Every finding on record at Chautauqua Health and Rehabilitation

Based on observation, interview, and facility policy review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety which had the potential to affect all residents who consumed meals from the kitchen. The findings include:1). Review of the facility's policy titled, Food Storage, dated 10/2019, revealed the Dietary Manager was to ensure all food items were stored properly in covered containers. Further review revealed the containers were to be labeled, dated, and arranged in a manner to prevent cross-contamination.Observation of the kitchen, on 05/05/2026 at 11:05 AM, revealed a dessert cart with 20 cups of chocolate trifle stored uncovered and undated in the freezer. Observation of the dry pantry storage revealed one large 6.61-pound canned peaches, two large 6.61-pound canned mandarin oranges, and three large 6.38-pound stewed tomatoes were dented but stored in active rotation to serve to residents. Chicken soup base was stored in the 1.25-pound original container with the lid lying on top, unsealed, and had an open date of 12/30/2025 but no use-by date. 2). Review of the facility's policy titled, Staff Attire, dated 10/2019, revealed all dining service staff were to wear approved attire for the performance of their duties. Further review revealed all staff members would take their hair off their shoulders, confine it in a hair net or cap, and facial hair was to properly restrained. Observation of Assistant Dietary Manager (ADM), on 05/05/2026 at 11:20 AM, revealed her hairnet was improperly worn and exposed approximately 2.5 inches of hair on her right side and 1.5 inches of hair on the left side and had receded 1-2 inches above her hairline on her forehead. In an interview with the ADM, on 05/05/2026 at 11:30 AM, she stated she did not realize her hair was exposed but stated she had a lot of hair and the hairnet had slipped off sometimes. She was aware that not properly wearing a hairnet was a concern and hair should always be covered to prevent hair from falling into the resident's food. 3). Review of the facility's policy titled, Record of Food Temperature, dated 01/02/2020, revealed food temperatures were to be verified using a clean, sanitized, and calibrated thermometer to ensure accuracy. Observation of the kitchen on 05/06/2026 at 11:45 AM, revealed the ADM used a thermometer to check the temperature of hamburger patties, but failed to clean the thermometer before taking the temperature (temping) the pureed corn. Further observation revealed the ADM used an ice cream scoop to remove the area of the pureed corn she had touched with the thermometer; however, did not discard the pureed corn.In interview with the ADM on 05/06/2026 at 11:55 AM, she stated she realized her mistake. She reported she should have discarded the pureed corn because it had become contaminated after the thermometer was used on the hamburger patties and was not sanitized prior to using on the corn.In interview with Dietary Manager (DM), on 05/08/2026 at 4:00 PM, she stated expectations for the dietary staff to follow facility's polices and procedures. She said all staff were aware of wearing hairnets and the importance of keeping all hair covered. The DM reported she would not want resident's served food contaminated with hair and residents would not be happy to find hair in their food. She explained when checking temperatures of food, her expectations for all dietary staff was to ensure thermometers were sanitized between each food item to prevent cross contamination and allergy concerns. The DM said if staff used the same thermometer in two different food items, the contaminated food item should be discarded. She stated all staff were trained on food safety, and the ADM would be completing courses through Servsafe (a nationally recognized food safety training program) to be certified in food safety and the registered dietician would proctor her training. Additionally, she stated expectations were for all staff, including dietary staff, was to ensure residents were provided with meals that were healthy and safe. In interview with the Administrator on 05/08/2026 at 5:52 PM, she stated her expectations for all dietary staff was for them to follow the facility's policies and procedures for food safety. She said all dietary staff should be wearing hairnets properly covering all visible hair to prevent food contamination. The Administrator reported staff were in-serviced by the Registered Dietician (RD). She explained she had performed audits in the kitchen to ensure safety processes were being followed. The Administrator further stated if staff were not following policies and procedures there was a potential for cross contamination and foodborne illnesses. In addition, she said if policies and procedures were not followed it could be worse for those with allergies if sanitation practices were not followed.

Based on interview, record review, facility document and policy review, the facility failed to report all alleged violations of abuse to the State Agencies (including the State Survey Agency (SSA) for 1 of 1 residents sampled for sexual abuse out of the total sample of 25 residents, (Resident (R)61).The findings include:Review of the facility policy titled, Abuse, Neglect and Exploitation, last reviewed 04/2026, revealed, under section II Employee Training, new employees were to be educated on abuse, neglect, exploitation and misappropriation of resident property during initial orientation and existing staff to receive annual education through planned in-services and as needed. Continued review under section VII Reporting/Response, the facility was to have written procedures that included reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes. Further review revealed for allegations involving abuse or that resulted in serious bodily injury, the allegations were to be reported immediately, but not later than two hours after the allegation was made.Review of the Resident Face Sheet revealed the facility admitted R61 on 07/12/2024, with diagnoses which included stage four pressure ulcer of sacral region, non-pressure chronic ulcer of skin of other sites with necrosis of muscle, and anxiety disorder. Review of the Annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 03/29/2026, revealed the facility assessed R61 to have a Brief Interview for Mental Status (BIMS) of 14 out of 15, which indicated intact cognitive function. Additionally, review of the Annual MDS Assessment revealed the facility identified no behaviors for R61.Review of the facility's grievance log from 01/01/2026 through 05/07/2026, revealed no documentation of grievances filed either from or on behalf of R61.Review of the Facility Investigation for R61 in February revealed a written statement noted by the Assistant Director of Nursing (ADON), dated 02/12/2026, which documented, Resident reported to this nurse that she did not want Licensed Practical Nurse (LPN 1), to work with her any longer. Per review of the ADON's statement, R61 said she felt like she had concerns with LPN 1 doing her treatment and she shouldn't have to spend so long cleaning and doing her treatment. Continued review revealed the ADON noted R61 said she did not particularly like LPN 1 and did not want her to take care of her any longer. Further review revealed the ADON documented explaining to R61 it was her right to prefer other caregivers, and the facility would accommodate her request, and the resident voiced no further complaints.Review of Facility Investigation for R61 in February revealed a statement from the Administrator, dated 02/12/2026, which stated On 02/12/2026 R61 voiced concerns related to LPN1 doing her wound care. R61 was interviewed by ADON on 02/12/2026. ADON reported during interview R61 stated she did not like LPN1 and no longer wanted her as her nurse because it took too long to do her treatment. ADON reported R61 stated she felt safe in the facility. LPN1 was removed from R61 care per resident request. Residents with a BIMS of eight or greater were interviewed on 02/12/2026 who were assigned to LPN1 as a precautionary measure, no complaints or concerns were voiced. Residents with a BIMS below eight head to toe skin assessments were completed as a precautionary measure, no concerns identified. Additional review of the February Facility Investigation revealed documentation noting skin assessments performed of residents with a BIMS score below eight, as well as interviews of residents with BIMS scores of eight or higher performed with no concerns noted.During interview on 05/05/2026 at 10:04 AM, R61 stated LPN 1 had been removed from this floor because of me. R61 stated she was recovering from flesh eating bacteria and said, They had to move my urethra to my vagina; my anatomy doesn't look like a normal female. She reported LPN 1 stuck her finger inside me and told her, Oh, you are so tight now. Like a virgin again. R61 explained Certified Nurse Aide (CNA) 8 overheard LPN 1 make that remark and got the ADON so I could tell her what happened. She said the Administrator got involved and removed LPN 1 from her care. R61 stated, I'm not devastated or anything but just floored that it had happened. She reported being concerned for other residents who could not speak up for themselves, as LPN 1 was now on an all-female dementia unit. R61 further stated she was told it was, not sexual assault, it was just inappropriate behavior; however, did not remember who had told her that. She additionally stated, This all happened about 3 months ago or so.During telephone interview on 05/06/2026 at 5:20 PM, CNA 8 stated she helped nurses with peri-care and wound care for R61. She reported on one occasion while assisting LPN 1 with R61's care, she observed LPN 1, after removing the wound packing, to stick her fingers inside the resident's vagina. CNA 8 said she had never seen other nurses do anything like that before. She stated, LPN 1, while moving her fingers clockwise in R61's vagina, said, [NAME] R61, it's getting tighter. Like a born-again virgin. If your husband was alive, he would like that. Some people pay for this. CNA 8 reported R61, CNA 6 (who was also assisting) and herself, all looked at each other like, what just happened? Did she really say that? The CNA said she knew that was wrong. She stated after completing R61's peri-care and wound care, all three staff members left the room. CNA 8 further stated she went back later to check on R61 and asked if she was okay, and the resident told her what LPN 2 had done, made her feel very uncomfortable. In addition, the CNA said she told R61 she needed to file a grievance about what LPN 1 had done. In an additional interview with CNA 8, on 05/07/2026 at 3:42 PM, she stated she had not reported the incident involving what LPN 1 had done to R61, as the resident asked her not to. During a phone interview on 05/06/2026 at 6:25 PM, with CNA 6, she stated that sometime near the end of January or in February she was assisting LPN 1 and CNA 8, with providing care for R61. She reported while LPN 1 had her fingers inside R61, the LPN said, you are getting tighter. It's like you are a born again virgin. If your husband was alive, he would have paid for this. CNA 6 said after R61's care was completed, all of the (the staff) left R61's room. She stated she did not believe R61 ever said anything about the interaction or reported it to anyone. The CNA further stated she was never questioned by anyone regarding the incident. During an additional interview on 05/07/2026 at 3:32 PM, with CNA 6, she stated did not report the incident to her leadership, but now regretted not doing so. She stated she wished she would have; however, then again I felt like no one would have taken it seriously. During interview on 05/07/2026 at 9:35 AM, CNA 10 stated she had worked at the facility since October 2025, mostly on the facility's Memory Care (dementia) unit. She said she received abuse training during orientation, and had no concerns of fellow co-workers mistreating or abusing residents. CNA 10 further stated however, if she ever had such concerns, she would report them to the facility's abuse coordinator. During interview on 05/07/2026 at 9:40 AM, CNA 11 stated she started at the facility in January and had always worked on the Memory Care unit. She said she had abuse training in orientation, and had no concerns of any staff mistreating a resident. CNA 11 further stated she would notify the (facility's) abuse coordinator or the Administrator of any concerns.During interview on 05/07/2026 at 9:50 AM, LPN 1, who was working at the time, stated she worked at the facility for about two and a half years. She said the staff received abuse training all the time, practically monthly. LPN 1 explained she had worked all the units in the facility; however, the Memory Care unit was her favorite. When the SSA Surveyor asked if LPN 1 had ever witnessed or been concerned about staff abusing a resident, she replied they got rid of someone who was snappy with a family member that very night. During a phone interview on 05/07/2026 at 7:20 PM, CNA 19 stated she had not been an eyewitness to the incident involving LPN 1 and R61. She stated however, when she entered R61's room later on, the resident looked really upset and asked if she could talk to her (CNA 19) about something. CNA 19 reported R61 then told her that during her peri-care, LPN 1 told her, You're a new, born-again virgin, and also expressed concern LPN 1 was re-opening wounds that had closed. She explained R61 told her she did not want her (LPN 1) in here because of that. CNA 19 said she tried to convince R61 to report that information, but the resident told her she was afraid of retaliation. The CNA stated she reported what R61 had told her to the ADON, and the ADON and Social Services (SS) talked to R61 and she (CNA 19) witnessed their conversation. She stated a few days later, R61 asked her if she heard anything about what was being done about LPN 1, and she told the resident no, but she would find out for her (R61). CNA 19 further stated she went to the ADON and asked about the progress of the investigation and was told by the ADON, there is an active investigation going and that is all I can say. Additionally, CNA19 stated she felt terrible, like she had let her resident down because she had not put anything in writing, saying, I trusted them and this was what it had led to.During interview on 05/08/2026 at 10:13 AM, CNA 3 stated on unknown date, R61 informed her she was uncomfortable with LPN 1 providing her care. She reported R61 told her LPN 1, touched her more than she should. CNA 3 stated R61 told her not to tell but said, of course I did. She explained she told the Social Services (SS) Worker what R61 had told her right then because SS happened to be on the resident's hall, and that was who they were supposed to go to about residents' behaviors.During interview on 05/08/2026 at 4:55 PM, the Director of Social Services (SS) stated she did not remember being told of concerns related to inappropriate touching of R61 by LPN 1. She said it was possible she was told, but had forgotten as she was dingy and if she did not write things down, she often forgot them. The Director of SS reported if the incident (involving LPN 1 and R61) occurred while the previous Administrator had been here, she could believe that Administrator had, swept it under the rug. She further stated LPN 1 was, rough as a cob and you never know what will come out of her mouth, but I have never known her to be intentionally mean to a resident.During interview on 05/07/2026 at 1:46 PM, the Administrator started in her position at the facility on 02/09/2026, and it had been maybe her third day here when she became aware of R61 requesting that LPN 1 not provide her care any longer. She said R61 voiced concerns about LPN 1 taking too long to do a dressing change and that she didn't really want that nurse to take care of her anymore. The Administrator explained LPN 1 was moved to another hall in the facility. She stated as she was still learning staff and residents, it had been her decision to re-assign LPN 1 to another unit. The Administrator said Interviews of interviewable residents, and skin assessments on other residents were performed just to make sure things were covered. She reported based on the concern presented she did not feel it had been necessary to interview R61 or the nurse involved as part of the facility's investigation. The Administrator stated the incident had been the only complaint like this she had experienced in her time at the facility, and if there were to be additional such incidents she would save a folder. She said there had been no additional concerns with R61 or LPN 1 since that time. The Administrator further stated there had been no reason to report the incident / complaint to the SSA because it had been related to resident care. Additionally, the Administrator said she had performed the interview with R61 and saw the resident for several days afterwards.During interview on 05/07/2026 at 2:13 PM, the ADON stated R61 had been in her care for a long time and she was a generally pleasant person. She said R61 had people she liked and those she did not like and there was no rhyme or reason for that. The ADON explained the only concern she remembered involved a nurse that R61 did not want taking care of her anymore. She stated, She (R61) didn't want LPN1 to care for her anymore. She said something about her treatment, and it took her (LPN 1) too long to do. The ADON said it was normal to move a nurse if the facility was able to accommodate a resident's wishes. The ADON reported she had never heard R61 make any accusations against anyone about sexually inappropriate behavior, and R61 had only told her she did not like her, but never gave a reason why. She stated it was normal to make a file if a resident complained as, We were told to cover all bases. The ADON further stated she would take an accusation of that nature very seriously; however, based on the concern reported to her, there had been no reason to report that information.

Based on observation, interview, and review of facility policy, the facility failed to follow standard precautions to prevent the spread of infection. Appropriate infection prevention and control practices were not implemented during medication administration. Hand hygiene was not performed while administering medications to 2 of 5 residents, sampled for medication observation out of the total sampled 25 sampled residents, (Resident (R)46 and R75). The findings include: Review of the facility policy titled, Infection Prevention and Control Program, last revised 01/2025, revealed the facility established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Additionally, all staff were to assume all residents were potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Review of the facility policy titled, Medication Administration, last reviewed 04/2026, revealed staff were to wash hands prior to and after administering medication.During observation of medication pass on the facility's 500- Hall on 05/05/2026 at 12:00 PM, Certified Medication Aide (CMA)1 failed to perform hand hygiene prior to administering medication to R46 and between administering medication to R46 and R75. Per observation, there was a stack of medication cups and a stack of water cups placed upside down on top of the medication cart. CMA 1 was observed to touch the rim of the water cups and medication cups, as well as the inside of the medication cups when obtaining the medication from the medication cards and carrying water to the resident. Continued observation revealed, after donning a glove and obtaining another glove from the Personal Protective Equipment (PPE) holder on R75's door, the CMA sorted through the medication cart contents. Observation revealed CMA 1 then, without changing gloves or performing hand hygiene, opened a gabapentin (an anticonvulsant medication) capsule in order to empty its contents into a medication cup. Further observation revealed the Assistant Director of Nursing (ADON) witnessed CMA 1 emptying the capsule with the contaminated gloves on. In addition, observation revealed the ADON addressed and educated CMA 1 at that time.During interview with CMA 1 on 05/05/2026 at 12:10 PM, she stated she had to get a glove from the PPE holder because there were no more gloves on the medication cart. She additionally stated she had not thought about what she was touching and had just forgotten to perform the necessary hand hygiene. During interview with the ADON on 05/05/2026 at 12:12 PM, she stated she would further educate CMA 1. She further stated she would conduct additional observations of CMA 1 administering medications later to ensure her compliance with standard precautions.

Based on observation, interview, and review of facility policy, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. Observation on 04/02/2025 at 8:45 AM, on the Dementia unit, revealed medication cups containing medications that had been pre-pulled for 3 residents. The cups were marked with the residents' names in black sharpie. The findings include: Review of the facility's policy titled, Medication Administration, revised 02/20/2024, revealed medications were administered by licensed nurses, or other staff who were legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice. Review of the facility's policy titled, Residents Rights, dated 01/20/2020 and revised on 01/2025, revealed the facility will ensure all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents. Observation of Medication Tech (MT)3 on the Dementia unit, on 04/02/2025 at 8:45 AM, revealed she was at the medication cart with the drawer open. There were three medication cups containing medications that had been pre-pulled for three different residents. (Pre-pulled medications is the preparation of medications in advance of administration, often for multiple residents or for a delayed time of administration). The cups were marked with resident names in black sharpie and were in the top drawer of the medication cart. MT3 immediately acknowledged the State Survey Agency Representative observing the cups of medications and disposed of the medications. In an interview with MT3, on 04/03/2025 at 2:30 PM, she stated she should not have pre-pulled the medications prior to administration on 04/02/2025. She further stated she was aware this was a risk for medication error, distraction and administering the wrong medication to residents. She further stated she felt residents on the unit were also vulnerable due to this being a Dementia Unit. During an interview with the Director of Nursing (DON), on 04/04/2025 at 9:15 AM, she stated it was her expectation staff follow the Medication Administration policy. She further stated she would not expect staff to ever pre-pull medications and place them in a cup with the resident's name. In further interview, she stated this was a huge safety risk due to the possibility of medication errors with this unsafe practice. During an interview with the Administrator, on 04/04/2025 at 9:00 AM, she stated it was her expectation staff follow the Medication Administration policy. She further stated she would not expect staff to pull medications for residents, place them in cups marked with their names, and leave them in the medication carts. In further interview, she stated this was a dangerous and unsafe practice as there was a high risk of administering the wrong medication to a resident.

Based on observation, interview, record review, and review of facility policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 26 sampled residents, Resident (R)1 and R97. 1. During observation of incontinence care for R97, provided by Certified Nursing Assistant (CNA)8 and CNA10, on 04/03/2025 at 10:14 AM, the CNAs removed the urine soaked sheets from the air mattress, used them to wipe the mattress and then threw the sheets on the floor while wearing gloves. The CNAs then failed to perform hand hygiene and don new gloves, but wore the same soiled gloves to provide incontinence care for the resident. Further, the CNAs failed to clean/disinfect the air mattress after providing incontinence care. 2. Furthermore, observation on 04/01/2025 at 9:10 AM, and 04/03/2025 at 9:05 AM, revealed the infusion stand which held R1's enteral feeding bag was soiled with an unidentified brownish matter streaking down the pole. Also the bottom of the stand was soiled with the same unidentified matter. The findings include: Review of the facility's policy titled, Infection Prevention and Control Program, revised 09/2024, revealed the facility has established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Standard Precautions: all staff shall assume all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. Environmental cleaning and disinfecting shall be performed according to facility policy. All staff have responsibilities related to the cleanliness of the facility, and are to report problems outside of their scope to the appropriate department. Review of the facility policy titled, Hand Hygiene, revised 02/05/2025, revealed all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hygiene prior to donning gloves, and immediately after removing gloves. 1. Review of R97's Admission record revealed the facility admitted the resident on 06/27/2024 with diagnoses which included non-traumatic brain injury, hypertension, dementia, and parkinson's disease. Review of R97's Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three out of fifteen, indicating severe cognitive impairment. Observation of incontinence care for R97, provided by CNA8 and CNA10, on 04/03/2025 at 10:14 AM, revealed the resident had a brief in place; however, when the CNAs turned the resident onto his back, the air mattress, and sheet, were visibly wet. The CNAs while wearing gloves, removed the urine soaked sheets from the mattress and CNA 8 used the wet sheets to wipe the mattress and then threw the sheets on the floor. The CNAs then failed to perform hand hygiene and don new gloves, but wore the same soiled gloves to provide incontinence care for the resident. After providing incontinence care, the CNAs while wearing the same soiled gloves, dressed the resident in clean clothes. Additionally, the CNAs did not clean/disinfect the mattress after providing the incontinence care. During an interview with the Director of Nursing (DON), on 04/04/2025 at 8:13 AM, she stated she expected staff to place soiled linen in a plastic bag and not on the floor. She further stated she expected staff to perform hand hygiene and don new gloves prior to performing incontinence care. Further, she stated she expected staff to remove soiled gloves, perform hand hygiene and don new gloves any time gloves became soiled during resident care. In further interview, she stated she expected staff to clean the mattress on the bed with bleach wipes if it became soiled, and then call housekeeping to perform a deep clean of the mattress. During an interview with the Assistant Director of Nursing (ADON)/Infection Preventionist, on 04/03/2025 at 10:18 AM, she stated she expected staff to follow the facility's policies regarding infection control practices. She stated staff should not throw soiled linen on the floor, but were to place it in a plastic bag. Further, she stated staff was to perform hand hygiene and glove changes at appropriate times as per policy. In continued interview, she stated resident air mattresses were to be cleaned/disinfected upon becoming soiled. Additionally, she stated education related to infection control practices was conducted annually and periodically during the year. During an interview with the Housekeeping Supervisor, on 04/04/2025 at 9:25 AM, she stated housekeeping services had specific cleaners to clean the floatation [air] mattresses. She stated there was a list of rooms that were periodically deep cleaned to ensure all beds were cleaned during the month. She further stated if a mattress became soiled before the scheduled deep clean, the staff should call housekeeping to perform an immediate cleaning. During an interview with the Administrator, on 04/04/2025 at 10:04 AM, she stated she expected staff to wash hands and don new gloves prior to providing care or performing a procedure for residents. Further, she stated staff should wash hands and don new gloves when the gloves became soiled. Further, she stated staff should never throw dirty linen on the floor. Additionally, the Administrator stated staff was to clean a soiled mattress the best that they could with bleach wipes until housekeeping could perform a deep clean of the mattress. 45914 2. Review of R1's Admission Record revealed the facility admitted R1 on 10/17/2023 with diagnoses which included cerebral palsy, anemia, diabetes mellitus, and malnutrition. Review of R1's Annual Minimum Data Set (MDS), dated [DATE], revealed the facility was unable to complete an assessment to determine R1's Brief Interview for Mental Status (BIMS), and the resident was rarely/never understood. Observation of R1, on 04/01/2025 at 9:10 AM, revealed the resident had an enteral feeding tube and the infusion stand that held the enteral feeding bag was soiled with an unidentified brownish matter streaking down the pole. Further observation revealed the bottom of the pole was soiled with the same unidentified matter. Observation of R1, on 04/03/2025 at 9:05 AM, revealed the infusion stand that held R1's enteral feeding bag was soiled from the top to the bottom with unidentified brownish matter. In an interview with Licensed Practical Nurse (LPN)5, on 04/03/2025 at 6:33 PM, she stated the nursing staff was responsible for changing the residents' enteral tube-feed bags. LPN5 stated in reference to R1, night shift changed the enteral tube-feed bag or at least hung a new enteral tube-feed bag for her when she arrived. She stated R1 was on Enhanced Barrier Precautions (EBP) because of the tube feeding. (EBP is a specific set of infection control practices designed to reduce the transmission of Multidrug Resistant Organisms.) In continued interview with LPN5, on 04/03/2025 at 6:33 PM, she stated since R1 was on EBP, she would don the appropriate Personal Protective Equipment (PPE) and ensure the pre-set settings were correct before starting the feeding. She stated part of the Infection Control Program (ICP) was to ensure the environment was clean/disinfected and that included the infusion stand that held the tube-feed bags. She further stated it was very important to follow the ICP to ensure residents were protected from potential infections or other hazards. In further interview, LPN5 stated she was surprised to learn the infusion stand in R1's room had been soiled. Additionally, she stated staff should have cleaned the pole with either bleach wipes or the Hydrogen wipes which worked well for disinfecting. During an interview, on 04/04/2025 at 8:45 AM, the DON stated the nursing staff was responsible for changing enteral tube-feed bags. She further stated as part of the infection control process, nursing staff should ensure the infusion stand holding the tube feeding bag was disinfected by wiping it down with either the bleach wipes or the Hydrogen wipes which were the disinfectant wipes that were utilized by the facility. She stated it was her expectation for all nursing staff to ensure they were following the facility's protocols regarding infection control practices to prevent the spread of infections. During an interview, on 04/04/2025 at 9:30 AM, with the Administrator, she stated it was her expectation the nursing staff cleaned and disinfected the tube feeding stands when soiled, especially related to a resident on EBP. Further, she stated it was her expectation all nurses follow their nursing scope of practice and training in ICP and ensure residents were protected from potential harm.

