 was reported to her by the DON in October 2019 but was not considered abuse at that time. During an interview on 3/3/2020 at 12:25 PM Resident #33 became tearful and began to cry, when she recalled the incident involving CNA #1 in October (2019), and she continued to cry through the remainder of the interview. During an interview on 3/3/2020 at 4:45 PM with Resident #33 in her room she stated, Every time I see (named CNA #1), I cry because there were a lot of things I could do before this happened and now I can't do them, now I have to ask for help to even pull myself up in bed. Resident #33 began to cry again and stated, I am afraid of (named CNA #1). During a telephone interview on 3/4/2020 at 4:00 PM with the Psychologist, he confirmed, I see (named Resident #33) once a week for anxiety and the injury had caused her pain and discomfort. Further interview he stated Resident #33 was frustrated and anxious about her arm and focused on the incident with her arm every week for 4 weeks right after the incident happened. An Immediate Action Removal Plan, which removed the immediacy of the Jeopardy, was received on 3/6/2020 at 2:55 PM and corrective actions were validated on site by the surveyors on 3/6/2020. The Immediate Action Removal Plan was verified by the surveyors on 3/6/2020 by: 1. The surveyors verified through review of CNA #1's employee file, CNA #1 was placed on suspension pending completion of investigation on 3/6/2020 and the facility substantiated the allegation of abuse. 2. The surveyors verified the facility's policy to report and investigate any events through review of staff education. Staff interviews on abuse allegation reporting and interview with the Administrator of events that occurred. Review of events reported on 3/4/2020. 3. The surveyors verified the facility's Incident Reporting System intake information regarding Resident #33 and CNA #1 was reported to the state agency on 3/4/2020. 4. The surveyors verified Resident #33 was seen on 3/4/2020 by the Psychiatric Nurse Practitioner through review of the Psychiatric Nurse Practitioner consult notes dated 3/4/2020 and by interview on 3/4/2020. 5. The surveyors verified the facility interviewed Resident #33 and her family member obtaining statements. 6. The surveyors verified an abuse investigation was conducted on 3/4/2020. The surveyors verified interviews with interviewable residents and skin assessments were conducted on non interviewable residents. 7. The surveyors reviewed the facility's abuse policy and verified there were no changes made to the policy. 8. The surveyors verified staff education of abuse to include the definition and examples of willful abuse. The facility's noncompliance at F-600 continues at a scope and severity of D for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on the facility's Quality Assurance Performance Improvement (QAPI) Plan review, policy review, medical record review, and interview, the QAPI committee failed to identify deficient practice for investigating allegations of abuse for 1 of 38 residents (Resident #33) reviewed for abuse; failed to identify no person centered care plan was implemented for 1 of 38 residents (Resident #77) reviewed for care plan implementation and interventions; and failed to identify the prescribed tube feeding formula was unavailable for 1 of 5 residents (Resident #77) reviewed for tube feedings which resulted in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator, Director of Nursing (DON) and Regional Nurse Consultants were notified of the Immediate Jeopardy on [DATE] 2020 at 7:31 PM. The facility was cited Immediate Jeopardy at F-600 and F-678 were cited at a scope and severity of J, which is Substandard Quality of Care. The facility was cited Immediate Jeopardy at F-600, F-656, F-678, F-835, and F-867 were cited at a scope and severity of J. The Immediate Jeopardy was removed onsite and was effective [DATE] through [DATE]. An Immediate Action Removal Plan which removed the immediacy of the jeopardy, was received on [DATE] at 2:55 PM. The corrective actions were validated onsite by the surveyors on [DATE]. The findings include: Review of the facility policy, Abuse Prohibition Plan, revised ,[DATE], revealed, .The facility has a zero-tolerance policy for abuse. Verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion is prohibited. The resident will not be subjected to mistreatment, neglect, exploitation or misappropriation of property. The facility will attempt to identify and will investigate any reported violation or allegation of abuse .Willful means the individual deliberately, not that the individual must have intended to, inflict injury or harm . Review of the facility's Quality Assurance Performance Improvement (QAPI) Plan dated ,[DATE] revealed, .The Quality Assurance Performance Improvement (QAPI) Plan is designed to establish and maintain an organized facility wide program that is data driven and utilizes a proactive approach to improving throughout the facility .The governing body and the facility administration shall provide general oversight for Quality Assurance and Performance Improvement activities related to resident care and services throughout the facility . Review of the facility policy, Comprehensive Care Plan, revised ,[DATE], showed .The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team or in accordance with the resident's preferences and potential for discharge, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record . Review of the facility policy, Advance Directives, revised on ,[DATE], showed, .The facility representative will assist the resident as needed to communicate any changes in the resident's Advance Directive to the physician and/or responsible party .The facility representative will discuss and provide written information explaining the Advance Directive Program, upon admission to the facility .The facility representative will periodically discuss the resident's Advance Directive to ensure the resident's wishes concerning end of life treatment have not changed . Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #33 was cognitively intact. Further review revealed the resident required 2 person total assist with transfers. Review of the Comprehensive Care Plan dated [DATE], showed, .Transfers-(Mechanical) Lift Assist . Review of Resident #33's Physician Visit note dated [DATE] showed Resident #33 was having left shoulder pain and an X-ray was ordered. Review of Resident #33's Mobile Radiology report dated [DATE], showed, .Impacted nondisplaced left humeral fracture .NP (Nurse Practitioner) made aware . Review of Resident #33's Physician Visit note dated [DATE], showed Resident #33 had a contusion to her left arm and the X-ray showed fracture. Further review showed, .Send to Ortho (Orthopedic) Urgent Care for further evaluation of L (Left) Shoulder pain to eval (evaluation) and fx(fracture)/treatment . Review of Resident #33's ER Note dated [DATE] showed, .a tech was transferring her from her wheelchair to a bed 2 days ago. He tried to lift her under her arms. When this occurred she felt a pop in her left shoulder. She has had pain ever since then. It is sharp and throbbing, 10 out of 10 in severity, it is worse with movement. She has noticed some increased bruising, she denies any other injuries . During an interview on [DATE] at 9:05 AM, Resident #33 stated about 4 months ago I was lying in bed when (named CNA #1) came in and was going to get me up for bingo. He didn't have a lift and I told him 'No!' I'm not going without the lift. I asked him to please get the lift, but he wouldn't go get it. During further interview revealed CNA #1 proceeded to lift the resident by her arms to transfer her to a chair from the bed. Resident #33 stated, When he pulled me up, I heard a loud pop and I started having pain in my left arm. I told him it hurt, but he just said, 'You didn't break your arm!' Then he picked up my arm and moved it around and said, 'see' It really hurt when he did that. During further interview revealed Resident #33 informed the Director of Nursing (DON) the next day that CNA #1 did not use the lift when he attempted to transfer her and she insisted for him to use the lift, but he didn't and when he pulled her up by her arms she heard a pop and began to have pain in her left arm. During an interview on [DATE] at 4:19 PM with Nurse Practitioner #1 she stated the facility told her this injury was chronic. However on her [DATE]'s assessment she found fresh bruising and contusions on her left arm. That's when I ordered for (named Resident #33) to be sent to Orthopedic Urgent care for further evaluation of left shoulder pain and fracture. During an interview on [DATE] at 4:51 PM with the Director of Nursing (DON) confirmed Resident #33 was a 2 person assist transfer with a mechanical lift, since admission. Further interview she stated Resident #33 felt CNA #1 was a little rough during the transfer when her arm was broken. During further interview the DON confirmed she was notified by Resident #33 on [DATE] that CNA #1 was rough with her during the attempted transfer on [DATE]. During an interview on [DATE] at 5:16 PM with the Administrator confirmed the incident involving Resident #33 was reported to her by the DON in [DATE] but was not considered abuse at that time and an investigation was not done. Review of the medical record showed Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] showed Resident #77 was severely cognitively impaired. Continued review revealed Resident #77 required tube feeding for nutrition. Review of the hospital History of Present Illness dated [DATE], showed .Today, the patient was altered and less interactive, and EMS (Emergency Medical Services) was called. EMS said they got a blood glucose of 12 at his home. He was brought to the emergency room where D5 was started and the patient's mental status recovered quickly to baseline .the patient's core temperature was also found to be 91 degrees . Review of the Comprehensive Care Plan dated [DATE] showed Resident #77 had no care plan for [DIAGNOSES REDACTED] or for monitoring for signs and symptoms of [DIAGNOSES REDACTED]; length of time to hold tube feeding when residual was too high; and appropriate physician notification. Further review showed no new interventions were placed for monitoring signs and symptoms of [DIAGNOSES REDACTED] for Resident #77 after his return to the facility after his hospitalization on [DATE]. Review of the Nursing Notes dated [DATE], showed, Resident #77 was receiving [MEDICATION NAME] 1.5 at 40 ml/hr (milliliters per hour). Review of the progress note dated [DATE], showed, approximately 1435 (2:35 PM) resident became non responsive after having a second BM (bowel movement). Resident had been disconnected from tube feeding