Every finding on record at Church Hill Post-Acute and Rehabilitation Center

Based on facility policy review, medical record review, and interview, the facility failed to establish and implement a process to ensure residents or resident representatives received the required written notice of transfer, including the specific reason for the transfer and information regarding the facility's bed-hold policy, when residents were transferred to the hospital with an anticipated return to the facility for 4 residents (Residents #13, #60, #6, and #14) of 5 residents reviewed for hospitalization. Based on facility policy review, medical record review, and interviews, the facility failed to establish and implement a process to ensure residents and resident representatives received the required written notice of transfer, including the specific reason for the transfer and information regarding the facility's bed-hold policy, when residents were transferred to the hospital with an anticipated return to the facility for 4 residents (Residents #13, #60, #6, and #14) of 5 residents reviewed for hospitalization. The findings include: Review of the facility's undated policy titled, Transfer and Discharge, revealed .Emergency Transfers/Discharges .initiated by the facility for medical reasons to an acute care setting such as hospital .Provide a notice of transfer and the facility's bed hold policy to the resident and representative as indicated . Review of the facility's undated policy titled, Bed Hold Policy, revealed .At the time the Resident is to leave the Facility for a temporary stay in a hospital .(or within 24 hours in case of emergency transfer) .the facility Bed Hold Policy will be discussed with either Resident/Legal Representative .A copy of the Bed Hold Policy will be provided to Resident/Legal Representative . Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Hypertensive Heart and Chronic Kidney Disease, Diabetes Mellitus, Cerebral Infarction, Dementia, Anxiety Disorder, Major Depressive Disorder, and Chronic Obstructive Pulmonary Disease (COPD). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #13 scored a 10 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Review of a Nursing Note for Resident #13 dated 4/25/2026, revealed .went into resident's room .to administer medication. resident lying flat on her back .eyes rolled up and body jerking very hard .unresponsive to sternal rub .became more responsive, but very lethargic .spoke to NP [Nurse Practitioner] .verbal order to have this resident sent to ER [Emergency Room] .ems [Emergency Medical Services] arrive 2000 [8:00 PM] . Review of the discharge MDS assessment dated [DATE], revealed Resident #13 had an unplanned discharge with return anticipated to a .Short Term General Hospital . Review of a Nursing Note for Resident #13 dated 4/25/2026, revealed .went into resident's room .to administer medication. resident lying flat on her back .eyes rolled up and body jerking very hard .unresponsive to sternal rub .became more responsive, but very lethargic .spoke to NP [Nurse Practitioner] .verbal order to have this resident sent to ER [Emergency Room] .ems [Emergency Medical Services] arrive 2000 [8:00 PM] . Review of the medical record revealed Resident #13 returned to the facility on 5/1/2026. Review of the discharge MDS assessment dated [DATE], revealed Resident #13 had an unplanned discharge with return anticipated. Review of a Nursing Note for Resident #13 dated 5/22/2026 at 12:08 AM, revealed .Assessed resident at 2050 [8:50 PM] blood sugar was 58 blood pressure 88/44 .alert and talking .felt clammy .administered oral glucagon .notified sister of situation .sister requested resident to be sent to [named hospital]. Called 911 at 2055 [8:55 PM]. EMS arrived at 2108 [9:08 PM] .left facility via EMS [Emergency Medical Services] at 2112 [9:12 PM] .notified sister of transfer . Review of the medical record revealed Resident #13 returned to the facility on 5/26/2026. Review of the Nursing Note for Resident #13 dated 6/5/2026 at 6:54 PM, revealed .resident requested to go to ER [Emergency Room] due to SOB [shortness of breath] and pain in her right side .received an order from [named provider] to have her sent to ER and evaluated, called [resident's son] .left a message, ems arrived at 1845 [6:45 PM]. Review of the discharge MDS assessment dated [DATE], revealed Resident #13 had an unplanned discharge to a .Short Term General Hospital . with return anticipated. Review of the medical record revealed Resident #13 returned to the facility on 6/11/2026. Review of a Nursing Note for Resident #13 dated 6/27/2026 at 3:04 AM, revealed .pitting edema to lower extremities .resident complains of difficulty breathing with audible wheezing .0250 [2:50 AM] [named provider] advised .to send resident to [named hospital] at 0254 [2:54 AM] .EMS called at 0255 [2:55 AM] family notified . Review of the discharge MDS assessment dated [DATE], revealed Resident #13 had an unplanned discharge to a .Short Term General Hospital . with return anticipated. Review of the medical record revealed Resident #13 returned to the facility on 7/2/2026. Review of the quarterly MDS assessment dated [DATE], revealed Resident #13 scored a 6 on the BIMS assessment which indicated the resident had severe cognitive impairment. Review of a Nursing Note dated 7/14/2026 at 9:40 PM, revealed .resident observed on the toilet by CNA [Certified Nursing Assistant]. resident stated she was light-headed, weak, 5/10 [5 out of 10 on a pain scale] pain in her head, and 'did not feel right'. Resident stated she would like to go to the hospital .called [provider] on call .hemoglobin results were critically low]. she needed to be sent to the ER for further evaluation .Ems arrived at 2115 [9:15 PM] . Review of the discharge MDS assessment dated [DATE], revealed Resident #13 had an unplanned discharge to a .Short Term General Hospital . with return anticipated. Review of the medical record revealed Resident #13 returned to the facility on 7/22/2026. Review of the medical record for Resident #13 revealed no documented evidence a written notice of transfer discharge or the facility's bed-hold policy for Resident #13's hospital transfers on 4/25/2026, 5/21/2026, 6/5/2026, 6/27/2026, and 7/14/2026 had been provided to the resident or resident representative. During a telephone interview on 8/7/2026 at 5:57 PM, Resident #13's sister stated she had never received any paperwork, or a bed hold policy on the dates when Resident #13 was transferred to the hospital. Review of the medical record revealed Resident #60 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Acute and Chronic Respiratory Failure, Anxiety Disorder, Obstructive Sleep Apnea, and Acute on Chronic Systolic Congestive Heart Failure. Review of the admission MDS assessment dated [DATE], revealed Resident #60 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of the Nursing Note dated 7/4/2026, revealed .he [Resident #60] stated he has pneumonia & [and] needs to go to the hospital now .NP gave verbal order to send resident out d/t [due to] low o2 [oxygen] saturation. EMS arrived @ [at] 1430 [2:30 PM] .left with resident [at] 1440 [2:40 PM] to be transferred to [named hospital]. Resident son called & notified of transfer . Review of the discharge MDS assessment dated [DATE], revealed Resident #60 had an unplanned discharge to a .Short-Term General Hospital . with return anticipated. Review of the medical record revealed Resident #60 returned to the facility on 7/8/2026. Review of the medical record for Resident #60 revealed no documented evidence a written notice of transfer discharge or the facility's bed-hold policy was provided to the resident or resident representative for Resident #60's hospital transfer on 7/4/2026. During an interview on 8/7/2026 at 7:01 PM, Resident #60 stated he was transferred to the hospital on 7/4/2026 for .pneumonia or breathing problems . Resident #60 stated he had not received any paperwork related to his hospital transfer or bed hold on 7/4/2026 and was unaware of what a Bed-Hold was. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including Chronic Respiratory Failure with Hypoxia, COPD, and Pneumonia. Review of the admission MDS assessment dated [DATE], revealed Resident #14 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. Review of a Nursing Note for Resident #14 dated 7/20/2026, revealed .resident to ER [Emergency Room] 2330 [11:30] . Review of a discharge MDS assessment dated [DATE], revealed Resident #14 had an unplanned discharge with return anticipated to a .Short Term General Hospital . Review of the medical record revealed Resident #14 returned to the facility on 7/24/2026. Review of the medical record for Resident #14 revealed no documented evidence a written notice of transfer discharge or the facility's bed-hold policy was provided to the resident or resident representative for Resident #14's hospital transfer on 7/20/2026.