Based on observations, interviews, review of facility policies and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure two (2) residents (Resident #1 and Resident #7) out of three (3) sampled residents were placed under transmission-based precautions (contact) after having a positive felt tip test (a test for scabies) as a precautionary measure to limit potential transmission to other residents and staff. The facility failed to ensure staff was provided with education/training on the prevention of transmission of scabies in a long-term care setting. The findings include: Review of the facility's policy titled, Infection Prevention and Control Program, dated 09/02/2020, revealed the facility established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. Further review of the policy revealed its intent was to help prevent the development and transmission of communicable diseases and infections. Continued review revealed a system of surveillance was utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. Review of the Centers for Disease Control and Prevention (CDC) website titled, Parasites-Scabies, last reviewed 11/02/2010, revealed control measures for multiple cases of non-crusted scabies would consist of heightened surveillance for early detection of new cases, proper use of infection control measures when handling patients (e.g. avoidance of direct skin-to-skin contact, handwashing, etc.), confirmation of the diagnosis of scabies, early and complete treatment and follow-up of cases, and prophylactic treatment of staff, other residents, and household members who had prolonged skin-to-skin contact with suspected and confirmed cases. Skin-to-skin contact with scabies residents should be avoided for at least eight (8) hours after treatment. In addition, an institution-wide information program should be implemented to instruct all management, medical, nursing, and support staff about scabies, the scabies mite, and how scabies were and were not spread. Epidemiologic and clinical data would be reviewed to determine the extent of the outbreak and risk factors for its spread. Further review of the CDC website revealed control measures for an outbreak involving one (1) or more cases of crusted scabies would involve rapid and aggressive detection, diagnosis, infection control, and treatment measures because this form of scabies was highly transmissible. Unrecognized crusted scabies had often been the source of institutional outbreaks of scabies. Infection control personnel and dermatologists would be involved as soon as scabies was suspected in an institution. An institution-wide information program would be implemented to instruct all management, medical, nursing, and support staff, about scabies, the scabies mite, and how scabies spread. Until successfully treated, residents with crusted scabies should be isolated from other residents who did not have crusted scabies. Continued review revealed that assigning a cohort of caretakers to care only for residents with crusted scabies would reduce the potential for further transmission. Direct skin-to-skin contact between a resident with crusted scabies and his/her caretakers and visitors should be eliminated by following strict contact precautions, including the use of protective garments such as gowns, gloves, and shoe covers. The resident's room should be cleaned thoroughly. Bedding and clothing used by a person with scabies should be machine-laundered using the hot water and hot dryer cycles. 1. Review of Resident #1's Admission Electronic Medical Record (EMR) revealed the facility admitted the resident on 05/03/2021. Review of Resident #1's Progress Notes, dated 08/10/2022, revealed the resident had a positive felt-tip marker procedure (Felt tip marker procedure: The tester placed a black water-soluble marker around a suspicious area. The tester then took an alcohol wipe and removed the ink from the area marked. If a dark residue remained, this area was noted to be positive for scabies). The Nurse Practitioner (NP) ordered permethrin cream (anti-parasitic used to treat scabies) to treat the resident's rash on the resident's abdomen and bi-lateral upper extremities. The NP gave scabies as a diagnosis. Review of Resident #1's Progress Notes, dated 08/24/2022, revealed Resident #1 was treated, for scabies, a second time with permethrin cream. During observation and interview of Resident #1, with Licensed Practical Nurse (LPN) #1, on 09/14/2022 at 9:15 AM, the resident was observed sitting in the recliner to the right of the bed. Resident #1's room was decorated with multiple dolls and personal items. Observation of the resident's skin revealed both of the resident's upper thigh areas had multiple patches of red areas which appeared to be inflamed and bright red on the left upper thigh as if the resident had been scratching these areas. Resident #1 had nothing on his/her buttocks; however, the resident was observed to have a light colored rash, which were shaped like bite marks on the resident's back, stomach area and upper chest area around his/her breast area. The resident stated that the rash was very itchy, adding, the itching was mostly at night. Resident #1 stated he/she knew where his/her ''bites came from. Resident #1 further stated, ''a brown bug (unknown name of the bug) came out at night, that released mites, which ate me. 2. Review of Resident #7's Admission EMR revealed the facility admitted the resident on 11/30/2016. Review of Resident #7's Progress Note, dated 08/15/2022, revealed the resident was seen by the NP as a follow-up for scabies/itching. The NP noted Resident #7 had a previous positive felt tip test for scabies and ordered permethrin cream. Further review of the NP note revealed the rash had improved but continued to have itching to the posterior thighs and re-ordered another dose of permethrin cream. Review of the facility's document titled, Infection Log, dated for the months of January 2022 through August 2022, revealed the facility failed to indicate the rashes identified and failed to document the two (2) confirmed cases of scabies. Further review revealed the facility failed to track and trend the cases of scabies. During an interview, on 09/13/2022 at 10:15 AM, with LPN #2, revealed that if a resident was being treated for scabies, the resident should have been placed under contact isolation. During an interview, on 09/13/2022 at 11:12 AM, with Certified Nursing Assistant (CNA) #1, revealed she was aware of a few residents with red rashes. CNA #1 stated she was not offered prophylactic treatment, by the facility, for scabies. CNA #1 revealed she had not received any training/in-services on scabies or how to prevent its transmission. Interview with CNA #4, on 09/13/2022 at 11:33 AM, revealed she was not aware of any official diagnosis of scabies with the residents. CNA #4 stated she had not been offered prophylactic treatment, by the facility for scabies. During an interview, on 09/13/2022 at 12:52 PM, the NP stated there were a few residents who were itching and completed a felt tip test. The NP stated there was some residual on the residents but did not confirm scabies. The NP stated she contacted the Medical Director about her findings. The NP stated she would expect the facility to monitor and track rashes as part of the infection prevention program. Continued interview with the NP revealed there were no scabies outbreaks at the facility. During an interview, on 09/13/2022 at 3:33 PM, the Infection Control Preventionist (ICP) stated she did not track rashes on residents. The ICP stated the rashes on the residents was sporadic and not an infection control issue. During an interview, on 09/14/2022 at 8:23 AM, the Environmental Services Manager (ESM) stated she was not informed of any positive cases of scabies. The ESM stated if she was notified of possible scabies, she would have instructed her staff to do a deep clean of each residents' room. The ESM stated laundry would also place clothing and linens under the isolation cycle of the washing machines. The ESM stated neither she nor her staff was provided training/in-services on scabies and transmission prevention. During an interview, on 09/14/2022 at 10:29 AM, the NP stated the reason she treated Resident #1 and Resident #7 with the scabies cream was because the residents overheard staff talking. The NP stated she discussed these residents with the Medical Director regarding treatment. Per the interview, the NP stated the Medical Director agreed to the scabies treatment as a prophylactic. She further revealed she did not discuss any isolation precautions with the MD. The NP stated she would have expected the facility staff to place these residents on contact precautions if that was what was expected from the facility's guidelines. The NP confirmed she was not aware of these guidelines. The NP confirmed she discussed with nursing staff to have a detailed cleaning of the residents' rooms and to clean their linen, along with their clothing. During an interview, on 09/14/2022 at 11:36 AM, the Medical Director revealed the NP informed him of one (1) to two (2) residents that had positive burrowing in the first part of August 2022; however, he could not recall any detailed information. He stated he told the NP to ''treat aggressively'' with the permethrin cream, and place the residents on containment, which would have been contact isolation. Further, the Medical Director stated he told the NP to keep an eye on other residents to see if other residents developed a rash. The Medical Director stated it was better to treat, than not and that treatment was a lower risk for the residents, than to have it spread. The Medical Director revealed the NP informed him that there were no other rashes of similar kind. During an interview, on 09/14/2022 at 12:06 PM, the DON and Assistant Director of Nursing (ADON) revealed they were not informed of any suggestive burrowing from the NP. The DON said the NP stated that she felt the rashes were not indicative of scabies even though there were progress notes that suggested burrowing. Continued interview with the ADON revealed she would have hoped the NP told them about the residents (Resident #1 and Resident #7), adding, the residents would have been placed in contact isolation and given the ordered treatment. The DON stated the nurses completed a weekly skin assessment on all residents. Further, she stated the CNAs completed skin assessments on the residents' skin daily and there were no reports made to them of any positive scabies in the facility. Further, the DON and ADON revealed they would reach out to the local health department for recommendations. 12679

Based on interviews, record reviews and facility policy review, it was determined that the facility failed to protect residents from physical, sexual, and verbal abuse for five (5) (Residents #35, #8, #58, #54, and #87) of five (5) sampled residents reviewed for abuse by Resident #85 and Resident #6. Specifically, Resident #85 knocked down Resident #35 down on 08/21/2021, and knocked Resident #8 down on 08/22/2021, resulting in a femur fracture. Resident #6 had multiple episodes of verbal and physical aggression towards other residents. Resident #6 exposed himself/herself, sexually during an activity, to Resident #58 and Resident #87. Staff reported that when Resident #6 came into the common area, other residents left due to the resident's behaviors. Staff indicated they were fearful Resident #6 would hurt another resident. The Director of Nursing (DON) indicated Resident's #6's behaviors created a stressful environment for the other residents. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was identified at 483.12 (Freedom from Abuse, Neglect, and Exploitation) at a scope and severity of K. The Immediate Jeopardy (IJ) was determined to exist on 04/01/2021 when Resident #6 was yelling and cursing at another resident and the facility failed to investigate the allegation of verbal abuse. The Director of Nursing (DON) and Nursing Home Administrator (NHA) were notified of the IJ and were provided the IJ Template on 08/26/2021 at 12:00 PM. AN acceptable Removal Plan was received on 08/27/2021. The IJ was determined to be removed on 08/27/2021, before exit. after the survey team performed onsite verification that the Removal Plans had been implemented. Noncompliance remained at the lower scope and severity of pattern E, no actual harm with potential for more than minimal harm that was not immediate jeopardy. The findings included: Review of the Abuse Prevention Program, revised 09/2020, indicated in Paragraph #1 that as part of the resident abuse prevention, administration would protect residents from abuse by anyone including, but not necessarily limited to staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individuals. Review of the facility's policy, titled, Abuse and Neglect - Clinical Protocol, revised July 2017, revealed Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. The management and staff, with the support of the physicians, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. Review of the Unmanageable Resident policy, revised 04/2010, indicated that if a resident's behavior became abusive, hostile, assaultive, or unmanageable in any way that would jeopardize his or her safety or the safety of others, the Nurse Supervisor/Charge Nurse must immediately provide for the safety of all concerned, notify the attending physician for instruction, and notify the Director of Nursing and the resident's representative. The policy further indicated complete documentation of the incident must be recorded in the resident's medical record, and an incident report must be filed with the Administrator. Additionally, unmanageable residents may not be retained by the facility. 1. Record review revealed the facility admitted Resident #6 on 01/19/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #6's cognition was severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15). The resident required supervision with ambulation using a walker. The MDS indicated the resident had no behaviors. The most recent Quarterly MDS, dated [DATE] indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a care plan, dated 02/02/2017, indicated Resident #6 exhibited or had the potential to exhibit or demonstrate verbal behaviors such as the use of abusive and sexually inappropriate language. Review of a care plan, dated 10/26/2020, indicated Resident #6 exhibited or had the potential to exhibit physical behaviors related to poor anger management, poor impulse control, and public masturbation. Review of a Progress Note, dated 03/26/2021, indicated Resident #6 had a resident-to-resident altercation. Resident #6 continued to curse other residents and threatened to harm self and other residents. Review of a Progress Note, dated 04/01/2021, indicated Resident #6 was cursing and yelling at another resident. There was no evidence provided that showed this incident was investigated. Review of a Progress Note, dated 04/03/2021, indicated Resident #6 was cursing other residents and making multiple verbal threats. There was no evidence provided that this incident was investigated. Review of a Progress Note, dated 04/04/2021 at 5:20 PM, indicated Resident #6 was extremely agitated and yelling at other residents. There was no evidence provided that this incident was investigated. Review of a Progress Note, dated 04/09/2021 at 10:04 AM, indicated Resident #6 was verbally aggressive with other residents, threatening harm, and cursing. There was no evidence provided that this incident was investigated. Review of a Progress Note, dated 04/13/2021 at 7:50 AM, indicated Resident #6 was cursing and threatening to harm other residents. There was no evidence provided that this incident was investigated. Review of a Progress Note, dated 04/16/2021, indicated Resident #6 was yelling and cursing at other residents, and the facility had the Director of Nursing come back to the unit. There was no evidence provided that this incident was investigated. Review of a Progress Note, dated 04/18/2021, indicated Resident #6 was yelling, throwing stuff, and cussing at other residents. There was no evidence provided that this incident was investigated. Review of a Progress Note, dated 04/30/2021, indicated Resident #6 was publicly masturbating during an activity. There was no evidence provided that this incident was investigated. Review of a Progress Note, dated 05/08/2021, indicated Resident #6 was yelling and cussing at other residents. There was no evidence provided that this incident was investigated. Review of a Progress Note, dated 05/29/2021, indicated Resident #6 had been cursing, yelling, and threatening other residents. There was no evidence provided that this incident was investigated. Review of a Progress Note, dated 06/05/2021, indicated Resident #6 was verbally aggressive with another resident. There was no evidence provided that this incident was investigated. Review of a Progress Note, dated 06/14/2021, indicated Resident #6 had been cursing and yelling at other residents and throwing items in the resident's room. There was no evidence provided that this incident was investigated. Review of a Physician's Progress Note, dated 06/16/2021, indicated Resident #6 was noted to have the potential to harm staff, other residents, or self. Review of a Physician's Progress Note, dated 06/17/2021, indicated Resident #6 had a long history with physical aggression related to [CONDITION(S)] [CONDITION(S)] disorder. Review of a Progress Note, dated 06/29/2021, indicated Resident #6 was threatening to hit, was cursing, and was being verbally aggressive with other residents. There was no evidence provided that this incident was investigated. Review of a Progress Note, dated 07/27/2021, indicated Resident #6 was cursing and threatening to hit other residents. There was no evidence provided that this incident was investigated. Review of a Progress Note, dated 08/11/2021, indicated Resident #6 was being verbally aggressive with other residents and was threatening to harm other residents. There was no evidence provided that this incident was investigated. Review of a Progress Note, dated 08/14/2021, indicated Resident #6 had exposed himself/herself and touched himself/herself inappropriately in front of other residents during an activity. The DON went to the unit to talk to the resident regarding his/her behaviors. There was no evidence provided that this incident was investigated. Review of a Physician's Progress Note, dated 08/18/2021 at 12:00 PM, indicated Resident #6 was verbally and physically aggressive, was throwing things, trying to break things, slamming the walker, and yelling and cursing. Record review revealed [MEDICATION(S)] 2.5 mg (milligrams) was given. During an interview on 08/24/2021 at 3:15 PM, Licensed Practical Nurse (LPN) #3 indicated Resident #6 threatened to kill other residents, and it was just a matter of time before the resident hurt another resident. She indicated the facility's administration was aware of Resident #6's aggressive physical and verbal behaviors. During an interview on 08/24/2021 at 2:16 PM, Resident #54 indicated Resident #6 had kicked him/her in the leg with three (3) staff members present who witnessed the incident. During an interview on 08/24/2021 at 3:30 PM, the Activity Assistant (AA) indicated she had witnessed Resident #6 kick Resident #54. During an interview on 08/26/2021 at 12:15 PM, the AA indicated Resident #6 exposed himself/herself to two residents during an airshow while outside in the courtyard. During an interview on 08/26/2021 at 12:20 PM, Resident #58 indicated Resident #6 had exposed himself/herself to Resident #58 during the airshow, and that it made the resident feel uncomfortable, wondering what [Resident #58] did to provoke this. During an interview on 08/26/2021 at 12:30 PM, Resident #87 indicated Resident #6 had their genitals in his/her hand and was exposing himself/herself to Resident #58. Resident #87 indicated (he/she) felt bad for Resident #58. During an interview on 08/25/2021, the DON indicated allegations of abuse were to be reported to their immediate supervisor, and it would then be reported to the DON or NHA. She indicated she was not aware of the allegations of physical, verbal, and sexual abuse. The DON indicated she would report verbal allegations of abuse depending on how the other residents felt about it. She indicated the incident of Resident #6 exposing self during an activity should have been reported. During an interview with the Administrator, on 8/26/2021 at 2:30 PM, she stated she was aware of behaviors that Resident #58 had been displaying and that the resident was like a child. She indicated she had not been notified that the resident kicked another resident or that the resident had exposed themself in front of female residents during the outside activity for the air show. 2. Record review revealed the facility admitted Resident #85 on 01/27/2020 and last readmitted him/her on 04/22/2021. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed Resident #85 was also readmitted on [DATE], and on readmission experienced agitation, restlessness, [CONDITION(S)], and sought companionship. Review of the most recent Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) of nine (9) out of fifteen (15). The resident's behaviors included physical aggression toward others occurring one (1) to three (3) days during the seven (7) day assessment period; other behaviors not directed toward others were documented as occurring one (1) - three (3) days; and, rejection of care one (1) to three (3) days during the assessment period. No verbal behaviors were identified as occurring during the assessment period. Review of Resident 85's medical record revealed the resident had previously been discharged from another skilled nursing facility due to two (2) resident-to-resident altercations in two (2) days with behaviors that had become more aggressive leading up to the transfer. Review of the Nurse's Progress Notes and/or incident reports indicated Resident #85 had physical or verbal altercations with other residents on the following days: 05/05/2021, 06/13/2021, 07/07/2021, 07/09/2021, 07/24/2021, 08/21/2021, and 08/22/2021. A review of the Nursing Progress Notes dated 03/10/2021 at 2:51 PM indicated Resident #85 was transferred to the hospital for geriatric psychiatric services due to anxiousness, agitation, and endangering self and others. The documentation did not reveal how the resident endangered self or others. A review of the care plan, did not indicate behavior interventions were put into place after readmission. On 08/21/2021 at 2:40 PM, a review of the Nursing Progress Notes, revealed Licensed Practical Nurse (LPN) #6, observed Resident #85 grab Resident #35 by the shirt. Resident #35 attempted to pull away, and Resident #85 pulled Resident #35 closer. When Resident #85 let go of the resident's shirt, Resident #35 fell to the floor. Resident #35 sustained no apparent injury. Review of a Facility Reported Incident, 08/22/2021, revealed on 08/22/2021, Resident #85 pushed Resident #8 down, resulting in a fracture requiring surgery. Resident #8 remained in the hospital. Record review revealed a verbal aggression behavior care plan, created 08/23/2021, had a goal of decreased impulsive behaviors. Continued review revealed no care plan for physical behaviors of grabbing residents, pushing residents down, or stealing food. Observation at 9:15 AM on 08/23/2021, this Surveyor overheard the Nurse Practitioner ask Resident #85, in the hallway, why the resident had pinched and pushed another resident during the past weekend. The resident's response was not heard. A telephone interview was conducted on 08/23/2021 at 1:43 PM, with Resident #85's Responsible Party (RP). The RP stated staff had called that weekend because Resident #85 had gotten into it with another resident. The RP added Resident #85 had been sent to inpatient behavioral health services multiple times. Interview with the Director of Nursing (DON), on 08/25/2021 at 9:53 AM, revealed she was aware that Resident #85 appeared to have had an altercation with Resident #8. The DON acknowledged Resident #85 grabbed at other residents, but she did not think Resident #85 meant this as an aggressive act. Interview with Certified Nursing Assistant (CNA) #1, on 08/25/2021 at 9:16 AM, revealed at the present time Resident #85 was on a special observation schedule of every 15 minutes due to an incident over the weekend. CNA #1 stated she had worked the weekend and added on Saturday, 08/21/2021, Resident #85 had pushed Resident #35 down in the living area. The CNA added Resident #85 had grabbed Resident #35 by the shirt and then as Resident #35 tried to get away, Resident #85 let go of the shirt causing Resident #35 to fall. On Sunday, 08/22/2021, Resident #85 hit Resident #8 with the left hand. Resident #8 fell and was transferred to the hospital for a fracture. The CNA stated the only thing done on Saturday to protect other residents was taking Resident #85 to the resident's room and turning on the television. After the incident on Sunday, the CNA stated Resident #85 was taken to the bedroom, where the resident stayed until dinner. The CNA added the 15-minute checks were started on Sunday afternoon after Resident #8 had been transferred to the hospital. CNA #1 stated she worked three (3) twelve (12)-hour shifts per week, and usually at least one day during her three (3) days working, Resident #85 would slap another resident's hand, spit on other residents, and pinch or push other residents. Interview with CNA #2 on 08/25/2021 at 10:19 AM, revealed she had worked on the secure unit on Saturday 08/21/2021. At around 1:00 PM - 1:30 PM, she stated Resident #85 had a hold on Resident #35. When Resident #85 let go, Resident #35 fell , but there was no apparent injury. The CNA stated staff took Resident #85 to his/her bedroom for rest. CNA #2 stated she also worked on Sunday 08/22/2021. The CNA stated that after breakfast (10:30 AM) she had been at the nurse's station and heard Resident #85 making sounds. When she looked up, she saw Resident #85 push Resident #8 with his/her hand and saw Resident #8 fall. At that time, 15-minute checks were started for Resident #85. The CNA added she worked three (3) twelve (12) hour shifts per week, and Resident #85 usually got into an altercation with another resident at least one (1) of the three (3) days. The altercations included grabbing or poking other residents, running over other residents with the wheelchair, pinching other residents, and taking the food of other residents. The CNA indicated she reported the incidents but could not remember exact dates or who the nurse was at the time. Interview with LPN #6, on 08/25/2021 at 11:43 AM revealed that on 08/21/2021 she was sitting at the nurse's station when she heard a CNA yell Resident #85's name. LPN #6 added Resident #85 was pulling Resident #35 close by grabbing Resident #35's clothing. When Resident #85 let go of Resident #35, Resident #35 fell to the floor. LPN #6 stated Resident #85 was put to bed and stayed in the resident's room until dinner. LPN #6 stated staff was not assigned to monitor Resident #85, adding that if another resident had wandered into the room, staff would have to have waited to see if anything happened. LPN #6 stated on Sunday, 08/22/2021, Resident #85 was sitting in the common area of the unit and Resident #8 was also in the area. The LPN stated she heard Resident #8 yell and hit the floor. She stated CNA #1 and CNA #2, who were working, reported to LPN #6 that Resident #85 had pushed Resident #8 down. LPN #6 stated that while she did not see the incident first-hand, she knew Resident #8 had no history of falls and she believed what the two CNAs reported. The LPN stated she averaged working three (3) twelve (12)-hour shifts per week. Of those three (3) days, Resident #85 had a negative interaction with another resident on at least one (1) day. She cited negative interactions to include yelling at other residents and stealing food off other residents' trays. LPN #6 stated the 15-minute check sheets started on Sunday after Resident #8 was transferred to the hospital. On 08/21/2021, when Resident #85 had the aggressive interaction with Resident #35, staff had kept an eye on Resident #85, but had no documentation to support this. LPN #6 stated both incidents were reported to the weekend supervisor. During an interview with LPN #7 on 08/25/2021 at 1:20 PM, he stated that while he was a contract nurse, he had worked in the facility many times and was familiar with Resident #85. LPN #7 described Resident #85 as combative with other residents and believed Resident #85 was aware of the incidents. He supported his position by saying that when asked why another resident had been hit, Resident #85 would respond, Because I wanted to. LPN #7 stated he had not seen Resident #85 hit anyone, but he had seen the resident trying to push other residents down, grabbing other residents, and grabbing other residents' food and drink. The nurse stated he had complained to the DON about the resident's aggressive behavior, but nothing had been done. Interview with the Director of Nursing (DON), on 08/25/2021 at 2:26 PM, revealed if one resident placed their hands on another, to include pushing, kicking, and hitting, it would be considered resident-to-resident abuse and would be reported to the State. The DON stated she had not read the 08/21/2021 Nurse's Note nor talked with any of the staff that were there. She added that based on what had been reported to her by the weekend supervisor, she had not thought aggression was a part of the incident and therefore had not been abuse. Further interview on 08/26/2021 at 8:21 AM, with the DON, revealed she was unaware of Resident #85's history of aggression toward other residents. She acknowledged there should have been a care plan revision and interventions placed on 08/21/2021, when Resident #85 grabbed Resident #35 causing him/her to fall. The DON stated she was unsure if placing interventions on Saturday would have prevented the fracture to Resident #8 on 08/22/2021. The facility provided an acceptable credible Action Plan that alleged removal of the Immediate Jeopardy (IJ). The facility's Action Plan included:1. Resident #85 was reported to push Resident #8 resulting in a fractured femur. The incident was reported on 08/26/2021 and the follow up investigation was finalized and reported 08/27/2021. Resident #6 was reported to have exposed himself/herself in a group activity on 08/14/2021. This event was reported to the State Survey agency/OIG (Office of the Inspector General) 08/27/2021. Investigations going forward will include: 2. Conducting observations of the alleged victim, identification of any injuries as appropriate, location where the situation occurred, interaction and relationships between staff and other residents. 3. Interviews conducted with the alleged victim representative, perpetrator, witness, practitioner, outside agencies as needed. The facility conducted a record review for pertinent information such as progress notes, social services notes, physician, therapist and consultant notes, financial records, incident reports, reports from hospital, lab or x ray, medication records and any other agencies as deemed necessary. 4. Depending on the nature of the allegation, the facility put effective measures in place to ensure that further abuse, neglect or exploitation or mistreatment does not occur while the investigation is in progress. The facility will monitor the alleged victim and monitor the other residents at risk, by conducting management visits at different times and shifts. The facility will evaluate if the alleged victim feels safe. If they do not, immediate action will be taken to alleviate fear, i.e. room relocation, increased supervision, etc., immediate notification of the victim's practitioner and the family or the victims responsible party. The facility will oversee the implementation of corrective action and evaluate effectiveness through the QAPI process. All alleged abuse, neglect or exploitation will be monitored and recorded on a reportable event log. The investigation is in progress. 5. All residents with BIMs of 8 or above were interviewed by Social Services on 08-25-2021 and 08-26-2021 to ensure there were no concerns of safety, or feelings of abuse while in this facility. None were noted. The MOS Nurse and SS (Social Services) assistant reviewed residents with BIMS of 7 and below for any signs of change in baseline mood or behavior and normal daily routine. No changes or concerns were identified. 6. The LNHA, DON, Unit Managers, ADON, MOS, Business office, Payroll, Activities, Maintenance, Therapy, Scheduling were educated per the Regional Director of Clinical services on 08-26-2021 at 2:15 PM, on What is abuse, how to prevent abuse and neglect, when to report abuse and neglect, and to report all abuse to the LNHA immediately. The licensed Nursing Home Administrator will make the initial report to the Office of the Inspector General, Department of Community Based Services, the State Ombudsman and local Ombudsman, the responsible parties and the MD or Nurse practitioner within two hours. 7. IDT meting was held on 08-27-2021, the team met and all residents with behaviors affecting others; have interventions and care plans in place. All interventions and care plans were communicated to the floor staff on 08-27-2021. Referrals were made to psychiatric services as appropriate by assistant the Social Services Director. DON, and LNHA, and or designee educated all staff on the following: - Identify types of Abuse and Neglect. - When to report suspected abuse and neglect - Reporting of abuse and neglect directly to the administrator immediately - This education completed by 8/27/2021 - In addition, a list of all staff has been developed and no persons will be allowed to work without having completed this education prior to assuming the floor. 1. Facility system changes: i. behavior monitoring added to TAR to be completed Q shift by [name redacted] RN/Clinical Support services. ii. Facility is reviewing TAR daily in morning clinical meeting. TAR reviewed by DON on 08/27/2021. iii. A trigger report was run by RDO on 08/27/2021 and all concerns were addressed immediately. iv. The facility identified characteristics that could increase the risk for abuse such as attitudes, increase in resident behaviors, reports of shame, fear or retaliation, change in psychological, behavioral or psychosocial outcomes. v. allegations including staff to resident, resident to resident, visitor to resident, neglect, or exploitation facility is to report immediately and immediately start investigation and protect residents. vi. The LNHA had reported all investigations 08-27-2021 2. DON, LNHA, and or designee will audit: i. The Abuse QAPI tool and the reportable events logs completed monthly by the LNHA. Events audited weekly x 3 months and then quarterly x 12 months. Any concerns documented, corrected immediately, and staff educated accordingly. ii. Findings/trends reported at the monthly quality assurance and performance improvement committee by the Director of Nursing or designee for a minimum of six months. iii. QAPI meetings will occur weekly for four weeks to monitor progress and then monthly thereafter.The IJ was removed on 08/27/2021 at 6:00 PM after the survey team performed onsite verification that the Removal Action Plans had been implemented. Onsite verification of the implementation of the Removal Plan was conducted during the survey. On 08/27/2021 between the hours of 11:00 AM and 6:00 PM. Review of the educational materials indicated 100% of staff to include all departments had been completed on 08/26/2021. Twelve interviews were conducted to verify in-service training had been completed on the facility's Abuse Policy and Procedure training to include the types of abuse, what to report, to whom to report the allegations of abuse and when to report. Of those interviewed included certified nursing assistants (CNAs), licensed practical nurses (LPNs), registered nurses (RNs), housekeeping and scheduling staff. The staff interviewed revealed knowledge of what constituted abuse, what to do if abuse was observed, both staff to resident abuse and in the event of resident-to-resident abuse, when to report abuse and to whom the abuse should be reported. The interviews revealed a consistent message that staff understood not only the different types of abuse, but that resident-to-resident altercations also constituted abuse. Staff indicated that through training they understood the need to intercede immediately and to always protect the resident before reporting any incident of abuse to the Administrator. Staff also acknowledged that after assuring resident safety, the abuse should be reported immediately. Observations during the survey revealed Resident #85 was receiving 1:1 supervision. Record review for Resident #85 indicated the care plan had been revised to include exhibited physical behaviors and stealing food from other residents' trays. Interventions for Resident #85 included 1:1 supervision, psychiatric referral, laboratory testing and a care conference with family members to determine the resident's past interest. Resident #6 had been placed on every 15 minute checks, and the care plan had been updated on measures to address behaviors, and an IDT meeting was held on 08/27/2021. Resident #6 was seen by psych services on 08/25/2021. Surveyors verified 54 Residents with BIMS 8 or above were interviewed and indicated they felt safe. The LNHA, DON, Unit Managers, ADON, MDS, business office, payroll department, activities, maintenance, therapy, scheduling received education on what constitutes abuse and when to report.