after checking residual and having > (greater than) 110 ml residual (replaced) x's 2. NP (Nurse Practitioner) notified and gave orders to send resident out for evaluation and treatment. Medical record review of the vital signs dated for [DATE], revealed no documented blood sugar prior to transfer to the hospital by the facility. Review of the Emergency Patient Record dated [DATE], showed .Per EMS (Emergency Medical Service) The initial call was for an unresponsive PT (patient). Nurses at this facility saw that he went unresponsive 40 minutes. Our glucometer read L0 for us. We gave him D10 ([MEDICATION NAME] 10%) infusion. He's had a low heart rate with 'us' and weak carotid pulses .Intraosseous special catheter (surgical steel IV (intravenous) catheter inserted directly into a patient's long bone in an emergency life threatening situation to provide rapid infusion of life saving medications/solutions) left tibia inserted at 1536 (3:36 PM) . Review of (Named Hospital) History of Present Illness dated [DATE], showed, .TF had reportedly been temporarily stopped D/T (due to) high gastric residuals/apparent constipation. Ultimately staff found resident unresponsive and checked BS (blood sugar) which read low. He was also hypothermic -T-max 89 F (maximum temperature 89 degrees Fahrenheit). Had significant BM today however TF was never resumed . During an interview on [DATE] at 3:50 PM with the Director of Nursing (DON) she confirmed Resident #77 had a history of [REDACTED]. glucose level should have been monitored. During an interview on [DATE] at 2:00 PM with the Administrator confirmed the incident involving Resident #33 was not recognized, reported and investigated as abuse but should have been and a person centered care plan was not implemented for Resident #77 to reflect the resident care needs. Further interview confirmed an AdHoc QAPI (an immediate Quality Assurance Performance Improvement Plan) meeting did not take place for these concerns until the IJ notification was given to them by the surveyors on [DATE]. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #49 was cognitively intact. Review of the Physician Orders for Scope of Treatment (POST) for Resident #49 dated [DATE] located in the POST Form Book at the Nurses station showed the resident's code status was a DNR (Do not resuscitate). Review of Resident #49's EMR (Electronic Medical Record) showed the Code Status Ribbon (which displayed for quick reference at the top of the resident's EMR) was blank, which indicated the resident's code status was Full Code (Cardiopulmonary Resuscitation (CPR)). Review of Resident #49's Comprehensive Care Plan dated [DATE], showed a Code Status of Full Code. Review of Resident #49's Face Sheet, the Advance Directives section showed the directive was listed as Full Code. During an interview on [DATE] at 6:44 PM, with Licensed Practical Nurse (LPN) #6, who was assigned to Resident #49, she stated she would refer to the POST Form Book located at the nurses' station to determine a resident's code status. During an interview on [DATE] at 6:45 PM, LPN #7 stated she would refer the POST Form Book located at the nurses' station to determine for a resident's code status. During an interview on [DATE] at 7:40 PM, Resident #49 stated he wanted CPR if his heart stopped and his decision had not changed since admission to the facility. Review of the medical record showed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's Admission MDS assessment dated [DATE], showed the resident was cognitively intact. Review of Resident #6's POST dated [DATE] located in the Post Form book showed the resident code status was Full Code. Review of Resident #6's EMR showed the Code Status Ribbon displayed an Advance Directive status of Do Not Resuscitate (DNR). Review of Resident #6's Face Sheet, the Advance Directives section for showed the directive was listed as Do Not Resuscitate. Review of Resident #6's Care Plan dated [DATE] showed Resident #6's code status was DNR. During an interview on [DATE] at 5:43 PM with LPN #1, who was assigned to Resident #6, she stated she would look on the computer for a resident's code status. Further interview she stated, The code status is in bold right next to the resident's name on the computer. She then demonstrated this on the computer screen by opening the resident's EMR and pointing to the ribbon at the top of the screen where DNR was highlighted in yellow. During an interview on [DATE] at 6:27 PM with the Administrator confirmed code status on the POST forms for Resident #49 and Resident #6 conflicted with their code statuses in the EMR. During an interview with Registered Nurse (RN) #1 on [DATE] at 6:40 PM, who was assigned to Resident #6, he stated, If a resident coded (if the resident had no pulse and was not breathing) I would go to the computer and check the resident's code status. Further interview RN #1 stated, I can tell if a resident has a Full Code or DNR status by looking at the Code Status ribbon at the top of their EMR, it is in bold letters on the face sheet. Further interview RN #1 demonstrated obtaining Resident #6's code status by opening his computer and pointing to the ribbon at the top of the screen of Resident #6's EMR where DNR was highlighted in yellow. During an interview on [DATE] at 7:10 PM, with Admissions Clerk stated she was responsible to get the POST form signed by the resident and the doctor. Further interview revealed once the POST form was signed by the resident and the doctor, she would enter the code status selection in the computer. Further interview she stated if the resident was a full code the ribbon was blank and if the resident was a DNR it would display in yellow on the ribbon in the Resident's EMR. Further interview she stated she placed the original POST form in the POST form book at the nurses station. During an interview on [DATE] at 8:19 PM, the Administrator confirmed staff were not to rely on the computer, but refer to the POST Form book located at the nurses' station for a resident's code status. Further interview confirmed the staff had not been educated on referring to the POST Form book, not the computer, for a resident's code status. During an interview on [DATE] at 10:00 AM, the Administrator stated Admissions personnel were responsible for getting a POST form signed by the resident and the doctor, putting the code status in the Resident's EMR, and putting the POST form in the book at the nurses' station. Further interview she stated the MDS nurse was to go to the POST book at the nurses' station to get a resident's code status for implementation of an Advance Directive care plan. Further interview confirmed this process did not happen for Residents #49 and #6. During an interview on [DATE] at 11:52 AM, MDS Coordinator confirmed she looked in the computer for the POST form she did not refer to the book at the nurses' station when implementing a resident's Advance Directive Care Plan. Further interview confirmed the code statuses on the POST forms for Resident #49 and #6 conflicted with the code status on their care plans. She stated, There was a process failure. REFER TO TAG #'S F-600, F-609, F-610, F-656, F-678, F-693, and F-835. The Immediate Action Removal Plan was verified by the surveyors on [DATE] by: 1. The surveyors verified through review of facility documentation dated [DATE], [DATE], and [DATE] QAPI meetings were held regarding Residents #6, #33, #49, and #77. 2. Verified the care plans with interventions were in place for 17 residents at risk for developing low blood sugar. 3. The surveyors verified the facility's Incident Reporting System intake information regarding Resident #33 and CNA #1 was reported to the state agency on [DATE]. The facility's noncompliance at F-867 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on facility policy review, facility documentation review, medical record review, and interview facility administration failed to recognize, report, and investigate an abuse allegation for 1 resident (Resident #33) reviewed for reporting an abuse allegation and failed to ensure the residents' Physician Orders for Scope of Treatment (POST) forms for 2 residents (Resident #6 and #49) reviewed for Advance Directives were accurately reflected in the resident's Electronic Medical Record (EMR) regarding the residents' Code status preferences, and failed to implement a Comprehensive care plan for [DIAGNOSES REDACTED] for 1 of 38 residents (Resident #77) reviewed for Comprehensive care plans. The facility's deficient practice placed 4 residents (Resident #33, #6, #49, and #77) of 91 residents reviewed in Immediate Jeopardy (a situation where the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) and had the potential to affect all residents in the facility. The Administrator, Director of Nursing (DON) and Regional Nurse Consultants were notified of the Immediate Jeopardy for the Advance Directives on [DATE] at 9:20 PM, for the Abuse on [DATE] 2020 at 7:31 PM, and for the Care Plan on [DATE] at 3:50 PM in the Administrator's office. The facility was cited Immediate Jeopardy at F-600 and F-678 were cited at a scope and severity of J, which is Substandard Quality of Care. The facility was cited Immediate Jeopardy at F-600, F-656, F-678, F-835, and F-867 were cited at a scope and severity of J. The Immediate Jeopardy was removed onsite and was effective [DATE] through [DATE]. An Immediate Action Removal Plan which removed the immediacy of the jeopardy, was received on [DATE] at 2:55 PM. The corrective actions were validated onsite by the surveyors on [DATE]. The findings include: Review of the facility policy, Abuse Prohibition Plan, revised [DATE], revealed .The facility has a zero-tolerance policy for abuse. Verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion is prohibited. The resident will not be subjected to mistreatment, neglect, exploitation or misappropriation of property. The facility will attempt to identify and will investigate any reported violation or allegation of abuse. Willful means the individual deliberately, not that the individual must have intended to, inflict injury or harm .reports of abuse, neglect, exploitation, misappropriation of resident's property and injuries of unknown origin are promptly and thoroughly investigated .The Administrator will investigate or assign the investigation to designated facility personnel such as the Director of Nursing. The investigation will begin immediately .abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Regulations and Law . Review of the facility policy, Advance Directives, revised on ,[DATE] revealed, .The facility representative will assist the resident as needed to communicate any changes in the residents Advance Directive to the physician and/or responsible party .The facility representative will discuss and provide written information explaining the Advance Directive Program, upon admission to the facility .The facility representative will periodically discuss the resident's Advance Directive to ensure the resident's wishes concerning end of life treatment have not changed . Review of the facility policy, Comprehensive Care Plan, revised ,[DATE], showed .The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team or in accordance with the resident's preferences and potential for discharge, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record . Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #33 was cognitively intact. Further review revealed the resident required 2 person total assist with transfers. Review of Resident #33's Physician Visit note dated [DATE] showed Resident #33 was having left shoulder pain and an X-ray was ordered. Review of Resident #33's Mobile Radiology report dated [DATE], showed, .Impacted nondisplaced left humeral fracture .NP (Nurse Practitioner) made aware . Review of Resident #33's Physician Visit note dated [DATE], showed Resident #33 had a contusion to her left arm and the X-ray showed fracture. Further review showed, .Send to Ortho (Orthopedic) Urgent Care for further evaluation of L (Left) Shoulder pain to eval (evaluation) and fx(fracture)/treatment . Review of Resident #33's ER Note dated [DATE] showed, .a tech was transferring her from her wheelchair to a bed 2 days ago. He tried to lift her under her arms. When this occurred she felt a pop in her left shoulder. She has had pain ever since then. It is sharp and throbbing, 10 out of 10 in severity, it is worse with movement. She has noticed some increased bruising, she denies any other injuries . During an interview on [DATE] at 9:05 AM, Resident #33 stated about 4 months ago I was lying in bed when (named CNA #1) came in and was going to get me up for bingo. He didn't have a lift and I told him 'No!' I'm not going without the lift. I asked him to please get the lift, but he wouldn't go get it. During further interview revealed CNA #1 proceeded to lift the resident by her arms to transfer her to a chair from the bed. Resident #33 stated, When he pulled me up, I heard a loud pop and I started having pain in my left arm. I told him it hurt, but he just said, 'You didn't break your arm!' Then he picked up my arm and moved it around and said, 'see' It really hurt when he did that. During further interview revealed Resident #33 informed the Director of Nursing (DON) the next day that CNA #1 did not use the lift when he attempted to transfer her and she insisted for him to use the lift, but he didn't and when he pulled her up by her arms she heard a pop and began to have pain in her left arm. During an interview on [DATE] at 4:19 PM with Nurse Practitioner #1 she stated the facility told her this injury was chronic. However on her [DATE]'s assessment she found fresh bruising and contusions on her left arm. That's when I ordered for (named Resident #33) to be sent to Orthopedic Urgent care for further evaluation of left shoulder pain and fracture. During an interview on [DATE] at 4:51 PM with the Director of Nursing (DON) confirmed Resident #33 was a 2 person assist transfer with a mechanical lift, since admission. Further interview she stated Resident #33 felt CNA #1 was a little rough during the transfer when her arm was broken. During further interview the DON confirmed she was notified by Resident #33 on [DATE] that CNA #1 was rough with her during the attempted transfer on [DATE]. During an interview on [DATE] at 5:16 PM with the Administrator confirmed the incident involving Resident #33 was reported to her by the DON in [DATE] but was not considered abuse at that time. Refer to F-600, F-609, and F-610 Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #49 was cognitively intact. Review of the Physician Orders for Scope of Treatment (POST) for Resident #49 dated [DATE] located in the POST Form Book at the Nurses station showed the resident's code status was a DNR (Do not resuscitate). Review of Resident #49's EMR (Electronic Medical Record) showed the Code Status Ribbon (which displayed for quick reference at the top of the resident's EMR) was blank, which indicated the resident's code status was Full Code (Cardiopulmonary Resuscitation (CPR)). During an interview on [DATE] at 6:44 PM, with Licensed Practical Nurse (LPN) #6, who was assigned to Resident #49, she stated she would refer to the POST Form Book located at the nurses' station to determine a resident's code status. During an interview on [DATE] at 7:40 PM, Resident #49 stated he wanted CPR if his heart stopped and his decision had not changed since admission to the facility. Review of the medical record showed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's Admission MDS assessment dated [DATE], showed the resident was cognitively intact. Review of Resident #6's POST dated [DATE] located in the Post Form book showed the resident code status was Full Code. Review of Resident #6's EMR showed the Code Status Ribbon displayed an Advance Directive status of Do Not Resuscitate (DNR). During an interview on [DATE] at 5:43 PM with LPN #1, who was assigned to Resident #6, she stated she would look on the computer for a resident's code status. Further interview she stated, The code status is in bold right next to the resident's name on the computer. She then demonstrated this on the computer screen by opening the resident's EMR and pointing to the ribbon at the top of the screen where DNR was highlighted in yellow. During an interview on [DATE] at 6:27 PM with the Administrator confirmed code status on the POST forms for Resident #49 and Resident #6 conflicted with their code statuses in the EMR. Refer to F-678 Review of the medical record showed Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] showed Resident #77 was severely cognitively impaired. Continued review revealed Resident #77 required tube feeding for nutrition. Review of the hospital History of Present Illness dated [DATE], showed .Today, the patient was altered and less interactive, and EMS (Emergency Medical Services) was called. EMS said they got a blood glucose of 12 at his home .the patient's core temperature was also found to be 91 degrees . Review of the Comprehensive Care Plan dated [DATE] showed Resident #77 had no care plan for [DIAGNOSES REDACTED] or for monitoring for signs and symptoms of [DIAGNOSES REDACTED]; length of time to hold tube feeding when residual was too high; and appropriate physician notification. Review of the progress note dated [DATE], showed, approximately 1435 (2:35 PM) resident became non responsive after having a second BM (bowel movement). Resident had been disconnected from tube feeding after checking residual and having > (greater than) 110 ml residual (replaced) x's 2. NP (Nurse Practitioner) notified and gave orders to send resident out for evaluation and treatment. Medical record review of the vital signs dated for [DATE], revealed no documented blood sugar prior to transfer to the hospital by the facility. Review of the Emergency Patient Record dated [DATE], showed .Per EMS (Emergency Medical Service) The initial call was for an unresponsive PT (patient). Nurses at this facility saw that he went unresponsive 40 minutes. Our glucometer read L0 for us. We gave him D10 ([MEDICATION NAME] 10%) infusion. He's had a low heart rate with 'us' and weak carotid pulses .Intraosseous special catheter (surgical steel IV (intravenous) catheter inserted directly into a patient's long bone in an emergency life threatening situation to provide rapid infusion of life saving medications/solutions) left tibia inserted at 1536 (3:36 PM) . Review of (Named Hospital) History of Present Illness dated [DATE], showed, .TF had reportedly been temporarily stopped D/T (due to) high gastric residuals/apparent constipation. He was also hypothermic -T-max 89 F (maximum temperature 89 degrees Fahrenheit). Had significant BM today however TF was never resumed . During an interview on [DATE] at 3:50 PM with the Director of Nursing (DON) she confirmed Resident #77 had a history of [REDACTED]. glucose level should have been monitored. Refer to F-656 During an interview on [DATE] at 2:00 PM with the Administrator confirmed she was the abuse coordinator. Further interview confirmed the incident for Resident #33 on [DATE] was not identified, reported, or investigated as an abuse allegation, and the advance directive preference inaccuracy for Resident #6 and Resident #49 were not identified until [DATE]. The Immediate Action Removal Plan, which removed the immediace of the Jeopardy, was received on [DATE] at 2:55 PM and corrective actions were validated onsite by the surveyors on [DATE]. The Immediate Action Removal Plan was verified by the surveyors on [DATE] by: 1. The surveyors verified through review of facility documentation dated [DATE], [DATE], and [DATE] QAPI meetings were held regarding Residents #6, #33, #49, and #77. 2. The surveyors verified the care plans with interventions were in place for 17 residents at risk for developing low blood sugar. 3. The surveyors reviewed the facility's abuse policy and verified there were no changes made to the policy. The facility's noncompliance at F-600, F-656, F-678, F-835, and F-867 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on medical record review, facility investigation and interview, the Quality Assurance/Performance Improvement (QAPI) committee failed to identify deficient practices for investigating allegations of abuse for 9 of 11 allegations of abuse including 9 of 11 sampled residents (Resident #1, Resident #19, Resident #26, Resident #33, Resident #44, Resident #62, Resident #64, Resident #163 and Resident #312) which resulted in Immediate Jeopardy (a situation where the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator and Regional Director of Operations were notified of the Immediate Jeopardy on 3/27/18 at 11:30 AM in the conference room. The Immediate Joepardy was effective from 7/6/17 through 3/27/18. The facility was cited at Immediate Jeopardy for F-610, F-835, F-837 and F-867. Substandard Quality of Care was cited under F-610 at a scope and severity of a L level. An acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received on 3/27/18 at 5:30 PM, and the corrective actions were validated onsite by the state surveyors on 3/27/18. Findings include: Review of 11 facility reported incidents revealed 8 of 11 investigations with allegations of abuse; misappropriation and injury of unknown origin were not thoroughly investigated for Resident #1, Resident #19, Resident #26, Resident #33, Resident #44, Resident #62, Resident #64, Resident #163 and Resident #312. Administration failed to implement policies addressing how they will utilize a systematic approach to determine the underlying causes of problems, how they will implement corrective actions, and how the facility will monitor the effectiveness and ensure improvements are sustained. This failure is evidenced by the following incomplete investigations regarding allegations of abuse, neglect, exploitation or mistreatment (includes injury of unknown origin): 1. Facility investigation with an occurrence date of 1/12/18 regarding alleged physical abuse which involved Resident #312, certified nursing assistant (CNA) #6, CNA #8, CNA #9 and licensed practical nurse (LPN) #4 did not contain: statements from other Residents on same hall (there were 7 with a BIMS of 14 or higher), interviews or documented signed statements from other staff who worked when the alleged abuse occurred, statements from all staff involved, no documentation of staff or alleged perpetrator provided with education after investigation was complete, information regarding outcome of facility investigation and no determination of whether the investigation was deemed substantiated or unsubstantiated. 