Based on facility policy review, medical record review, observation, and interview, the facility failed to revise the care plans for 5 residents (Residents #9, #33, #74, #75, and #85) of 21 residents sampled and failed to conduct interdisciplinary team (IDT) care conferences including the resident and resident representatives for 2 residents (Residents #53, and #54) of 21 residents and resident representatives interviewed. The findings include: Review of the facility policy titled, Care Plan Revision guidelines, revised on 9/2025, revealed .resident care plans will .be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review .The IDT .will also review and revise a resident's comprehensive care plan as necessary, when a resident experiences a status change .Upon identification of a change in status .The IDT will review and update/modify the care plan with the new or modified interventions . Review of the facility's undated policy titled, Fall Prevention & Management Program guidelines, revealed .When any resident experiences a fall, the facility will .Review the resident's care plan and update as indicated . Review of the facility's undated policy titled, Abuse, Neglect and Exploitation, revealed .Prevention of Abuse .The facility will implement policies and procedures to prevent and prohibit all types of abuse .that achieves .The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict . Review of the facility's undated policy titled, Interdisciplinary Care Conference guidelines, revealed .Each resident has the right to participate in choosing treatment options and must be given the opportunity to participate in the development, review and revision of his/her care plan. Residents also have the right to refuse treatment. The interdisciplinary care conference provides the interdisciplinary team an opportunity to review each resident's comprehensive plan of care .Care conferences will support resident-centered care planning, communication with the resident and/or representative .The facility staff must develop the comprehensive care plan .and review and revise the care plan after each assessment. 'After each assessment means after each assessment known as the Resident Assessment Instrument (RAI) or Minimum Data Set (MDS) .'Interdisciplinary' means the professional disciplines, as appropriate, will work together to provide the greatest benefit to the resident .must reflect involvement of the resident and resident representative .and other members of the IDT, as appropriate .The facility staff have a responsibility to assist residents to engage in the care planning process .must provide the resident and resident representative .with advance notice of care planning conferences to enable resident/resident representative participation .Steps .Care conference will be held by the IDT to review the tentative plan of care .IDT must, at a minimum, consist of the resident's attending physician, a registered nurse and nurse aide with responsibility for the resident, a member of the food and nutrition services staff, and to the extent possible, the resident and resident representative .The resident, family, or legal representative will be informed of the scheduled care conference date and time through written or verbal communication before the meeting .A designated team member will record a brief summary of the plan of care discussion on the Interdisciplinary Care Conference form . 1. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Fracture of Unspecified Part of neck of Left Femur, Muscle Weakness, Anxiety Disorder, Dementia, Osteoporosis, Unsteadiness on Feet, Repeated Falls, Adult Failure to Thrive, and Fracture of Nasal Bones. Review of the comprehensive care plan for Resident #9 dated 4/9/2026, revealed .ADL self-care performance deficit .Encourage the resident to participate to the fullest extent possible with each interaction .Encourage the resident to use bell to call for assistance . Continued review revealed .At risk for falls .Ensure call light is within reach while in room .Ensure environment is clean and clutter free .Keep frequently used items within reach . Review of the comprehensive care plan for Resident #9 dated 4/10/2026, revealed .up as tolerated . Continued review revealed .impaired cognitive function related to diagnosis of Dementia . Review of the facility fall investigation documentation for Resident #9 revealed the resident had an unwitnessed fall on 4/13/2026 at 9:50 AM, in the resident's bathroom. Resident #9 was assisted to the bathroom by a Certified Nursing Assistant (CNA). The CNA exited the room to get some gloves and returned to the room immediately and Resident #9 was on the floor of the bathroom when the CNA returned. Resident #9 had no injury and stated she was trying to get her clothes on. It was noted .root cause of fall .Poor judgement [and] overestimates ability to be independent .Immediate interventions placed to prevent further reoccurrence/falls .Lowered back of WC [wheelchair] . Review of the facility fall investigation documentation for Resident #9 revealed the resident had an unwitnessed fall on 4/13/2026 at 4:35 PM, in the resident's room. Resident #9 was last toileted at 4:30 PM and the resident was in the wheelchair after being toileted. Resident #9 stated she was trying to walk at the time of the fall. Resident #9 stated she had hit her head during the fall, denied pain, and was able to move both legs without any complaints of pain. Resident #9 was transferred to the emergency room (ER) because she stated she hit her head when she fell. It was noted .root cause of the fall .overestimates Abilities to be independent .Immediate interventions placed to prevent reoccurrence/fall .Sent to ER .Additional intervention to prevent recurrence and address Identified Root Cause(s) .Dycem [non-slip material] to wheelchair .Drop back of wc [wheelchair] seat . Review of the incident report for Resident #9 for the 4/13/2026 4:35 PM fall, revealed the post fall incident included .Fracture .Left thigh . Review of the admission MDS assessment dated [DATE], revealed Resident #9 scored a 2 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Resident #9 required a wheelchair for mobility and partial/mod assist for toileting hygiene, sit to lying, lying to sitting, sit to stand, chair/bed-to-chair transfer, and toilet transfer. Resident #9 had falls prior to admission and 1 fall without injury and 1 fall with major injury since admission/reentry. Review of the comprehensive care plan for Resident #9 dated 4/14/2026, revealed .drop w/c [wheelchair] seat .dycem in wheelchair . Review of the facility fall investigation documentation for Resident #9 revealed the resident had an unwitnessed fall on 4/26/2026 at 9:15 PM in the resident's room. A CNA observed the resident on the floor, and it was noted .Resident states she was trying to get off of the airplane .Immediate Action Taken .When awake and up .place in visual line of sight of staff . During an observation on 8/4/2026 at 3:40 PM, Resident #9 was lying in the bed with call light in reach and fall mat to the left side of the bed. During an observation on 8/5/2026 at 8:18 AM, Resident #9 was seated in a Broda chair (a specialized positioning wheelchair designed for long term care) beside the bed. Resident #9 was resting with her eyes closed. There was a fall mat to the left side of the bed. Resident #9 was wearing non-skid socks with call light in reach. During an observation on 8/5/2026 at 3:44 PM and 10:42 PM, Resident #9 was lying in bed with fall mat to the left side of the bed with call light in reach. During an observation on 8/6/2026 at 11:05 AM, Resident #9 was lying in bed resting with eyes open. There was a fall mat present to the left side of the bed and the Broda chair at bedside. Call light was in Resident #9's reach. During an interview on 8/7/2026 at 10:16 AM, the Assistant Director of Nursing (ADON) stated on admission to the facility, Resident #9 was assessed as being a high fall risk. The ADON stated she was responsible for revision of care plans. The ADON stated Resident #9 had an unwitnessed fall on 4/13/2026 at 9:50 AM and the new intervention was to add dycem to the w/c and for staff to not leave Resident #9 alone in the bathroom. The ADON stated she told the CNA on the shift not to leave Resident #9 alone in the bathroom but failed to revise the care plan with the new interventions. The ADON stated Resident #9 had a 2nd unwitnessed fall on 4/13/2026 at 4:35 PM, had dycem in her w/c at the time of the 2nd fall on 4/13/2026 and was transferred to the emergency room (ER) for evaluation. A new intervention was initiated to drop the back of the w/c to help with positioning. Resident #9 returned from the hospital and was switched from a regular drop back wheelchair to a Broda chair and dycem was no longer needed for the Broda chair. The ADON confirmed Resident #9's care plan had not been revised to include the use of the Broda chair and for the discontinuation of the dycem and the drop back w/c. During an interview on 8/7/2026 at 3:46 PM, the ADON stated Resident #9 had an unwitnessed fall on 4/26/2026 at 9:15 PM and the new intervention was to place Resident #9 in the hallway for monitoring to be in line of sight of staff while awake. The ADON confirmed the new intervention for keeping the resident in line of sight when out of bed after the 4/26/2026 fall had not been added to the care plan. During an observation on 8/7/2026 at 4:00 PM, in Resident #9's room, with the ADON, Resident #9 was seated in the Broda chair beside the bed with nonskid socks on, call light in reach, and fall mat to the left side of the bed. The seat of the Broda chair was slightly reclined and included a nonskid surface (not dycem). During an interview on 8/7/2026 at 4:27 PM, the ADON confirmed Resident #9 had a fall mat to the side of the bed and confirmed the fall mat had not been added to the care plan. The ADON confirmed Resident #9's care plan had not been revised with Resident #9's active fall interventions. 2. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including Osteoarthritis, Unsteadiness on Feet, Epilepsy, Dysthymic Disorder (chronic low-grade form of depression), Anxiety Disorder, Delusional Disorders, and Dementia. Review of the comprehensive care plan for Resident #33 dated 11/30/2021, revealed .impaired cognitive function/dementia or impaired thought processes r/t [related to] Dementia . Continued review revealed .psychosocial well-being problem r/t delusions and dysthymia .when conflict arises, remove residents to a calm safe environment and allow to vent/share feelings . Review of the quarterly MDS assessment dated [DATE], revealed Resident #33 scored a 3 on the BIMS assessment which indicated the resident had severe cognitive impairment. Resident #33 did not exhibit any behavioral symptoms directed towards others during the look back period. Review of the comprehensive care plan for Resident #33 dated 11/30/2021 and revised on 3/24/2025, revealed .uses, antipsychotic medications .r/t Delusional Disorder . Review of the comprehensive care plan for Resident #33 dated 11/30/2021 and revised on 2/12/2026, revealed .Behaviors .states he sees people that are not actually there .History of accusing roommates of taking his belongings. Interventions included .Administer medications as ordered .Anticipate and meet his needs If reasonable, discuss his behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable .Intervene as necessary to protect the rights and safety of others and resident .Approach/Speak in a calm manner .Divert attention .Remove from situation and take to alternate location as needed .enjoys religious activities. Please assist him to these activities as he will allow .I enjoy music. Assist me to music activities as appropriate . 3. Review of the medical record revealed Resident #74 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Schizophrenia, Schizoaffective Disorder, Major Depressive Disorder, Anxiety Disorder, Unspecified Mental Disorder due to known Physiological Condition, and Other Symptoms and Signs Involving Cognitive Functions and Awareness. Review of the comprehensive care plan for Resident #74 dated 6/20/2024, revealed .impaired cognitive function .impaired thought processes r/t depression, history of confusion .Administer meds [medications] as ordered .Monitor/document/report to MD [medical doctor] any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status . Review of the comprehensive care plan for Resident #74 dated 6/20/2024, revealed .potential for mood state issues related to history of schizophrenia, depression, insomnia, and anxiety and receives antipsychotic medications . Review of the comprehensive care plan for Resident #74 dated 12/18/2025, revealed .at risk for behaviors .attention seeking behaviors .fabricates stories that are found untrue . Review of the 5-day MDS assessment dated [DATE], revealed Resident #74 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Resident #5 exhibited rejection of care behaviors on 4 to 6 days of the look back period. Review of a facility investigation documentation revealed a resident-to-resident altercation incident occurred on 2/19/2026 at 3:59 PM between Residents #33 and #74 in the hallway outside the business office. It was noted .