Based on interviews, record reviews, and facility policy review, it was determined the facility failed to report abuse allegations and injuries of unknown origin to the State Survey Agency for six (6) (Residents #35, #8, #58, #54, #83, and #87) out of six (6) residents reviewed for abuse. Resident #6 had multiple occurrences of cursing, yelling, throwing things, threatening other residents, and publicly masturbating in front of other residents. These incidents were not reported. Resident #85 had physical or verbal altercations with other residents and the incidents were not reported. One of the physical altercations with Resident #85 caused Resident #8 to fall, and Resident #8 sustained a [CONDITION(S)]. Resident #83 had injuries of unknown origin, including bruising and a [CONDITION(S)], that were not reported to the State Survey Agency. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was identified at 483.12 (Freedom from Abuse, Neglect, and Exploitation) at a scope and severity of K. The Immediate Jeopardy (IJ) determined to exist on 04/01/2021 when Resident #6 was yelling and cursing at another resident and the facility failed to investigate the allegation of verbal abuse. The Director of Nursing (DON) and Nursing Home Administrator (NHA) were notified of the IJ and provided with the IJ Template on 08/26/2021 at 12:00 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 08/27/2021 at 6:00 PM. The IJ was removed on 08/27/2021 at 6:00 PM after the survey team performed onsite verification that the Removal Plans had been implemented. Noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that was not immediate jeopardy. The findings included: Review of the facility's policy, The Abuse Prevention Program, reviewed September 2020 indicated under Paragraph #7 that allegations of abuse would be investigated and reported within the timeframes required by federal requirements.A review of the facility;s policy, titled, Abuse and Neglect - Clinical Protocol, revised July 2017, revealed abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. The management and staff, with the support of the physicians, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. 1. Record review revealed the facility admitted Resident #6 on 01/19/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] indicated Resident #6's cognition was severely impaired with a Brief Interview for Mental Status (BIMS) of three (3) out of fifteen (15). The resident required supervision with ambulation using a walker. This MDS indicated the resident had no behaviors. The most recent Quarterly MDS, dated [DATE] indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Progress Note, dated 04/01/2021, indicated Resident #6 was cursing and yelling at another resident. There was no evidence provided that this was reported to the State Survey Agency. Review of a Progress Note, dated 04/03/2021, indicated Resident #6 was cursing other residents and making multiple verbal threats. There was no evidence provided that this was reported to the State Survey Agency. Review of Progress Note, dated 04/04/2021 at 5:20 PM, indicated Resident #6 was extremely agitated and yelling at other residents. There was no evidence provided that this was reported to the State Survey Agency. Review of a Progress Note, dated 04/09/2021 at 10:04 AM, indicated Resident #6 was verbally aggressive with other residents, threatening harm, and cursing. There was no evidence provided that this was reported to the State Survey Agency . Review a Progress Note, dated 04/13/2021 at 7:50 AM, indicated Resident #6 was cursing and threatening to harm other residents. There was no evidence provided that this was reported to the State Survey Agency. Review of a Progress Note, dated 04/16/2021, indicated Resident #6 was yelling and cursing at other residents, and the facility had the Director of Nursing come back to the unit. There was no evidence provided that this was reported to the State Survey Agency. Review of a Progress Note, dated 04/18/2021, indicated Resident #6 was yelling, throwing stuff, and cussing at other residents. There was no evidence provided that this was reported to the State Survey Agency . Review of a Progress Note, dated 05/08/2021, indicated Resident #6 was yelling and cussing at other residents. There was no evidence provided that this was reported to the State Survey Agency. Review of a Progress Note, dated 05/29/2021, indicated Resident #6 had been cursing, yelling, and threatening other residents. There was no evidence provided that showed this was reported to the State Survey Agency. Review of a Progress Note, dated 06/29/2021, indicated Resident #6 was threatening to hit, was cursing, and was being verbally aggressive with other residents. Review of a Progress note, dated 07/27/2021, indicated Resident #6 was cursing and threatening to hit other residents. There was no evidence provided that showed this was reported to the State Survey Agency. Review of a Progress Note, dated 08/11/2021, indicated Resident #6 was being verbally aggressive with other residents and was threatening to harm other residents. There was no evidence provided that showed this was reported to the State Survey Agency. During an interview on 08/24/2021 at 3:15 PM, Licensed Practical Nurse (LPN) #3 indicated Resident #6 threatened to kill other residents, and it was just a matter of time before the resident hurt another resident. During an interview on 08/24/2021 at 2:16 PM, Resident #54 indicated Resident #6 had kicked Resident #54 in the leg with three (3) staff members present who witnessed the incident. During an interview on 08/24/2021 at 3:30 PM, the Activity Assistant (AA) indicated she had witnessed Resident #6 kick Resident #54. Record review and interview revealed there were no reports filed with the State Survey Agency for the verbal, physical, or sexual abuse allegations. During an interview on 08/25/2021, with the DON revealed allegations of abuse were to be reported to their immediate supervisor, and it would then be reported to the DON or NHA. She indicated she was not aware of the allegations of physical, verbal, and sexual abuse. The DON indicated she would report verbal allegations of abuse depending on how the other residents felt about it. She indicated the incident of Resident #6 exposing self during an activity should have been reported. 2. Record review revealed the facility admitted Resident #85 on 01/27/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 85's medical record revealed the resident had previously been discharged from another skilled nursing facility due to two (2) resident-to-resident altercations in two (2) days with behaviors that had become more aggressive leading up to the transfer. Review of the Nursing Progress Notes dated 03/10/2021 at 2:51 PM revealed Resident #85 was transferred to the hospital for geriatric psychiatric services due to anxiousness, agitation, and endangering self and others. The documentation did not reveal how the resident endangered self or others. The facility readmitted Resident #85 on 03/22/2021. Upon readmission Resident #85 experienced agitation, restlessness, [CONDITION(S)], and sought companionship. Review of a SBAR dated 05/22/2021 indicated Resident #85 pushed another resident down. Review of the facility's list of State-Reported Incidents for the past three (3) months revealed there was no report for this incident. There was no documentation presented that supported an investigation of this incident had been completed. Review of a facility reported incident (FRI) dated 07/06/2021 indicated a certified nursing assistant (CNA) came out of the shower room and saw Resident #85 in the hallway with two (2) other unidentified residents, with all residents hitting one another. Review of the facility's list of state-reported incidents revealed a report had not been submitted to the State. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #85 as moderately cognitively impaired with a Brief Interview for Mental Status score of nine (9). Physical behaviors occurred (1) - three (3) days during the assessment period, other behaviors not directed toward others were documented as occurring (1) - three (3) days, and rejection of care (1) - three (3) days. No verbal behaviors were identified as occurring during the assessment period. A review of the facility's list of state-reported incidents revealed no reports had been submitted to the State during the assessment period, although the MDS indicated there had been one (1) - three (3) incidents during the assessment period. Record review revealed on 08/21/2021 at 2:40 PM, Licensed Practical Nurse (LPN) #6 documented she observed Resident #85 grab Resident #35 by the shirt. Resident #35 attempted to pull away, and Resident #85 pulled the resident closer. When Resident #85 let go of the resident's shirt, Resident #35 fell to the floor. Resident #35 sustained no injury. Review of the facility's list of state-reported incidents revealed there had been no submission of a report for Resident #85's incident on 08/21/2021. Licensed Practical Nurse (LPN) #6 was interviewed on 08/25/2021 at 11:43 AM. She stated on 08/21/2021, she was sitting at the nurse's station when she heard a CNA yell Resident #85's name. LPN #6 stated the 08/21/2021 incident with Resident #85 was reported to the weekend supervisor. The Director of Nursing (DON) was interviewed on 08/25/2021 at 2:26 PM. She stated if one (1) resident placed their hands on another, to include pushing, kicking, and hitting, it would be considered resident-to-resident abuse and would be reported to the State agencies. The DON stated she had not read the 08/21/2021 Nurse's Note or talked with any of the staff that were there. She added that based on what had been reported to her by the Weekend Supervisor, she had not thought aggression was a part of the incident and therefore, it was not considered abuse. The DON stated that was the reason the 08/21/2021 incident involving Resident #85 had not been reported or investigated. The DON reviewed the state-reported folder for the 05/07/2021 incident, including the CNA's statement dated 05/05/2021, and stated the CNA might have dated the statement wrong. Observation revealed that on 08/25/2021 at 12:16 PM, the Nursing Home Administrator (NHA) brought in the facility's state-reported incidents for the past three (3) months. When asked, the NHA confirmed the folders she brought in represented all she had reported to the State Agency or investigated for the past three (3) months. A review of the information provided by the facility indicated Resident #85 had two (2) incidents reported to the State agencies, one (1) incident for 05/05/2021 and another for 08/22/2021. The DON was interviewed on 08/26/2021 at 8:21 AM. She stated she had not reported the incident or investigated the incident involving Resident #85 that occurred on 08/21/2021 due to the way the incident had been presented to her. She reviewed the remaining physically aggressive incident reports and Nurse's Notes and had no reason why those incidents had not been reported or investigated. 3. Record review revealed the facility admitted Resident #83 on 10/16/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change Minimum Data Set (MDS) for Resident #83, dated 07/27/2021, revealed the facility assessed that Resident #83 had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated significant cognitive impairment. Resident #83 required extensive assistance of two (2) people with bed mobility, dressing, and toileting. Resident #83 required limited assistance of one person with eating. The resident was totally dependent on staff for bathing. Review of a Progress Note dated 07/20/2021 at 1:05 PM revealed, CNAs asked this nurse to come to room to look at resident. When this nurse went in the room the CNA's (sic) showed me that the resident had some yellow bruising to [the resident's] right inner thigh that wrapped around to the front and back of [the] thigh, 3 small open areas to [the] scrotum, and some discoloration spots to [the] right outer foot. An interview on 08/26/2021 at 12:48 PM with the DON revealed that if an injury was found that has no immediate known cause, it would be unknown and should be reported. The DON stated that when staff reported on 07/20/2021, significant bruising was observed on the resident's thigh it was not reported to the State Survey Agency at that time. The DON stated she concluded it was most likely a result of improper incontinent care. 3b. Review of a Progress Note dated 07/23/2021 at 5:46 PM, for Resident #83 revealed, ER nurse called to inform of acute right [CONDITION(S)], unknown cause at this time, DON [Director of Nursing] aware. [The resident had been sent out for a possible bowel obstruction. During the CT scan for this, the fracture was found.] An interview on 08/26/2021 at 12:48 PM with the Director of Nursing (DON) revealed she did not report the right [CONDITION(S)] to the State Survey Agency that was discovered in the hospital and reported to the facility on [DATE]. The DON stated it was not reported since she felt it was also a result of improper incontinent care and that she did not feel either incident met the criteria for reporting. The facility's Removal Plan included: 1. Resident #85 was reported to push Resident #8 resulting in a fractured femur. The incident was reported on 08/26/21 and the follow up investigation was finalized and reported 08/27/21. Resident #6 was reported to have exposed (himself/herself) in a group activity on 08/14/21. This event reported to OIG (Office of the Inspector General/Sttae Survey Agency) 08/27/21. 2. All incidents identified during the survey reported on 08/27/2021 3. All alleged violations involving abuse, neglect, exploitation, mistreatment, including injuries of unknown source and misappropriation were reported immediately but not later than two hours after the allegation if they result in serious bodily injury, but not later than 24 hours if they do not involve abuse and do not result in serious bodily injury. 4. All the findings of the investigation reported to the Administrator and to the Survey Agency within 5 working days. 5. Alleged violations identified are reported to the Administrator. LNHA will immediately report and protect the identified residents prior to conducting the investigation. 6. LNHA, DON, Unit Managers [UM], ADON, MOS [sic] [Minimum Data Set, MDS], Business office, Payroll, Activities, Maintenance, Therapy, Scheduling were educated per Regional Director of Clinical services on 08-26-2021 at 2:15 pm on What is abuse, how to prevent abuse and neglect, when to report abuse and neglect, and to report all abuse to the LNHA immediately. The licensed Nursing Home Administrator makes the initial report to the Office of the Inspector General, Department of Community Based Services, the State Ombudsman and Local Ombudsman, the responsible parties and the MD or Nurse practitioner within two hours. 7. IDT [interdisciplinary team] meeting held 8-27-2021 reviewed behaviors for all residents that have behaviors affecting others. Interventions and care plans were put in place by DON, UM and MOS [sic, MDS]. All interventions and care plans communicated to floor staff per Kardex, and referrals made to psychiatric services as appropriate. DON, and LNHA, and or designee educated all staff on the following: - Identify types of Abuse and Neglect. - When to report suspected abuse and neglect - Reporting of abuse and neglect directly to the administrator immediately - This education completed 08/27/2021 - In addition, a list of all staff has been developed and no persons will be allowed to work without having completed this education prior to assuming the floor. 1. DON, LNHA, and or designee reported all findings to QAPI i. The Abuse QAPI [quality assurance performance improvement] tool and the reportable events logs completed monthly by the LNHA. Events audited weekly x 3 months and then quarterly x 12 months. Any concerns will be documented, corrected immediately, and staff educated accordingly. ii. Findings/trends reported at the monthly quality assurance and performance improvement committee by the Director of Nursing or designee for a minimum of six months. iii. QAPI meetings weekly for four weeks to monitor progress and then monthly thereafter. The IJ was removed on 08/27/2021 at 6:00 PM after the survey team performed onsite verification that the Removal Plans had been implemented. Onsite verification of the implementation of the Removal Plan was conducted during the survey. On 08/27/2021 between the hours of 11:00 AM and 6:00 PM. Review of the educational materials indicated 100% of staff to include all departments had been completed on 08/26/2021. Twelve interviews were conducted to verify in-service training had been completed on the facility's Abuse Policy and Procedure training to include the types of abuse, what to report, to whom to report the allegations of abuse and when to report. Of those interviewed included certified nursing assistants (CNAs), licensed practical nurses (LPNs), registered nurses (RNs), housekeeping and scheduling staff. The staff interviewed revealed knowledge of what constituted abuse, what to do if abuse was observed, both staff to resident abuse and in the event of resident-to-resident abuse, when to report abuse and to whom the abuse should be reported. The interviews revealed a consistent message that staff understood not only the different types of abuse, but that resident-to-resident altercations also constituted abuse. Staff indicated that through training they understood the need to intercede immediately and to always protect the resident before reporting any incident of abuse to the Administrator. Staff also acknowledged that have assuring resident safety, the abuse should be reported immediately. Observations during the survey revealed Resident #85 was receiving 1:1 supervision. Record review for Resident #85 indicated the care plan had been revised to include exhibited physical behaviors and stealing food from other resident's trays. Interventions for Resident #85 included 1:1 supervision, psychiatric referral, laboratory testing and a care conference with family members to determine the resident's past interest. Resident #6 had been placed on every 15 minute checks, and the care plan had been updated on measures to address behaviors, and an IDT meeting was held on 08/27/2021. Resident #6 was seen by psych services on 08/25/2021. Surveyors verified 54 Residents with BIMS 8 or above were interviewed and indicated they felt safe. The LNHA, DON, unit managers, ADON, MDS, business office, payroll department, activities, maintenance, therapy, scheduling received education on what constitutes abuse and when to report.