2. Facility investigation with an occurrence date of 1/1/18 regarding misappropriation of [MEDICATION NAME] which involved Resident #1, LPN #1, LPN #7, LPN #5, LPN #15, LPN #20, LPN #21, registered nurse (RN) #3 and RN #5 did not contain: any attempted interviews with Resident #1, attempted interviews or documented statements with any certified nursing assistants (CNAs) providing direct care to the Resident during the alleged misappropriation, information regarding outcome of local Police Department final determination or follow-up to investigation, no determination of whether the investigation was deemed substantiated or unsubstantiated and nothing provided to QAPI or Governing body to address involvement in process. 3. Facility investigations with two occurrence dates of 12/3/17 and 12/12/17 regarding misappropriation of [MEDICATION NAME] which involved Resident #33, LPN #1, LPN #4, LPN #5, LPN #8, LPN #12, LPN #13 and RN #3 did not contain: any statements from staff involved, any statements from Resident #33/other residents/potential witnesses, drug screen for 2 nurses as provided to the SSA (only 1 was provided), information regarding outcome of facility investigation, no determination of whether the investigation was deemed substantiated or unsubstantiated and nothing provided to QAPI or Governing body to address involvement in process. 4. Facility investigation with an occurrence date of 8/8/17 regarding alleged withholding of pain medication and verbal abuse by staff involved Resident #163 and CNA #3 did not include the following: documentation CNA #3 received any abuse education after alleged incident, documentation the CNA was suspended during the investigation, statement from nurse involved, documentation the Physician was notified of the allegation of abuse, no determination of whether the investigation was deemed substantiated or unsubstantiated and nothing provided to QAPI or Governing body to address involvement in process. 5. Facility investigation with occurrence dates of 7/3/17, 7/4/17, 7/6/17 and 7/10/17 regarding misappropriation of liquid [MEDICATION NAME] involved Resident #64, LPN #4, LPN #14, RN #4 and RN #8 and did not contain: written statements from all staff directly involved, no results of drug screens (were conducted as stated by Administration on 3/21/18 at 10:05 AM in her office), information regarding outcome of facility investigation and no determination of whether the investigation was deemed substantiated or unsubstantiated. Interview with the Administrator and Regional Director of Operations on 3/27/18 at 3:30 PM in the Administrator's office stated all allegations of abuse were reviewed during monthly QAPI meetings but the process for facility investigation was not recognized as a deficient practice until brought to their attention by the surveyors during the recertification and complaint survey. The Administrator confirmed the facility failed to recognize and determine a consistent process for thoroughly completing investigations for allegations of abuse by the QAPI committee. Verification of the Allegation of Compliance was conducted onsite on 3/27/18 by review of facility documentation and interview. The surveyor verified the Allegation of Compliance by: 1. Validation by review on 3/27/18 of a facility investigation dated 3/22/18 for alleged resident abuse confirmed the investigation was completed and thorough. All applicable components of the federal regulation, facility policy and Reportable Event Folder Checklist were addressed and documented. All residents were protected from abuse during the investigation by suspension of CNA #5 on 3/22/18 until the investigation was found to be unsubstantiated. CNA #5 was allowed to return to work on 3/27/18. 2. Validation by review of facility documentation and interview of an Ad Hoc (arranged with specific purpose) QAPI meeting was held on 3/22/18 during the investigation and resulted in recommendations for re-education and testing of all staff regarding Center for Medicate and Medicaid Services (CMS) federal regulations on abuse, neglect, misappropriation, exploitation and mistreatment. The Regional staff reviewed all investigations and allegations and monitoring of the investigation process and corrections were put into place to prevent reoccurrence. 3. Validation by review of facility documentation and interview an Ad Hoc (arranged with specific purpose) QAPI meeting was held on 3/27/18 to educate all members and to plan corrective actions regarding concerns identified by surveyors resulting in Immediate Jeopardy deficiencies. Noncompliance continues at a scope and severity of F, for monitoring the effectiveness of corrective actions and evaluation of monitoring the Quality Assurance Performance Improvement (QAPI) committee. The Regional Director of Operations and the Regional Nurse Consultant will review all investigations prior to final submission to the state survey agency to ensure investigations are complete and thorough. The facility is required to submit a plan of corrections. Noncompliance continues at a scope and severity of F substandard quality of care for the facilities failure to monitor the effectiveness of corrective actions and evaluation of monitoring by the Quality Assurance Performance Improvement (QAPI) committee. The facility is required to submit a plan of correction. Refer F-610 Substandard Quality of Care

Based on facility investigation review, medical record review and interview, the Governing Body failed to oversee the safety and protection of residents by failing to prevent and thoroughly investigate 9 of 11 allegations regarding injury of unknown origin, misappropriation of narcotic medications and allegations of verbal and physical abuse for 9 of 11 sampled residents (Resident #1, Resident #19, Resident #26, Resident #33, Resident #44, Resident #62, Resident #64, Resident #163 and Resident #312) reviewed which resulted in Immediate Jeopardy (a situation where the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator and Regional Director of Operations were notified of the Immediate Jeopardy on 3/27/18 at 11:30 AM in the conference room. An acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received on 3/27/18 at 5:30 PM, and the corrective actions were validated onsite by the state surveyors on 3/27/18. Findings Included: Review of 11 facility reported incidents revealed 9 of 11 investigations for 9 residents (Resident #1, Resident #19, Resident #26, Resident #33, Resident #44, Resident #62, Resident #64, Resident #163 and Resident #312) were reviewed for allegations of abuse; misappropriation of medication and injury of unknown origin and were not thoroughly and completely investigated. Administrations failure to identify deficit practice regarding incomplete investigations of alleged abuse, misappropriation, and injury of unknown origin were never addressed in Quality Assurance and Process Improvement (QAPI). The Governing body is legally responsible for the QAPI program, establishing and implementing policies regarding the management of the facility and ensure all allegations are properly investigated. The Governing body failed to ensure all alleged abuse, misappropriation, and injury of unknown origin were thoroughly investigated as per their policy and failed to take action(s) as appropriate: 1. Facility investigation with an occurrence date of 1/12/18 regarding alleged physical abuse which involved Resident #312, certified nursing assistant (CNA) #6, CNA #8, CNA #9 and licensed practical nurse (LPN) #4 did not contain: statements from other Residents on same hall (there were 7 with a BIMS of 14 or higher), interviews or documented signed statements from other staff who worked when the alleged abuse occurred, statements from all staff involved, no documentation of staff or alleged perpetrator provided with education after investigation was complete, information regarding outcome of facility investigation and no determination of whether the investigation was deemed substantiated or unsubstantiated. 2. Facility investigation with an occurrence date of 1/1/18 regarding misappropriation of [MEDICATION NAME] which involved Resident #1, LPN #1, LPN #7, LPN #5, LPN #15, LPN #20, LPN #21, registered nurse (RN) #3 and RN #5 did not contain: any attempted interviews with Resident #1, attempted interviews or documented statements with any certified nursing assistants (CNAs) providing direct care to the Resident during the alleged misappropriation, information regarding outcome of local Police Department final determination or follow-up to investigation, no determination of whether the investigation was deemed substantiated or unsubstantiated and nothing provided to QAPI or Governing body to address involvement in process. 3. Facility investigations with two occurrence dates of 12/3/17 and 12/12/17 regarding misappropriation of [MEDICATION NAME] which involved Resident #33, LPN #1, LPN #4, LPN #5, LPN #8, LPN #12, LPN #13 and RN #3 did not contain: any statements from staff involved, any statements from Resident #33/other residents/potential witnesses, drug screen for 2 nurses as provided to the SSA (only 1 was provided), information regarding outcome of facility investigation, no determination of whether the investigation was deemed substantiated or unsubstantiated and nothing provided to QAPI or Governing body to address involvement in process. 