[Resident #74] rolled in front of [Resident #33] in w/c [wheelchair] .No med. [medication] Changes, no behaviors .single occurrence .No documentation of behavior for either Resident .Sent [Resident #74] to ED [emergency department] .Psych [Psychiatric] NP [Nurse Practitioner] . Review of a facility investigation documentation revealed .Does the resident have a history of prior physical or verbal altercations .No .Did the resident (victim) suffer any injuries or exhibit behavior changes because of the reported allegation? .No .Resident to Resident altercation. Both residents [Resident #33 and #74] in corridor in w/c. When resident [Resident #33] passes [Resident #74] there appeared to be verbal exchange and .[Resident #74] grabbed .[Resident #33] by the leg. Residents immediately separated and .[Resident #74] placed on 1:1 [one to one] monitoring .Allegation: Physical Abuse .(Victim) .[Resident #33] .Perpetrator .[Resident #74] . Review of the current comprehensive care plan for Residents #33 revealed the care plan had not been revised to include the resident-to-resident altercation or aggressive behaviors between Residents #33 and #74. Review of the current comprehensive care plan for Residents #74 revealed the care plan had not been revised to include the resident-to-resident altercation or aggressive behaviors between Residents #33 and #74. During an interview on 8/6/2026 at 3:19 PM, the Director of Nursing (DON) stated there was an altercation between Residents #33 and #74 on 2/19/2026 .around 4:15 . in front of the business office. The DON was unaware if Resident #33 had made contact when he tried to kick Resident #74. The residents' Providers were notified and an order was obtained to send Resident #74 to the ER for evaluation due to him making statements to staff after the incident about .wanting to kill people . Resident #74 was placed on 1:1 observation until he was transferred to the ED. The DON stated the incident was an isolated incident for both residents and confirmed the comprehensive care plans had not been revised to include the aggressive behaviors or the altercation between Residents #33 and #74. The DON confirmed the MDS Coordinator was responsible for updating the care plan and confirmed the resident-to-resident altercation should have been added to the care plan to reflect the aggressive behaviors. During an interview on 8/6/2026 at 4:24 PM, the MDS Coordinator stated she was responsible for revising care plans with new interventions. The MDS Coordinator confirmed the care plans for Residents #33 and #74 had not been revised to include the resident-to-resident altercation or aggressive behaviors that occurred on 2/19/2026. 4. Review of the medical record revealed Resident #75 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Hemiplegia and Hemiparesis, and Dementia. Review of a quarterly MDS assessment dated [DATE], revealed .Severely Impaired .upper and lower extremity .impairment of one side .Cognitive Skills for Daily Decision Making .Severely Impaired . Review of a Physical Therapy Contracture assessment dated [DATE] revealed severe left upper extremity contracture without any change. Further review revealed .patient refuses ROM [Range of motion] as well as splinting . Review of a quarterly MDS assessment dated [DATE], revealed Resident #75 scored a 99 on the BIMS assessment which indicated the resident was unable to complete the interview. Further review revealed the resident had impairment of one side, Hemiplegia or Hemiparesis. Review of the comprehensive care plan for Resident #75 dated 6/10/2026, revealed .left sided weakness from stroke .severely impaired cognition .Monitor and report decline inabilities .if resident is presenting with problems or paralysis, obtain order for Physical Therapy and Occupational Therapy to evaluate and treat . Further review revealed the resident's refusal of physical/occupational therapy services and refusal of a splint had not been revised on the care plan. Review of a Physical Therapy Contracture assessment dated [DATE], revealed severe left upper extremity contracture without any change. Further review revealed .patient refuses ROM as well as splinting . During an interview on 8/6/2026 at 9:12 AM, the ADON stated the resident is not on restorative services and confirmed Resident #75 refuses ROM and at one time had a splint for his left hand. The ADON further stated the resident would remove the splint when applied and throw it. The ADON confirmed Resident #75's refusal of care and therapy services had not been added to the resident's care plan. During an interview on 8/6/2026 at 10:36 AM, the Director of Nursing (DON) confirmed Resident #75's refusal of care not been added to the resident's care plan and stated it was her expectation for any changes in the resident's care to be revised on the care plan. During an interview on 8/6/2026 at 10:38 AM, the Director of Rehabilitation (DOR) stated Resident #75 had a left arm and hand contracture and stated the resident was not on therapy case load. The DOR stated Resident #75, .hates therapy and refuses it . The DOR stated Occupational Therapy had tried using a splint and Resident #75 refuses to wear it. The DOR confirmed she had not added Resident #75's refusal of therapy services and splint application to the resident's care plan. 5. Review of the Medical Record revealed Resident #85 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including Dementia, Developmental Disorder, Diabetes Mellitus, and Traumatic Brain Injury. Review of the quarterly MDS assessment dated [DATE], revealed Resident #85 scored a 6 on the BIMS assessment which indicated severe cognitive impairment. Further review revealed Resident #85 was independent with toilet transfers, toileting hygiene, and required a w/c for mobility. Review of a facility fall incident report for Resident #85 dated 4/5/2026, revealed Resident #85 had unwitnessed fall with no injury attempting to take self to restroom. The root cause analysis determined the wheelchair rolled back when the resident tried to transfer, .New Intervention .anti-roll backs to be placed on wheelchair . Review of the significant change MDS assessment dated [DATE], revealed Resident #85 scored a 7 on the BIMS assessment which indicated severe cognitive impairment. Further review revealed Resident #85 was dependent on staff for assist with toileting transfers, toileting hygiene, and required a w/c for mobility. Review of the comprehensive care plan for Resident #85 dated 7/23/2026, revealed .at risk for falls related to impulsiveness, weakness, unsteadiness on feet, potential side effects of medications, History of Falls . Continued review revealed no new intervention had been added after the fall on 4/5/2026 including the anti-roll backs to the w/c. During an observation on 8/4/2026 at 1:54 PM, revealed Resident #85 had self-propelled down the hallway in a w/c with anti-roll backs in place. During an observation on 8/5/2026 at 12:53 PM, revealed Resident #85 was seated in a w/c eating lunch with anti-roll backs in place. During an observation on 8/6/2026 at 10:30 AM, revealed Resident #85 was seated in a w/c in the hallway with anti-roll backs in place. During an interview on 8/6/2026 at 11:09 AM, the ADON confirmed she was responsible for adding new fall interventions after the Interdisciplinary Team morning meeting took place and discussed interventions to make sure the interventions were appropriate. The ADON confirmed Resident #85's comprehensive care plan had not been revised to include anti-roll backs on the w/c after a fall on 4/5/2026. 6. Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including Deaf Non-Speaking, Heart Failure, and Chronic Obstructive Pulmonary Disease. Review of a quarterly MDS assessment dated [DATE], revealed Resident #53 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed the resident was Deaf Non-Speaking. Review of the medical record revealed Resident #53's last care plan meeting was on 1/6/2026. Review of the comprehensive care plan dated 7/25/2026, revealed .Use whiteboard by resident bedside to communicate with her as she states this is her preferred method of communication . During an interview on 8/4/2026 at 1:14 PM, Resident #53 called a friend using face time to perform sign language. The interpreter communicated with Resident #53 and interpreted for the surveyor. The Resident stated she had not been invited to a care plan meeting regarding her care and stated, .I feel left out .they use a white board to communicate with me, but I do not fully understand what they are saying .I prefer sign language to communicate . During an interview on 8/6/2026 at 7:58 AM, The Director of Social Services (DSS) stated the IDT meetings consist of the leadership team to include the DON, Administrator, Business office manager, Dietary, Social Services, Activities, Medical Director and Therapy. The SSD stated and confirmed .I have not been involved with the IDT care plan meetings involving the resident. I am supposed to send the letters out for the IDT meetings and have not been sending them out [to the residents] .I was unaware until today it was my responsibility . During an interview on 8/6/2026 at 10:07 AM, Quality Monitoring Specialist (QMS) B confirmed Resident #53 had not had a care plan meeting since 1/7/2026 and there were no IDT notes related to the care plan meetings in the resident's medical record. QMS B stated it was the expectation for the DSS to schedule, send notification, and upload the care plan documentation into the resident's medical record. 7. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses including Unspecified Dementia, Insomnia, Anxiety Disorder, and Essential Hypertension. Review of an IDT Care Conference Note and Care Planning Process form for Resident #54 dated .2/10 [2/10/2026] . revealed .Reason for the Care Conference .Quarterly . Review of an annual MDS assessment dated [DATE], revealed Resident #54 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. During an interview on 8/5/2026 at 8:32 AM, Resident #54 stated she had not been invited to or participated in a care plan meeting in .several months . During an interview on 8/6/2026 at 1:56 PM, the DSS stated he was unaware he needed to conduct a quarterly care plan meeting with residents and confirmed, prior to today, no care plan meeting had been held with Resident #54 since 2/10/2026. During an interview on 8/7/2026 at 5:06 PM, QMS A confirmed IDT care plan meetings were to be held quarterly.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to implement Registered Dietician (RD) Recommendations timely for 2 Residents (Residents #68 and #3) of 4 residents reviewed for RD recommendations. The findings include: Review of the facility's undated policy titled, Weight Management guidelines, revealed .weight can be a useful indicator of nutritional status .process includes .consistently implementing pertinent approaches .Interventions will be .implemented .weight monitoring .If clinically indicated-monitor weight weekly . Review of the facility's undated policy titled, Registered Dietician [RD] Recommendation Management Policy, revealed .The facility shall ensure that all recommendations made by the Registered Dietician .are .implemented when clinically appropriate, documented .The Director of Nursing [DON] shall review each Registered Dietician recommendation timely .Accepted recommendations shall be implemented promptly .including .monitoring parameters . Review of the medical record revealed Resident #68 was admitted to the facility on [DATE] with diagnoses including Heart failure, Dementia, and Chronic Obstructive Pulmonary Disease (COPD). Review of a Physicians Order for Resident #68 dated 4/18/2026, revealed .monthly weights .active . Review of the weights and vitals summary for Resident #68 dated 6/3/2026, revealed a weight of 157.2 pounds. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #68 had a Brief Interview for Mental Status (BIMS) assessment score of 5 which severe cognitive impairment. Further review revealed weight loss, not on physician prescribed weight loss regimen, heart failure, and diuretic use. Review of a diet order for Resident #68 dated 6/30/2026, revealed .regular diet .fortified foods TID [3 times per day] and a frozen nutritional treat at lunch and dinner . Review of the comprehensive care plan for Resident #68 dated 7/2/2026, revealed .Actual/potential impaired nutritional status r/t [related to] .Dementia .Observe and evaluate any weight loss .provide and serve diet as ordered .weigh resident per facility protocol .electrolyte imbalance r/t/diuretic .Observe weight .fortified foods 3 times daily .frozen nutritional treat lunch and dinner .med pass [nutritional drink] as ordered . Review of a Weights and Vitals Summary for Resident #68 dated 7/13/2026, revealed a weight of 155.2 pounds (lbs.). Review of a Dietician Progress note for Resident #68 dated 7/22/2026, revealed .obtain and monitor weights weekly . Review of a Nutrition Risk Evaluation for Resident # 68 dated 7/22/2026, revealed .Recommend .obtain and monitor weekly weights x [times] 3 . Review of an email dated 7/22/2026 at 3:39 PM from the RD to the DON revealed ' .Medical Nutrition Therapy Recommendation Log .[Resident #68] .Recommend .obtain and monitor weekly weights x 3 .Weight loss .Malnutrition dx [diagnosis] / risk . Review of the medical record for Resident #68 revealed no weights had been recorded after the RD recommendation on 7/22/2026. During an observation on 8/7/2026 at 7:05 PM, revealed 2 staff members weight Resident #68 with a mechanical lift. The weight results were 154.8 lbs. (.26 percent weight loss from 7/13/2026 - 8/7/2026). Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses including Dementia, Anxiety, Gastro-Esophageal Reflux Disease (GERD) and Chronic Pain. Review of the Weights and Vitals Summary for Resident #3 dated 5/4/2026, revealed a weight of 107.6 lbs. Review of the Weights and Vitals Summary for Resident #3 dated 6/3/2026, revealed a weight of 104.8 lbs. Review of the comprehensive care plan for Resident #3 dated 6/10/2026, revealed .resident has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] .dependent upon staff for meals .Resident requires sub [substantial] max [maximal] assist .Actual/potential impaired nutritional status r/t .At risk for electrolyte imbalance r/t daily diuretic use .Has weight loss .Observe and evaluate any weight loss. Determine percentage lost . Review of the quarterly MDS assessment dated [DATE], revealed Resident #3 scored a 9 on the BIMS assessment, which indicated moderate cognitive impairment. Resident #3 was noted for weight loss, not on a prescribed weight-loss regimen, and was dependent on staff for eating. Review of the Weights and Vitals Summary for Resident #3 dated 7/10/2026, revealed a weight of 105 lbs. Review of the progress note for Resident #3 dated 7/22/2026, revealed .Dietary-Progress Note: Weight Loss .Monitor weekly weights x 3 . Review of the Medical Nutrition Therapy Recommendation Log dated 7/22/2026, revealed .monitor weekly weights x3, weight loss maybe considered unavoidable weight loss . Review of the active Physician Orders for Resident #3 dated 8/5/2026, revealed .Regular Diet Pureed Texture, Thin Liquids consistency, yogurt at B [Breakfast], fortified foods TID [three times per day], nutritional treat L&D [Lunch and Dinner], cottage cheese @L [at Lunch] .Med Pass two times a day .120 mL [milliliters] BID [twice a day] . During an observation on 8/5/2026 at 7:55 AM, revealed Resident #3 sitting up in bed and the resident's son assisting the resident with breakfast. Review of the medical record revealed the weekly weights had not been obtained or recorded after the RD recommended on the Medical Nutrition Therapy notes to the DON on 7/22/2026. During an observation on 8/7/2026 at 6:42 PM, revealed 2 staff members obtained Resident #3's weight using the mechanical lift with a weight result of 106.2 lbs. On 07/10/2026, the resident weighed 105 lbs. which was a 1.14% weight gain. During an interview on 8/7/2026 at 6:26 PM, the RD stated she entered oral nutritional supplement orders into the computer system, and the daily, weekly, or monthly weight orders were entered by the DON. During a telephone interview on 8/7/2026 at 8:25 PM, the Medical Director (MD) stated dietician recommendations for weekly weights should be implemented .right away . Further interview revealed the MD had not denied recommendations for any weekly weights for 7/22/2026 for any residents. During an interview on 8/7/2026 at 9:00 PM, the Chief Operating Officer (COO) confirmed Registered Dietician recommendations should be implemented within 24 hours for critical recommendations and weekly weights should be implemented within a week.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to assess a resident (Resident #14) of 3 residents reviewed for self-administration of medications. The findings include: Review of the facility's undated policy titled, Administration of Nebulizer Treatment guidelines, revealed, .The facility will administer nebulizer treatments .to be administered by nursing staff .using proper technique .Instruct resident on how to use the nebulizer .Observe resident during the procedure for any changes in condition . Review of the facility's undated policy titled, Self-Administration of Medication guidelines, revealed, .When determining if self-administration is clinically appropriate for a resident .at minimum consider the following .medications appropriate and safe for self-administration . Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease (COPD), and Pneumonia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #14 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Continued review revealed the resident received Respiratory Therapy services. Review of a Physician Order for Resident #14 dated 7/24/2026 revealed an order for Budesonide Inhalation Suspension 0.5 Milligrams (mg)/2 Milliliters (ml) 1 application [a medication used for Chronic Obstructive Pulmonary Disease] [COPD] .administered by Clinician . Review of the comprehensive care plan for Resident #14 dated 7/4/2026, revealed the resident had COPD with interventions including .Administer medications/respiratory treatments per order . During an observation on 8/5/2026 at 7:30 AM, in Resident 14's room revealed the resident resting in bed with Oxygen at 6 liters per minute (l/m) by nasal cannula (NC) in place. During a medication administration observation on 8/5/2026 at 8:06 AM, the Assistant Director of Nursing (ADON) entered Resident #14's room with Budesonide Inhalation Suspension 0.5 mg/2 ml application. The ADON opened the plastic vial of medication, poured the liquid into the nebulizer cylinder, turned on the machine, handed the mask to Resident #14 and walked out of the room with the nebulizer treatment in progress. During an interview on 8/5/2026 at 8:57 AM, the ADON stated the nursing staff were expected to stay with a resident during the course of a nebulizer treatment and confirmed she had not remained with Resident #14 during the nebulizer treatment. During an interview on 8/6/2026 at 10:38 AM, the Director of Nursing confirmed she was aware the ADON had not remained with Resident #14 for the duration of the nebulizer treatment and stated it was the facility expectation the nurses remain with residents during the entirety of medication administration of nebulizers to assess for any complications.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to provide interpretation services or an effective communication service for resident (Resident # 53) of 1 resident reviewed for hearing and speech impairment. The findings include:Review of the facility's undated policy titled, Communication with a Resident who is Deaf, revealed, .it is the policy of the facility to accommodate needs when communicating with residents who are deaf to promote dignity, understanding, and safety .the staff will obtain information regarding the residents current process for communication .the resident and .representative will discuss .communication with staff so that care is individualized to meet the resident's needs .the staff will utilize communication techniques with the resident in accordance with .his/her established routine for communication . Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including Deaf Non-Speaking, Heart Failure, and Chronic Obstructive Pulmonary Disease.Review of the comprehensive care plan for Resident #53 dated 7/5/2025, revealed, .resident has a communication problem r/t [related to] deafness .may use language line .Use whiteboard by resident bedside to communicate .as she states this is her preferred method of communication .Review of a Nursing Monthly Summary document for Resident #53 dated 3/9/2026, revealed the resident was alert to self, place, time, was absent of useful hearing, unclear speech, and ability to make requests was limited.Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #53 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed the resident's hearing was highly impaired, Deaf Non-Speaking, and able to understand verbal content with device used. Review of a Nursing Monthly Summary for Resident #53 dated 7/10/2026, revealed the resident was alert to self, place, time, was absent of useful hearing, Speech clarity-no speech, and ability to make requests was limited.Review of an email dated 7/21/2026 from the Quality Monitoring Specialist (QMS) B to the Business Office Manager (BOM) revealed a tablet for language Line use had been ordered. During an observation and interview on 8/4/2026 at 1:14 pm, in Resident #53's room, Resident # 53 began to point to her ears and mouth and gestured with her hands for me to wait. Resident #53 picked up her tablet and used face time to call a friend to interpret. Permission was granted by Resident #53 for me to communicate with the interpreter. The Interpreter was signing to communicate with the resident and surveyor and conveyed Resident #53 had concerns regarding difficulty understanding everything the staff were writing on the white board. Resident #53 continued to convey she (Resident #53) preferred to communicate via sign language and had communicated this several times via her friend (Interpreter) to the staff. Further interview revealed Resident #53 was asked by the facility to load the Language application (app) on her tablet and declined because the service incurred a fee and Resident #53 could not afford the service. Further interview revealed she has not had use of a facility Language Line [a service to provide persons with translation services and sign language]during her residence at the facility. The interpreter confirmed the Language app had been requested several times by Resident #53 and herself and stated the request had not been implemented. During an interview on 8/5/2026 at 1:22 PM, Certified Nursing Assistant (CNA) B stated she communicated with Resident #53 using pen and paper. CNA B was not aware of Resident #53's preferred method of communication and stated she would find another CNA to assist in communicating with the resident. CNA B stated she was unaware of the language line for the hearing impaired. During an interview on 8/6/2026 at 7:56 AM, the Social Service Director (SSD) stated he used a communication board, and printed pictures for Resident #53's assessment and Resident #53's friend communicated via sign language for the SSD and Resident #53. The SSD stated at one time there was a tablet for use, but it was broken. The SSD stated he was asked by Resident #53 to meet with her and her friend on 4/7/2026 to discuss the language barrier and Resident #53 expressed she would like to have accommodations for her hearing impairment in the form of a language line interpreter for occasions when she needs to speak with the nurses, and physician to fully understand her care. The SSD stated after the meeting on 4/7/2026, he brought Resident #53's request to the morning meeting leadership team which consisted of the Director of Nursing (DON), Administrator, Business Office Manager, Dietary, Therapy, Activities, Housekeeping, and Maintenance Director and had requested a new tablet. The SSD confirmed he could not provide any documentation regarding this meeting or provide names to whom he had requested the tablet. The SSD confirmed Resident #53 preferred sign language as her method of communication, the facility did not provide the requested services and stated it was his expectation for the staff to utilize the language line tablet when communicating with the resident. During an interview on 8/6/2026 at 8:30 AM, Housekeeper A stated she spoke with a CNA to communicate with residents who had language barriers and stated she was unaware of the Language Line for the hearing impaired.During an interview on 8/6/2026 at 8:31 AM, Housekeeper B stated she spoke with a CNA to communicate with residents who had language barriers and stated she was unaware of the Language Line for the hearing impaired.During an interview on 8/6/2026 at 8:40 AM, Licensed Practical Nurse (LPN) C stated she did not know Resident #53's preferred method of communication and was not aware of the language line or tablet for the use of communication with sign language. LPN C stated she communicated with the resident using hand gestures and had minimal communication with the resident.During an interview on 8/6/2026 at 8:45 AM, the Assistant Director of Nursing (ADON) stated the staff write out communications with the resident, however the resident would prefer sign language. The ADON stated there was a device used in the past but the device had been broken for .sometime . and unavailable for use. The ADON further stated the resident refused to add the language app to her personal device because it would incur a fee.During an interview on 8/6/2026 at 9:30 AM, the Director of Recreation (DOR) stated the tablet used for the Language Line had not been available for use for over .6 months . and had been told it was broken and stated Resident #53's preferred method of communication was the white board. During an interview on 8/6/2026 at 9:31 AM, Patient Care Assistant (PCA) A stated she worked in the activities department and stated the tablet used for the Language Line had not been available for the past .18 months . and had been told it was broken. PCA A stated Resident #53's preferred method of communication was the whiteboard and stated she also communicated using sign language with the resident if she worked but was not always at the facility. During an interview on 8/6/2026 at 10:07 AM, QMS B stated the facility did not have a Language Line tablet available for use for Resident #53. QMS B further confirmed it was the facilities responsibility to provide Language Line services for residents who require the service and confirmed the service had not been used for the resident. During an interview on 8/6/2026 at 10:25 AM, the Business Office Manager (BOM) stated she was notified verbally in the 7/2026 meeting of the need for a tablet to communicate with a resident. The BOM stated she placed the request via email 7/21/2026 to the Information Technology (IT) department. During an interview on 8/6/2026 at 10:32 AM, the SSD stated .it was known there was a need. I discussed it back in April [4/2026] with the team; I'm not sure what the delay was in ordering the tablet .