Based on interviews, record reviews, and facility policy review, it was determined that the facility failed to investigate abuse allegations for six (6) (Residents #35, #8, #58, #54, #87 and #83) out of six (6) residents reviewed for abuse by Resident #85 and Resident #6. Resident #6 had multiple occurrences of cursing, yelling, throwing things, threatening other residents, and publicly masturbating in front of other residents. These incidents were not investigated. Resident #85 had physical or verbal altercations with other residents and the incidents were not investigated. One of the physical altercations with Resident #85 caused Resident #8 to fall, and Resident #8 sustained a [CONDITION(S)]. Resident #83 had injuries of unknown origin, including bruising and a [CONDITION(S)], that were not thoroughly investigated. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 (Freedom from Abuse, Neglect, and Exploitation) at a scope and severity of K. The Immediate Jeopardy (IJ) began on 04/01/2021 when Resident #6 was yelling and cursing at another resident and the facility failed to investigate the allegation of verbal abuse. The Director of Nursing (DON) and Nursing Home Administrator (NHA) were notified of the IJ and provided with the IJ Template on 08/26/2021 at 12:00 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 08/27/2021 at 6:00 PM. The IJ was removed on 08/27/2021 at 6:00 PM after the survey team performed onsite verification that the Removal Plans had been implemented. Noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that was not immediate jeopardy. The findings included: Review of the facility's The Abuse Prevention Program reviewed September 2020 indicated under Paragraph #7 that allegations of abuse would be investigated and reported within the timeframes required by federal requirements.A review of the facility's policy, titled, Abuse and Neglect - Clinical Protocol, revised July 2017, revealed abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also included the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. The management and staff, with the support of the physicians, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. 1. Record review revealed the facility admitted Resident #6 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set, dated dated dated [DATE] indicated Resident #6's cognition was severely impaired with Brief Interview for Mental Score (BIMS) of three (3) out of fifteen (15). Review of a Progress Note, dated 04/01/2021, indicated Resident #6 was cursing and yelling at another resident. There was no evidence provided that showed this was investigated. Review of a Progress Note, dated 04/03/2021, revealed Resident #6 was cursing other residents and making multiple verbal threats. There was no evidence provided that showed this was investigated. Review of a Progress Note, dated 04/04/2021 at 5:20 PM, indicated Resident #6 was extremely agitated and yelling at other residents. There was no evidence provided that showed this was investigated. Review of a Progress Note, dated 04/09/2021 at 10:04 AM, indicated Resident #6 was verbally aggressive with other residents, threatening harm, and cursing. There was no evidence provided that showed this was investigated. Review of a Progress Note, dated 04/13/2021 at 7:50 AM, indicated Resident #6 was cursing and threatening to harm other residents. There was no evidence provided that showed this was investigated. Review of a Progress Note, dated 04/16/2021, indicated Resident #6 was yelling and cursing at other residents, and the facility had the Director of Nursing come back to the unit. There was no evidence provided that showed this was investigated. Review of a Progress Note, dated 04/18/2021, indicated Resident #6 was yelling, throwing stuff, and cussing at other residents. There was no evidence provided that showed this was investigated. Review of a Progress Note, dated 04/30/2021, indicated Resident #6 was publicly masturbating during an activity. There was no evidence provided that showed this was investigated. Review of a Progress Note, dated 05/08/2021, indicated Resident #6 was yelling and cussing at other residents. There was no evidence provided that showed this was investigated. Review of a Progress Note, dated 05/29/2021, indicated Resident #6 had been cursing, yelling, and threatening other residents. There was no evidence provided that showed this was investigated. Review of a Progress Note, dated 06/05/2021, indicated Resident #6 was verbally aggressive with another resident. There was no evidence provided that showed this was investigated. Review of a Progress Note, dated 06/14/2021, indicated Resident #6 had been cursing and yelling at other residents and throwing items in the resident's room. There was no evidence provided that showed this was investigated. Review of a Physician's Progress Note, dated 06/16/2021, indicated Resident #6 was noted to have the potential to harm staff, other residents, or self. Review of a Physician's Progress Note, dated 06/17/2021, indicated Resident #6 had a long history with physical aggression related to [CONDITION(S)] [CONDITION(S)]. Review of a Progress Note, dated 06/29/2021, indicated Resident #6 was threatening to hit, was cursing, and was being verbally aggressive with other residents. There was no evidence provided that showed this was investigated. Review of a Progress Note, dated 07/27/2021, indicated Resident #6 was cursing and threatening to hit other residents. There was no evidence provided that showed this was investigated. Review of a Progress Note, dated 08/11/2021, indicated Resident #6 was being verbally aggressive with other residents and was threatening to harm other residents. There was no evidence provided that showed this was investigated. Review of a Progress Note, dated 08/14/2021, indicated Resident #6 had exposed himself/herself and touched self inappropriately in front of other residents during an activity. The DON had come to the unit to talk to the resident regarding behaviors. There was no evidence provided that showed this was investigated. Review of a Physician's Progress Note, dated 08/18/2021 at 12:00 PM, indicated Resident #6 was verbally and physically aggressive, was throwing things, trying to break things, slamming the walker, and yelling and cursing. [MEDICATION(S)] 2.5 mg (milligrams) was given. During an interview on 08/24/2021 at 3:15 PM, Licensed Practical Nurse (LPN) #3 indicated Resident #6 threatened to kill other residents, and it was just a matter of time before the resident hurt another resident. She indicated the facility's administration was aware of Resident #6's aggressive physical and verbal behaviors. During an interview on 08/24/2021 at 2:16 PM, Resident #54 indicated Resident #6 had kicked Resident #54 in the leg with three (3) staff members present who witnessed the incident. During an interview on 08/24/2021 at 3:30 PM, the Activity Assistant (AA) indicated she had witnessed Resident #6 kick Resident #54. During an interview on 08/26/2021 at 12:15 PM, the AA indicated Resident #6 exposed self to two (2) female residents during an airshow while outside in the courtyard. During an interview on 08/26/2021 at 12:20 PM, Resident #58 indicated Resident #6 had exposed self to Resident #58 during the airshow, and that it made the resident feel uncomfortable, wondering what [Resident #58] did to provoke this. During an interview on 08/26/2021 at 12:30 PM, Resident #87 indicated Resident #6 had their genitals in his/her hand and was exposing self to Resident #58. Resident #87 indicated (gender) felt bad for Resident #58. There were no investigations completed for these verbal, physical, or sexual abuse allegations. During an interview on 08/25/2021 at 2:23 PM, the DON indicated allegations of abuse were to be reported to their immediate supervisor, and it would then be reported to the DON or Nursing Home Administrator (NHA). The DON stated she was not aware of the allegations of physical, verbal, and sexual abuse. The DON indicated she would report verbal allegations of abuse depending on how the other residents felt. She indicated the incident of Resident #6 exposing self during an activity should have been reported. 2. Review of the facility's Abuse Prevention Program, under Paragraph #7, revealed that allegations of abuse would be investigated and reported within the timeframes required by federal requirements. Record review revealed the facility admitted Resident #85 on 01/27/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS), dated [DATE], indicated the facility assessed Resident #85 as moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15). Physical behaviors occurred one (1) to three (3) days during the assessment period, other behaviors not directed toward others were documented as occurring one (1) to three (3) days, and rejection of care one (1) to three (3) days. No verbal behaviors were identified as occurring during the assessment period. Review of the Nurse's Progress Notes and/or incident reports indicated Resident #85 had physical or verbal altercations with other residents on the following days: 06/13/2021, 07/09/2021, 07/24/2021, 08/21/2021 and 08/22/202; however, there was no documented evidence the incidents were investigated by the facility. Record review revealed that on 08/21/2021 at 2:40 PM, Licensed Practical Nurse (LPN) #6 documented she observed Resident #85 grab Resident #35 by the shirt. Resident #35 attempted to pull away, and Resident #85 pulled Resident #35 closer. When Resident #85 let go of Resident #35's shirt, Resident #35 fell to the floor. Resident #35 sustained no apparent injury. Certified Nursing Assistant (CNA) #1 was interviewed on 08/25/2021 at 9:16 AM. CNA #1 stated at the present time, Resident #85 was on a special observation schedule of every 15 minutes due to an incident over the weekend. CNA #1 stated she had worked the weekend and stated on Saturday, 08/21/2021, Resident #85 had pushed Resident #35 down in the living area. The CNA stated Resident #85 had grabbed Resident #35 by the shirt, and. then as Resident #35 tried to get away, Resident #85 let go of the shirt causing Resident #35 to fall. The CNA stated Resident #85 had been taken to the room and remained in the room until dinner. No special monitoring had been placed for Resident #85. The CNA stated 15-minute checks had not started until 08/22/2021 when Resident #85 pushed Resident #8 down, resulting in a fracture for Resident #8. CNA #2 was interviewed on 08/25/2021 at 10:19 AM. She stated she had worked in the secure unit on Saturday 08/21/2021. Further interview revealed around 1:00-1:30 PM, Resident #85 had a hold on Resident #35's shirt. When Resident #85 let go, Resident #35 fell , but there was no apparent injury. The CNA stated staff took Resident #85 to the bedroom for rest. CNA #2 stated she also worked on Sunday 08/22/2021. The CNA stated after breakfast (10:30 AM) she was at the nurse's station and heard Resident #85 making sounds. When she looked up, she saw Resident #85 push Resident #8 and saw Resident #8 fall. At that time, 15-minute checks were started for Resident #85. Licensed Practical Nurse (LPN) #6 was interviewed on 08/25/2021 at 11:43 AM. She stated on 08/21/2021 she had been sitting at the nurse's station when she heard a CNA yell Resident #85's name. LPN #6 added Resident #85 was pulling Resident #35 close by grabbing Resident #35's clothing. When Resident #85 let go of Resident #35, Resident #35 fell to the floor. LPN #6 stated Resident #85 was put to bed and stayed in the room until dinner. Staff was not assigned to monitor Resident #85, adding that if another resident had wandered into the room, staff would have to have waited to see if anything happened. The nurse stated the incidents had been reported to the weekend supervisor. During the survey, the weekend supervisor was supposed to come in for an interview, but she did not. Follow up phone calls made to the weekend supervisor were not answered. The DON was interviewed on 08/25/2021 at 2:26 PM. The DON stated she had not investigated the incident that occurred on 08/21/2021. She had not read the Nurse's Notes regarding the incident nor talked to any staff involved based on the report received from the weekend supervisor. The DON stated the incident was investigated by the weekend supervisor. Requests were made several times for investigative information related to the 08/21/2021 incident. No information was provided. The DON reviewed the Nurse's Progress Notes and incident reports from other physically aggressive incidents involving Resident #85 and other residents. She stated she would look for any investigations and if found would return them to the Surveyors for review. No investigations were provided. When the DON reviewed the SBARs or the incident reports for the other incidents, she was unable to provide documentation of investigation. 3a. Record review revealed Resident #83 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Significant Change Minimum Data Set for Resident #83 dated 07/27/2021 indicated that Resident #83 had a Brief Interview for Mental Status (BIMS) score of zero (00) out of fifteen (15), indicating significant cognitive impairment. Resident #83 required extensive assistance of two (2) persons with bed mobility, dressing, and toileting. Resident #83 required limited assistance of one person with eating. The resident was totally dependent on staff for bathing. A review of a Progress Note dated 07/20/2021 at 1:05 PM revealed, CNAs [Certified Nurse Aide] asked this nurse to come to room to look at resident. When this nurse went in the room the CNA's [sic] showed me that the resident had some yellow bruising to [the resident's] right inner thigh that wrapped around to the front and back of [the] thigh, 3 small open areas to [the] scrotum, and some discoloration spots to [the] right outer foot. An interview on 08/26/2021 at 12:48 PM, with the Director of Nursing (DON) revealed that when staff reported observing significant bruising on Resident #83's thigh on 07/20/2021, the Assistant Director of Nursing (ADON) talked to the staff about their observations. The DON stated that after the ADON spoke to staff, it was determined that CNA staff probably accidentally caused the bruising while providing care. The DON stated that due to the resident's contractures, staff must hold the resident's thighs apart while providing incontinent care. The DON acknowledged there was no documentation of those conversations or determination of the cause. The DON stated she did not ask the ADON for any documentation related to her findings, but there was education provided to the staff. The DON further stated that the nurse practitioner (NP) was made aware, and that she followed up on it. During the interview, the DON reviewed the progress notes and verified the NP did not document anywhere that there was ever any follow up on the bruising when she saw the resident on 07/20/2021. When asked if she would expect staff to document that injuries of an unknown origin are followed up on, the DON stated she would expect nurses to act according to their license and document accordingly. An interview on 08/26/2021 at 12:48 PM with the Nursing Home Administrator (NHA) revealed that when the bruise on Resident #83 was reported by the CNA staff, the ADON talked to staff about the bruise. The NHA stated she did not follow up with the ADON to see if she documented anything in relation to her investigation. The NHA stated there was no documentation that an investigation into how the bruising occurred was completed. An interview on 08/26/2021 at 1:38 PM with the ADON revealed she was on E Hall on 07/20/2021 when staff observed bruising to Resident #83's thigh and staff informed the DON and NP. The ADON stated she looked at the resident's thigh and confirmed bruising and assumed it occurred when CNAs were providing perineal care. The ADON stated staff would use the bend of their arms to open the resident's legs in order to clean the resident's groin and thigh area, and that may have caused the bruising. The ADON stated there was no documentation that staff were interviewed about the bruising. The ADON stated at that time, the ADON provided information to staff on proper perineal care and did education, but there was no documentation in relation to the education and that no staff signed that they attended. The ADON stated it was very informal, and she did not document anything in the electronic medical record because the NP was aware. The ADON stated she assumed the NP was documenting about it. The ADON was unaware that the NP never mentioned or documented anything in relation to the bruising on the resident's thigh but confirmed she never checked to make sure there was documentation. 3b. Review of Resident #83's Progress Note dated 07/23/2021 at 5:46 PM, revealed, ER nurse called to inform of acute right [CONDITION(S)], unknown cause at this time, DON aware. [The resident had been sent out for a possible bowel obstruction. During the computer tomography (CT) scan for this, the fracture was found.] An interview on 08/25/2021 at 12:00 PM, with the Director of Nursing (DON) revealed she was aware that the hospital reported on 07/23/2021 that Resident #83 had an acute right [CONDITION(S)]. The hospital did additional testing, and it was ruled as a chronic condition and not a new acute injury. The DON stated she would get the hospital records and provide those to the Surveyor. The DON also stated she was not sure why there was not any documentation in the Progress notes related to the follow-up or outcome of the final diagnosis. Review of the Imaging dated 07/24/2021 of the CT Cystogram per contrast protocol revealed Resident #83 had a comminuted and impacted fracture in the proximal right femur in the sub-capital region. Further review revealed the assessment was right femoral neck fracture of undetermined age. An interview on 08/26/2021 at 12:48 PM with the DON revealed she did not feel Resident #83's fracture was an injury of unknown origin and therefore it did not need to be investigated. The DON stated they received a report on 07/24/2021 from urology and from the CT scan, and that there were two different findings, but she did not follow up with either urology or with the hospital about the CT scan to verify both results. The DON stated she never contacted urology to ask how they made their determination that it appears to be a chronic since the CT scan contradicted the urology report stating there was a comminuted and impacted fracture in the right femur of undetermined age. The DON stated the facility never initiated an investigation into how the fracture occurred or interviewed any staff in relation to the fracture. The DON stated she felt the fracture was also a result of how the bruising was determined to have been caused due to staff separating the resident's legs during care.The facility's Removal Plan included: 1. Resident #85 was reported to push Resident #8 resulting in a fractured femur. The incident was reported on 08/26/21 and the follow up investigation finalized and reported 08/27/21. Resident #6 was reported to have exposed [himself/herself] in a group activity on 08/14/21. This event reported to OIG [Office of Inspector General] 08/27/21. Investigations going forward will include: - Conducted observations of the alleged victim, identification of any injuries as appropriate, location where the situation occurred, interaction and relationships between staff and other residents. - Interviews conducted with the alleged victim representative, perpetrator, witness, practitioner, outside agencies as needed. The facility conducted a record review for pertinent information such as progress notes, social services notes, physician, therapist and consultant notes, financial records, incident reports, reports from hospital, lab or x ray, medication records and any other agencies as deemed necessary. - Depending on the nature of the allegation, the facility has put effective measures in place to ensure that further abuse, neglect or exploitation or mistreatment does not occur while the investigation is in progress. The facility will monitor the alleged victim and monitor the other residents at risk, by conducting management visits at different times and shifts. The facility evaluated if the alleged victim felt safe. If they do not, immediate action will be taken to alleviate fear, i.e. room relocation, increased supervision, etc., immediate notification of the victim's practitioner and the family or the victims responsible party. The facility oversees the implementation of corrective action and evaluates effectiveness through the QAPI process. All alleged abuse, neglect or exploitation monitored and recorded on a reportable event log. 2. All residents with BIMs of 8 or above were interviewed by Social Services on 08-25-2021 and 08-26-2021 to ensure there were no concerns of safety, or feelings of abuse while in this facility. None were noted. MOS nurse and SS assistant reviewed residents with BIMS of 7 and below for any signs of change in baseline mood or behavior and normal daily routine. No changes or concerns were identified. 3. LNHA, DON, Unit Managers, ADON, MOS, Business office, Payroll, Activities, Maintenance, Therapy, Scheduling were educated per regional director of Clinical services on 8-26-2021 at 2:15 PM on What is abuse, how to prevent abuse and neglect, when to report abuse and neglect, and to report all abuse to the LNHA immediately. The licensed Nursing Home Administrator will make the initial report to the Office of the Inspector General, Department of Community Based Services, the State Ombudsman and Local Ombudsman, the responsible parties and the MD or Nurse practitioner within two hours. 4. IDT meeting held 8-27-2021; behaviors reviewed to ensure all residents that have behaviors affecting others have interventions and care plans in place. All interventions and care plans were communicated to floor staff by way of the Kardex. Education on this provided by DON on 8-27-2021. Referrals were made to psychiatric services as appropriate by Social services assistant. DON, and LNHA, and or designee educated all staff on the following: - Identify types of Abuse and Neglect. - When to report suspected abuse and neglect - Reporting of abuse and neglect directly to the administrator immediately - This education completed by 8/27/2021 - In addition, a list of all staff has been developed and no persons will be allowed to work without having completed this education prior to assuming the floor. 1. Facility system changes: i. Behavior monitoring to TAR to be completed every shift. By the RN ii. Facility has reviewed TAR daily in morning clinical meeting. Reviewed 8-27-2021 by DONs iii. Weekend Manager reviews TAR every weekend. iv. IDT team reviews weekly TAR meeting to ensure new interventions were effective and care plans were updated. Review nursing notes for trigger words daily to identify events that occurred throughout the day. Any triggers reported to the Administrator immediately and the licensed Nursing Home Administrator will make the initial report to the Office of the Inspector General (State Survey Agency), Department of Community Based Services, the State Ombudsman and Local Ombudsman, the responsible parties and the MD or Nurse practitioner within two hours. v. Behaviors affecting others addressed immediately as appropriate, residents with noted behaviors will be referred to psych services. DON, LNHA, and or designee audited: i. The Abuse QAPI tool and the reportable events logs completed monthly by the LNHA. Events audited weekly x 3 months and then quarterly x 12 months. Any concerns documented, corrected immediately, and staff will be educated accordingly. ii. Findings/trends reported at the monthly quality assurance and performance improvement committee by the Director of Nursing or designee for a minimum of six months. iii. QAPI meetings weekly for four weeks to monitor progress and then monthly thereafter. The IJ was removed on 08/27/2021 at 6:00 PM after the survey team performed onsite verification that the Removal Plans had been implemented. Onsite verification of the implementation of the Removal Plan was conducted during the survey. On 08/27/2021 between the hours of 11:00 AM and 6:00 PM. Review of the educational materials indicated 100% of staff to include all departments had been completed on 08/26/2021. 1. Resident #85 was reported to push Resident #8 resulting in a fractured femur. The incident was reported on 08/26/2021 and the follow up investigation finalized and reported 08/27/2021. Resident #6 was reported to have exposed [himself/herself] in a group activity on 08/14/2021. This event was reported to OIG on 08/27/2021. 2. Surveyors verified 54 Residents with BIMS 8 or above were interviewed and indicated they felt safe. 3. Review of the educational materials indicated 100% of staff to include all departments had been completed on 08/26/2021. Twelve interviews were conducted on 08/27/2021 between the hours of 11:00 AM - 6:00 PM to verify in-service training had been completed on the facility's Abuse Policy and Procedure training to include the types of abuse, what to report, to whom to report the allegations of abuse and when to report. Of those interviewed included certified nursing assistants (CNAs), licensed practical nurses (LPNs), registered nurses (RNs), housekeeping and scheduling staff. The staff interviewed revealed knowledge of what constituted abuse, what to do if abuse was observed, both staff to resident abuse and in the event of resident-to-resident abuse, when to report abuse and to whom the abuse should be reported. The interviews revealed a consistent message that staff understood not only the different types of abuse, but that resident-to-resident altercations also constituted abuse. Staff indicated that through training they understood the need to intercede immediately and to always protect the resident before reporting any incident of abuse to the Administrator. Staff also acknowledged that have assuring resident safety, abuse should be reported immediately. The LNHA, DON, unit managers, ADON, MDS, business office, payroll department, activities, maintenance, therapy, scheduling received education on what constitutes abuse and when to report. 4. Observations during the survey revealed Resident #85 was receiving 1:1 supervision. Record review for Resident #85 indicated the care plan had been revised to include exhibited physical behaviors and stealing food from other resident's trays. Interventions for Resident #85 included 1:1 supervision, psychiatric referral, laboratory testing and a care conference with family members to determine the resident's past interest. Resident #6 had been placed on every 15-minute checks, and the care plan had been updated on measures to address behaviors, and an IDT meeting was held on 08/27/2021. Resident #6 was seen by psych services on 08/25/2021.

Based on interviews, record reviews and reviews of the facility's policies, it was determined the facility failed to ensure each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychological well-being, in accordance with the comprehensive assessment and plan of care. This deficient practice affected one (1) (Resident #6) of six (6) sampled residents reviewed for behaviors. Specifically, Resident #6 displayed behaviors directed toward other residents, and no new interventions were implemented to address behaviors. Resident #6 had multiple episodes of verbal and physical aggression towards other residents. Resident #6 exposed self sexually during an activity. Staff reported that when Resident #6 came into the common area, other residents left due to the resident's behaviors. Staff indicated they were fearful Resident #6 would hurt another resident. The Director of Nursing (DON) indicated Resident's #6's behaviors created a stressful environment for the other residents. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.40 (Behavioral Health) at a scope and severity of J. The Immediate Jeopardy (IJ) began on 04/01/2021 when Resident #6 was yelling and cursing at another resident and the facility failed to investigate the allegation of verbal abuse. The Director of Nursing (DON) and Nursing Home Administrator (NHA) were notified of the IJ and provided with the IJ Template on 08/26/2021 at 12:00 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 08/27/2021 at 6:00 PM. The IJ was removed on 08/27/2021 at 6:00 PM after the survey team performed onsite verification that the Removal Plans had been implemented. Noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that was not immediate jeopardy. The finding included: On 08/26/2021 at 1:45 PM, the Director of Nursing (DON) provided the policy on, Unmanageable Residents, dated 09/2010, and indicated this was the policy currently being used by the facility. Review of the facility's policy revealed that should a resident's behavior become abusive, hostile, assaultive, or unmanageable in any way that would jeopardize his or her safety or the safety of others, the Nurse Supervisor/Charge Nurse must immediately: a) provide for the safety of all concerned, b) notify the resident's attending physician for instructions, notify the Director of Nursing. Complete documentation of the incident must be recorded in the resident's medical record and an incident report must be filed with the Administrator. On 08/26/2021 at 1:45 PM, the DON provided the policy on, Behavioral Assessment, Intervention and Monitoring, dated 12/2016, and indicated this was the policy currently being used by the facility. The policy indicated the interdisciplinary team would evaluate behavior symptoms in a resident to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. The care plan will incorporate findings from the comprehensive assessment and be consistent with current standards of practice. Interventions will be individualized and part of an overall care environment that supports physical, functional, and psychosocial needs, and strives to understand, prevent, or relieve the resident's distress or loss of abilities. Interventions and approaches will be based on a detailed assessment of physical, psychological, and behavioral symptoms and their underlying causes. Record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] indicated Resident #6's cognition was severely impaired with a Brief Interview for Mental Status (BIMS) of three (3) out of fifteen (15). The resident required supervision with ambulation using a walker. Further review revealed the MDS indicated the resident had no behaviors. The most recent Quarterly MDS, dated [DATE] indicated a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a care plan, dated 02/02/2017, indicated Resident #6 exhibited or had the potential to exhibit or demonstrate verbal behaviors such as the use of abusive language and sexually inappropriate language. Interventions included to place resident on one on one, place in lobby to provide decreased stimulation, provide consistent, trusted caregivers and structured daily activities, and postpone activities if resident becomes combative or resistive. Review of the care plan, dated 10/26/2020, indicated Resident #6 exhibited or had the potential to exhibit physical behaviors related to poor anger management, poor impulse control, and public masturbation. Interventions included: resident will have quite time in room to include rest time, listening to music, and to divert by giving alternative choices. Review of a Progress Note, dated 03/26/2021, indicated Resident #6 had a resident-to-resident altercation. Resident #6 continued to curse other residents and threatened to harm self and other residents. Record review revealed a Progress Note, dated 04/01/2021, that indicated Resident #6 was cursing and yelling at another resident. Further review revealed a Progress note, dated 04/03/2021, that indicated Resident #6 was cursing other residents and making multiple verbal threats. Review of a Progress Note, dated 04/04/2021 at 3:57 PM, revealed Resident #6 was inappropriately touching another resident. Further review revealed a Progress Note, dated 04/04/2021 at 5:20 PM, indicated Resident #6 was extremely agitated and yelling at other residents. Review of a Progress Note, dated 04/09/2021 at 10:04 AM, indicated Resident #6 was verbally aggressive with other residents, threatening harm, and cursing. Review of a Progress Note, dated 04/13/2021 at 7:50 AM, indicated Resident #6 was cursing and threatening to harm other residents. Review of a Progress Note, dated 04/16/2021, indicated Resident #6 was yelling and cursing at other residents, and the facility had Director of Nursing (DON) come back to the unit. Record review revealed a Progress Note, dated 04/18/2021, indicated Resident #6 was yelling, throwing stuff, and cussing at other residents. On 04/30/2021, Resident #6 was publicly masturbating during an activity. Continued review revealed on 05/08/2021, Resident #6 was yelling and cussing at other residents. On 05/29/2021, Resident #6 had been cursing, yelling, and threatening other residents. Record review revealed a psychiatrist initial visit, dated 06/04/2021, indicated Resident #6 was being seen for depression. However, there was no mention of verbal and physical aggression documented. Continued review revealed a Progress Note, dated 06/05/2021, that indicated Resident #6 was verbally aggressive with another resident. Review of a Psychotherapy Comprehensive Clinical Assessment, dated 06/09/2021, revealed Resident #6 was referred due to concern of increased anxiety, impulsive behavior, and feeling angry. However, there was no mention of verbal and physical aggression documented. Record review revealed a Progress Note, dated 06/14/2021, that indicated Resident #6 had been cursing and yelling at other residents and throwing items in the resident's room. Review of a Physician's Progress Note, dated 06/16/2021, revealed Resident #6 was noted to have the potential to harm staff, other residents, or self. Record of a Physician's Progress Note, dated 06/17/2021, revealed Resident #6 had a long history with physical aggression related to [CONDITION(S)] [CONDITION(S)] disorder. Review of Psychotherapy Progress Notes, dated 06/18/2021, 06/23/2021, 07/04/2021, 07/05/2021, 07/17/2021, 07/21/2021, 07/31/2021, 08/06/2021, 08/14/2021 indicated Resident #6 was being seen for individual psychotherapy. However, there was no mention of verbal and physical aggression documented. Record review revealed a Progress Note, dated 06/29/2021, that indicated Resident #6 was threatening to hit other residents, was cursing, and being verbally aggressive with other residents. Record review revealed a psychiatry follow-up note, dated 07/16/2021, indicated Resident #6 was being seen for depression. There was no mention of verbal and physical aggression documented. Record review revealed a Progress Note, dated 07/27/2021, that indicated Resident #6 was cursing and threatening to hit other residents. Continued review revealed a Progress Note, dated 08/11/2021, that indicated Resident #6 was being verbally aggressive with other residents and was threatening to harm other residents. Review of a psychiatry follow-up note, dated 08/15/2021, indicated Resident #6 was being seen for depression. There was no mention of verbal and physical aggression documented. Review of a Progress Note, dated 08/14/2021, indicated Resident #6 had exposed self and touched self inappropriately in front of other residents during an activity. The DON had come to the unit to talk to the resident regarding behaviors. Record review revealed a Progress Note, dated 08/18/2021 at 12:00 AM, indicated Resident #6 was verbally and physically aggressive, was throwing things, trying to break things, slamming the resident's walker, and yelling and cursing. [MEDICATION(S)] 2.5 mg (milligrams) was given. Record review revealed a Social Service Note, dated 08/19/2021, that indicated Resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no social service notes available to indicate the facility was providing a plan of care for Resident #6's behaviors. Review of a Psychotherapy Progress Note, dated 08/23/2021, indicated Resident #6 had generalized anxiety and other specified depressive disorders and was seen for individual psychotherapy to explore and utilize coping techniques to manage isolation and depressed mood. During an interview on 08/24/2021, Licensed Practical Nurse (LPN) #3 indicated Resident #6 threatened to kill other residents, and it was just a matter of time before the resident hurt another resident. She indicated administration was aware of Resident #6's aggressive physical and verbal behaviors. During an interview on 08/24/2021 at 2:16 PM, Resident #54 indicated Resident #6 had kicked (Resident #54) in the leg with 3 staff members present who witnessed the incident. During an interview on 08/24/2021 at 3:30 PM, the Activity Assistant (AA) indicated she had witnessed Resident #6 kick Resident #54. During an interview on 08/25/2021 at 12:59 PM, the SSD (Social Service Director) indicated she was aware of the Resident #6 kicking someone and exposing himself/herself. She indicated the resident was sent back to their room for quite time. She stated she was new to her position, and she was unsure of the previous incidents in the progress notes. During an interview on 08/25/2021 at 2:23 PM, the Director of Nursing (DON) indicated she was familiar with Resident #6. She stated they have had behavioral issues with the resident before. The resident had a room to themself so they could go cool off if the resident got upset. The DON stated Resident #6 yelled and sometimes used explicit words. She stated, the resident may say I'm going to hit you., but he/she had not. She was not aware if the resident had ever hit any staff. The DON stated Resident #6 had emptied the catheter bag on the floor. She was not aware that the resident punched the TV or had thrown the walker. She stated he/she had moved the walker towards people. The DON stated she did not doubt that the resident had cursed or yelled at other residents. She stated she did not know any specifics, I don't doubt that there are incidents documented, but I don't know any specifics. Since her time at the facility, they had intervened between the resident and who ever was involved. Continued interview revealed they had called for EMS (emergeny medical services) or an officer for back up if needed. She stated to protect residents, the resident's room was near the nurse's station. When the resident was near people, it made the resident's behaviors worse. They had tried to reward Resident #6's good behavior. Review of a statement for the psychotherapy provider, dated 08/25/2021, indicated Resident #6 started receiving therapy in June of 2021 to decrease mood and reduce anger outbursts. The interventions included using a stress ball for 5-10 minutes when the resident felt his/her stress level was at a five (5) or higher and to practice deep breathing exercises 2-3 times a week. Record review revealed there were no other updates noted to Resident #6's plan of care for behaviors. During an interview on 08/26/2021 at 12:15 PM, the AA indicated Resident #6 exposed self to two female residents during an airshow while outside in the courtyard. During an interview on 08/26/2021 at 12:20 PM, Resident #58 indicated Resident #6 had exposed self to (Resident #58) during the airshow, and that it made the resident feel uncomfortable, Wondering what [Resident #58] did to provoke this. During an interview on 08/26/2021 at 12:30 PM, Resident #87 indicated Resident #6 was exposing self to Resident #58. The resident indicated he/she felt bad for Resident #58. During an interview on 08/26/2021 at 12:20 PM, the Assistant Director of Nursing (ADON) indicated there were no other notes available for psychotherapy services or social services in relation to multiple behaviors displayed over the last several months. The facility provided a Removal Plan that included: 1. Resident #6 was placed on 15 min checks when [the resident] was out of [his/her] room as of 08-26-2021. Resident was seen on 08-25-2021 by psychiatric services and seen again on 08-27-2021. Care plan updated to observe for signs of over stimulation such as grumbling while walking, complaints of other residents, etc. Staff to take resident to room, close the door and practice the interventions recommended by the psychologist such as using a stress ball and deep breathing. IDT met on 08-26-2021 and developed new interventions and updated care plan. 2. All residents with 8 or above were interviewed by social services on 08-25-2021 and 08-26-2021 to ensure there were no concerns of safety, or feelings of abuse while in this facility. None were noted. Unit Manager Nurse, MDS, and SS [social services] assistant evaluated all residents with BIMS 7 and below for any signs of change in baseline mood or behavior and normal daily routine. Documentation placed in medical record 08-26-2021 and 08-27-2021. No concerns or changes noted. 4. LNHA [licensed nursing home administrator], DON [DON], Unit Managers [UM], ADON, MOS [sic, MDS, Minimum Data Set], Business office, Payroll, Activities, Maintenance, Therapy, Scheduling were educated per Regional Director of Clinical Services on 08-26-2021 at 2:15 PM on What is abuse and neglect, when to report abuse and neglect, and to report all abuse to the LNHA. 5. IDT [interdisciplinary team] meeting held 8-27-2021; behaviors reviewed to ensure all residents that have behaviors per the comprehensive assessment have intervention and care plan in place. All interventions and care plans communicated to floor staff per DON 8-27-2021. 6. DON, and LNHA, and or designee will educate all staff on the following: - Abuse and Neglect - When to report suspected abuse and neglect - Reporting of abuse and neglect directly to the administrator immediately - This education completed 8/27/2021 - If any behaviors occur on your shift please protect the resident, stay with them until the Administrator has been notified and intervention is in place. - In addition, a list of all staff has been developed and no persons will be allowed to work without having completed this education prior to assuming the floor. 7. Facility system changes: i. Facility added behavior monitoring to TAR [treatment administration record] to be completed Q [every] shift. ii. All residents with noted behaviors were referred to psych services by assistant social services. iii. Residents with identified behavioral health needs have person centered care plans that were updated on 08-27-2021 by MDS. Care plans include behavioral health needs which are identified in the comprehensive assessment. iv. Individualized interventions related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . DON, LNHA, and/or designee audited: i. Behavior documentation audited weekly x 3 months and then quarterly x 12 months. Any concerns will be documented, corrected immediately, and staff will be educated accordingly. ii. A trigger report was run by RN, BSN, RDO on 08-27-2021 and all issues were immediately addressed. The results of the assessments/audits reported reviewed and trended for compliance through the campus quality assurance performance improvement committee for a minimum of 6 months. QAPI [quality assurance performance improvement] meetings weekly times 4 weeks and then monthly thereafter. The IJ was removed on 08/27/2021 at 6:00 PM after the survey team performed onsite verification that the Removal Plans had been implemented. Onsite verification of the implementation of the Removal Plan was conducted during the survey. On 08/27/2021 between the hours of 11:00 AM and 6:00 PM. Review of the educational materials indicated 100% of staff to include all departments had been completed on 08/26/2021. Twelve interviews were conducted to verify in-service training had been completed on the facility's Abuse Policy and Procedure training to include the types of abuse, what to report, to whom to report the allegations of abuse and when to report. Of those interviewed included certified nursing assistants (CNAs), licensed practical nurses (LPNs), registered nurses (RNs), housekeeping and scheduling staff. The staff interviewed revealed knowledge of what constituted abuse, what to do if abuse was observed, both staff to resident abuse and in the event of resident-to-resident abuse, when to report abuse and to whom the abuse should be reported. The interviews revealed a consistent message that staff understood not only the different types of abuse, but that resident-to-resident altercations also constituted abuse. Staff indicated that through training they understood the need to intercede immediately and to always protect the resident before reporting any incident of abuse to the Administrator. Staff also acknowledged that have assuring resident safety, the abuse should be reported immediately. Resident #6 had been placed on every 15-minute checks, and the care plan had been updated on measures to address behaviors, and an IDT meeting was held on 08/27/2021. Resident #6 was seen by psych services on 08/25/2021. Surveyors verified 54 Residents with BIMS 8 or above were interviewed and indicated they felt safe. The LNHA, DON, unit managers, ADON, MDS, business office, payroll department, activities, maintenance, therapy, scheduling received education on what constitutes abuse and when to report.