4. Facility investigation with an occurrence date of 8/8/17 regarding alleged withholding of pain medication and verbal abuse by staff involved Resident #163 and CNA #3 did not include the following: documentation CNA #3 received any abuse education after alleged incident, documentation the CNA was suspended during the investigation, statement from nurse involved, documentation the Physician was notified of the allegation of abuse, no determination of whether the investigation was deemed substantiated or unsubstantiated and nothing provided to QAPI or Governing body to address involvement in process. 5. Facility investigation with occurrence dates of 7/3/17, 7/4/17, 7/6/17 and 7/10/17 regarding misappropriation of liquid [MEDICATION NAME] involved Resident #64, LPN #4, LPN #14, RN #4 and RN #8 and did not contain: written statements from all staff directly involved, no results of drug screens (were conducted as stated by Administration on 3/21/18 at 10:05 AM in her office), information regarding outcome of facility investigation and no determination of whether the investigation was deemed substantiated or unsubstantiated. Interview with the Administrator and Regional Director of Operations on 3/27/18 at 3:30 PM in the Administrator's office stated all allegations of abuse were reviewed monthly but the process for facility investigation was not recognized as a deficient practice until brought to their attention by the surveyors during the recertification and complaint investigation survey. The Administrator confirmed the Governing body failed to recognize facility reported incidents for allegations of abuse were not thoroughly investigated. The Regional Director of Operations was not aware the Governing body had not been following the policy for investigating abuse allegations. Verification of the Allegation of Compliance was conducted onsite on 3/27/18 by review of facility documentation and interview. The surveyor verified the Allegation of Compliance by: 1. Verification by review on 3/27/18 of a facility investigation dated 3/22/18 for alleged resident abuse confirmed the investigation was completed and thorough. All applicable components of the federal regulation, facility policy and Reportable Event Folder Checklist were addressed and documented. All residents were protected from abuse during the investigation by suspension of CNA #5 on 3/22/18 until the investigation was found to be unsubstantiated. CNA #5 was allowed to return to work on 3/27/18. 2. Verification by interviews on 3/27/18 with 44 facility staff members including 8 Management Staff, 3 Registered Nurses, 7 Licensed Practical Nurses, 21 Certified Nursing Aides and 5 Housekeeping/Dietary/Office Staff working all three shifts revealed staff were educated and knowledgeable of the facility policy on abuse, neglect, misappropriation and injury of unknown origin procedures, investigating and reporting to the Abuse Coordinator. With the exception of PRN (as needed) staff which will not be allowed to work until all education is complete. 3. Verification by interviews on 3/27/18 with 31 residents revealed no concerns regarding abuse to them and the residents had not witnessed abuse to other residents, and all residents felt safe in the facility. 4. Verification by review of facility documentation and interview of the Abuse Coordinator (Administrator) revealed in-service by the Regional Director of Operations regarding the Abuse Policy, Investigation Process and Role of the Abuse Coordinator. 5. Verification by review of facility documentation revealed nursing leadership or members of the Governing Body will complete medication cart audits and [MEDICATION NAME] audits within the facility in order to prevent narcotic diversion. All findings will be reviewed and included in the QAPI process. Records of audits will be kept by the Director of Nursing (DON) on file and audited by the Governing Body. Noncompliance continues at a scope and severity of F due to the Governing body's failure to ensure all alleged abuse, misappropriation, and injury of unknown origin were thoroughly investigated as per their policy and failed to take action(s) as appropriateandard quality of care for the facilities failure to conduct thorough investigations. The facility is required to submit a plan of correction. Refer F-610 Substandard Quality of Care

Based on facility policy, medical record review, facility investigations and interview, the Administrator failed to ensure facility reported incidents of alleged abuse were thoroughly and completely investigated for 9 of 11 investigations including 10 of 11 sampled residents (Resident #1, Resident #19, Resident #26, Resident #33, Resident #44, Resident #62, Resident #64, Resident #163 and Resident #312) reviewed which resulted in Immediate Jeopardy (a situation where the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator and Regional Director of Operations were notified of the Immediate Jeopardy on 3/27/18 at 11:30 AM in the conference room. An acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received on 3/27/18 at 5:30 PM, and the corrective actions were validated onsite by the state surveyors on 3/27/18. Findings include: Review of the facility Abuse Policy revised 11/27/16 revealed .In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: Have evidence that alleged violations are thoroughly investigated .Report the results of all investigation to the administrator . Review of 11 facility self-reports revealed 9 of 11 investigations regarding allegations of abuse, misappropriation, and injury of unknown origin were not thoroughly investigated. Review of facility investigation documents revealed Administration had knowledge of all allegations and failed to take action to correct their deficit practice related to incomplete investigations. Incomplete investigations were noted to have the following missing information: interview(s) and/or documented responses with involved resident(s), interview(s) and signed documented statements with all witnesses/roommates/residents in adjoining rooms/staff members in the area or providing care to Resident(s) involved, failure to suspend the accused employee pending completion of an investigation, failure to notify the Physician regarding allegation, failure to provide documentation of drug screens when diversion was identified as stated by facility to State Survey Agency, documentation regarding outcome of investigation, identified corrective actions if allegation was substantiated and how the facility intends to monitor ongoing corrective actions. The following information supports the Administration was aware of allegations of abuse, misappropriation, and injury of unknown origin and failed to take action(s) as appropriate: 1. Facility investigation with an occurrence date of 1/12/18 regarding alleged physical abuse which involved Resident #312, certified nursing assistant (CNA) #6, CNA #8, CNA #9 and licensed practical nurse (LPN) #4 did not contain: statements from other Residents on same hall (there were 7 with a BIMS of 14 or higher), interviews or documented signed statements from other staff who worked when the alleged abuse occurred, statements from all staff involved, no documentation of staff or alleged perpetrator provided with education after investigation was complete, information regarding outcome of facility investigation and no determination of whether the investigation was deemed substantiated or unsubstantiated. 2. Facility investigation with an occurrence date of 1/1/18 regarding misappropriation of [MEDICATION NAME] which involved Resident #1, LPN #1, LPN #7, LPN #5, LPN #15, LPN #20, LPN #21, registered nurse (RN) #3 and RN #5 did not contain: any attempted interviews with Resident #1, attempted interviews or documented statements with any certified nursing assistants (CNAs) providing direct care to the Resident during the alleged misappropriation, information regarding outcome of local Police Department final determination or follow-up to investigation, no determination of whether the investigation was deemed substantiated or unsubstantiated and nothing provided to QAPI or Governing body to address involvement in process. 3. Facility investigations with two occurrence dates of 12/3/17 and 12/12/17 regarding misappropriation of [MEDICATION NAME] which involved Resident #33, LPN #1, LPN #4, LPN #5, LPN #8, LPN #12, LPN #13 and RN #3 did not contain: any statements from staff involved, any statements from Resident #33/other residents/potential witnesses, drug screen for 2 nurses as provided to the SSA (only 1 was provided), information regarding outcome of facility investigation, no determination of whether the investigation was deemed substantiated or unsubstantiated and nothing provided to QAPI or Governing body to address involvement in process. 4. Facility investigation with an occurrence date of 8/8/17 regarding alleged withholding of pain medication and verbal abuse by staff involved Resident #163 and CNA #3 did not include the following: documentation CNA #3 received any abuse education after alleged incident, documentation the CNA was suspended during the investigation, statement from nurse involved, documentation the Physician was notified of the allegation of abuse, no determination of whether the investigation was deemed substantiated or unsubstantiated and nothing provided to QAPI or Governing body to address involvement in process. 5. Facility investigation with occurrence dates of 7/3/17, 7/4/17, 7/6/17 and 7/10/17 regarding misappropriation of liquid [MEDICATION NAME] involved Resident #64, LPN #4, LPN #14, RN #4 and RN #8 and did not contain: written statements from all staff directly involved, no results of drug screens (were conducted as stated by Administration on 3/21/18 at 10:05 AM in her office), information regarding outcome of facility investigation and no determination of whether the investigation was deemed substantiated or unsubstantiated. Interview with the Administrator on 3/21/18 at 6:00 PM in the Social Worker's office confirmed she and the facility failed to ensure the facility reported incidents were thoroughly investigated for 9 of 11 allegations of abuse. Interview with the Administrator/Abuse Coordinator on 3/27/18 at 8:55 AM in the conference room confirmed she was the facility Abuse Coordinator and stated, It is a new role for me. Continued interview revealed when asked if the Administrator felt like she was properly trained for her role as the Abuse Coordinator stated, No .The company realizes training is an issue. Verification of the Allegation of Compliance was conducted onsite on 3/27/18 by review of facility documentation and interview. The surveyor verified the Allegation of Compliance by: 1. Validation by review of facility documentation and interview with Abuse Coordinator (Administrator) was educated by the Regional Director of Operations regarding the abuse policy, investigation process and role of the abuse coordinator. 2. Validation by interview with the Regional Director of Operations and the Regional Nurse Consultant revealed they will begin review from here on out all investigations prior to final submission to ensure investigations are complete and thorough. Noncompliance continues at a scope and severity of F for Administrations failure to ensure facility reported incidents of alleged abuse were thoroughly and completely investigated. The facility is required to submit a plan of correction. Refer F-610 Substandard Quality of Care