Based on facility policy review, medical record review, observation, and interview, the facility failed to implement a care plan intervention for a specialty mattress for 1 resident (Resident #52) of 21 residents reviewed for care plans. The findings include: Review of the facility's undated policy titled, Fall Prevention & [and] Management Program guidelines, revealed .Each resident .will receive care .to minimize the likelihood of falls .Interventions will be monitored for effectiveness . Review of the medical record revealed Resident #52 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's Disease, Diabetes Mellitus, Unsteadiness on Feet, and Repeated Falls. Review of a Progress Note for Resident #52 dated 8/5/2025, revealed .noted .lying on her left side by bed . Review of the medical record revealed Resident #52 had not sustained any further falls since 8/5/2025. Review of a comprehensive care plan for Resident #52 dated 8/14/2025, revealed .hx [history] of falls .Implement appropriate intervention(s) to minimize the risk of falls .8/5/25 Concave mattress to bed . Review of a Physician's Order for Resident #52 dated 8/14/2025, revealed .concave mattress [mattress] to bed related to falls . Review of a quarterly Fall Risk Evaluation for Resident #52 dated 4/6/2026, revealed .fall risk score .16 .Is the resident at risk for falls .Yes . Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #52 scored a 4 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. During an observation in Resident #52's room on 8/4/2026 at 3:42 PM and on 8/5/2026 at 8:40 AM, revealed Resident #52 lying in bed with a low air loss mattress in place. No concave mattress was present. During a medical record review and interview on 8/6/2026 at 1:22 PM, Licensed Practical Nurse (LPN) E reviewed Resident #52's orders and care plan and confirmed there was an order for a concave mattress to Resident #52's bed related to falls dated 8/14/2025 and a care plan intervention for a concave mattress to Resident #52's bed dated 8/5/2025. During an observation and interview in Resident #52's room on 8/6/2026 at 1:32 PM, LPN E confirmed Resident #52 was lying on a low air loss mattress and there was no concave mattress on Resident #52's bed. During an interview on 8/6/2026 at 4:05 PM, The Director of Nursing confirmed it was her expectation for a resident to have a concave mattress in place if a concave mattress was ordered and on the care plan. During an interview on 8/7/2026 at 9:18 AM, the Wound Care Nurse stated she had never known Resident #52 to have a concave mattress on her bed. Further interview revealed the Wound Care Nurse had performed a skin assessment on Resident #52 to ensure no skin issues were present, no skin issues were found, and the low air loss mattress was removed from Resident #52's bed and replaced with a concave mattress on 8/6/2026 as ordered (over 1 year later).

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure nebulizer masks were stored appropriately for 1 resident (Residents #60) of 8 residents observed for nebulizer mask storage. The findings include: Review of the facility's undated policy titled, Administration of Nebulizer Treatment guidelines, revealed .store the nebulizer cup and mouthpiece in a zip lock bag .Change nebulizer tubing every seventy-two hours or per facility policy . Review of the medical record revealed Resident #60 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Acute and Chronic Respiratory Failure, Anxiety Disorder, Obstructive Sleep Apnea, and Acute on Chronic Systolic Congestive Heart Failure. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #60 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of the comprehensive care plan for Resident #60 dated 6/11/2026, revealed .risk for impaired respiratory status r/t [related to] chronic respiratory failure, COPD [chronic obstructive pulmonary disease] .Administer Respiratory treatment as directed . Review of the Order Summary Report for Resident #60 revealed an order dated 7/29/2026, .Ipratropium – Albuterol [combination medication used to treat and prevent symptoms of chronic obstructive pulmonary disease] 0.5 -2.5 (3) MG [milligrams]/3 ML [milliliters] 1 vial inhale orally two times a day for lung disease . Review of the Medication Administration Record (MAR) for Resident #60 dated 8/1/2026 – 8/5/2026, revealed the resident received Ipratropium-Albuterol Solution via nebulizer on 8/2/2026 at 6:00 AM, 8/3/2026 at 8:00 PM, 8/4/2026 at 8:00 PM, and 8/5/2026 at 6:00 AM. During an observation on 8/4/2026 at 12:24 PM and 4:43 PM, in Resident #60's room revealed a nebulizer machine placed on the table beside the bed. Further observation revealed a nebulizer mask was lying on the table uncovered, undated, and open to air. During an observation and interview on 8/5/2026 at 8:15 AM, in Resident #60's room, revealed a nebulizer machine placed on the table beside the bed. Further observation revealed a nebulizer mask was lying on the table uncovered, undated, and open to air. Resident #60 stated he had a breathing treatment earlier this morning. During an observation and interview on 8/5/2026 at 8:44 AM, in Resident #60's room, with Licensed Practical Nurse (LPN) A revealed a nebulizer machine placed on the table beside the bed. Further observation revealed a nebulizer mask was lying on the table uncovered, undated, and open to air. LPN A stated Resident #60 received an Ipratropium treatment twice daily; she had administered the treatment this morning and stated the nebulizer masks were to be stored in a plastic bag. LPN A confirmed Resident #60's nebulizer mask was not stored correctly and was uncovered, undated, and open to air. During an interview on 8/6/2026 at 3:16 PM, the Director of Nursing (DON) stated nebulizer masks were to be stored in a plastic bag and dated. The DON confirmed Resident #60's nebulizer mask stored on the bedside table uncovered, undated, and open to air was not stored appropriately.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure safety requirements were met for food storage for 2 residents (Residents #26 and #50) of 10 resident refrigerators observed.The findings include: Review of the facility's undated policy titled, Foods Brought by Family/Visitors Guidelines, revealed .Staff must be aware of, and approve, food(s) brought to a resident by family/visitors .Non-perishable foods retained in the residents' rooms must be stored in re-sealable containers with tightfitting lids .Perishable foods must be stored in re-sealable container with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name, the item, and the 'use by' date .The dietary staff and/or nursing staff is responsible for discarding perishable foods on or before the 'use by' date .The nursing and/or food service staff must discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates) . Review of the facility's undated policy titled, Personal Food Storage - Room Refrigerators, revealed .Food brought in by outside sources will be monitored by designated staff to ensure safe food handling and storage .Purpose: To allow residents the enjoyment of foods brought into the facility by family and other visitors while maintaining the safety and sanitation requirements for the residents .Staff will examine food quality (visual, smell, packaging) to identify potential concerns .All food and beverages brought in by outside sources will be labeled, dated, and stored appropriately .Facility staff (designated) will be assigned to monitor .the disposal of food and beverages as needed to ensure food safety .Food Safety .Food will be labeled and dated to monitor for food safety .Food or beverages in their original containers marked with a manufacturer's expiration date and unopened will be considered safe for consumption in accordance with expiration date .Food or beverage items that have exceeded the manufacturer's expiration date will be discarded .Food items in unmarked or unlabeled containers will be labeled with contents, the date the food item was stored, a use-by date (3 days) .Any food that is suspected to be contaminated or obviously contaminated will be discarded immediately . Review of the medical record revealed Resident #26 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Cerebral Palsy, Nontraumatic Subarachnoid Hemorrhage, Encephalopathy, Lack of Coordination, Schizophrenia, Dementia, Anxiety Disorder, Dysphagia, and Anorexia. Review of the comprehensive care plan for Resident #26 dated 10/28/2021 and revised on 11/15/2024, revealed .has a diagnosis of difficulty with swallowing and is at risk for aspiration .follow diet as ordered .ADL [Activities of Daily Living] self-care performance deficit r/t [related to] TBI [Traumatic Brain Injury], cerebral palsy, lack of coordination, dementia .EATING: Resident most often requires staff to feed him at meal times. He is dependent upon another person for eating . Continued review of the care plan revisedon 3/11/2025, revealed .provide Pudding Thickened beverages . Further review of the care plan revised 3/24/2025, revealed .impaired cognitive function or impaired thought processes . Review of the Order Summary Report for Resident #26 revealed an order dated 1/31/2025 for .Regular diet Pureed texture, Pudding Thickened Fluids consistency . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #26 had unclear speech, .rarely/never understands . others, and .Rarely/never understood . by others. Resident #26 was unable to complete the Brief Interview for Mental Status (BIMS) assessment and had severely impaired cognitive skills for daily decision making. Resident #26 was dependent on staff for eating. Resident #26 received a .Mechanically altered diet .change in texture of food or liquids . During an observation on 8/4/2026 at 12:11 PM, in Resident #26's room, there was a personal refrigerator that contained 2 plastic containers of pink liquid. The top of the container was labeled .SD . (Resident's initials) with no date present. Continued observation revealed an opened and undated 4 fluid ounce container of .Thickened Apple Juice . with a spoon in it. During an observation and interview on 8/4/2026 at 12:15 PM, in Resident #26's room, with Certified Nursing Assistant (CNA) A there were 2 plastic containers of pink liquid labeled .SD . that were undated and 1- opened 4 fluid ounce container of .Thickened Apple Juice . with a spoon in it. CNA A stated the plastic containers contained .thickened pink lemonade and thickened cranberry juice . This surveyor asked CNA A how she knew what was in the containers and she stated .you can smell it . CNA A was unaware when and who had placed the containers in Resident #26's personal refrigerator. CNA A confirmed the containers were not labeled with the contents of the containers or dated. CNA A stated Resident #26 was on thickened liquids and picked up the containers to show this surveyor the thickness of what was inside the containers. During an interview on 8/4/2026 at 1:02 PM, the Registered Dietician (RD) stated the dietary manager was responsible to check resident personal refrigerators 5 days a week (Monday through Friday) for expired items and to ensure food was properly stored, labeled, and dated. The RD confirmed foods that were opened were to be labeled with the date opened and discarded within 7 days of the open date. The RD confirmed food items brought in by resident family members were to be labeled including the date and discarded with 72 hours. The RD confirmed unopened foods were to be discarded by the expiration date. During an observation and interview on 8/4/2026 at 1:26 PM, in Resident #26's room with the RD, the 2 plastic containers of pink liquids labeled .SD . and the opened 4 fluid ounce container of .Thickened Apple Juice . had been dated 8/4/2026. The RD confirmed the 2 plastic containers of pink liquids were not labeled correctly to identify what was in the container. The RD confirmed the 4 fluid ounce container of .Thickened Apple Juice . was open to air, not stored appropriately and stated .it's single use .it should have been thrown away . This surveyor showed the RD pictures of the contents of Resident #26's refrigerator from the 8/4/2026 12:15 PM observation and the RD confirmed the 2 containers of pink liquids were not labeled or dated and the .Thickened Apple Juice . container was not dated or stored properly being open to air. During an interview on 8/5/2026 at 2:57 PM, the Certified Dietary Manger (CDM) stated she had been at the facility since January 2026. The CDM stated she had a list of resident's with personal refrigerators and she observed resident refrigerators daily Monday through Friday to check for expired food items and to ensure food items were properly labeled and dated. The CDM confirmed food items were to be labeled and dated. Food items that were opened were to be dated and discarded within 3 days. Unopened items were to be discarded by the expiration date. Leftovers were to be labeled, dated, and discarded within 3 days. Items with mold were to be discarded immediately. Foods were to be covered, sealed, and not open to air. This surveyor showed the CDM the pictures of Resident #26's personal refrigerator and the CDM stated the containers with pink liquid were .pudding thickened Fruit Punch . and confirmed the containers were not labeled or dated. The CDM stated Resident #26 received pudding thickened liquids three times a day and was unable to say when the fruit punch was placed in the refrigerator. The CDM confirmed resident refrigerators were not checked on Monday 8/3/2026 and had last been checked 7/31/2026. The CDM confirmed no food borne illness in the facility in the last 6 months. Review of the medical record revealed Resident #50 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Unspecified Injury to Unspecified Level of Lumbar Spinal Cord, Epilepsy, Acquired Absence of Right Leg Above the Knee, Anxiety Disorder, and Paraplegia. Review of the comprehensive care plan for Resident #50 dated 1/31/2022, revealed .Self Care Deficit .history of paraplegia .Assist with bed mobility .set up with meals . Review of the comprehensive care plan for Resident #50 dated on 1/6/2023, revealed .Risk for impaired nutritional status .Provide diet as ordered . Review of the comprehensive care plan for Resident #50 dated on 9/16/2023, revealed .Resident will request his Mother to bring food from the grocery store and from restaurants . Review of the Order Summary Report for Resident #50 revealed an order dated 5/14/2026, for .Regular diet .Regular texture . Review of the quarterly MDS assessment dated [DATE], revealed Resident #50 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. During an observation and interview on 8/4/2026 at 12:44 PM, in Resident #50's room, there was a personal refrigerator in the room. Resident #50 stated his family shopped for food items for him and gave this surveyor permission to look in his personal refrigerator. Resident #50's personal refrigerator contained the following items:1 sealed plastic bag of opened .CHICKEN, PORK, AND BEEF PRODUCT .FRANKS . with 9 remaining that was undated. 