Based on interviews, record review, and facility policy review, it was determined the facility failed to ensure there was a qualified food and nutrition director with appropriate competencies and skill sets to carry out food and nutrition services for all one hundred eleven (111) residents in the facility. The facility failed to ensure the Director for Food and Nutrition Services was a Certified Dietary Manager (CDM), a Certified Food Service Manager, had a national certification for food service management or had an Associates or higher degree in food service management. The findings included: Review of the facility's policy titled, Professional Staffing revised 10/2019, revealed a qualified Food Services Director was one who: was a Certified Dietary Manager; or was a Certified Food Service Manager; or had similar national certification for food service management and safety from a national certifying body; or had an Associate's or higher degree in food service management or in hospitality, if the course of study included food service or restaurant management from an accredited institution of higher learning, and in states that have established standards for Food Service Manager or Dietary Managers, meet state requirements for food service managers or dietary managers .The qualified Dietitian or other clinically qualified nutrition professional would provide guidance and oversight to the Dining Services Director for the consistent preparation and service of all regular and therapeutic diets and the training and supervision of all department staff. Cross reference: F803 (Menus) and F812 (Kitchen sanitation) Review of the Dietary Manager's (DM) personnel records revealed it contained no specific training related to food service management. Continued review revealed the DM had a chef position from 03/05/2019 to 07/01/2021 and was placed in the current position of DM July 1,2021. Interview with the Registered Dietitian (RD) and the Regional Director of Culinary Services (RDCS), on 08/25/2021 at 12:15 PM, revealed a new company for the kitchen staff had been contracted about seven (7) weeks ago. The RD said the DM would not be in the facility the rest of the week. Continued interview revealed the RDCS was the Dietary Manager's supervisor. Per interview, the Dietary Managere was not a Certified Dietary Manager and had not been enrolled in the Certified Dietary Manager (CDM) course. Interview with the Nursing Home Administrator (NHA), on 08/26/2021 at 9:39 AM, revealed she was aware they needed to have a qualified dietary manager or CDM in place. Continued interview revealed the Dietary Manager had previously worked at the facility as a cook and then went to an assisted living facility. Per inteview, the Dietary Manager came back to the facility with the new contract company, on 07/01/2021, as the Dietary Manager. The Administrator stated, she was under the impression the Dietary Manager was a qualified DM. She said the Registered Dietician was only contracted for two (2) days a week. Further interview revealed the current Dietary Manager was not a CDM or qualified DM and not certified in ServSafe (Safe food handling).

Based on observations, interviews, record reviews, and facility policy review, it was determined the facility failed to ensure the menus and recipes were followed in one (1) of one (1) facility kitchen with the potential to affect one hundred and eleven (111) residents. The findings include: Review of the facility's polic,y titled Menus revised 10/2019, revealed menu cycles would include standardized recipes. Continued review revealed the Menus were served as written, unless changed in response to preference, unavailability of an item, or a special meal. Review of the menus provided by the Registered Dietitian (RD), on 08/25/2021 at 12:15 PM, revealed the following menu: 08/24/2021 Tuesday lunch: Southern fried chicken, orange twist, macaroni and cheese, buttered chopped spinach, dinner roll, and cookie, 08/25/2021 Wednesday lunch: Salisbury steak, beef gravy, chopped parsley rice pilaf, buttered kernel corn, dinner roll, and orange sherbet. Observations of the lunch preparation in the kitchen, on 08/25/2021 at 9:51 AM, revealed the Dietary Aide (DA) was preparing a pureed dessert. Continued observation revealed the DA put a spoonful of the fruit/marshmallow mixture into the food processer and added thickener at various times, without measuring or referring to a recipe for puree texture. The DA said the mixture was called raspberry ambrosia. Per interview, the Dietary Manager (DM) was out of the facility for the next couple of days. The DA stated, a fill-in Dietary Manager was in the facility the day before. Interview with Resident #98, on 08/24/2021 at 12:16 PM, revealed the resident received chicken tenders, macaroni salad, green beans, and a cookie. Interview with an unsampled resident, on 08/25/2021 at 2:18 PM, revealed the resident received a lot of the same alternates, and the grilled cheese was more like a buttered sandwich. The resident said they received too many fruit cups. Interview with Cook #1, on 08/25/2021 at 10:09 AM, revealed the dietary staff did not have any supervision at this time, and they were just winging it. Continued interview revealed the lunch meal consisted of a chicken sandwich with chicken patties, potato wedges, and peas. Interview with Cook #1 and Registered Dietician (RD), on 08/25/2021 at 11:24 AM, revealed the RD was noted to have the menus from the menu book. Per intrview, Cook #1 had not seen the menus before. Cook #1 stated she changed the menu because she could not prepare seafood and the residents had green beans the day before so she changed the vegtable to peas. The RD advised Cook #1 that after she made the changes, the whole meal consisted of starches. Continued interview revealed Cook #1 was not aware that peas were a starch. Interview with the Cook #1, on 08/25/2021 at 11:35 AM, revealed she did not have any recipes for the food items she prepared. She stated the only thing she knew for sure were the serving sizes. Continued interview revealed she had been making up her own recipes as she went along. She said the Dietary Manager would type up a menu every day and would give that to them to prepare, but no standard menu was available. Interview with the Registered Dietitian (RD) and the Regional Director of Culinary Services (RDCS), on 08/25/2021 at 12:15 PM, revealed they provided the Dietary Manager with a copy of the necessary in-services for the staff, the menu, and the recipes that accompanied the menu. They said they did not know what happened to them after that point. Per interview, the kitchen was managed by a different contract company. The RD stated the menu book in the kitchen had missing sections and was not the same as the official menus provided by the RDCS. The RDCS stated the menus and recipes had been printed for the Dietary Manager, but they were unable to find them in the kitchen. Interview with the Nursing Home Administrator (NHA), on 08/26/2021 at 9:39 AM, revealed she was unaware the menus and recipes were not being followed until this week. She stated the menu and recipe binders were presented to the Dietary Manager by the new company weeks ago.

Based on observations, interviews, record reviews, and review of the facility's policies, it was determined the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one (1) of one (1) kitchen and one (1) of two (2) nourishment refrigerators with the potential to affect all one hundred and eleven (111) residents. Staff failed to ensure cold foods were covered, expired foods were disposed of, the kitchen and equipment were cleaned, food was stored at the proper temperature, and food was prepared and held at the proper temperatures prior to meal service. The findings include: Review of the facility's policy titled, Food Preparation revised ,d+[DATE], revealed time/temperature control for safety (TCS) hot food items would be heated according to the following guidelines: mechanically altered foods: reheated to one hundred and sixty-five (165) degrees Fahrenheit (F) for fifteen (15) seconds; reheated foods: one hundred and sixty-five (165) degrees Fahrenheit for 15 seconds and then discarded after two (2) hours. The cook ensures that all foods were held at appropriate temperatures, greater than one hundred and thirty-five (135) degrees Fahrenheit for hot holding and less than forty-one (41) degrees Fahrenheit for cold food holding. Temperature for TCS foods should be recorded at time of serving and monitored periodically during meal service periods as indicated. Review of the facility's policy titled, Food Storage: Cold revised ,d+[DATE], revealed the Dining Services Director/ Cook(s) ensure that all perishable foods would be maintained at a temperature of forty-one (41) degrees Fahrenheit or below except during necessary periods of preparation and service. The Dining Service Director/ Cook(s) ensured that all food items were stored properly in covered containers, labeled, and dated and arranged in a manner to prevent cross contamination. Review of the facility's policy titled, Ice revised ,d+[DATE], revealed the Dining Services Director would ensure that the ice bins were cleaned monthly and as needed. The Dining Services Director would ensure that proper utensils or clean gloved hands were used for handling. Review of the facility's policy titled, Environment revised ,d+[DATE], revealed the Dining Services Director would ensure that the physical plant was maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation. 1. Observations of the kitchen walk-in refrigerator, on [DATE] at 8:47 AM, revealed a five (5) pound container of cottage cheese with a use-by-date of [DATE]. Continued observation revealed a hard plastic container of [MEDICATION(S)] salad that was open to air and not fully covered. There was a package of bologna, opened to air and not fully covered. 2. Observations of the kitchen, on [DATE] at 8:47 AM, revealed the walk-in refrigerator flooring had dirty brown grout throughout. The flooring was dirty with food debris. The walk-in freezer flooring had areas of melted ice cream, frozen and unclean. The dry storage area flooring had food debris and old spills throughout. The inside of the ice machine was dirty with liquid spatter throughout. The dish machine area flooring was dirty with food debris. Observations of the kitchen, on [DATE] at 7:30 AM, revealed thick lint and food debris along the racks in the walk-in refrigerator. The inside of the ice machine remained dirty with liquid spatter throughout. Observations of the lunch preparation in the kitchen, on [DATE] at 9:51 AM, revealed the Dietary Aide (DA) was preparing a pureed dessert. Observation revealed she took out a food processer from the lower shelf. Continued observation revealed the food processer had various dried-on liquid spatter throughout the outside of the container. Further observation revealed the DA continued to puree a fruit/marshmallow dish with the soiled equipment. After using the food processor, the DA cleaned the outside of the food processor and placed it on the lower shelf. Observation of the food processor on the lower shelf revealed it remained soiled with liquid spatter along the crevices and the lower shelf had food debris on the shelf. Interview with DA, on [DATE] at 10:12 AM, revealed the Dietary Manager (DM) was out of the facility for the next couple of days. She stated a fill-in Dietary Manager was in the facility the day before. Observations of the kitchen, on [DATE] at 10:04 AM, revealed the wall behind the hand washing sink was soiled with brown smears, the trash container was soiled all along the outside of the container, the steam table remained soiled from the breakfast meal, the table behind the steam table was soiled with food debris, the ceiling above the trash container and above the steam table was soiled with an unknown liquid spatter. A dietary staff member used a beverage pitcher to scoop ice out of the ice machine with bare hands. The ice scoop was not used. The dietary staff member touched the bottom of the pitcher with a bare hand and the bottom of the pitcher touched the ice inside of the ice machine. At 11:12 AM, food was placed onto the dirty steam table and the steam table was not cleaned prior. An interview with the Registered Dietitian (RD) on [DATE] at 1:41 PM said they had no logs and did not know the last time the ice machine was cleaned. She said, It's disgusting. She confirmed the kitchen had been dirty since she started in the building, and she had been trying to get things cleaned and fixed. 3. Observations of the nourishment refrigerator nearest the main dining room on [DATE] at 11:36 AM revealed a temperature of sixty (60) degrees F. The door to the refrigerator lacked the ability to seal closed. The refrigerator contained resident food items, including yogurt containers. A dietary staff member in the area said she was the Dietary Manager. At 11:42 AM, she said she was not aware she needed to monitor the refrigerator temperatures. She acknowledged the temperature was high and the food needed to be disposed of as soon as possible. 4. Observations of food preparation on [DATE] at 10:18 AM revealed the Cook blended some chicken for the mechanical texture. She placed the food into the oven. She took out some breaded chicken from the oven and temped the food item. The temperature was one hundred twenty (120) degrees F, and the food was placed back into the oven. At 10:53 AM, she took the breaded chicken out of the oven and took the temperature again with a temperature of one hundred twenty (120) degrees F. At 11:12 AM, hamburger patties were placed onto the steam table. The Cook took the breaded chicken out of the oven and the food item had a temperature of one hundred thirty-one (131) degrees F. At 11:18 AM, the peas were placed onto the steam table. At 11:30 AM, the Cook placed the breaded chicken into the Robo Coupe for processing. She said the temperature of the chicken was one hundred forty (140) degrees F. At 11:35 AM, she said the ground chicken had a temperature of one hundred forty-five (145) degrees F. She said she only needed to reheat the food. The pureed chicken had a temperature of one hundred thirty-five (135) degrees after processing and was placed onto the steam table, without reheating. The Cook said that the pureed chicken stayed hot because of the added hot water. The tall cart next to the steam table contained pimento cheese sandwiches, out at room temperature. The tray line started at 11:45 AM with no temperatures taken of the food items prior to service. The Cook finished pureeing the peas with a temperature of one hundred twenty-seven (127) degrees F, and they were placed back into the oven. The mashed potatoes remained on the stove with a temperature of one hundred twenty-nine (129) degrees F. An interview with the Cook on [DATE] at 12:00 PM revealed the food items were not reheated to the proper temperatures. She said since the food was precooked, then it needed to be reheated to one hundred forty (140) degrees F. The Cook was unaware food items needed to be reheated to a temperature of one hundred sixty-five (165) degrees F. An interview with the RD and the Regional Director of Culinary Services (RDCS) on [DATE] at 12:15 PM revealed the RD said the kitchen was responsible for checking the temperature of the nourishment refrigerators. She confirmed that had not been done, and there were no temperature logs available. An interview with the Nursing Home Administrator (NHA) on [DATE] at 9:39 AM revealed orientation should have been completed with the Dietary Manager at the start. She said all the refrigerators should have been checked with temperatures maintained at less than 40 degrees F. She said she was not aware of the kitchen concerns until this week.

Based on observations, interviews, record reviews, and the review of a facility policy, it was determined that the facility failed to keep the indwelling catheter drainage bag off the floor for one (1) of four (4) sampled residents (Resident #67); and, failed to maintain social distancing in the main hallway and wear the face mask properly in three (3) locations within the building. The deficient practice occurred during the COVID-19 pandemic and had the potential to affect all residents. The findings included: Review of the facility's policy, titled Catheter Care, Urinary, revised 09/2014, indicated under the section Infection Control that the catheter tubing and bag were to be kept off the floor. 1. Record review revealed the facility admitted Resident #67 on 01/18/2021 and readmitted him/her on 02/14/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #67's Quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident was cognitively intact with a Brief Interview for Mental Status score of fourteen (14) out of fifteen (15). The assessment indicated the resident had an indwelling urinary catheter. Observations of the urinary drainage bag with at least half of the bag lying on the floor were made on 08/23/2021 at 2:47 PM; 08/24/2021 at 2:00 PM; and, on 08/25/2021 at 10:30 AM An interview was conducted with Certified Nursing Assistant (CNA) #2 on 08/25/2021 at 10:33 AM. The CNA, who was assigned to the resident, stated she had not noticed the drainage bag on the floor. Interview with Registered Nurse (RN) #1 on 08/25/2021 at 10:34 AM, who was assigned to the resident, stated urinary drainage bags should be kept off the floor. She was unable to say how Resident #67's urinary drainage bag was positioned since she had not been in the resident's room that shift. An interview with CNA #3 was conducted on 08/25/2021 at 11:12 AM. The CNA stated she had emptied the urinary drainage bag and had not noticed when the bed was lowered that the bag landed on the floor. The Director of Nursing (DON) was interviewed on 08/26/2021 at 8:15 AM. The DON stated a basic standard of care included that the catheter drainage bag should not be placed on the floor related to infection control issues. 2. On 08/24/2021 at 10:50 AM, Licensed Practical Nurse (LPN) #9 was observed sitting at the A Unit nurse's station. His mask was below his nose. Interview with the LPN, at that time, revealed he had been taught to wear his mask above his nose, but the mask kept sliding down. LPN #9 stated he had tried many different types of masks with the same results. On 08/24/2021 at 10:51 AM, six (6) members of housekeeping staff were seen in the hall outside of the laboratory door. The staff members, in some cases, were almost shoulder to shoulder. Housekeeper #1 stated someone in housekeeping had tested positive and the six (6) standing in front of the lab were waiting to be tested since they had close contact with the positive member of their team. Unit Manager (UM) #1 was interviewed on 08/24/2021 at 10:56 AM. She stated staff had been taught to social distance. She denied any active cases of COVID-19 in the building at this time. Observation on 08/24/2021 starting at 12:30 PM, revealed three (3) employees came through the front door and stopped at the front desk to be screened. Two (2) of the three (3) employees were wearing their masks below their noses. The receptionist, who was screening employees, did not direct the employees to reposition their masks above their noses. Both employees went down the front hall to be COVID-19 tested . When interviewed, the receptionist stated she had been taught the proper way to wear a mask was above the nose. She stated there were so many things going on, she had not noticed the two (2) employees wearing the mask below their noses. An interview was conducted on 08/24/2021 at 3:00 PM with the Nursing Home Administrator (NHA) and DON to discuss concerns with the breaks in infection control protocols considering the COVID-19 positive employee reported on 08/24/2021. The interview included staff coming through the front door and walking up to the screening desk with no mask, nurses throughout the building not wearing their mask properly and the lack of social distancing. The NHA stated initially a basket of masks had been placed by the door for employees to wear before screening, but someone had told her to remove the basket and place the basket of masks on the screening table. The NHA and the DON stated they understood the seriousness of the situation since they now had a positive employee. The NHA stated residents and staff had a choice of wearing a mask or not.

Based on interview, record reviews, and facility policy review, it was determined the facility failed to ensure an effective Quality Assurance (QA) program was in place. The facility's census was 111 residents. Staff failed to ensure the QA program put plans in place to correct past deficiencies, identify its' own deficiencies, and resolve those deficiencies. The findings included: A review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Committee, dated 07/2016, revealed the primary goals of the QAPI Committee are to .help identify actual and potential negative outcomes relative to resident care and resolve them appropriately; support the use of root cause analysis to help identify where patterns of negative outcomes point to underlying systemic problems; help departments, consultants and ancillary services implement systems to correct potential and actual issues in quality of care. 1. Review of the facility's repeat deficiencies from the 07/25/2019 survey included: -F686- failure to provide care and services related to pressure ulcers. -F690- failure to provide catheter care. -F695- failure to ensure proper oxygen care and services. -F880- failure to ensure proper infection control practices were in place 2. Cross reference tags: -F550- failed to ensure residents were dressed and catheter cover was provided. -F600- failed to ensure residents were safe from abuse. -F609- failed to ensure allegations of abuse were reported timely. -F610- failed to ensure allegations of abuse were thoroughly investigated. -F656- failed to ensure care plans were implemented. -F686- failed to provide care and services related to pressure ulcers. -F689- failed to provide care and services for the prevention of falls. -F690- failed to ensure proper catheter care. -F740- failed to ensure proper behavioral plans were in place. -F801- failed to ensure qualified dietary manager was in place. -F803- failed to ensure menus and recipes were followed. -F812- failed to ensure adequate kitchen sanitation. -F880- failed to ensure proper infection control practices were in place An interview with the Nursing Home Administration (NHA) on 08/27/2021 at 6:25 PM revealed they had not completed a live QA meeting in months. She stated they completed Zoom QA meetings with the Interdisciplinary Team (IDT) and then would report that information to the medical director. Three (3) staff members were recorded in attendance according to the sign-in sheets. She stated the current QA focus was the new company transition and the accuracy of weights. The Administrator stated they also reviewed COVID-19 and visitation. She said those were the primary areas of concern. Continued interview revealed they discussed reportable incidents with the medical director this day. She said they had some Performance Improvement Plans (PIP) areas of focus which included employee retention and the dining program. She said they did not have any documentation for the PIPs. She said she did not think there was any improvement in the PIPs. She said they reviewed falls every week in the critical at risk (CAR) meetings. She said she attended the CAR meetings when she was available. The Administrator stated she was not aware of any kitchen sanitation or menu issues until this week. She said everything had been a struggle with COVID-19 and they had been overwhelmed.

Based on interviews, record reviews, and facility policy review, it was determined the facility failed to ensure one (1) of five (5) sampled residents (Resident #42) reviewed for hospitalization s received a bed-hold notice. Staff failed to ensure a bed-hold notice was provided to Resident #42 or the resident's representative prior to the hospitalization on [DATE]. The findings included: Review of the facility's policy titled, Bed Hold, not dated, revealed that prior to transfer, written information would be given to the residents and the residents' representatives that explained in detail: a.) the rights and limitations of the resident regarding bed holds; b.) the reserve bed payment policy as indicated by the state plan (Medicaid residents); c.) the facility's per diem rate required to hold a bed (non-Medicaid residents) or to hold a bed beyond the state bed-hold period (Medicaid residents); and d.) the details of the transfer (per the Notice of Transfer). Record review revealed the facility admitted Resident #42, on 05/24/2021, with a recent hospitalization on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 07/02/2021, revealed the facility assessed Resident #42's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of four (4) out of fifteen (15). The resident was not interviewable. Record review revealed a bed-hold notice was provided to Resident #42 for the hospitalization s on 06/10/2021 and 07/16/2021. These were signed by the resident. However, there was no bed-hold notice for the hospitalization on [DATE]. Interview with the Business Office Manager (BOM), on 08/24/2021 at 1:24 PM, revealed the facility had not completed a bed-hold notification for Resident #42. An interview with the Director of Nurses (DON), on 08/24/2021 at 1:47 PM, revealed the nurse on the floor was supposed to ensure all the necessary paperwork was completed prior to transfers. She stated there was a red folder at the nurses' station that had all the paperwork. The DON stated they used agency staff, and that could have been how it was missed. An interview with the DON, on 08/26/2021 at 9:23 AM, revealed she did not know why the bed-hold notice was not completed for this resident. An interview with the Nursing Home Administrator (NHA), on 08/26/2021 at 9:39 AM, revealed the bed-hold notice should have been completed at the time of the transfer, and the BOM was the staff who followed up on them the next day.