Based on facility policy review, medical record review, review of facility self-reported incident investigations and interview, the facility failed to conduct thorough investigations for 9 of 11 abuse allegations which placed Resident #1, Resident #19, Resident #26, Resident #33, Resident #44, Resident #62, Resident #64, Resident #163, and Resident #312, as well as other unnamed residents at risk for abuse and misappropriation which resulted in Immediate Jeopardy (a situation where the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator and Regional Director of Operations were notified of the Immediate Jeopardy on [DATE] at 11:30 AM in the conference room. An acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received on [DATE] at 5:30 PM, and the corrective actions were validated onsite by the state surveyors on [DATE]. Substandard Quality of Care was cited under F-610 at a scope and severity of 'L'. Findings include: Review of facility policy Abuse, Neglect, Exploitation revised [DATE] revealed, .When .reports of abuse, neglect .occur, an investigation is immediately warranted .Components of an investigation .include .Interview the involved resident .and document all responses. If resident is cognitively impaired, interview the resident several times to compare responses .Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area .All statements should be signed and dated by the person making the statement. Document the entire investigation chronologically .Notify the attending physician, resident's family/legal representative .Suspend the accused employee pending completion of the investigation .In response to allegation of abuse, neglect .or mistreatment the facility must .Have evidence that all alleged violations are thoroughly investigated .Front line supervisors or other departments heads should provide education as situations arise .The Administrator should .report the results of the investigation when final, as required by state agencies . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 3 out of 15. Medical record review revealed a physician's orders [REDACTED].#1. Continued review revealed the old patch was to be removed from Resident #1's skin prior to the application of a new patch. Continued review of the physician's orders [REDACTED].#1 after the patch was discovered missing and the resident was then started on oral pain medication. Review of the (MONTH) Medication Administration Record [REDACTED]. Review of a facility investigation with an occurrence date of [DATE] revealed at approximately 9:45 AM Licensed Practical Nurse (LPN) #1 discovered Resident #1's [MEDICATION NAME] was missing from her body. After a search was conducted, the [MEDICATION NAME] remained missing. Continued review revealed the [MEDICATION NAME] was reported as missing to the Director of Nursing (DON). Continued review revealed a facility investigation was initiated to rule out misappropriation of the [MEDICATION NAME]. Continued review revealed on [DATE] the off-going 3:00 PM-11:00 PM nurse and the 11:00 PM to 7:00 AM oncoming nurse validated placement of Resident # 1's [MEDICATION NAME]. Further review revealed the oncoming day shift (7:00 AM - 3:00 PM) nurse and the off-going night shift (11:00 PM - 7:00AM) nurse failed to validate [MEDICATION NAME] placement at change of shift. Continued review revealed when the day shift nurse realized it had not been validated and went to check the placement at 9:45 AM it was discovered missing. Continued review revealed no documented statements per facility policy with the Certified Nurse Aides (CNAs) who had cared for Resident #1 when the patch was discovered missing. Further review revealed no attempted interviews were documented with Resident #1 per facility policy. Continued review revealed only 1 nurse was drug tested although other nursing staff was involved with Resident #1's care during the time of the incident. Continued review revealed the facility investigation provided to the State reporting system included .both ongoing and off going nurse to check for placement and document and drug screens done. Both tested negative . Continued review revealed only the off going nurse was drug tested . Medical record review revealed Resident #33 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly MDS dated [DATE] revealed Resident #33 was severely cognitively impaired with a BIMS score of 3 out of 15. Medical record review revealed Resident #33 was prescribed a [MEDICATION NAME] 12 mcg/hr. apply 1 patch every third day and remove old patch prior to application of new one. Continued review revealed the [MEDICATION NAME] was discontinued on [DATE] and oral pain medication was ordered. Continued review revealed Resident #33's pain was not manageable with the oral pain medication ordered and on [DATE] the [MEDICATION NAME] 12 mcg/hr. 1 patch every third day was reordered. Further review revealed the [MEDICATION NAME] was discontinued again on [DATE] and oral pain medications were restarted. Review of a facility investigation with an occurrence date of [DATE] revealed LPN #8 was the oncoming 11:00 PM to 7:00 AM nurse this date and LPN #12 was the off-going 3:00 PM to 11:00 PM nurse. Continued review revealed both LPN # 8 and LPN #12 checked Resident #33 at shift change to confirm patch placement and was unable to locate the [MEDICATION NAME]. Continued review revealed LPN #12 had relieved a nurse at 9:00 PM from the medication cart and had accepted the medication cart keys without checking Resident #33's [MEDICATION NAME] placement. Continued review revealed after a search the [MEDICATION NAME] was not found and was reported to RN #3, who was the interim DON at the time. Continued review of the facility investigation revealed no documented statements from the CNAs who had cared for Resident #33 during the time the [MEDICATION NAME] was discovered missing. Continued review revealed no documented evidence of attempting interviews with Resident #33 per facility policy. Continued review revealed only one nurse (LPN #4) was drug tested with this incident. Review of a facility investigation with an occurrence date of [DATE] and time of 3:00 PM revealed Resident #33's [MEDICATION NAME] was missing from her body at shift change when LPN #13 and Resident #9 was checking Resident #33's [MEDICATION NAME] placement. Continued review revealed after a facility search the [MEDICATION NAME] was not found and the incident was reported to RN #3. Continued review of the facility investigation for possible misappropriation of the [MEDICATION NAME] revealed no documented statements from CNAs or nurses who had cared for Resident #33 during the time the patch was identified as missing. Continued review revealed no documented evidence of attempted interviews with Resident #33 per facility policy. Further review revealed there were no staff tested for drugs with this incident. Medical record review revealed Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #64 received hospice services for Terminal Heart Failure. Medical record review of an Admission MDS dated [DATE] revealed Resident #64 was severely cognitively impaired with a BIMS score of 3 out of 15. Medical record review revealed a physician's orders [REDACTED]. Review of a facility investigation with occurrence dates of [DATE] and [DATE] revealed possible misappropriation of [MEDICATION NAME] belonging to Resident #64. Further review revealed on [DATE] when the nurse was preparing to administer the 6:00 AM dose of [MEDICATION NAME] for Resident #64, she noted the color and smell of the [MEDICATION NAME] concentrate was inconsistent with the usual color and smell for [MEDICATION NAME] housed in the facility. Continued review revealed the bottle of [MEDICATION NAME] was compared to other bottles of [MEDICATION NAME] and the color of the bottle in question was different from the other bottles. Continued review revealed the bottle of [MEDICATION NAME] was considered contaminated and was discarded. Continued review of the investigation revealed on [DATE] the day shift nurse noted a discrepancy in the color of the [MEDICATION NAME] for Resident #64. Further review revealed the bottle of [MEDICATION NAME] was compared to other bottles of [MEDICATION NAME] and was found to be inconsistent in color and was considered to have been tampered with and was discarded and replaced. Further review revealed some, but not all of the nurses who had access to the [MEDICATION NAME] had been drug tested . Continued review revealed statements from all nurses who had access to the [MEDICATION NAME] were not obtained/documented per facility policy. Continued review revealed there was no documentation of attempted interviews with Resident #64 per facility policy. Further review revealed no documented statements were obtained from other residents who were receiving pain medications. Interview with the Administrator on [DATE] at 10:05 AM in her office confirmed the facility failed to conduct a thorough investigation for the possible misappropriation of medications for Resident #1, Resident #33, and Resident #64. Medical record review revealed Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly MDS dated [DATE] revealed Resident #26 was moderately cognitively impaired with a BIMS score of 9 out of 15. Medical record review revealed Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly MDS revealed Resident #44 was severely cognitively impaired with a BIMS score of 3 out of 15. Medical record review revealed Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly MDS dated [DATE] revealed Resident #62 was moderately cognitively impaired with a BIMS score of 10 out of 15. Review of a facility investigation with an occurrence date of [DATE] revealed a former employee, Registered Nurse (RN) #5 had written a letter to the Administrator alleging Resident #26, Resident #44, and Resident #62 as well as other unnamed residents had been allowed to experience verbal abuse. She also alleged LPN #4 had bullied residents and employees. She alleged pain medication had been withheld from unnamed: residents. Continued review revealed no documentation of residents, other than Resident #26, Resident #44, and Resident #62 had been interviewed regarding abuse by staff. Further review revealed no interviews documented with residents concerning the