1 package of 2 microwavable hamburgers that were thawed, unlabeled, and undated. 1 sealed plastic bag that contained an unidentified food item wrapped in aluminum foil that was unlabeled and undated. 1 sealed plastic bag that contained an opened 6 ounce package of .Liver Cheese . with a small circular area with a black fuzzy substance on the corner of the Liver Cheese that was undated. 1 opened container of vanilla pudding that was undated and open to air. 1 unopened 6-ounce package of .Liver Cheese . with a sell by date of .JUL3126 [7/31/2026] . The resident stated facility staff managed his food items in the refrigerator and was unaware of any expired or contaminated items. This surveyor asked Resident #50 if he knew some of his food items were contaminated or expired and he stated .throw it out . if it's expired or molded. Resident #50 denied any foodborne illnesses. During an observation and interview on 8/4/2026 at 1:06 PM, with the RD, in Resident #50's room, revealed the resident's personal refrigerator contained the above stated food items. The RD stated she cleaned Resident #50's personal refrigerator out herself .4 weeks ago . The RD confirmed the package of opened .Liver Cheese . was .molded . and not dated when opened, the unopened package of .Liver Cheese . was expired, the sealed plastic bag with food product wrapped in aluminum foil was a .baked potato . and was unlabeled and undated, the sealed plastic bag with a package of opened .hot dogs . was unlabeled with the open date, the plastic container of 2 thawed .hamburgers . should have been kept frozen until prepared and was not labeled or dated, the opened container of vanilla pudding was open to air. The RD confirmed all food items listed above were available for resident consumption and had not been stored according to the facility's policy. During an interview on 8/4/2026 at 3:09 PM, the RD stated resident refrigerators were last checked by the dietary manager on 7/31/2026. The dietary manager didn't check them .yesterday [8/3/2026] . The RD confirmed there had been no food borne illness in the facility in the last 6 months.

Based on facility policy review, medical record review, and interviews, the facility failed to document insulin as administered for 1 resident (Resident #11) of 3 residents reviewed for insulin administration documentation. The findings include:Review of the facility's undated policy Medication Administration Guidelines, revealed .Medications are administered by licensed nurses .as ordered by the physician and in accordance with professional standards of practice .Ensure that the six rights of medication administration are followed .Right documentation .Administer medication as ordered .Sign MAR [Medication Administration Record] after administered .Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Vascular Dementia, and Abnormal Weight Loss.Review of a comprehensive care plan for Resident #11 revised 8/1/2023, revealed .Diabetes Mellitus .Diabetes medication as ordered by doctor .Review of a Physician's Order for Resident #11 dated 12/9/2025, revealed .May complete finger stick PRN [as needed]. Notify MD [Doctor of Medicine] if Blood Sugar below 70 or Greater then [than] 400 .Review of a Physician's Order for Resident #11 dated 3/29/2026, revealed .Insulin Glargine [a medication used to treat Diabetes] .inject 10 unit subcutaneously in the evening for diabetes . Review of the Medication Administration Record for Resident #11 dated 4/1/2026-4/30/2026, revealed no electronic signature for the administration of Insulin Glargine 10 units at 5:00 PM on 4/15/2026, 4/21/2026, and 4/26/2026. Review of the Medication Administration Record for Resident #11 dated 5/1/2026-5/31/2026, revealed no electronic signature for the administration of Insulin Glargine 10 units at 5:00 PM on 5/16/2026, 5/20/2026, 5/23/2026, 5/25/2026, 5/27/2026, and 5/30/2026. Review of a Nurse Practitioner progress note for Resident #11 dated 5/27/2026, revealed .Diabetes type 2 Most recent hemoglobin A1c was therapeutic .Review of the Medication Administration Record for Resident #11 dated 6/1/2026-6/30/2026, revealed no electronic signature for the administration of Insulin Glargine 10 units at 5:00 PM on 6/8/2026, 6/26/2026, and 6/28/2026. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 scored a 9 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. During a telephone interview on 8/6/2026 at 7:21 PM, Licensed Practical Nurse (LPN) D stated the only reason she would not have signed the Insulin Glargine on the Medication Administration Record (MAR) as being given on her shifts (4/15/2026, 4/21/2026, and 5/27/2026) was if Resident #11's blood sugar was low and she did not administer the insulin, and the results would have been noted in the medical record. During a telephone interview on 8/6/2026 at 8:56 PM, Registered Nurse A stated Resident #11 .definitely got . the Insulin Glargine on her shifts (5/16/2026, 5/20/2026, 5/25/2026, 5/30/2026, 6/8/2026, 6/26/2026, and 6/28/2026) unless it was refused, which she stated would have been noted on the MAR as a refusal. Further interview revealed RN A suspected a computer issue as being the cause of the missed signatures. During a medical record review and interview on 8/7/2026 at 1:47 PM, the Director of Nursing (DON) reviewed MARs for Resident #11 for 4/1/2026-4/30/2026, 5/1/2026-5/31/2026, and 6/1/2026-6/30/2026 and confirmed there were days Insulin Glargine 10 Units in the evening was not signed as administered by the nurse. The DON confirmed it was her expectation for nurses to sign the MAR after administering medications.

Based on facility policy review, medical record review, and interviews, the facility failed to ensure a current coordinated plan of care with the hospice provider was available in the medical record for 1 resident (Resident #52) of 3 residents reviewed for hospice. The findings include:Review of the facility's undated policy titled, Hospice Care Guidelines, revealed .The facility staff will work with hospice representative and will .Collaborate with hospice representatives and coordinating LTC [Long Term Care] facility staff participation in the hospice care planning process for those residents receiving these services .Obtain the following information from the hospice .The most recent hospice plan of care specific to each resident .Review of Nursing Facility Services Agreement, between the facility and the hospice provider dated 6/9/2023, revealed .Plan of Care means a written care plan established, maintained, reviewed and modified .The Plan of Care will reflect the participation of the Hospice, Facility and the Hospice Patient and family .Hospice and Facility will jointly develop and agree upon a coordinated Plan of Care .Facility will assist with periodic review and modification of the Plan of Care .Hospice shall provide .The most recent Plan of Care .Review of the medical record revealed Resident #52 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's Disease, Type 2 Diabetes Mellitus, Moderate Protein-Calorie Malnutrition, and Hyperlipidemia. Review of a Physician's Order for Resident #52 dated 6/30/2025, revealed .[hospice provider name] hospice effective .6/20/2025 .Review of a comprehensive care plan for Resident #52 revised 10/10/2025, revealed .Resident is under hospice care . Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #52 scored a 4 on the Brief Interview for Mental Status assessment which indicated the resident had severe cognitive impairment. Further review revealed the resident received hospice services. Review of the medical record revealed no current hospice plan of care in Resident #52. During an interview on 8/7/2026, at 8:25 AM, Registered Nurse A confirmed the current hospice plan of care for Resident #52 was dated 12/17/2025-2/14/2026. During a medical record review and interview on 8/7/2026 at 8:40 AM, the MDS Coordinator stated the most recent hospice plan of care for Resident #52 was dated 12/17/2025-2/14/2026. The MDS Coordinator confirmed there was no current hospice plan of care available in Resident #52's medical record.

Based on facility policy review, medical record review, transportation calendar review, and interviews, the facility failed to notify a resident representative of appointments outside of the facility for 1 resident (Resident #1) of 3 resident families interviewed for notifications. The findings include: Review of the facility's undated policy titled, Transporting a Resident, revealed .Facility will ensure that residents who require an escort to appointments, due to cognitive or physical limitations, have arrangements made ahead of time. The facility will notify the family of the appointment . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Dementia, Cerebral Infarction (stroke), and Hemiplegia (paralysis of one side). Review of a comprehensive care plan for Resident #1 dated 10/22/2023, revealed .Cognition .I have problems with my memory and cognition . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored a 9 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. The resident required supervision/touching assistance with transfers and moving from sitting to standing position. Review of the transport calendar for 6/2025, revealed Resident #1 was transported for an outpatient physician/provider appointment on 6/26/2025. Review of a quarterly MDS assessment dated [DATE], revealed Resident #1 scored a 4 on the BIMS assessment which indicated the resident had severe cognitive impairment. Resident #1 required supervision/touching assistance with transfers and substantial/maximal assistance from sitting to standing position. Review of the transport calendar for 12/2025, revealed Resident #1 was transported for an outpatient physician/provider appointment on 12/4/2025. Review of an Appointment Communication form for Resident #1 dated 12/4/2025, revealed .Rx [treatment] Steroid Shots No New Rx just injections WBAT [weight bearing as tolerated] .Follow Up Appointment Scheduled for .3 months . Review of a Family Nurse Practitioner (FNP) note for Resident #1 dated 12/5/2025, revealed the resident .recently followed outpatient with orthopedics where [Resident #1] received steroid injections into his knees . During a telephone interview on 2/10/2026 at 9:58 AM, Resident #1's responsible party stated the facility had transported the resident for an appointment where Resident #1 .had shots in knees . without notifying the resident's responsible party of the outpatient appointments. The resident's responsible party stated this had happened twice (failure to notify family of the outpatient provider appointments). During an interview on 2/11/2026 at 3:46 PM, Transportation Technician A in presence of the [NAME] President (VP) for Clinical Services, stated she had transported Resident #1 to 2 orthopedic appointments for knee injections on 6/26/2025 and 12/4/2025. Transportation Technician A confirmed she had not notified Resident #1's responsible party of the resident's orthopedic appointments for 6/26/2025 and 12/4/2025. During an interview on 2/12/2026 at 10:00 AM, the VP for Clinical Services confirmed the transportation technician was expected to notify the resident's responsible party of appointments to include type of appointment, location, date, and time of appointment .to give the family the opportunity to meet the resident at the appointment or to transport the resident themselves .