Based on observations, interviews, record review, and facility policy review, it was determined the facility failed to implement fall care plan interventions for bed wedges for one (1) of three (3) sampled residents (Resident #3)reviewed for falls. The facility failed to develop a care plan for physical behaviors for one (1) of six (6) residents reviewed for behaviors (Resident #85). The findings included: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised December 2016, revealed: A comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident. The comprehensive care plan would describe the services that were furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Per the policy, the care plan would incorporate identified problem areas and incorporate risk factors associated with identified problems. Record review revealed the facility admitted Resident #3 on 02/09/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) Assessment for Resident #3, dated 05/18/2021, revealed the facility assessed Resident #3 to have a Brief Interview for Mental Status (BIMS) score of eleven (11) out of fifteen (15), indicating no cognitive impairment. Resident #3 required limited assistance of two (2) persons with bed mobility, transfer, dressing, and toileting. The resident was totally dependent on staff for bathing. Review of a Progress Note, dated 08/03/2021 at 4:15 PM, revealed Resident #3 was sitting on the mat next to bed. The resident stated [they] slid onto the mat because the bed was small. Per the note, the resident tends to sleep sideways most of the time. Continued review of the note revealed updated care plan to place wedges on bilateral sides of the bed to help stabilize theresident while sleeping. Per the note, the intervention were effective and the resident stated [he/she] was sleeping more comfortably. Further review of the note, the resident refused to keep non-skid socks on with three (3) staff attempts, fall mats on bilateral sides of bed, fluids and bedside table within reach and the call light within reach. There were no signs or symptoms or complaints of pain or discomfort noted. Safety measures were maintained. Review of Resident #3's care plan for falls, initiated on 02/22/2021, revealed an intervention added on 08/03/2021 for wedges on bilateral sides of the bed. An observation of Resident #3, on 08/23/2021 at 10:59 AM, revealed the resident lying in bed with fall mats on both sides of the bed and grab bars in the up position; however, no wedges were observed in the bed with the resident. An observation of Resident #3, on 08/24/2021 at 2:20 PM, revealed the resident in bed with grab bars in the up position, fall mats to both sides of the bed, and no wedges in the bed. An observation of Resident #3, on 08/25/2021 at 1:07 PM, revealed the resident in bed with grab bars in the up position and fall mats to both sides of the bed, but no wedges in the bed. An interview on 08/26/2021 at 10:40 AM, with Certified Nurse Aide (CNA) #5, revealed she had checked on Resident #3 three (3) times that morning. The CNA stated staff could access the resident's care plan to see what type of interventions were in place. CNA #5 stated she checked the care plan daily. Continued interview revealed CNA #5 stated Resident #3 had a bed in the lower position and fall mats. The CNA stated she was aware Resident #3 should have wedges. However, she stated she puts pillows under the resident sometimes. CNA #5 stated it was not her place to decide to use pillows instead of the wedges that the resident was care planned to have. CNA #5 stated she did not request wedges that morning from therapy when she observed that Resident #3 did not have them. She stated she did not report it to any nurse or supervisor. An interview on 08/26/2021 at 11:42 AM, with CNA #7, revealed Resident #3 did not have a wedge or anything, so staff put pillows under the resident at times. CNA #7 stated she looked at the care plans daily when she charted. CNA #7 stated the last time she looked at Resident #3's care plan was on Sunday 08/22/2021. CNA #7 stated there were currently no wedges available in the facility for Resident #3. Continued interview revealed the lack of wedges was reported to nursing staff about a week ago, but she was not sure of who specifically it was reported to. An interview on 08/26/2021 at 1:25 PM, with the Director of Nursing (DON), revealed she was unaware why the care plan was not being implemented related to wedges for Resident #3 as the care plan was updated for the resident to have bilateral wedges in bed on 08/03/2021. The DON stated she was unaware that staff stated there were not any wedges available in the building for residents. She stated she expected staff to implement and ensure interventions were in place and in use after they had been identified and the care plan was updated. The DON stated it was ultimately her responsibility, along with the clinical team, to ensure care plans were implemented. Continued interview revealed they currently had a partner program with department managers in place. The DON stated that department managers walked around at least once weekly to check on residents and ensure all things such as current interventions were in place. The DON stated it was supposed to be completed weekly, but the DON was unsure of when it was completed last, and there was no documentation related to this. On 08/26/2021 at 1:40 PM, an observation of the linen closet with the DON revealed that wedges were stored in there, but there were none currently on the shelves. The DON stated there should be some around in the building. 2. Resident #85 was initially admitted by the facility on 01/27/2020 and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #85's Quarterly Minimum Data Set (MDS) Assessment, dated 07/30/2021, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15), indicating moderately impaired cognition. The resident's behaviors included physical aggression toward others. Review of Resident #85's hospital discharge summary, dated 01/11/2020, revealed the resident had been admitted to a geriatric behavior unit, on 01/11/2020, from a nursing home due to increasingly aggressive behaviors and altercations with two (2) different residents in two (2) days. A review of the nurse's progress notes and/or incident reports indicated Resident #85 had physical or verbal altercations with residents on 05/05/2021, 06/13/2021, 07/07/2021, 07/09/2021, 07/24/2021, 08/21/2021 and 08/22/2021. Review of Resident #85's care plan, with a start date of 08/23/2021, addressed the resident's verbal aggression. There was not a care plan that addressed Resident #85's physically aggressive behaviors directed toward other residents. Interview with the Director of Nursing (DON), on 08/25/2021 at 2:26 PM, revealed Resident #85's physical behaviors should have been care planned. The DON reviewed the care plan for Resident #85 and confirmed physically aggressive behaviors had not been addressed.

Based on observations, interviews, record review, and review of the facility's policy, it was determined the facility failed to ensure dignity for three (3) of three sampled residents (Residents #22, #83 and #67) reviewed for dignity. Resident #22 was observed not dressed or covered. Resident #83 and Resident #67 did not have a privacy bag for their urinary catheter drainage bags. The findings included: Review of the facility's policy, titled, Quality of Life-Dignity, revised August 2009, revealed, Residents should be treated with dignity and respect at all times. Treated with dignity means the resident would be assisted in maintaining and enhancing his or her best self-esteem and self-worth. Residents should be encouraged and assisted to dress in their own clothes rather than hospital gowns. Helping the resident to keep urinary catheter bags covered. 1. Record review revealed the facility admitted Resident #22 on 06/08/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #22 to have a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15), which indicated significant cognitive impairment. Further review revealed Resident #22 required the extensive assistance of two (2) persons with bed mobility, transfer, dressing, and toileting, and required supervision of one (1) person with eating. The resident was totally dependent on staff for bathing. Review of the care plans, dated 07/11/2019, revealed Resident #22 was not care planned for any preference related to clothing or lack of clothing. Further review revealed Resident #22 was not care planned for being resistive to care related to dressing. Observation on 08/23/2021 at 11:11 AM, revealed Resident #22 lying in bed without any clothing on and covered by only a sheet. Further observation revealed the sheet was only partially covering Resident #22, leaving the resident almost fully exposed. Observation on 08/24/2021 at 10:31 AM, revealed Resident #22 lying down in bed covered with only a sheet. Further observation revealed when the sheet was pulled back Resident #22 had nothing on under the sheet other than briefs. Observation on 08/25/2021 at 9:07 AM, revealed Resident #22 lying in bed wearing a hospital gown. Observation on 08/26/2021 at 9:10 AM, revealed Resident #22 lying in bed wearing a hospital gown. Interview with Certified Nurse Aide (CNA) #5, on 08/26/2021 at 9:31 AM, revealed staff complete a spot check in the morning first, then they get breakfast trays and get residents up and ready for breakfast. CNA #5 stated staff go back around at nine o'clock to complete resident bed baths, showers, and clothing changes. The CNA stated Resident #22 typically wore a hospital gown, and she was unsure if Resident #22 had his/her own personal clothing. Further interview revealed Resident #22 would put clothes on if the resident was out of bed. CNA #5 stated she was not aware of any issues with Resident #22 being resistive to care. CNA #5 stated after activities of daily living (ADL) care was provided, all residents would and should have on either clothing or a hospital gown. CNA #5 stated that no resident should ever be left naked or undressed. Interview with CNA #6, on 08/26/2021 at 10:13 AM, revealed that at 6:30 AM, staff did a walk-through and checked on residents. She stated at that time, staff started incontinent care and wiped residents' faces before breakfast. CNA #6 stated after breakfast, staff started ADL care such as providing bed baths, showers, or partial baths. The CNA stated all residents were provided full ADL care which included providing clean clothes, denture/oral mouth care, washing their faces, and grooming. CNA #6 stated Resident #22 was unable to verbalize and make his/her needs known, and that Resident #22 required staff to turn him/her every two hours. CNA #6 stated Resident #22 did not like ADL care but allowed staff to complete it. Continued interview revealed Resident #22 primarily wore a hospital gown and liked to pull down the arms but had never completely removed the gown. CNA #6 stated Resident #22 would allow staff to adjust the gown when that occurred. She stated there should never be an occasion when Resident #22 was completely naked. Interview with the Director of Nursing (DON), on 08/26/2021 at 8:15 AM, revealed she would need to check the facility's ADL and dignity policy. No policy was presented. During a follow up interview, on 08/26/2021 at 12:48 PM, revealed the DON stated she still had not had a chance to review the policy. 2. Record review revealed the facility admitted Resident #83 on 10/16/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change Minimum Data Set, dated dated [DATE], revealed the facility assessed Resident #83 to have a Brief Interview for Mental Status (BIMS) score of zero (00) out of fifteen (15), which indicated significant cognitive impairment. Resident #83 required extensive assistance of two persons with bed mobility, dressing, and toileting. Further review revealed Resident #83 required limited assistance of one person with eating. The resident was totally dependent on staff for bathing. Review of Resident #83's care plan, initiated on 10/17/2019, revealed the resident required an indwelling suprapubic catheter due to [CONDITION(S)] bladder. Further review revealed interventions were to provide a privacy bag. Observation on 08/23/2021 at 10:25 AM, revealed Resident #83 lying in bed, with a catheter drainage bag on the right side of the bed, exposed and not in a privacy bag. Interview with CNA #5, on 08/26/2021 at 10:52 AM, revealed the CNA staff were responsible for cleaning a resident's catheter tubing and ensuring that the catheter drainage bag was in a privacy bag. The CNA stated that catheter privacy bags were in central supply, and staff could ask a nurse to get a bag. CNA #5 stated it was staff's responsibility to correct issues such as a catheter bag not placed in a privacy bag. Interview with CNA #6, on 08/26/2021 at 11:24 AM, revealed the CNA staff were responsible for emptying catheter bags, checking the color of output, ensuring the catheter bag were placed in a privacy bag, tubing was never on the floor, and the bag was not overflowing or leaking. 3. Record review revealed the facility admitted Resident #67 on 01/18/2021 and readmitted the resident on 02/14/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set, dated dated [DATE], indicated Resident #67 was cognitively intact with a Brief Interview for Mental Status score of fourteen (14) out of fifteen (15). The assessment further indicated the resident had an indwelling urinary catheter and surgical wounds. Review of the 08/2021 Treatment Administration Record (TAR), revealed an entry to check placement of the privacy bag for the indwelling urinary catheter every shift. Further review revealed each day had been checked and initialed which indicated the privacy bag was in place. Review of the care plan for Resident #67, last reviewed on 08/12/2021, indicated a privacy bag should be provided for the resident's indwelling urinary catheter. Observation of Resident #67 on 08/23/2021 at 2:47 PM, revealed the drainage bag for the indwelling urinary catheter did not have a privacy bag. Further observation revealed urine was visible to anyone in the hall as the door to the room was opened. Observation on 08/24/2021 at 2:00 PM, revealed no privacy bag was seen covering the urinary drainage bag. Interview with the resident, at that time, revealed the last time he/she remembered the bag being covered was about three (3) weeks ago. Interview with Certified Nursing Assistant (CNA) #2, on 08/25/2021 at 10:33 AM, revealed Resident #67 should have a privacy bag covering the urinary drainage bag. CNA #2 added she had served breakfast to the resident and had not noticed the drainage bag was not covered. Interview with Registered Nurse (RN) #1, on 08/25/2021 at 10:34 AM, revealed the urinary drainage bag should be always covered to maintain privacy. The nurse stated she was uncertain about the facility's policy for covering catheter drainage bags. RN #1 added she was unaware if Resident #67's catheter drainage bag was covered since she had not been in the resident's room yet that shift. Interview with the Director of Nursing (DON), on 08/26/2021 at 8:15 AM, revealed the standard of care was to cover the urinary drainage bag, but to be sure she needed to review the facility policy. The DON did not return a policy for covering the urinary drainage bag.

Based on observations, interviews and record review it was determined the facility failed to complete weekly wound assessments for two (2) of two (2) sampled residents (Residents #7 and #25) reviewed for wound assessments and failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: Review of the facility's policy titled, Pressure Injuries Overview, revised October 2019, revealed that an avoidable ulcer developed due to one or more of the following not being completed. This list included implementation of interventions that were consistent with the resident's needs, goals, and professional standards of practice. The policy also indicated lack of monitoring, evaluation, or reassessment of the interventions could lead to the development of pressure ulcers. 1. Review of the medical record revealed the facility admitted Resident #7, on 11/21/2018, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's Significant Change in Status Minimum Data Set (MDS) Assessment, dated 05/20/2021, revealed Resident #7 had both short- and long-term memory impairment. Behaviors occurring during the assessment period included physical behaviors, verbal behaviors, and rejection of care. The resident was identified as requiring the extensive assistance with bed mobility, eating and personal hygiene. Per the MDS, Resident #7 had a pressure ulcer over a bony prominence, and was at risk of developing additional pressure ulcers. The assessment indicated the existing pressure ulcer was an unstageable wound described as a deep tissue injury (DTI). While nutritional and hydration interventions were not identified as used, the MDS indicated Resident #7 received specialized turning and repositioning and had both a pressure reducing device for the bed and chair. Review of Resident #7's current Comprehensive Care Plan, revealed interventions to prevent further skin breakdown and to assist in healing current breakdown included floating both heels while in bed, treatments as ordered and weekly assessments by a licensed nurse. A review of the 07/2021 Treatment Administration Record (TAR) indicated nurses had signed daily that Resident #7's heels had been elevated. Also signed daily was that Resident #7 had been out of bed daily. Review of the 08/2021 TAR indicated Resident #7's feet had been elevated while in bed and Resident #7 had been out of bed daily. An observation made, on 08/23/2021 at 11:42 AM, revealed Resident #7's feet were flat on the bed. There was no pillow seen on the bed or near the bed on which to float the resident's heels. Observations were made on 08/24/2021 at 8:10 AM. The resident was in bed with feet/heels lying flat on the bed. No wedges or pillows for elevating Resident #7's feet were seen in the room. A decorative pillow was observed in the wheelchair that was positioned at the head of the resident's bed. During an observation on 08/24/2021 at 4:00 PM, revealed Resident #7 was seen lying in bed on his/her left side with his/her feet on the bed. Further observation revealed no boots or pillows elevated the resident's feet. A decorative pillow remained in a wheelchair next to the resident's bed. An observation of Resident #7 was made on 08/25/2021 at 9:28 AM with Certified Nursing Assistant (CNA) #1. Resident #7 was lying in bed with his/her feet not elevated. The CNA removed the resident's left sock to reveal a quarter sized area on the left heel that was covered in black tissue. Interview with Certified Nursing Assistant (CNA) #1, on 08/25/2021 at 9:28 AM, revealed Resident #7 had the pressure ulcer on the heel since 05/2021. The CNA added she had been told the pressure ulcer was the result of the resident lying in bed and that when Resident #7 was in bed, both feet should be elevated. The CNA added the resident had a special boot at one time, but she had not seen the boot for at least two (2) weeks. Per interview, the CNA could give no reason why the resident's feet were not elevated while in bed. An interview was held, on 08/25/2021 at 10:28 PM, with CNA #2. She stated she was familiar with Resident #7. The CNA stated Resident #7 had special boots to elevate his/her feet for a while. She added the last time she had seen the boots was about three (3) weeks ago when the boots had been sent to the laundry and had not been returned. An observation was made with Licensed Practical Nurse (LPN) #7, on 08/25/2021 at 3:30 PM, of Resident #7. Observation revealed Resident #7 was lying in bed with his/her feet not elevated. Interview with LPN #7, on 08/25/2021 at 3:39 PM, revealed Resident #7 was in bed and did not have his/her feet elevated. Per interview he was unaware why the resident's feet were not elevated and did not know why the resident was still in bed. Observations throughout the survey revealed Resident #7 was not out of bed during the survey. The Director of Nursing (DON) was interviewed, on 08/26/2021 at 8:41 AM. She stated the administrative nursing team was responsible for making sure pressure ulcer reducing interventions were in place. The DON added the team should be checking daily to make sure all interventions were in place and all refusal of any intervention should be documented. 2. Review of Resident #7's Weekly Pressure Wound Observation Tool revealed no weekly assessment of Resident #7's left heel deep tissue injury (DTI) for the months of May 2021 and June 2021. Review of the Weekly Pressure Wound Observation Tool, dated 07/17/2021, revealed the date Resident #7 acquired the DTI was 06/22/2021. The location was documented as the right heel. Measurements were one point two (1.2) centimeters (cm) by one (1) cm with 100% necrotic (dead) tissue. The overall condition of the wound was listed as improving. The treatment was to apply skin prep. Review of the 07/2021 Treatment Administration Record (TAR) indicated skin prep had been applied to the left heel daily. Record review revealed on 08/12/2021, a nurse indicated on the weekly skin review that Resident #7's DTI was on the left heel. Review of the Weekly Wound Observation Tool dated 08/14/2021 identified a left heel DTI for Resident #7. The DTI had an onset date of 06/22/2021. Measurements were 3.0 cm x 2.2 cm with 100% necrotic tissue. Overall impression of the wound was documented as improving. The treatment remained for skin prep daily. Review of the August 2021 TAR indicated skin prep daily to the heel per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with the Director of Nursing (DON), on 08/26/2021 at 8:41 AM revealed a wound care physician had just started in the facility and would be responsible for weekly measurements and weekly wound assessments. Prior to the wound physician, the DON stated the nurses on the halls were responsible for weekly assessments of their assigned residents. She could offer no explanation why Resident #7 had missing weekly wound assessments. 3. Record review revealed the facility admitted Resident #25 on 03/07/2020 and readmitted the resident on 03/25/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #25's Significant Change in Condition Minimum Data Set (MDS) Assessment, dated 06/03/2021, indicated the resident had a Staff Assessment of Mental Status (SAMS) showing severe cognition deficit. The MDS indicated the resident required extensive assistance for transfers with two (2) plus persons, toileting, and personal hygiene. The resident required total dependence on staff for bed mobility, dressing, and eating. Further review revealed the resident had limited range of motion in all four (4) extremities. Review of the care plan, indicated Resident #25 had skin breakdown to the heel and thigh. Review of the Treatment Administration Record (TAR), dated 08/01/2021 - 08/31/2021, indicated Resident #25 had orders for low air loss mattress, apply skin prep to left heel once daily, and clean the right heel with soap and water, cover with foam, and wrap with Kerlix gauze. Review of a Weekly Pressure Wound Observation Note, dated 07/10/2021, indicated Resident #25 had a pressure ulcer to the left gluteal fold measuring one and two tenths (1.2) centimeters (cm) by one and two tenths (1.2) cm that was initially identified. Review of a Weekly Pressure Wound Observation Note, dated 07/11/2021, indicated Resident #25 had a pressure ulcer to the left heel measuring one and four tenths (1.4) cm by three and two tenths (3.2) cm by zero (0) cm and a pressure area to the left heel measuring one and one tenth (1.1) cm by one (1) cm by zero (0) cm, and another to the left heel measuring one and two tenths (1.2) cm by zero and four tenths (0.4) cm by zero (0) cm that was originally identified on 05/07/2021. Review of a shower sheet, dated 08/14/2021, indicated Resident #25 had two (2) wounds to the left heel measuring three (3) cm by two and two tenths (2.2) cm and one (1) wound to the left buttock measuring one (1) cm by three and two tenths (3.2) cm, and one (1) wound to the right buttock measuring one (1) cm by three and two tenths (3.2) cm. Review of a Wound Evaluation & Management Summary, dated 08/20/2021, indicated Resident #25 had an unstageable pressure ulcer to the left heel measuring one (1) cm by (0.5) cm by zero (0). Further review revealed there was no other wound documentation available. During an interview on 08/26/2021, at 8:41 AM, the ADON (Assistant Director of Nursing) indicated pressure ulcers were to be assessed and documented weekly. She indicated there was no other wound documentation available for review for Resident #25.