withholding of pain medications. Continued review revealed the facility performed a pain medication audit and no discrepancies were discovered. Continued review revealed no documented statements from the alleged perpetrator or other staff regarding any knowledge of resident abuse or of withholding pain medications. Further review revealed no documentation of the alleged perpetrator being suspended during the abuse investigation. Continued review revealed the facility investigation was documented as completed (although it was not) on [DATE] and the allegations were unsubstantiated. Review of time punch records for LPN #4 revealed she did not work from [DATE] - [DATE] during the time of the facility investigation. Interview with the Administrator on [DATE] at 10:05 AM in her office confirmed the facility failed to conduct a thorough investigation of the allegations of verbal abuse for residents, including Resident #26, Resident #44, and Resident #62 and the allegations of withholding pain medications and thus the facility placed these and other residents at risk for abuse. Medical record review revealed Resident #163 was admitted to the facility on [DATE] and expired on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission MDS dated [DATE] revealed Resident #163 had a BIMS of 15 and was cognitively intact. Further review revealed she received hospice services for [MEDICAL CONDITION] Fibrosis. Review of a facility investigation with an occurrence date of [DATE] at 1:00 AM alleged Resident #163 suffered verbal abuse from CNA #3. Further investigation determined the allegations were unsubstantiated and no deficient practice for abuse was identified. Continued review of the facility's investigation revealed no documentation or proof CNA #3 was suspended during the investigation or received additional educational training on abuse after the allegation. Further review revealed no other staff working that shift or hall were interviewed; no documentation the Physician was notified of the allegation; no staff were educated after allegations of abuse per facility policy; and no documentation stating the allegation was found to be substantiated or unsubstantiated by the facility. Interview with the Administrator on [DATE] at 5:30 PM in the Social Worker's office confirmed the facility failed to conduct a thorough investigation for allegations of abuse for Resident #163. Medical record review revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #19 had a BIMS score of 3 indicating he was severely cognitively impaired. Continued review revealed the resident was usually understood and usually understood others. Further review revealed the resident required extensive assist for bed mobility, transfer, locomotion on and off unit, dressing, toilet use and personal hygiene. Continued review revealed the resident did not walk in room or corridor. Review of a facility investigation received by the State Survey Agency on [DATE] revealed an initial report of a fracture of unknown origin discovered on [DATE] by x-ray to the left anterior distal tibia (ankle) and was nondisplaced. Continued review of the investigation revealed at least 12 staff members had provided care to Resident #19 a week prior to the injury and written statements were only obtained from 5 of those employees. Further review revealed no interviews were conducted with interviewable residents and skin checks were not performed on the noninterviewable residents on the hall on which Resident #19 resided. Continued review revealed Resident #19 was interviewed one time by the DON who did not follow the facility policy regarding ways to interview a cognitively impaired resident. Further review revealed no documentation of education provided to the staff regarding nonverbal cues of pain and safe transfers as reported in the investigation summary reported to the state survey agency on [DATE] Interview with the DON on [DATE] at 6:05 PM in her office revealed the surveyor reviewed the facility investigation and the missing components of the investigation. The DON stated I see what you are talking about. Medical record review revealed Resident #312 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility investigation with an occurrence date of [DATE] at 1:00 AM alleged Resident #312 suffered physical abuse from CNA #6. Further investigation by the facility determined the allegation was found to be unsubstantiated. Continued review revealed no documentation CNA #6 was interviewed. Continued review revealed no interviews from other residents on the hall. Medical record review of the MDS's of the other residents on the hall (where Resident #312 resided) revealed all were cognitively intact with a BIMS of 13 or greater. Further review of the facility investigation revealed no interviews from staff who worked during the shift when the abuse was reported to have occurred. Interview with the Administrator on [DATE] at 9:45 AM in her office confirmed no statements were obtained from other residents on the hall, staff who worked the shift when the incident was said to have occurred or with CNA #6. The Administrator confirmed the facility failed to conduct a thorough investigation of alleged physical abuse for Resident #312. Verification of the Allegation of Compliance was conducted onsite on [DATE] by review of facility documentation and interview. The surveyor verified the Allegation of Compliance by: 1. Verification by review of facility documentation revealed nursing staff were in-serviced on notifying leadership and relevant time frames. 2. Verification by review of facility documentation revealed the facility leadership was in-serviced regarding reportable events/injuries of unknown origin. Investigation and interviews of staff who cared for Resident #19 were completed with no root cause identified for the fracture. 3. Verification by review of facility documentation revealed the staff were in-serviced on body assessments on all potentially affected residents during investigations. Validation by review of facility documentation body audits were completed with no negative findings. 4. Verification by interviews on [DATE] with 31 residents revealed no concerns regarding abuse to them and the residents had not witnessed abuse to other residents, and all residents felt safe in the facility. 5. Verification by interviews on [DATE] with 44 facility staff members including 8 Management Staff, 3 Registered Nurses, 7 Licensed Practical Nurses, 21 Certified Nursing Aides and 5 Housekeeping/Dietary/Office Staff working all three shifts revealed staff were educated and knowledgeable of the facility policy on Abuse and Neglect procedures, investigating and reporting to the Abuse Coordinator. 6. Verification by review of facility documentation and interview of the Abuse Coordinator (Administrator) revealed in-service by the Regional Director of Operations regarding the Abuse Policy, Investigation Process and Role of the Abuse Coordinator. 7. Verification by review of facility documentation revealed the Social Service Director completed assessments on all residents who were interviewable on [DATE] to assess for any concerns or psychosocial issues regarding abuse and all new admissions since [DATE] were also interviewed. No negative findings were found. 8. Verification by review of facility documentation revealed all employees working on [DATE] and [DATE] were in-serviced and tested regarding facility policies: abuse, neglect, misappropriation, exploitation, and mistreatment of [REDACTED]. 9. Verification by review of facility documentation revealed leadership was in-serviced regarding completing drug testing on all nursing staff during diversion investigations. 10. Verification by review of facility documentation and staff interview revealed a liquid narcotic drug sheet was developed as well as implemented and nursing staff were educated on use of and how to prevent further issues. No discrepancies had been identified since implementation of the form. 11. Verification by review of facility documentation and interview revealed in-service of counting narcotics, the proper assessing of liquid narcotics for inconsistencies such as color, smell and viscosity were completed for all staff. 12. Verification by review of facility documentation and interview revealed there were no residents in the facility with liquid narcotic orders during the investigation. 13. Validation by review of facility documentation revealed leadership was in-serviced concerning notification of law enforcement in regarding missing narcotics. 14. Validation by review of facility documentation revealed nursing staff were in-serviced on [MEDICATION NAME] placement as well as the verification process. 15. Validation by review of facility documentation revealed an update regarding the facility's process to include drug testing aides when narcotic patches are missing. 16. Validation by review of facility documentation revealed leadership was in-serviced on the importance of obtaining complete statements from all staff involved in allegations. 17. Validation by review of facility documentation revealed clinical staff were in-serviced regarding misappropriation of medications and the consulting Pharmacist continuing to complete monthly audits. 18. Validation by review of facility documentation revealed nursing staff were in-serviced on obtaining medication orders at discharge for residents. 19. Validation by review of documentation revealed a total body audit was completed on Resident #19 with no additional injuries found, the resident's pain was addressed and a referral was made to the Orthopedic Physician. 20. Verification by review of facility documentation revealed the injury of unknown origin for Resident #19 was re-investigated by the Regional Nurse Consultant and the Regional Director of Operations with the finding of a facility record prior to electronic medical records with a previous [DIAGNOSES REDACTED]. 21. Verification by interview with CNA #3 on [DATE] revealed he was suspended for 3 days during the facility investigation for Resident #163. 22. Verification by review on [DATE] of a facility investigation dated [DATE] for alleged resident abuse revealed Resident #163 the investigation was complete and thorough. All applicable components of the regulation, facility policy and Reportable Event Folder Checklist were addressed and documented. All residents were protected from abuse during the investigation by the suspension of CNA #3 on [DATE] until the investigation was found to be unsubstantiated and the CNA returned to work on [DATE]. Noncompliance continues at a scope and severity of F substandard quality of care for the facilities failure to conduct thorough investigations. The facility is required to submit a plan of correction.