Based on facility policy review, facility documentation review, and interviews, the facility failed to employ a qualified social worker on a full-time basis.Review of the facility's undated policy titled, Social Services guidelines, revealed .A facility will employ a social worker on a full-time basis . Review of a facility typed document dated 2/12/2026, signed by the Administrator revealed from 5/9/2025 to 5/27/2025, 6/10/2025 to 8/11/2025, 10/8/2025 to 11/26/2025, and from 1/5/2026 to current (2/12/2026) the facility did not employ a qualified social worker for approximately 167 days or 5.5 months out of 9 months reviewed. During an interview on 2/10/2026 at 8:15 AM, the Social Worker stated .I [Social Worker] started here [employed by the facility] in October .it was the 13th [10/13/2025] .I was concierge from October 13th thru January the 5th .now I am the Social Worker .no I don't have a social worker degree or training .I am helping out with the social worker stuff until they get [hire] a social worker . During an interview on 2/12/2026 at 12:30 PM, the Administrator confirmed the facility did not have a qualified social worker employed from 5/9/2025 to 5/27/2025, from 6/10/2025 to 8/11/2025, from 10/8/2025 to 11/26/2025, and from 1/5/2026 to current (2/12/2026).

Based on facility policy review, medical record review, and interviews, the facility failed to obtain a physician's order and assess a resident's ability to perform tracheostomy (surgical opening into the windpipe) self-care for 1 resident (Resident #2) of 1 resident reviewed for tracheostomy.The findings include: Review of the facility's undated policy titled, Care Services and Resident Choices & [and] Preferences, revealed .As appropriate, the residents will be involved in .the implementation of interventions and administration of care .While allowing residents to exercise his/her autonomy, the facility is responsible to determine if the residents' choice presents a risk or safety challenge to the resident .It is the resident's right to determine what, if anything, they would prefer to do or not to do each day in accordance with physician orders and resident's abilities . Review of the facility's undated policy titled, Tracheostomy Care Guidelines, revealed .The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice .The facility, in collaboration with the attending practitioner, must perform a comprehensive assessment of the resident's respiratory needs .Tracheostomy care will be provided according to the physician's orders, comprehensive and individualized care plan . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease and Tracheostomy. Review of a Nursing Admission/readmission Nursing Evaluation for Resident #2 dated 2/3/2026, revealed the resident was alert and oriented to person, place, time, and situation. Continued review revealed the resident had a tracheostomy. Review of a physician order for Resident #2 dated 2/4/2026 revealed .Change inner cannula [a removable, tube-shaped liner that fits inside the main outer tracheostomy tube] daily & [and] PRN [as needed] every shift for trach [tracheostomy] care .Trach Care done Q [every] 12 hours and PRN using Sterile Technique every shift . Continued review revealed no order for the resident self-care of the tracheostomy. Review of the medical record for Resident #2 revealed no documentation to show the resident had been assessed for his ability to change the inner cannula or perform his own tracheostomy care. During an observation on 2/9/2026 at 11:30 AM, revealed Resident #2 had a tracheostomy. During an interview on 2/10/2026 at 3:12 PM, Licensed Practical Nurse (LPN) A stated Resident #2 performed his own tracheostomy care. LPN A stated she had not observed Resident #2 perform his tracheostomy care. During an interview on 2/11/2026 at 8:00 AM, Resident #2 stated he changed his tracheostomy inner cannula and provided his own tracheostomy care while in the facility. During an interview on 2/11/2026 at 8:45 AM, LPN B stated Resident #2 performed his own tracheostomy care. During medical record review and interview on 2/11/2026 at 10:40 AM, the Director of Nursing (DON) confirmed there was not an order for Resident #2 to perform his own tracheostomy care and confirmed the resident had not been assessed to ensure he could perform his tracheostomy care appropriately using a sterile technique. During a telephone interview on 2/11/2026 at 1:20 PM, Resident #2's physician stated .I told nursing they have to monitor that it's being done and that it's being done properly .He is adamant about doing it and not entrusting it [tracheostomy care] to someone else .I don't know that I wrote that order for him to do his own trach care . During an interview on 2/12/2026 at 10:45 AM, the DON confirmed the order for Resident #2 to perform his own tracheostomy care was not added until 2/11/2026 (8 days after the resident was admitted to the facility and 2 days after the State Survey Agency survey began investigating).

Based on facility policy review, medical record review, and interview, the facility failed to ensure a resident or resident representative consented to the use of psychotropic medications prior to administration of the medication for 1 resident (Resident #19) of 5 residents reviewed for unnecessary medications.The findings include: Review of the facility's undated policy titled, Psychotropic Medication Use Guidelines, revealed .Residents and/or representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments/non-pharmacological interventions . Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including Dementia, Psychosis, Depression, and Anxiety Disorder. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #19 scored a 10 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Review of a Medication Administration Record (MAR) dated 1/1/2026 - 1/31/2026, revealed .ClonazePAM [a psychotropic medication used to treat anxiety and agitation] .0.5 MG [milligrams] .Give 1 tablet by mouth three times a day related to ANXIETY DISORDER .Start Date .01/13/2026 . Further review revealed .RisperiDONE [Risperdal] [antipsychotic/psychotropic medication] .0.25 MG .Give 1 tablet by mouth three times a day related to UNSPECIFIED PSYCHOSIS .Start Date .1/27/2026 . Continued review revealed Resident #19 received the medications according to the provider's order. Review of a MAR dated 2/1/2026 - 2/11/2026, revealed .ClonazePAM .0.5 MG .Give 1 tablet by mouth three times a day related to ANXIETY DISORDER .Start Date .01/13/2026 . Further review revealed .RisperiDONE .0.25 MG .Give 1 tablet by mouth three times a day related to UNSPECIFIED PSYCHOSIS .Start Date .01/27/2026 .D/C [discontinue] Date .02/03/2026 .RisperiDONE .0.25 MG .Give 2 tablet by mouth three times a day [TID] related to UNSPECIFIED PSYCHOSIS .Start Date .02/04/2026 . Continued review revealed Resident #19 received the medications according to the provider's order. Review of a Consent form for Psychotropic Medications dated 2/11/2026 (29 days after the order was initiated), revealed .Medication 1 .Risperdal .0.25 mg 2 tab PO [by mouth] TID [three times daily] .Specific Target Behaviors .hallucinations, agitation .Medication 2 .Clonazepam 0.5 mg TID .Specific Target Behaviors .anxiety .agitation . Continued review revealed less restrictive non-drug approaches were proven to be ineffective, potential side effects, and expected duration of each medication was discussed. The consent was obtained from the resident's family member on 2/11/2026 (30 days after the start of the Clonazepam and 15 days after the start of the Risperidone). During an interview on 2/12/2026 at 1:22 PM, the Director of Nursing (DON) stated new medications and treatments were to be discussed with the resident or resident representative to make them aware of the risks and benefits and the consent was to be obtained prior to initiation of the medication by the nurse that received the new order. The DON stated Resident #19 was started on Clonazepam on 1/13/2026 and Risperdal on 1/27/2026 and the consent was not obtained by the resident's representative until 2/11/2026. The DON confirmed the consent was not obtained prior to the starting of the medications.

Based on facility policy review, medical record review, and interview the facility failed to provide a rationale for the continued use of an as needed (PRN) antianxiety medication beyond 14 days for 1 resident (Resident #19) of 5 residents reviewed for unnecessary medications. The findings include: Review of the facility's undated policy titled, Psychotropic Medication Use Guidelines, revealed .PRN orders all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. [that is] 14 days) .If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order . Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including Unspecified Dementia, Unspecified Psychosis, Depression, and Anxiety. Review of a comprehensive care plan dated 6/19/2025, revealed .Potential for mood state issues related to anxiety .administer medication as ordered . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #19 scored a 10 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Resident #19 had an active diagnosis of Anxiety Disorder and received Antianxiety medications. Review of a Psychiatric Periodic Evaluation dated 1/13/2026, revealed .Chief Complaint/Nature of Presenting Problem .anxiety .mood .tolerated change to klonopin [Clonazepam] [ClonazePAM] [a psychotropic medication used to treat anxiety] with improved anxiety. Continues having anxiety especially mid afternoon .Recommendations .Klonopin [ClonazePAM] 0.5 mg [milligram] .qdprn [every day as needed] anxiety x [times] 14 days . Review of a physician's order dated 1/13/2026, revealed .ClonazePAM [Klonopin] 0.5 MG [milligrams] .by mouth as needed for anxiety for 60 days .Once daily as needed . The order was entered by the provider (the same provider who conducted the Psychiatric Periodic Evaluation) for 60 days and not the 14 days as noted on the Psychiatric Evaluation. Review of a Medication Administration Record (MAR) dated 1/1/2026 - 1/31/2026, revealed an order dated 1/13/2026 for .ClonazePAM 0.5 MG .Give 1 tablet by mouth as needed for anxiety for 60 Days [the evaluation noted 14 days and entered as 60 days] Once daily as needed .Start Date .01/13/2026 . Review of a Psychiatric Periodic Evaluation dated 2/3/2026 (21 days after the PRN Clonazepam was ordered), revealed .Chief Complaint/Nature of Presenting Problem .anxiety .mood .delusions .Evaluating psychiatric medications for effectiveness and side effects .appears to be tolerating current medications well at this time .Evaluating mood and behaviors .Current Psychiatric Medications .Klonopin 0.5 mg TID and qd PRN .Recommendations .Continue the following medications .Klonopin 0.5 mg three times daily and qdprn anxiety x 14 days . Continued review revealed no rationale documented for the PRN dose of Clonazepam to be continued beyond the 14 days. Review of a MAR dated 2/1/2026 - 2/11/2026, revealed an order dated 1/13/2026 for .ClonazePAM .0.5 MG .Give 1 tablet by mouth as needed for anxiety for 60 Days [the evaluation noted 14 days, was not corrected and continued for the 60 days] Once daily as needed .Start Date .01/13/2026 . During an interview on 2/12/2026 at 10:26 AM, the [NAME] President (VP) of Clinical Services stated a PRN psychotropic medication was to be ordered for 14 days and a justification note should be entered in the resident's chart if the order was extended beyond 14 days. The Psychiatric Periodic Evaluation note dated 1/13/2026 revealed Resident #19 was to receive Clonazepam 0.5 mg daily PRN anxiety for 14 days. The psychiatric provider entered the order on 1/13/2026 for 60 days (and not the 14 days). The VP of Clinical Services stated the provider entered the order duration in error. Attempted telephone interview with the Psychiatric Nurse Practitioner (NP) on 2/12/2026 at 11:11 AM with no response. During an interview on 2/12/2026 at 1:22 PM, the Director of Nursing (DON) stated the facility had a clinical meeting daily Monday through Friday attended by the Interdisciplinary Team (IDT) and medication changes and new orders were reviewed by the IDT. The DON confirmed Resident #19 had a new order for Clonazepam 0.5 mg by mouth daily as needed for anxiety on 1/13/2026 for 60 days. The DON confirmed PRN orders for Psychotropic medications were to be only for 14 days and a rationale was required to extend on a PRN basis beyond 14 days and confirmed a rationale was documented for the PRN medication to be continued beyond the 14 days.