Based on observations, interviews, record reviews, and review of the facility's policies, it was determined the facility failed to provide nail care and failed to shave one (1) of four (4) dependent residents (Resident #46) from the sampled residents reviewed for activities of daily living (ADLs). The findings included: Review of the facility's policy on Care of Fingernails/Toenails, revised 2010, indicated the purpose of the policy was to clean the nail bed, to keep the nails trimmed, and to prevent infection. Under General Guidelines, the policy nail care included daily cleaning and regular trimming. Documentation including the date and time nail care was provided, the name of the person who administered nail care, and documentation of refusal with the intervention(s) attempted. Review of the facility's policy, titled Shaving the Resident, revised 2010, indicated the purpose was to promote cleanliness and to provide skin care. After shave documentation should include the time and date of the shave along with the name of the person that provided the shave. Directions included notifying the supervisor of any refusals. Record review revealed Resident #46 was initially admitted by the facility on 04/28/2019 and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #46's Quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident had severe cognitive impairment with a Brief Interview of Mental Status (BIMS) score of four (4) out of fifteen (15). Resident #46 was not identified to have physical or verbal behaviors or rejection of care. The facility assessed Resident #46 to require extensive assistance with bathing and personal hygiene. Review of Resident #46's Comprehensive Care Plan for refusal of care, last revised 05/16/2020, indicated a goal of the resident refusing care less than ten (10) times through the next review. Interventions included providing the resident with opportunities for choice, allowing time for expression of feelings, encouragement, explaining care and the reason for the care and simplifying tasks into simple one step directions. A review of the resident's progress notes from 08/23/2021 through 08/25/2021, revealed no documented evidence Resident #46 refused nail care or shaving. Review of the Behavior Observation sheet from 08/23/2021 through 08/25/2021, revealed one (1) episode of rejection of care on 08/23/2021. Observations of Resident #46, on 08/23/2021 at 12:19 PM, 08/24/2021 at 10:40 AM, 11:10 AM and 3:55 PM, revealed Resident #46's nails were extended over the end of the fingertips and black matter was seen underneath the nails. Continued observations revealed unshaven facial hair was present. Observation of Resident #46, on 08/25/2021 at 8:55 AM, revealed the resident was sitting in the common area on the unit. The resident's facial hair was long and black matter was seen under long nails. The resident had no socks or shoes on. Interview with Certified Nursing Assistant (CNA) #1, on 08/25/2021 at 8:58 AM, revealed she had worked on that unit for five (5) months and knew the residents. The CNA stated if residents refused care, she reported the refusal to the nurse for documentation. She added if the resident refused, she would leave the resident and return later and try again to provide the needed care. CNA #1 stated, Resident #46 was dependent on staff for all ADLs including nail care and shaving. She acknowledged the CNA assigned to a given resident was responsible for shaving the resident, cleaning and clipping nails. The CNA added Resident #46 did not refuse care. Per interview, CNA #1 saw Resident #46 and stated the resident needed a shave and the resident's nails needed to be cleaned and clipped. Interview with CNA #2, on 08/25/2021 at 10:11 AM, revealed she typically worked the unit where Resident #46 lived and was familiar with the resident. Continued interview revealed the resident was dependent on staff for daily care and did not have a history of refusing care. Interview with the Director of Nursing (DON), on 08/26/2021 at 8:38 AM, revealed she would need to review the facility's policy on nail care and shaving residents prior to and questions. Per interview, the DON stated, from a standard of care perspective, shaving should be done with showers. The DON stated she would hope there was no black matter under any residents' nails and added the danger of long nails would be a resident could sustain scratches or skin tears.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to periodically review and revise the Comprehensive Care Plan (CCP) by a team of qualified persons after each assessment related to not providing the appropriate interventions related to food and fluid consumption, for one (1) of three (3) sampled residents (Resident #1). The facility failed to have an effective system to ensure communication between Speech Therapy (ST), the Registered Dietician (RD), and the Nursing Department related to Resident #1. The facility failed to provide Resident #1 with close supervision, or specialized directions for safe eating and drinking, as the facility assessed the resident to require; and, the facility failed to ensure these interventions were addressed on the CCP or the Certified Nurse Aide (CNA) care plan. Multiple staff were not aware of the special instructions assessed and recommended by ST. Review of the Emergency Department (ED) Notes, dated [DATE] at 8:09 AM, revealed Resident #1 choked on scrambled eggs in the facility on [DATE]. Resident #1 passed away on [DATE] after being removed from life support. The facility's failure to periodically review and revise the comprehensive care plan has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.21 Comprehensive Person-Centered Care Plans, at F657, and 42 CFR 483.25 Quality of Care, at F689 and F695. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care, at F689 and F695. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE] and the facility alleged removal of the Immediate Jeopardy effective [DATE]. A Partial Extended Survey was initiated on [DATE] and completed on [DATE], and determined that the Immediate Jeopardy was not removed prior to exit on [DATE]. The Immediate Jeopardy is ongoing. The findings include: Review of the facility's policy titled, Standards of Clinical Gerontological Nursing Care, not dated, and under the section titled Planning revealed the gerontological nurse develops a plan of care that describes interventions to attain expected outcomes. Rationale: A plan of care is used to structure and guide therapeutic interventions and achieve expected outcomes. It is developed in conjunction with older adults, significant others, and interdisciplinary team members. Measurement Criteria: The plan is individualized to the older adult's health status or needs and meets the following objectives .a.) Identifies priorities of care in relation to expected outcomes; .b.) Identifies effective interventions to achieve outcomes; .c.) Specifies interventions that reflect current gerontological nursing practice and research; .d.) Includes, when appropriate, an educational program related to health maintenance and the older adult's health problems, treatment,and self-care activities; .e.) Indicates responsibilities of the gerontological nurse and the older adult and may include responsibilities for interdisciplinary team members to carry out the plan of care; .f.) Identifies a sequence of actions for achieving outcomes, as priorities; .g.) Provides for quality of life as perceived by the older adult and when appropriate, a good death; . h.) Identifies the settings in which services may be safely and appropriately delivered; .i.) Purposes alternatives for continuity of care for long term needs; .j.) Identifies resources required to accomplish the plan of care; .k.) Includes a discharge page, when appropriate .2. The plan is developed in collaboration with the older adult's significant others, and interdisciplinary team members, when appropriate .3. The plan is documented so that the team members can review and modify it as necessary. Record review revealed the facility admitted Resident #1 on [DATE], with [DIAGNOSES REDACTED]. The resident was a Full Code (start CPR in the event of cardiac or respiratory arrest). Review of the resident's Admission Minimum Data Set (MDS), dated [DATE], revealed he/she had a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated the resident was interviewable. Further review of the MDS revealed, under Section G for eating, ,[DATE], an indication he/she was independent (no help or staff oversight at any time) with set-up help only, and received ST at the time of the assessment. Review of the Comprehensive Care Plan (CCP), dated [DATE], revealed, Resident is at potential nutritional risk related to diagnosis, diuretic use, needs assist at meals. However, it did not include any interventions related to the amount of assistance needed, or the need for cueing at mealtime to encourage the resident to rest, and encourage proper breathing technique related to the resident getting in a hurry, or taking in food at a fast rate, which interfered with his/her breathing and becoming short of breath. Review of the Speech Therapy Treatment Encounter Note date of service [DATE], revealed staff reported the resident demonstrated significant swallowing distress with the afternoon meal on [DATE], so he/she was observed the next day during the morning meal, with one (1) instance of respiratory distress. The resident was asked to take a break and complete a breathing technique. Further review revealed, that with rest and the breathing technique, the resident returned to baseline ability. Review of Resident #1's Diet Order, titled Diet Order and Communication Form, dated [DATE], revealed the resident was to have a Regular/Liberalized-Dysphagia Pureed diet with nectar-like liquids. Under the title Preferences revealed needs assist. No other instructions were documented on the form related to the need for rest and breathing techniques to prevent the resident from eating too fast. Interview with Resident #1's Spouse, on [DATE] at 11:30 AM, revealed, on [DATE], the resident choked on eggs that were found in his/her windpipe by the paramedic at the nursing home, and by the time the resident arrived at the ER (emergency room ), he/she was brain dead. The Spouse further stated the facility had been made aware the resident had problems choking on food due to a hiatal hernia. He stated the resident had trouble self-feeding, because he/she would get in a hurry and become short of breath. Interview with the Speech Therapist, on [DATE] at 12:00 PM, revealed Resident #1 received Speech Therapy (ST) starting [DATE] and was discharged on [DATE]. She stated the resident was on a mechanical soft diet and nectar thickened liquids, and was a meal assist because of his/her cognitive deficit. Further interview revealed the resident required stand-by assistance for verbal and physical cueing to eat at a slow rate or pace and the use of the proper breathing techniques. She further stated there were three (3) levels of assistance Dependent (total assistance), Independent (needs no assistance), and needs assist. The ST stated needs assist covered a broad category which meant different eating techniques for different residents. She stated Resident #1 was at risk for aspiration, which required him/her to eat in the little dining room. (Review of the definition of The little dining room, dated [DATE], revealed often, but not always, utilized by the resident who required supervision, and/or cues, and/meal assistance when eating.) Further interview revealed the Speech Therapist stated she had worked with nursing to show them how to properly assist Resident #1 to safely eat. However, she was unable to produce any inservicing or staff who attended. Continued interview with the Speech Therapist, on [DATE] at 9:20 AM, revealed Resident #1 took large bites, and would lose attention to the meal task. She stated she did not think ,[DATE] for the ADL (Activities of Daily Living) eating, aligned with her recommendations. Interview with the Registered Dietician (RD), on [DATE] at 9:20 AM, revealed after the Speech Therapist made recommendations for a resident, they were given to him and it was his responsibility to update the care plan and resident meal cards. The RD stated Resident #1 would eat really fast and required assistance when eating. During the interview, the RD defined the resident's level of assistance as,keep eyes on while eating. He further stated more information should have been on Resident #1's CCP and CNA care plans to prevent aspiration/choking. Interview with Unit Manager #9, on [DATE] at 1:00 PM revealed when Dietary placed a new order, it was the nurse's responsibility to update the CCP and CNA care plans. However, she thought at the time of Resident #1's incident, it was the MDS Nurse who updated the care plans. Further interview, on [DATE] at 11:00 AM, revealed she was aware of Resident #1 being on thickened liquids, but she was not aware of the resident being a choking risk or of the need to encourage the resident to slow down and cut food in small bites. She stated, It was not on a care plan anywhere. Interview with the MDS Coordinator, on [DATE] at 2:15 PM, revealed she was responsible for updating the CCP and CNA care plans on admission, quarterly, annually and with a significant change MDS, and the charge nurses were responsible for any new and daily orders. She stated Resident #1 was coded as a ,[DATE] (independent with set up assist only), but should have been updated to reflect the ADL of eating as a ,[DATE] indicating the resident required supervision while eating at all times. She further revealed it would not necessarily be on the Dietary CCP, but on the ADL care plan. However, she was unable to find the information on any of Resident #1's care plans. She stated when Dietary completed their assessment and wrote orders, it was nursing's responsibility to add the information to the care plan. Interview with Registered Nurse (RN) #2, on [DATE] at 12:10 PM, revealed the process was when ST wrote an order, it was put into the computer, a communication slip was to be filled out; add it to the Dietary care plan; and verbally tell nursing about the new order, as well. When interviewed related to the CNA's understanding about nectar thickened liquids, or Dysphagia Advanced diet, she stated, she would understand it to mean watch closely, but CNA's may not understand. Interview with CNA #1, on [DATE] at 3:00 PM, revealed when asked about Resident #1's diet and Dysphagia, she stated the resident was on thickened liquids, but was very capable of feeding and drinking with only set-up assistance. She further stated the only precautions she was aware of, related to Resident #1, was that he/she was a fall risk. Interview with the Cooperate Clinical Quality Specialist, on [DATE] at 4:15 PM, revealed this incident should have never occurred. She stated she was aware of the concerns related to the lack of communication between therapy and nursing. Interview with the Director of Nursing (DON), on [DATE] at 5:30 PM, revealed it was her expectation that the nurse who took off an order of any kind, was responsible to put the information on the CCP and CNA care plans.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure a resident received adequate supervision and assistive devices to prevent accidents, for one (1) of three (3) sampled residents (Resident #1). Review of an Order Summary Form, dated ,[DATE], revealed Resident #1 was diagnosed with [REDACTED]. On [DATE], Resident #1 became unresponsive, asystolic (heart not functioning) after eating breakfast, resulting in cardiorespiratory arrest and [MEDICAL CONDITIONS]. The resident was transferred to the hospital by the Emergency Medical Service (EMS). Review of the Hospital emergency room (ER) Physician's Notes, dated [DATE] at 8:09 AM, revealed Suspect hypoxemia from aspiration. Apparently large amounts of breakfast were pulled from the resident's mouth by the EMS prior to intubation. I suspect the resident is acidotic from hypoxemia. The resident expired at the hospital on [DATE]. The facility's failure to ensure residents received adequate supervision and assistive devices to prevent accidents has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.21 Comprehensive Person-Centered Care Plans, at F657, and 42 CFR 483.25 Quality of Care, at F689 and F695. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care, at F689 and F695. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE] and the facility alleged removal of the Immediate Jeopardy effective [DATE]. A Partial Extended Survey was initiated on [DATE] and completed on [DATE], and determined that the Immediate Jeopardy was not removed prior to exit on [DATE]. The Immediate Jeopardy is ongoing. The findings include: Review of the facility's policy, Cardiac and/or Respiratory Arrest, revised [DATE], revealed if a patient has a Do Not Resuscitate (DNR) order, Cardiopulmonary Resuscitation (CPR) will not be initiated and Advanced life Support (ALS) will not be activated. However, under certain emergency circumstances, a patient who has a DNR order will receive life saving treatment. For example, if a patient who has a DNR is choking, staff should begin the obstructed airway intervention. Review of the definition of The little dining room, dated [DATE], revealed is often, but not always, utilized by the resident who requires supervision, and/or cues, and/meal assistance when eating. Record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. The resident was a Full Code (start CPR in the event of cardiac or respiratory arrest). Review of the resident's Admission Minimum Data Set (MDS), dated [DATE], revealed he/she had a Brief Interview for Mental Status (BIMS) score of nine (9), indicating the resident was interviewable. Further review of the MDS revealed, under Section G for eating, ,[DATE], which indicated he/she was independent (no help or staff oversight at any time) with set-up help only. Resident #1 received Speech Therapy (ST) at the time of the assessment. Review of the Comprehensive Care Plan (CCP), dated [DATE], revealed, Resident is at potential nutritional risk related to diagnosis, diuretic use, needs assist at meals. However, further review of the CCP revealed no interventions related to the amount of assistance needed; the need for cueing at mealtime to encourage the resident to rest; or encouraging proper breathing techniques related to the resident getting in a hurry. Further review of the CCP revealed the resident would eat food at a fast rate, which interfered with his/her breathing. Review of the Speech Therapy Treatment Encounter Note date of service [DATE], revealed staff reported the resident demonstrated significant swallowing distress with the afternoon meal on [DATE], so he/she was observed the next day during the morning meal, with one (1) instance of respiratory distress. Further review revealed the resident was asked to take a break and complete a breathing technique; with rest and the breathing technique, the resident returned to baseline ability. Review of Resident #1's Diet Order, titled Diet Order and Communication Form, dated [DATE], revealed the resident was to have a Regular/Liberalized-Dysphagia Pureed diet with nectar-like liquids. Under the title Preferences revealed needs assist. Further review revealed no other instructions were documented on the form related to the need for rest and breathing techniques to prevent the resident from eating too fast. Review of the Certified Nurse Aide (CNA) Care Plan, dated ,[DATE] and ,[DATE], revealed no interventions were listed for the amount and type of supervision required to safely assist Resident #1 with eating. All that was listed on the CNA Care Plan was nectar thickened liquids, Dysphagia Advanced diet. Review of Resident #1's Assistance for Daily Living (ADL) Record, dated ,[DATE], revealed the staff was coding the resident under eating to be ,[DATE], indicating the resident was independent with set-up help only. Review of the Nursing Progress Notes, dated [DATE] at 8:02 AM, revealed Staff initiated a Code Blue (all nursing staff are to respond with the crash cart) due to the resident becoming unresponsive and found to have no pulse/respirations. There was no evidence of any further documentation in the progress notes. Review of Resident #1's hospital Discharge Summary, dated [DATE] at 7:58 PM, revealed date of death was [DATE]. Review of the History and Physical and Hospital Course revealed . a patient who basically was brought to the hospital by EMS after suffering [MEDICAL CONDITION]. (He/she) was in [MEDICAL CONDITION] for around thirty (30) minutes, and was admitted to the Intensive Care Unit (ICU) on the vent. (He/she) was placed on the hypothermic protocol {used for post [MEDICAL CONDITION] patients to improve mortality and neurological outcomes in patients who have survived [MEDICAL CONDITION]}, and within twenty-four (24) hours of protocol was finished. (He/she) was warmed up and mentation was assessed. The patient had indicative changes consistent with [MEDICAL CONDITIONS] (a condition where brain tissue is deprived of oxygen and there is global loss of brain function). Goals of care were addressed with the family, and they decided to terminally extubate (remove life support) the patient. Interview with Resident #1's spouse, on [DATE] at 11:30 AM, revealed the resident had choked on eggs that were found in his/her windpipe by the paramedic at the nursing home on [DATE]. Further interview revealed by the time resident arrived at the ER (emergency room ), he/she was brain dead. The resident's Spouse further stated the facility had been made aware the resident had problems choking on food due to a hiatal hernia. He stated the resident had trouble self-feeding, because he/she would get in a hurry and become short of breath. Interview with the Speech Therapist, on [DATE] at 12:00 PM, revealed Resident #1 received ST starting [DATE] and was discharged on [DATE]. She stated the resident was on a mechanical soft diet and nectar thickened liquids, and was a meal assist because of his/her cognitive deficit. Further interview revealed the resident required stand-by assistance for verbal and physical cueing to eat at a slower rate or pace and the use of the proper breathing techniques. She further stated there were three (3) levels of assistance Dependent (total assistance), Independent (needs no assistance), and needs assist. The ST stated needs assist covered a broad category which meant different eating techniques for different residents. She stated Resident #1 was at risk for aspiration, which required him/her to eat in the little dining room. She stated she had worked with nursing to show them how to properly assist Resident #1 to safely eat. However, she was unable to produce any inservicing or staff who attended. Further interview with the Speech Therapist, on [DATE] at 9:20 AM, revealed Resident #1 took large bites, and would lose attention to the meal task. She stated she did not think ,[DATE], for the ADL eating, aligned with her recommendations. Interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 2:30 PM, revealed she recalled starting CPR after breakfast. She stated Resident #1 was not breathing, and she thought he/she was choking. LPN #1 stated she started chest compressions, but she did not recall if anyone provided respirations. She further stated she continued CPR until the ambulance arrived and the Emergency Medical Technicians (EMT's) took over. She stated she did not chart the event because it was not her resident; she had just responded to a Code Blue. Interview with LPN #5, on [DATE] at 3:00 PM, revealed she was in the little dining room the morning of the incident. She stated she noticed Resident #1 had become short of breath and was coughing, so she took the resident back to his/her room and was going to administer a breathing treatment. Upon return to the resident's room, she noticed the resident's color was off so a code was called and she tried to get the suction machine together. LPN #5 stated she did not recall anyone doing respirations during the code, and they did not use an AED (automated external defibrillator) or the perform the [MEDICATION NAME] Maneuver. She stated she had only worked at the facility a few weeks and had never been through a code drill. Further interview revealed the code could have gone better if the suction machine had been set up. LPN #5 stated she had to locate the parts to the suction machine; the parts were in three (3) different drawers. She stated it would have made a difference if she could have suctioned the resident. The LPN stated she could not answer why she did not chart the event in the Progress Notes, but was sorry (she) did not chart. Interview with the Paramedic, on [DATE] at 12:00 PM, who responded to the 911 call on [DATE], revealed when he arrived, Resident #1 was lying in bed and the staff were performing CPR. He stated that staff revealed five (5) minutes prior to the incident, the resident had been eating and was now completely unresponsive, in [MEDICAL CONDITION] and asystole. He stated an intravenous (IV) line was started after the resident was loaded into the ambulance, a full code was started, and the resident was intubated. He further revealed when he opened the resident's airway, he saw scrambled eggs and was able to remove them with forceps. Interview with LPN #3, on [DATE] at 12:10 PM, who worked Resident #1's unit, revealed she was not aware the resident had passed away, but thought he/she had been discharged to home. She stated Resident #1 always ate in the little dining room and required assistance. she stated the resident needed to be watched because he/she was at risk for aspiration. LPN #3 stated all staff were CPR certified and trained to do the [MEDICATION NAME] Maneuver (a first-aid procedure for dislodging an obstruction from a person's windpipe in which strong pressure is applied on the abdomen, between the navel and the rib cage). Interview with the MDS Nurse, on [DATE] at 2:15 PM, revealed the CCP and CNA care plan should have been updated to reflect that the resident required supervision while eating at all times. Interview with the Director of Nursing (DON), on [DATE] at 12:30 PM, revealed Resident #1 had been eating in the small dining room. When she arrived on the scene, the resident was lying in the bed, still breathing, but looked gray and was having difficulty breathing. She stated she went to call the resident's Spouse, who said to send (him/her) out. She then stated she recalled seeing LPN #5 giving chest compressions, but she did not know who was performing respirations. She stated she did not know if oxygen (02) was started or if 02 saturations were checked. She revealed night shift staff were responsible to check the cart every night to ensure the cart was set up and ready for an emergency. She stated there was a book at each nurse's station that explained, who and when, the nurses were to perform their duties. She revealed she was unable to provide any documented training or nursing skills check off related to staff Code Blue competencies or skills performance. Interview with the Medical Director, on [DATE] at 11:20 AM, revealed choking absolutely could cause [MEDICAL CONDITION]. He stated he was not sure if providing suctioning or the [MEDICATION NAME] Maneuver could have prevented Resident #1's death, but it looked as though the facility did have some failures. Interview with the Administrator, on [DATE] at 5:17 PM, revealed he was not aware Resident #1 had choked. He stated he was told the resident was talking at the time the incident occurred, but realized nursing failed to chart anything related to the incident. He further stated his expectations were, after training and education, nothing like this situation will ever happen again.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure a resident with special needs receives proper treatment and care for respiratory care/suctioning related to not having immediate access to a suction machine and not following through with crash cart checks, for one (1) of three (3) sampled residents (Resident #1). Review of an Order Summary Form, dated ,[DATE], revealed Resident #1 was diagnosed with [REDACTED]. On the morning of [DATE], after eating breakfast, he/she started showing signs of respiratory difficulty. The resident was taken to his/her room, and become unresponsive. A Code Blue was called; however, because a suction machine was not set up for quick access, the nurse who assisted with Cardiopulmonary Resuscitation (CPR) was unable to suction the resident. Review of the Hospital emergency room (ER) Provider Notes, dated [DATE] at 8:09 AM, revealed the patient was from the nursing home, was at the hospital due to [MEDICAL CONDITION], and suspected hypoxemia from aspiration. Apparently large amounts of breakfast were pulled from the patient's mouth by the Emergency Medical System (EMS) prior to intubation. The patient arrived to the hospital pulseless. The resident expired at the hospital on [DATE]. The facility's failure to ensure a resident with special needs receives proper treatment and care for respiratory care/suctioning has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.21 Comprehensive Person-Centered Care Plans, at F657, and 42 CFR 483.25 Quality of Care, at F689 and F695. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care, at F689 and F695. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE] and the facility alleged removal of the Immediate Jeopardy effective [DATE]. A Partial Extended Survey was initiated on [DATE] and completed on [DATE], and determined that the Immediate Jeopardy was not removed prior to exit on [DATE]. The Immediate Jeopardy is ongoing. The findings include : Review of the facility policy titled, NSG106 Emergency Cart, revised [DATE], revealed the facility will maintain at least one (1) emergency cart per nursing care floor. Additional emergency carts may be added as deemed necessary for larger buildings. Emergency carts will contain all supplies required to establish and sustain life support. The Purpose is to ensure all supplies critical to basic life support are readily available on the emergency cart. Review of Practice Standards revealed: 1. The emergency cart is stored in a location where it is readily accessible; 2. Staff are notified of the location; 3. Equipment from the cart is used only when emergency care is provided. Equipment/supplies used are noted and replaced promptly; 4. The emergency cart is checked every 24 hours and after each use. Review of the facility's policy titled, Cardiac and/or Respiratory Arrest, revised [DATE], revealed if a patient has a Do Not Resuscitate (DNR) order, CPR will not be initiated and Advanced life support (ALS) will not be activated. However, under certain emergency circumstances, a patient who has a DNR order will receive life saving treatment. For example, if a patient who has a DNR is choking, staff should begin the obstructed airway intervention. Record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. The resident was a Full Code (start CPR in the event of cardiac or respiratory arrest). Review of the resident's Admission Minimum Data Set (MDS), dated [DATE], revealed he/she had a Brief Interview for Mental Status (BIMS) score of nine (9), indicating the resident was interviewable. Further review of the MDS revealed, under Section G for eating, ,[DATE], an indication he/she was independent (no help or staff oversight at any time) with set-up help only. Review of the Nurse's Progress Notes, dated [DATE] at 8:02 AM, revealed staff initiated a Code Blue (all nursing staff were to respond) due to the resident becoming unresponsive and was found to have no pulse/respirations. Review of the CPR/AED (automated external defibrillator) Flow Sheet, dated [DATE], revealed Resident #1 was on Unit D of the facility. Further review revealed the resident was was a Full Code (perform CPR) and was recognized by Licensed Practical Nurse (LPN) #5 at 7:40 AM, with gray skin color. There was no documentation or name of staff performing ventilations. Compressions were done by LPN #1 at 7:40 AM, the Physician was called at 7:40 AM, family called at 7:40 AM, and EMS arrived at 7:45 AM. Continued review revealed there was no documentation related to suctioning except the oral cavity was checked at 7:45 AM; no documentation related to checking vital signs, pupils, or initiation of an IV (intravenous) as indicated on the form; and no documentation related to the use of oxygen (02), checking (O2) saturation, or performing the [MEDICATION NAME] Maneuver. Review of the Hospital ER Notes, dated [DATE] at 8:09 AM, revealed Resident #1 was brought in by EMS with a complaint of cardiopulmonary arrest. The note stated that EMS reported they were called to the patient's nursing home today for [MEDICAL CONDITION]. Further review of the notes revealed EMS stated the patient was witnessed by nursing home staff eating breakfast on the side of (his/her) bed this morning. Staff came back sometime later and found the patient to be unresponsive. EMS noted the patient was found to have a blocked airway from food with concerns for potential aspiration. They stated the patient was asystole on arrival. Further review revealed EMS stated they were able to remove a large piece of egg from the resident's mouth and intubated the patient. CPR was performed while enroute to the hospital. Review of Resident #1's hospital Discharge Summary, dated [DATE] at 7:58 PM, revealed date of death was [DATE]. Review of the History and Physical and Hospital Course revealed . a patient who basically was brought to the hospital by EMS after suffering [MEDICAL CONDITION]. (He/she) was in [MEDICAL CONDITION] for around thirty (30) minutes, and was admitted to the Intensive Care Unit (ICU) on the vent. (He/she) was placed on the hypothermic protocol {used for post [MEDICAL CONDITION] patients to improve mortality and neurological outcomes in patients who have survived [MEDICAL CONDITION]}, and within twenty-four (24) hours of protocol was finished. (He/she) was warmed up and mentation was assessed. The patient had indicative changes consistent with [MEDICAL CONDITIONS] (a condition where brain tissue is deprived of oxygen and there is global loss of brain function). Goals of care were addressed with the family, and they decided to terminally extubate (remove life support) the patient. Review of the facility's form Emergency Cart Checklist, on [DATE] at 4:30 PM, revealed the following instructions: Place Yes or No in the box for Cart Locked (the lock tag was intact). If the cart was locked, check the external items, replace if missing, and initial. If the cart was unlocked, check each item, replace the missing items, initial each item, lock the cart, and initial as being locked. Observation of the facility's Emergency Carts, on [DATE] at 4:35 PM, revealed, on Unit A, there was no suction machine on the cart. Review of Unit A's emergency cart checklist revealed four (4) of seven (7) nights ([DATE], [DATE], [DATE] and [DATE]) on the checklist were not checked off. On Unit C, one (1) of eight (8) nights ([DATE]) was not checked off. On Unit D, the entire checklist was blank thus far for (MONTH) 2019. Upon request, the facility was unable to provide previous emergency cart checklists, dating back to (MONTH) (YEAR). Interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 2:30 PM, revealed she recalled starting CPR after breakfast because the resident was not breathing, she thought he/she was choking. She revealed she started chest compressions, but did not recall if anyone provided respirations. LPN #1 stated she continued CPR until the ambulance arrived and the EMTs took over. Interview with LPN #5, on [DATE] at 3:00 PM, revealed she was in the little dining room the morning of the incident. She stated she noticed Resident #1 had become short of breath and was coughing, so she took the resident back to his/her room and was going to administer a breathing treatment. Upon return to the room, she noticed the resident's color was off so a code was called and she tried to get the suction machine together. LPN #4 stated she did not recall anyone doing respirations during the code, and they did not use an AED or the perform the [MEDICATION NAME] Maneuver. Further interview revealed she had only worked at the facility a few weeks and had never been through a code drill. The LPN stated the code could have gone better if the suction machine had been set up. She stated she had to locate the parts that were in three (3) different drawers. LPN #5 stated it would have made a difference if she could have suctioned the resident. Interview with the Paramedic, on [DATE] at 12:00 PM, who responded to the 911 call on [DATE], revealed when he arrived, Resident #1 was lying in bed and the staff were performing CPR. Staff revealed five (5) minutes prior, the resident had been eating, and now was completely unresponsive, in [MEDICAL CONDITION] and asystole. He stated an intravenous (IV) line was started after the resident was loaded into the ambulance, a full code was started, and the resident was intubated. He further stated when he opened the resident's airway, he saw scrambled eggs and was able to remove them with forceps. Interview with the Director of Nursing (DON), on [DATE] at 4:10 PM, revealed after the incident on [DATE], all crash carts were stocked with a suction machine set-up and ready to go, and it was night shift who was responsible for doing the nightly cart check-offs. The DON stated all nurses were taught it was night shift's responsibility to check the crash cart each shift, during orientation. Also, there was an instruction book at each nurse's station describing what task each nurse was responsible to do, for each shift, and the cart checkoff was in that book. Further interview with the DON, on [DATE] at 5:30 PM, revealed the facility was using a lot of agency nurses and felt that was the reason the crash carts were not being inspected nightly. She stated it was the Unit Managers' and her responsibility to ensure the carts were being checked properly, but they had failed to do so. The DON was unable to provide information related to the last Code Blue drill and nursing skills competencies when responding to a code. She stated she did not have the information. Interview with the Medical Director, on [DATE] at 11:20 AM, revealed choking could cause [MEDICAL CONDITION]. He stated he was not sure if providing suctioning or the [MEDICATION NAME] Maneuver could have prevented Resident #1's death, but looked as though the facility did have some failures. Interview with the Administrator, on [DATE] at 5:17 PM, revealed he was not aware Resident #1 had choked. He stated he was told the resident was talking at the time the incident occurred, but realized nursing failed to chart anything related to the incident. He further revealed his expectations were, after training and education, nothing like this situation will ever happen again.