Based on medical record review, review of facility investigations, review of Performance Improvement Plan, and interview, the facility failed to provide required assistance when transferring residents for four (#155, #78, #58, #2) of eleven residents reviewed for falls. The facility's failure resulted in harm to resident #155. The findings included: Resident #155 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the care plan dated June 5, 2013, revealed the resident was at risk for falls; needed assistance with transfers and bed mobility due to left sided weakness and poor safety awareness; and was unable to hold onto the Sara lift (type of mechanical lift) and required the vander lift (a type of mechanical lift). Continued review of the care plan revealed the intervention was "...to use mechanical lift with proper technique for safe transfers in and out of wheelchair and bed..." Review of the Minimum Data Set, dated dated dated [DATE], revealed the resident was severely impaired cognitively; was dependent for bathing, dressing, grooming, toileting, and transfers; and was incontinent of bowel and bladder. Medical record review of a Nurse Event Note dated August 14, 2013, at 5:30 p.m., revealed "...Tech (Certified Nurse Technician) called for this nurse over loud speaker. This nurse notified tech that I was across the hall dealing with a resident that was trying to get out of bed. Tech ran into room and told me this resident fell out of the lift. I ran across the hall. Patient was on the floor. Called patient's name and no response. Checked pulse, had pulse. Check head, noted the hematoma and bleeding from the back. I then ran out to the nurses' station and told the nurse out there that I needed one to call 911, one to get info from res (resident) chart, and the rest to come help me in res room. VS (vital signs), resp (respirations) and temp (temperature). Applied first aid to head to stop bleeding. Applied pressure the whole time res was on floor. Res was more responsive still it was 5 minutes passed then res made a sound that...normally makes. 4 person lift back to bed keeping head and neck secure. Immediately following being placed in bed EMTs (Emergency Medical Technicians) arrived and took over, prepped for transport..." Medical record review of a nursing note dated August 14, 2013, at 6:30 p.m., revealed "...Daughter returned call to facility, this nurse informed daughter that res was sent to...(named hospital) due to fall. Informed daughter that res had a hematoma, laceration, and was unresponsive for about 5 minutes...stated res fell out of sling/lift upon transfer to chair. Review of a note in the investigation written by the CNA (Certified Nurse Aide) involved in the incident dated August 14, 2013, revealed "...I went to look for help with get resident up for dinner. I couldn't get help with transfer so I did it myself. I was using the vander lift with the purple sling. I rolled the sling under the resident, I place the straps in the hooks and I began the transfer. Resident looked secure in the sling so I went on the transfer...from the bed to...chair and as I turned the lift one of the straps came off and resident fell out of the sling onto the floor. I realize one of the straps wasn't secure causing resident to fall out of the sling. I went to get my charge nurse..." Review of a note written by the former Administrator in the facility investigation dated August 14, 2013, revealed "...Entered room to assist nursing staff with resident noted on floor. A nurse was applying pressure to left side of head; others were taking vital signs, etc. pt (patient) was responsive as usually, eyes open, groaning sounds, lips moving, non-verbal, no grimacing, flinching, or other gestures of pain noted. Pressure was maintained to laceration and left side of head. pt was log rolled onto blanket with head and neck securely held with 4 man lift and placed onto bed at which time EMTs were arriving..." Review of a note in the investigation written by a CNA dated August 16, 2013, revealed "...I was assisting a resident on 400 hall when...(named CNA) walked in and ask for assistance. I told...I couldn't leave the resident...then turned away and waved...hand and said OK and walked away..." Review of the Performance Improvement Action Plan dated August 15, 2013, revealed "...This accident occurred without the assistant following guidelines for mandatory 2 person assist with all mechanical lift transfers. The employee was immediately sent home after the incident and was called back on August 16, 2013, when...was terminated by the interim DON. The CNA documents that...did not wait on assistance and clearly knew...should wait on help when using the lifts..." Medical record review of notes from the receiving hospital dated August 14, 2013, revealed the resident was found to have "...multiple old rib fractures and an acute nondisplaced fracture of the left ischium. Ortho stated this was inoperable given the resident's baseline. Patient has a hematoma on...forehead and a laceration to...ear..." Continued review of a CT (computerized tomography) of the chest, abdomen, pelvis, and thoracolumbar spine revealed "...an acute minimally displaced fracture of the posterior aspect of the inferior ramus (pelvis) on the left; old right anterior third through fifth rib fractures; old left second through seventh rib fractures; old comminuted fracture of the left clavicular (collar bone) head; old fractures of transverse processes of L4 and L5 (lumbar vertebrae with fractures)..." Interview with the Director of Nursing (DON) on July 31, 2014, at 10:20 a.m., in the DON's office, revealed the DON was not employed by the facility when the incident occurred and documentation indicated the CNA did not follow policy when transferring the resident. Continued interview with the DON revealed the CNAs complete a check list of skills with return demonstration during orientation. Further interview with the DON revealed the CNAs have a monthly calendar where they receive education on various topics. Continued interview with the DON revealed "...We observe them caring for residents and we would know if someone wasn't doing well." Interview with the Maintenance Director on July 31, 2014, at 10:30 a.m., and on August 1, 2014, at 9:00 a.m., in the conference room, revealed the vander lift had been in the facility since 2008. Continued interview with the Maintenance Director revealed the facility stopped using the vander lift in December 2013, and it was disposed of in January 2014 due to an inability to obtain replacement parts and the company had gone out of business. Resident #78 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Care Plan dated March 24, 2014, revealed, "...Provide assistance and support of two persons using transfer aid to ensure safety..." Medical record review of the 14-day Minimum Data Set (MDS) dated [DATE], revealed the resident scored 14 out of 15 on the Brief Interview for Mental Status, indicating the resident was cognitively intact for daily decision making. Continued review of the MDS revealed the resident required extensive assistance of two persons for bed mobility and transfers. Medical record review of a Nurse's Note dated April 20, 2014, revealed, "...Called to resident's room where resident was observed sitting on floor in front of wheelchair. CNA (Certified Nurse Aide) stated...was transferring resident from recliner into wheelchair when...began to sit down and...assisted...to floor..." and there were no injuries. Interview with the Director of Nursing in the conference room on July 31, 2014, at 3:15 p.m., confirmed the resident's fall was the result of an improper transfer. Continued interview confirmed two persons were required to assist the resident with transfers and only one was present at the time of the fall. Resident #58 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Care Plan, effective February 7, 2014, revealed, "...At risk for falls r/t (related to) impaired ability to self-transfer...Foot wear will fit properly and have non-skid soles..." Medical record review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had severe cognitive impairment and required extensive assistance of two persons for bed mobility, transfers, locomotion on unit, dressing, toileting, and personal hygiene. Review of the Nurse's Event Note dated March 31, 2014, at 8:45 p.m., revealed, "...Called to resident's room by sitter and observed resident sitting on floor next to bed with NA (Nurse Aide) at...side...Gait belt was around resident and...was not wearing shoes or non-skid socks. CNA and sitter stated that during transfer, resident's feet started to slide and they had to lower...to floor. Assessed and no injuries found..." Interview with the Director of Nursing (DON) in the DON's office on July 31, 2014, at 3:30 p.m., confirmed the resident's fall was the result of an improper transfer. Continued interview confirmed the resident was to have on non-skid footwear before the staff attempted to transfer the resident. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. other dementia. Medical record review of the Care Plan dated March 11, 2014, revealed, "...Assist with transfers with 2 to 3 staff members and gait belt..." Review of the Annual MDS dated [DATE], revealed the resident required extensive assistance of "Two+ (plus) persons physical assist" for bed mobility, transfer, walking in room and toilet use. Further review revealed the resident had two or more falls with no injury since the prior MDS assessment. Medical record review of a Nurse's Event Note dated May 17, 2014, revealed the resident had a witnessed fall on May 17, 2014, at 8:50 p.m., in the resident's bathroom. Further reivew revealed, "...CNA was cleaning resident...reported that pt was holding on to the safety rail in bathroom and went to assist (resident) to WC (wheelchair) and (resident) missed the chair. 0 (no) head strike no injuries noted..." Review of the facility investigation dated May 17, 2014, revealed "...Physical function problems that may have contributed to the fall...Muscle weakness...2-3 persons for transfer...resident requires 2-3 persons..." Further review revealed one CNA was assisting the resident without the use of a gait and the resident was "...standing in the bathroom holding the grab bar..." Interview with Certified Nurse Aide (CNA) #3 on July 31, 2014, at 8:00 a.m., in the hallway outside the resident's room, confirmed two staff members were always needed to assist the resident with care. Interview with CNA #4 on July 31, 2014, at 8:05 a.m., at the nursing station, confirmed the resident was to be assisted by two staff members at all times. Interview with the Director of Nursing on July 31, 2014, at 3:35 p.m., in the conference room, confirmed precautions were not used resulting in a fall. c/o #

Based on medical record review, facility investigation review, and interview, the facility failed to take appropriate measures to prevent accidents with one (#1) of eleven residents reviewed. The failure to take appropriate safety measures results in actual harm to the resident. Medical record review revealed resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had a BIMS (Brief Interview for Mental Status) score of 3, or severe cognitive deficits. Continued review revealed the resident required assist of two persons for transfer; required extensive assistance for bathing, dressing, and grooming; was incontinent of bowel and bladder; was able to eat after set-up. Review of a facility Nurse's Event Note dated July 29, 2011, revealed the nurse was called to the resident's room by the CNA (Certified Nursing Assistant). Continued review revealed "... walked in room and observed res. (resident) lying face down actively bleeding copious amounts of blood from nose and mouth; laceration noted to bridge of nose and top lip. Res. c/o (complained of) pain to head. Couldn't recall what happened. This nurse called 911; res was transported to ... (named hospital) via ambulance...". Review of the facility investigation revealed "Resident put feet down when being assisted with staff with w/c (wheelchair) mobility and fell forward out of w/c...". Appropriate interventions included "... Staff educated to reapproach with refusals of assist from staff...". Review of the Occurrence Investigation Statement written by the CNA assisting the resident and dated July 29, 2011, revealed "... I began to wheel the patient in ... room to go to dinner. As I began to turn ... in ... wheelchair and go forward the patient said ... did not want to go, ... feet were slightly on the floor as I proceeded slowly to turn ... and go forward ... fell . I immediately went for help...". Review of the physician's report dated July 29, 2011, revealed the resident was [DIAGNOSES REDACTED]. The resident's POA agreed with closed nonsurgical management of the elbow fracture but fixation of the humeral fracture. Interview with the Physical Therapist on August 22, 2011, at 3:00 p.m., in the conference room, revealed foot rests are not used on all wheelchairs. Continued interview revealed it the resident can hold the feet up then foot rests are not used. Further interview revealed holding the feet up is a good isometric exercise. Continued interview revealed if the lower extremities are weak then the resident needs foot rests. Further interview revealed the Physical Therapist was unable to recall the resident. Interview with the administrator on August 22, 2011, at 3:20 p.m., in the conference room revealed the resident was unable to hold the feet off the floor. Continued interview revealed foot rests have been applied to the resident's wheelchair and now the resident is pushed to and from meals. Telephone interview on August 23, 2011, with the CNA pushing the resident in the wheelchair on July 29, 2011, when the accident occurred, revealed "I went to the dining room and realized the resident was not there. I was asked to go and get ... and ... was facing the window. I told ... I was taking ... to the dining room. As I was turning the chair around ... put feet down and said "no". As I turned ... and moved forward ... fell . I hadn't gone a foot with ... If we had gone further I would have told ... to lift up feet. This was the first time ... said no. I had moved her before and ... lifted up feet".