Based on interview, record review and review of the facility's policy it was determined the facility failed to revise the care plan for one (1) of four (4) sampled residents (Resident #1). Resident #1 was care planned on 05/12/15 to remind him/her to use the call light when attempting to ambulate or transfer, even though the facility had assessed the resident's cognition as severely impaired. On 08/26/15, Resident #1 attempted to transfer and ambulate to the bathroom without calling for assistance. Resident #1 fell and sustained a compression [MEDICAL CONDITION] lumbar vertebral which resulted in the resident having to wear a back brace for approximately two (2) months. The facility revised the resident's care plan to address the resident continuing to get up without using the call light to ask for assistance on 09/08/15 with interventions to encourage resident to vent feeling/needs and document interventions and resident's response. However, the facility failed to develop an intervention to address the need for increased supervision to ensure staff would be aware if the resident attempted to get up in his/her room without assistance. On 12/05/15, Resident #1 sustained another fall in the bathroom after ambulating to the bathroom without calling for assistance. The resident was hospitalized with a non-displaced left femoral head fracture which required surgical intervention. Further review of the Comprehensive Care Plan revealed there was still no revision to the care plan to address the resident's continued need for increased supervision to ensure staff would be aware if the resident attempted to get up in his/her room without assistance. The findings include: Review of the facility's Care Plan Policy, last revised 01/02/14, revealed a comprehensive, individualized care plan will be developed by the interdisciplinary team for each resident, and include measurable objectives to meet resident needs. Further review revealed a Practice Standard was to ensure the care plan was reviewed and revised a minimum of quarterly and, as needed to reflect response to care and changing needs and goals. Record review revealed the facility admitted Resident #1 on 05/03/15 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 07/16/15, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of six (6), which indicated the resident was not able to make decisions and was not interviewable. In addition, the facility assessed Resident #1 as independent with transfers, ambulation and toilet use; and, his/her balance was steady when transferring from seated to standing, walking with assistive devices and moving on and off the toilet. The resident used a walker and was always continent of bowel and bladder. Review of Resident #1's Comprehensive Care Plan, for at risk for falls due to decreased safety awareness/confusion, dated 05/12/15, revealed interventions included for staff to place the call light in reach at all times and remind the resident to use the call light when attempting to ambulate or transfer even though the facility had assessed the resident's cognition as severely impaired. Review of the Nurse's Note, dated 08/26/15 at 10:54 PM, revealed Resident #1 was found on the floor of the bathroom and was assessed as having a scrape to his/her lower back and on 08/27/15 at 12:27 AM, the resident complained of lower back pain and was sent out to the hospital emergency room (ER). Review of a Hospital Discharge Summary, dated 08/29/15, revealed Resident #1 was diagnosed with [REDACTED]. Review of the Risk Management System (fall investigation), dated 08/26/15, revealed Resident #1 had an unwitnessed fall in the bathroom on 08/26/15 at 10:54 PM. The nurse determined the root cause of the fall was the walker was not in use at the time of the fall. Even though the facility assessed the resident to be cognitively impaired, the corrective action was to encourage the resident to use call light for assistance, which was already in place prior to the fall. Review of a Significant Change MDS assessment, dated 09/07/15, revealed the facility assessed Resident #1's cognition as severely impaired with a BIMS score of five (5) which indicated the resident was still unable to make decisions. In addition, the facility identified the resident was totally dependent on two (2) plus staff for transfers and toilet use; and, the resident was not steady and was only able to stablelize with human assistance when transferring on and off the toilet and surface to surface. Further review of the Comprehensive Care Plan revealed the care plan was revised on 09/08/15, to address the resident's non-compliance with asking for help and not using the call light with interventions to encourage resident to vent feeling/needs and document interventions and resident's response. However, there were no interventions to address how the facility was going to ensure staff would be aware if the resident was attempting to get up in his/her room without assistance (increased supervision). Review of Nurse's Note, dated 12/05/15 at 10:20 AM, revealed Registered Nurse (RN) #1 found Resident #1 on the floor of the bathroom and the resident had not called for assistance. On 12/05/15 at 8:23 PM, after the resident had complained of pain a mobile x-ray was completed. After the results were received, the physician gave an order to send the resident to the hospital ER. Review of the facility's Advanced Practice Registered Nurse (APRN) Progress Note, dated 12/10/15, revealed Resident #1 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. The surgical repair was completed and the resident returned to the facility on [DATE] with an incision on the left hip. Review of the RMS Summary (fall investigation), dated 12/05/15, revealed Resident #1 was found in his/her bathroom on the floor on his/her left side. Further review revealed the immediate interventions were to conduct an assessment, complete neurological-checks, and the resident was placed in the lobby to be within the visual field of the nurse's station. However, review of the Comprehensive Care Plan revealed the care plan was still not revised to address the need for an intervention to address the resident's need for increased supervision when the resident was in his/her room to ensure staff would be aware if the resident attempted to get up in room without assistance. Interviews on 01/12/16 with Unsampled Resident A (Resident #1's roommate) at 2:00 PM, with Certified Nurse Aide (CNA) #4 at 12:30 PM and CNA #3 at 11:30 AM, revealed Resident #1 would get up to use the restroom without calling for assistance and Unsampled Resident A would use the call light to call for staff. The CNAs stated Resident #1 was not steady on his/her feet and would get up approximately two (2) times a week. They stated the resident liked to stay in his/her room in bed. The CNAs stated they made rounds every two (2) hours. Interview (Post Survey) with Licensed Practical Nurse (LPN) #2, on 01/25/16 at 9:25 AM, revealed Resident #1 had a significant change in cognition and functional decline during the summer. LPN #2 stated she thought Resident #1 was no longer capable of learning to use the call light even after repeated encouragement. Interview with the C Wing Unit Manager, on 01/13/16 at 2:45 PM, revealed he as well as the licensed nurses were responsible for updating the Care Plan and the Nurse Aide Kardex immediately after any fall or significant change of condition of a resident. He stated he knew Resident #1 was cognitively unable to learn to use the call light or to remember to ask for help even after repeated encouragement. He stated, We just were on higher watch and and aware (he/she) was at risk for falls. Interview with the Director of Nursing (DON) and the Administrator, on 01/14/16 at 10:30 AM, revealed they expected the licensed staff to update and revise the care plan after any re-admission and implement new interventions. They stated they felt they were between a rock and a hard place for this resident because the resident was not cognitively capable of using the call light but was still able to be mobile. When asked how they provided increased supervision for this resident they stated the facility had discontinued alarms at the facility but expected the staff to make rounds every two (2) hours and look into the resident's room every time they walked by.

Based on interview, record review and review of the facility's policy it was determined the failed to have an effective system to ensure each resident receives adequate supervision to prevent accidents for one (1) of four (4) sampled residents (Resident #1). The facility care planned Resident #1 on 05/12/15, to remind him/her to use the call light when attempting to ambulate or transfer. However, the facility had assessed Resident #1's cognition on 05/12/15 as severely inpaired. On 08/26/15, Resident #1 sustained a fall in the bathroom after getting up without using the call light when attempting to ambulate. This fall resulted in a compression fracture of the lower lumbar vertebral; the resident had to wear a back brace for approximately two (2) months. On 09/08/15, the facility identified and care planned that the resident was continuing to get up without using the call light to ask for assistance. However, the facility failed to provide increased supervision to ensure staff would be aware if the resident attempted to get up without assistance in his/her room. On 12/05/15, Resident #1 sustained another fall in the bathroom when he/she ambulated to the bathroom without staff assistance or knowledge. This fall resulted in the resident being hospitalized with a non-displaced left femoral head fracture which required surgical intervention. The facility still failed to provide increased supervision to ensure staff would be aware if the resident attempted an unassisted transfer in his/her room. The findings include: Review of the facility's Falls Management Policy, last revised 05/15/14, revealed residents would be assessed for fall risks as part of the nursing assessment process and those determined to be at risk would receive appropriate interventions to reduce the risk and minimize injury. Further review revealed the facility's Practice Standards for when a resident falls included to document the accident/incident in the risk management system and on the change of condition note; to investigate using the appropriate tools in the Risk Management System (RMS); update care plan to include new interventions; conduct an interdisciplinary team meeting within seventy-two (72) hours of fall; and, for the Administrator and Director of Nursing (DON) to conduct a post fall review. Record review revealed the facility admitted Resident #1 on 05/03/15 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 07/16/15, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of six (6), which indicated the resident was not interviewable. In addition, the facility assessed Resident #1 as independent with transfers, ambulation and toilet use; and his/her balance was steady when transferring from a seated to standing position, walking with assistive devices and moving on and off the toilet. The resident used a walker and was always continent of bowel and bladder. Review of the Comprehensive Care Plan for resident at risk for falls due to decreased safety awareness/confusion, dated 05/12/15, revealed interventions for staff to place the call light in reach at all times. Staff was to remind the resident to use the call light when attempting to ambulate or transfer, even though they had assessed the resident as having confusion, poor safety awareness and his/her cognition was severely impaired. Review of the Nurse's Note, dated 08/26/15 at 10:54 PM, revealed Resident #1 was found on the floor of the bathroom and was assessed as having a scrape to his/her lower back. The resident was assisted back to his/her bed by two (2) Certified Nurse Aides (CNA). Review of a Nurse's Note, dated 08/27/15 at 12:27 AM, revealed the resident complained of lower back pain and was sent out to the hospital emergency room (ER). Review of a Hospital Discharge Summary, dated 08/29/15, revealed Resident #1 was diagnosed with [REDACTED]. Review of the Risk Management System (fall's investigation), dated 08/26/15, revealed Resident #1 had an unwitnessed fall in the bathroom on 08/26/15 at 10:54 PM. The nurse determined the root cause of the fall was that the walker was not in use at the time of the fall. Further review revealed the corrective action was to encourage the resident to use the call light for assistance. However, this intervention was already in place, and the facility had assessed the resident to be severely cognitive impaired. Review of a Significant Change MDS assessment, dated 09/07/15, revealed the facility assessed Resident #1's cognition as severely impaired with a BIMS' score of five (5) which indicated the resident was unable to make decisions. In addition, the facility identified the resident was totally dependent on two (2) plus staff for transfers and toilet use; was not steady; and, was only able to stablelize with human assistance with transferring on and off the toilet and surface to surface. Review of the Comprehensive Care Plan revealed on 09/08/15, Resident #1's care plan was revised to include resident exhibits behavior: non-compliance with asking for help and using the call light. Further review revealed the interventions developed were to allow time for the resident to vent feelings and to document interventions and the resident's response. However, there were no interventions to address how they were going to ensure staff would be aware if the resident attempted to get up without assistance or an intervention to increase the resident's supervision. In addition, further review of the care plan revealed an intervention for the resident to ambulate with a walker with one (1) assist on 10/01/15. Review of Nurse's Note, dated 12/05/15 at 10:20 AM, revealed Registered Nurse (RN) #1 documented she found Resident #1 on the floor of the bathroom and the resident was identified to have an abrasion on the left elbow and complained of mild hip pain. The resident was assisted by two (2) CNAs back to bed and neurological (neuro) checks were initiated. Review of a Nurse's Note, dated 12/05/15 at 10:56 AM, revealed to continue to encourage resident to use call light. The resident complained of mild left hip pain and the On Call Physician was contacted with an order received to obtain a portable radiograph (x-ray). Further review revealed the On-Call Physician was called at 8:23 PM with the x-ray results. An order was received to send the resident to the hospital ER. Review of the Advanced Practice Registered Nurse (APRN) Progress Note, dated 12/10/15, revealed Resident #1 was admitted to the hospital with [REDACTED]. The surgical repair was completed and the resident returned to the facility on [DATE] with an incision on the left hip. Review of the RMS Summary (fall's investigation), dated 12/05/15, revealed Resident #1 was found in his/her bathroom on the floor on his/her left side. Further review revealed there was no documented evidence that the root cause of the fall was identified. The immediate interventions included to conduct an assessment and neuro-checks; and, the resident was placed in the lobby to be within the visual field of the nurse's station. Review of the Comprehensive Care Plan revealed the care plan was revised on 12/14/15 to include an intervention for the resident to ambulate with a walker with one (1) to two (2) assist with weight bearing as tolerated. Interventions on 12/18/15, included to encourage the resident to use call light for assistance from staff; and, on 12/21/15 to encourage resident to stay in common areas and participate in activities. However, further review revealed there were still no interventions to increase the resident's supervision, to ensure staff would be aware if the resident attempted to get up without assistance. Interview with Unsampled Resident A (Resident #1's roommate), on 01/12/16 at 2:00 PM, revealed he/she saw Resident #1 get up and go to the bathroom by himself/herself, then he/she heard the resident in the bathroom trying to get up and calling for help. Unsampled Resident A stated Resident #1 was always getting up without calling for assistance so he/she would use the call light to call the nurse. Interview (Post Survey) with Licensed Practical Nurse (LPN) #2, on 01/25/16 at 9:25 AM, revealed Resident #1 had been independent prior to the 08/26/15 fall but had required a lot more assistance since then. She stated Resident #1 had a significant change in cognition and functional decline after the first fall and he/she was no longer capable of learning to use the call light, even after repeated encouragement. Interview with Certified Nurse Aide (CNA) #4, on 01/12/16 at 12:30 PM; and, on 01/13/16 at 2:30 PM, revealed RN #1 and CNA #3 found Resident #1 on the floor in the bathroom on 12/05/15. CNA #4 stated the resident was not steady on his/her feet before he/she fell the first time (08/26/15). She stated the resident would get up without calling for assistance approximately two (2) times a week and his/her roommate would usually let them know. She stated the CNAs made rounds every two (2) hours. Interview with CNA #3, on 01/12/16 at 11:30 AM; and on 01/13/16 at 2:35 PM, revealed Resident #1 would get up by himself/herself and he/she wasn't supposed too. CNA #3 stated the resident did not remember to call for assistance and liked to stay in his/her room in bed. She stated the resident would get up without assistance approximately two (2) times a week and his/her roommate would usually let them know. Interview with RN #1, on 01/12/16 at 10:15 AM, revealed Resident #1 was found on the floor in the bathroom on 12/05/15 in the morning. She stated the resident ambulated with a little bit of an unsteady gait with the assistance of one (1) staff. RN #1 stated she immediately initiated to place the resident in direct view of the nurse's station for observation after the 12/05/15 fall. Review of a Interdisciplinary Team (IDT) Note, dated 01/13/16, revealed the team met to review the resident's history of falls. The Note stated Resident #1 had a fall on 08/26/15 ambulating self to restroom, and the resident was encouraged to use the call light but continues with non-compliance and attempting to maintaining independence. In addition, the Note stated the resident started to allow them (staff) to assist with transfers and the next fall did not occur until 12/05/15. The resident attempted to ambulate self to bathroom and fell resulting in fractured left hip. There was no documented evidence the IDT had identified there was no intervention in place to ensure staff would be aware the resident was attempting to get up without calling for assistance. Interview with the C Wing Unit Manager (IDT), 01/13/16 at 2:45 PM, revealed he, as well as the licensed nurses were responsible for updating the Care Plan and the Nurse Aide Kardex immediately after any fall or significant change of condition of a resident. He stated he knew Resident #1 was cognitively unable to learn to use the call light or to remember to ask for help even after repeated encouragement. He stated, We just were on higher watch and aware he/she was at risk for falls. Interview with the Assistant Director of Nursing (ADON), on 01/13/16 at 3:00 PM, revealed she knew Resident #1 was cognitively unable to learn to use the call light, or to remember to ask for help when getting out of bed. She stated she was aware Resident #1 was at high risk for falls and she expected staff to monitor the resident closely every time they passed by the room as well as conducting routine continence checks and toileting every two (2) hours. She stated the facility no longer used bed or chair alarms. Interview with the DON and Administrator, on 01/14/16 at 10:30 AM, revealed they felt they were between a rock and a hard place for this resident because the resident was not cognitively capable of using the call light but was still able to be mobile. They stated the IDT recommended Resident #1 be moved closer to the nurse's station after the fall on 08/26/15, but the resident refused. They stated they knew the resident was a high fall's risk and expected staff to conduct every two (2) hour rounds and to be on a higher alert with him/her by looking into his/her room anytime they walked by the door.

Based on observation, interview, record review, review of the facility's investigation, and review of the facility's policy/procedure, it was determined the facility failed to ensure one resident (#1), in the selected sample of fifteen residents, was provided care in accordance with the plan of care. The resident was totally dependant on staff for mobility and was care planned for transfers with the assistance of two staff. On 09/04/12, a Hospice Certified Nurse Aide (CNA) transferred Resident #1 from a geri-chair to his/her bed without additional assistance as required per the plan of care. The Hospice CNA immediately noticed a discoloration to the resident's right foot and notified the nurse. An X-ray was obtained and revealed the resident sustained [REDACTED]. The facility determined the fracture occurred when the Hospice CNA transferred the resident without assistance. (Refer to F309) Additionally, review of Resident #1's care plan, Risk for Falls, revealed an intervention dated 08/06/12 to keep the resident's bed in a low position. However, during the abbreviated survey, Resident #1 was observed in a bed which was not in low position in accordance with the resident's care plan. Findings include: A review of the facility's policy/procedure, Interdisciplinary Care Plan, dated 01/2008, revealed "The Interdisciplinary Team (IDT) develop care plans within 24 hours of admission addressing the resident's most acute problems. The care plan is comprehensive for each resident including measurable objectives and timetable to meet resident's medical, nursing, and mental and psychosocial needs." Record review revealed the facility admitted Resident #1 on 07/01/05 with [DIAGNOSES REDACTED]. Further review revealed Resident #1 was placed on the Hospice case load on 06/29/11. Review of a quarterly Minimum Data Set (MDS) assessment, dated 03/20/12, revealed the facility assessed the resident to be unable to complete the interview in order to determine his/her cognitive status. The facility assessed the resident was totally dependent, requiring two staff for bed mobility and two staff for transfers. A review of the comprehensive care plan, Self Care Deficit, revealed an intervention to include "Requires two total staff for bed mobility, transfers, dressing, toileting, bathing and grooming." A review of the Hospice care plan, dated 04/23/12 for Activity/Mobility, revealed "Managed with current Plan of Care interventions/monitoring." Further review of the Hospice care plan did not specify the amount of assistance required for transfers. Review of an annual MDS assessment, dated 06/18/12, revealed the facility assessed the resident's cognitive status as modified independence, having some difficulty in new situations only. He/she was totally dependent, requiring two staff for bed mobility and two staff for transfers. Review of the Nurse Aide Care Plan, dated 09/2012, revealed bed mobility and transfers were to be two person assistance. Review of a Change of Condition document, dated 09/04/12 at 2:10 PM, revealed notes that described a bruise on the top of the resident's right foot measuring 6.6 centimeters (cm) long by 4.7 cm wide and bluish purple in color. The right foot was was turned inward at the ankle and the resident complained about pain when lifted. The physician was notified and an order was received to obtain an X-ray. Review of the facility's investigation revealed, on 09/04/12, the Hospice CNA notified the nurse about the resident's foot being discolored, and the facility determined the Hospice CNA transferred the resident without assistance and was unaware that Resident #1 was a two-assist transfer. The facility determined the injury was the result of the inappropriate transfer. Interview with the Hospice CNA, on 11/08/12 at 11:25 AM, revealed she provided care for Resident #1 two times a week such as bathing, appropriate activities, and feeding. The Hospice CNA revealed she did not get a report related to the residents she cared for each time she came to the facility; however, she did talk to the facility CNAs from time to time. The Hospice CNA stated she never looked at the facility Nurse Aide care plan and never documented on any facility document. She always transferred Resident #1 alone except when using a shower chair. The CNA had a Call Track (palm held information device) that she referred to for information about the residents she cared for. She stated the information in the Call Track did not specify Resident #1 to be a two person assist with transfers. She stated she observed facility CNAs transferring Resident #1 alone on multiple occasions and the facility nurse did oversee the care she provided. Additionally, the Hospice CNA stated, that on 09/04/12, Resident #1 was up in a geri chair when she arrived and she transferred him/her to the bed without assistance, as usual. She was going to provide a bed bath to Resident #1 and when she removed the resident's sock from the right foot, she noticed it "did not look right and felt funny." The nurse on duty was notified. The Hospice CNA filled out an incident report at the Hospice office, and the facility Director of Nursing (DON) spoke to her about the resident being a two person assist the next time she came to the facility. Further review of the comprehensive care plan, Risk for falls, revealed an intervention, dated 08/06/12, "Keep the bed in low position." An observation, on 11/06/12 at 3:10 PM, revealed Resident #1's bed was at regular middle height. CNA #5 verified the bed position was at the middle setting, and then lowered the bed to the low position; however, the CNA revealed she was unaware Resident #1's bed was suppose to be in the low position. An interview with the Clinical Case Manager, MDS Coordinator, on 11/09/12 at 11:00 AM, revealed the facility charge nurses were responsible to ensure care was provided as per the resident's care plan. She stated "When they (referring to Hospice staff) were in the building, we have to watch and ensure they know what to do." She stated Hospice nurses attended the facility care plan meetings and signed off on the signature log about understanding the plan of care. An interview with Hospice Director of Quality Compliance and Education and Clinical Team Coordinator, on 11/09/12 at 11:15 AM, revealed the Hospice and facility care plans should mirror each other. The Hospice Director of Quality Compliance stated Resident #1's Hospice care plan did not specify the resident required two person assist transfers nor about the resident's low bed, but should have. The facility was responsible to ensure care was provided per the care plan and stated "hopefully they are observing." An interview with the DON, on 11/06/12 at 6:45 PM, revealed Resident #1 was in a low bed. Further interview with the DON, on 11/07/12 at 8:30 AM, revealed when a resident was accepted for the Hospice program, that Hospice provided their own care plans. However, she revealed that it was she and the facility staff who were responsible to ensure care plans were followed by the Hospice CNAs.

Based on interview, record review, review of the facility's policy/procedure and investigation, it was determined the facility failed to ensure it provided the necessary care and services to attain or maintain the highest practicable physical, mental well being in accordance with the comprehensive assessment and Plan of Care for one resident (#1), in the selected sample of fifteen residents. The facility assessed Resident #1 to require two person assistance with transfers and developed a plan of care detailing the assistance required. The facility failed to ensure a Hospice Certified Nurse Aide (CNA) was knowledgeable and followed the care plan related to two person assist with transfers. On 09/04/12, Resident #1, who was a Hospice resident, was transferred by a Hospice CNA without the recommended second person assist. The resident sustained [REDACTED]. (Refer to F282) Findings include: A review of the facility's policy/procedure, Interdisciplinary Care Plan, dated 01/2008, revealed "The Interdisciplinary Team (IDT) develop care plans within 24 hours of admission addressing the resident's most acute problems. The care plan is comprehensive for each resident including measurable objectives and timetable to meet resident's medical, nursing, and mental and psychosocial needs." A record review revealed the facility admitted Resident #1 on 07/01/05 with [DIAGNOSES REDACTED]. Resident #1 was placed on Hospice case load on 06/29/11. Review of a quarterly Minimum Data Set (MDS) assessment, dated 03/20/12, revealed the facility assessed the resident to be unable to complete the interview in order to determine his/her cognitive status. He/she was totally dependent, requiring two staff for bed mobility and two staff for transfers. A review of the comprehensive care plan, Self Care Deficit, revealed an intervention to include "Requires two total staff for bed mobility, transfers, dressing, toileting, bathing and grooming." A review of the Hospice care plan, dated 04/23/12 for Activity/Mobility, revealed "Managed with current Plan of Care interventions/monitoring." Further review of the Hospice care plan did not specify the amount of assistance required for transfers. Review of an annual MDS assessment, dated 06/18/12, revealed the facility assessed the resident's cognitive status as modified independence, having some difficulty in new situations only. He/she was totally dependent, requiring two staff for bed mobility and two staff for transfers. A review of the Nurse Aide Care Plan, dated 09/2012, revealed bed mobility and transfers were to be two person assistance. Review of a Change of Condition Document, dated 09/04/12 at 2:10 PM, revealed notes that described a bruise on the top of the resident's right foot measuring 6.6 centimeters (cm) long by 4.7 cm wide and bluish purple in color. The right foot was was turned inward at the ankle and the resident complained about pain when lifted. The physician was notified and an order was received to obtain an X-ray. Review of a radiology report, dated 09/04/12, revealed "Conclusion: acute or subacute fractures of the tibia and fibula with valgus angulation." The physician was notified regarding the findings. An order was received to wear an Aircast on the right ankle at all times, and may remove daily for skin care. Review of the facility's investigation revealed, on 09/04/12, the Hospice CNA notified the nurse about the resident's foot being discolored, and the facility determined the Hospice CNA transferred the resident without assistance and was unaware that Resident #1 was a two-assist transfer. The facility determined the injury was the result of an accident and took steps to work with Hospice to prevent another such accident in the future. An interview with the Hospice CNA, on 11/08/12 at 11:25 AM, revealed she provided care for Resident #1 for a long time. She provided care to the resident two times a week such as bathing, appropriate activities, and feeding. The Hospice CNA revealed she did not get a report related to the residents she cared for each time she came to the facility; however, she did talk to the facility CNAs from time to time. The Hospice CNA stated she never looked at the facility Nurse Aide care plan and never documented on any facility document. She always transferred Resident #1 alone except when using a shower chair. The CNA had a Call Track (palm held information device) that she referred to for information about the residents she cared for. She stated the information in the Call Track did not specify Resident #1 to be a two person assist with transfers. She stated she observed facility CNAs transferring Resident #1 alone on multiple occasions and the facility nurse did oversee the care she provided. Additionally, the Hospice CNA stated, that on 09/04/12, Resident #1 was up in a geri chair when she arrived and she transferred him/her to the bed without assistance, as usual. She was going to provide a bed bath to Resident #1 and when she removed the resident's sock from the right foot, she noticed it "did not look right and felt funny." The nurse on duty was notified. The Hospice CNA filled out an incident report at the Hospice office, and the facility Director of Nursing (DON) spoke to her about the resident being a two person assist the next time she came to the facility. An interview with the Clinical Case Manager, MDS Coordinator, on 11/09/12 at 11:00 AM, revealed the facility charge nurses were responsible to ensure care was provided as per the resident's care plan. She stated "When they (referring to Hospice staff) were in the building, we have to watch and ensure they know what to do." She stated Hospice nurses attended the facility care plan meetings and signed off on the signature log about understanding the plan of care. An interview with Hospice Director of Quality Compliance and Education and Clinical Team Coordinator, on 11/09/12 at 11:15 AM, revealed Hospice nurses attended resident care plan meetings and CNAs do not attend those meetings. Hospice received a copy of the facility care plans and the facility had a copy of Hospice care plans. Hospice and facility care plans should mirror each other. The Hospice Director of Quality Compliance stated Resident #1's Hospice care plan did not specify the resident required two person assist transfers, but they should have. The Hospice nurses conducted supervisory visits every fourteen days to ensure care was being provided appropriately; however, they only watched the CNAs provide care once a year. The facility was responsible to ensure care was provided per the care plan and stated "hopefully they are observing." An interview with the DON, on 11/07/12 at 8:30 AM, revealed when a resident was accepted for the Hospice program, that Hospice provided their own care plans. She stated the Hospice CNAs communicated with the nursing staff, but did not know if the Hospice CNA had a copy of the resident's facility care plan. The DON stated she did not meet with the Hospice CNA because Hospice had directed the care they provided; however, she revealed that it was she and the facility staff who were responsible to ensure care plans were followed by the Hospice CNAs.