Based on facility policy review, medical record review, observation, and interview, the facility failed to obtain a physician's order for the use of a seatbelt, failed to perform an assessment for the use of a seatbelt, and failed to identify medical symptoms that would require the use of a seatbelt for 1 resident (Resident #13) of 1 resident reviewed for physical restraints. The findings include: Review of the facility's undated policy titled, Restraint Free Environment Guidelines, revealed .The facility .limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints .A physician's order alone is not sufficient to warrant the use of a physical restraint. The facility is responsible for the appropriateness of the determination to use a restraint .Before a resident is restrained, the facility will determine the presence of a specific medical symptom that would require the use of restraints, and determine .How the use of restraints would treat the medical symptom .The length of time the restraint is anticipated to be used to treat the medical symptom, who may apply the restraint, and the time and frequency that the restraint will be released .Medical symptoms warranting the use of restraints should be documented in the resident's medical record . Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including Spastic Quadriplegic Cerebral Palsy, Lennox-Gastaut Syndrome (rare form of early childhood epilepsy characterized by multiple daily seizures), Adult Failure to Thrive, Gastrostomy Status, Epileptic Seizures, and Unspecified Convulsions. Review of the comprehensive care plan initiated on 9/19/2024, revealed .limited physical mobility r/t [related to] cerebral palsy .prefers to sit in Indian style and rock back and forth . Review of the comprehensive care plan initiated on 9/20/2024, revealed .resident has a seizure disorder as well as Lennox Gastaut Syndrome. At risk for intractable seizures, seizures that can change over time, injury related seizures . Continued review revealed .at risk for falls r/t involuntary and uncoordinated movements, frequently sits cross legged on bed and rocks back and forth, poor trunk strength, seizures, poor safety awareness, potential side effects of medications . Further review revealed .ADL [Activities of Daily Living] self-care performance deficit related to cerebral palsy, seizure disorder. Unable to identify or verbalize wants or needs. All needs must be anticipated and met by staff . Review of the comprehensive care plan initiated on 10/1/2024, revealed .alert but unable to understand/comprehend what is being said to him .does not follow directions and is nonverbal . Review of a physician's order dated 4/30/2025, .enhanced supervision by staff. placed 1 to 1 [1 staff member to 1 resident] .every shift for safety . Review of the comprehensive care plan revised on 8/11/2025, revealed .seat belt/harness to wheelchair due to very poor trunk control . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #13 had no speech and was rarely/never able to make himself understood and rarely/never understood others. Resident #13 had severely impaired cognitive skills for daily decision making. Resident #13 had functional limitation in range of motion on both sides of the upper and lower extremities and required a wheelchair for mobility. Resident #13 was dependent on staff for all Activities of Daily Living (ADL) care. Continued review revealed physical restraints were defined as .any manual method or physical or mechanical device, material or equipment attached to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body . Resident #13's Physical Restraint portion of the MDS assessment stated Physical Restraints were .Not used .in chair or Out of Bed . Review of the medical record revealed a physician's order for the seatbelt had not been obtained and no documentation a restraint assessment had been completed for Resident #13's seatbelt. During an observation and interview on 2/9/2026 at 3:12 PM, Resident #13 was seated in a positioning wheelchair with a seatbelt across the waist and visiting with family. Resident #13's responsible party stated Resident #13 had seizures and the seatbelt was used for safety to keep the resident in the chair during seizures. Resident #13 had contractures to upper and lower extremities. Resident #13's responsible party stated the resident was unable to release the seatbelt on his own and it helped to restrict body movements. During an interview on 2/9/2026 at 3:32 PM, Licensed Practical Nurse (LPN) A stated Resident #13 was on 1 to 1 observation due to seizure precautions. Resident #13 used a seatbelt when out of bed in the chair .in case he has a seizure so he doesn't fall out of the chair . LPN A stated the seatbelt was not considered a restraint and confirmed Resident #13 was unable to release the seatbelt on his own. LPN A further stated she was not aware if a restraint assessment had been completed due to the seatbelt not being considered a restraint. During an observation and interview on 2/10/2026 at 4:14 PM, Resident #13 was seated in his positioning wheelchair with the seatbelt on. There was a 1 to 1 sitter at Resident #13's bedside. Sitter A stated a seatbelt was used when Resident #13 was in the wheelchair for safety due to his seizures. Sitter A was only responsible for notifying staff when Resident #13 had a seizure and for documenting the length of the seizure and did not provide direct care. During an interview on 2/11/2026 at 8:44 AM, the MDS Coordinator stated Resident #13 used a seatbelt while up in the wheelchair due to poor trunk control. The MDS Coordinator was unaware when Resident #13 began using the seatbelt in the wheelchair and confirmed there was no order for the seatbelt. The MDS Coordinator confirmed the seatbelt was a restraint by definition and stated .I was not aware he was using that until recently . The MDS Coordinator was made aware of restraints by physician's orders and during her visual observation conducted for the MDS assessment. The MDS Coordinator stated on an unknown date she observed Resident #13 up in his wheelchair and . I noticed it [seatbelt] .went and asked about it [unaware of date or who she asked] .was told yes he is using it [seatbelt] . The MDS Coordinator stated the Resident Assessment Instrument (RAI) was used to code MDS assessments. During an interview on 2/11/2026 at 2:11 PM, the DON stated Resident #13 had been using a seatbelt in his wheelchair since he was admitted to the facility and was used at home prior to admission. The DON confirmed the seatbelt met the definition of a restraint because Resident #13 was unable to remove it on his own. The Interdisciplinary Team (IDT) team met today (2/11/2026), regarding the use of the seatbelt and the DON discussed the seatbelt with Resident #13's responsible party explaining that the seatbelt met the regulation's definition of a restraint. The DON confirmed an order for the seatbelt had not been obtained until today (2/11/2026) and the seatbelt had not been assessed by the facility as a restraint. The DON confirmed an order for the seatbelt should have been obtained prior to the seatbelt being initiated and a restraint assessment performed. During an interview on 2/11/2026 at 3:20 PM, LPN B stated Resident #13 had a 1 to 1 sitter for seizures. Resident #13 had seizures daily. Resident #13 had a seatbelt when up in the wheelchair to keep him in the chair in the event of a seizure. LPN B stated there was no monitoring, set times for checking and releasing the seatbelt, or any documentation required when the resident was in the seatbelt. LPN B stated the seatbelt was not considered a restraint because it was for safety. LPN confirmed Resident #13 was unable to release the seatbelt on his own.

Based on facility documentation review, medical record review, and interview the facility failed to have the minimum required disciplines attend the Interdisciplinary (IDT) care plan meetings for 1 (Resident #1) of 4 residents reviewed for care plan timing and revision. The findings include: Review of the facility policy titled, Care Planning - Interdisciplinary Team, revised 3/2022, revealed .The interdisciplinary team is responsible for the development of resident care plans .The IDT includes but is not limited to .the residents attending physician .a registered nurse .a nursing assistant .a member of the food and nutrition services .resident and or the resident's representative .other staff as appropriate . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Hepatic Encephalopathy, Alcoholic Cirrhosis of Liver with Ascites, Dependance on Renal Dialysis, and Esophageal Varices. Resident #1 was discharged to the hospital on 4/29/2025. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 scored a 14 on the Brief Interview of Mental Status (BIMS) assessment which indicated the resident was cognitively intact. The resident required assistance of 1 or more staff persons with activities of daily living (ADL's). Review of 3 facility documents titled, INTERDISCIPLINARY TEAM CARE CONFERENCE NOTE/CARE PLANNING PROCESS, for the care plan meeting documentation dated 2/25/2025, 3/11/2025, and 4/16/2025 for Resident #1 revealed the resident or a resident representative, the Social Services Director (SSD), and the Dietary Manager attended all three meetings, no other disciplines were in attendance. During an interview on 4/30/2025 at 1:00 PM, the Director of Nursing (DON) stated .no we did not have the full IDT staff at those care plan meetings .no nurse or doctor was at those meetings for [Resident #1] . During an interview on 5 /1/2025 at 8:30 AM, The Social Services Director (SSD) stated .I [SSD] set the care plan meetings up it was just me and the dietary manager there was no other staff .those meetings did not have the full team together everybody was just tied up .

Based on facility policy review, medical record review, observation, and interview, the facility failed to administer a feeding tube formula (liquid nutrition delivered through a tube inserted into the stomach) as ordered by the physician for 1 resident (Resident #1) of 2 residents reviewed for tube feeding nutrition. The findings include: Review of the facility's undated policy titled, Feeding Tube guidelines, revealed .Ensuring that the administration of enteral nutrition is consistent with and follows the practitioner's orders . Review of the medical record revealed, Resident #1 was admitted to the facility on [DATE] with diagnoses including Stroke, Epilepsy, Type 2 Diabetes, Gastrointestinal (GI) Bleed, Dysphagia (difficulty swallowing), and Aphasia. Review of the Physicians Order for Resident #1 dated 10/16/2024, revealed .Glucerna [tube feeding liquid nutrition] 1.5 at 70ML/HR [milliliters per hour] Water Flush 45ML/HR x [times] 22 hrs [hours] .Pleasure pureed [pudding like consistency], thin liquid tray as requested . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident was not able to complete the test due to cognitive impairment. Continued review revealed the resident had a Gastrostomy feeding tube (surgically placed device to give direct access to the stomach for feeding, hydration, and medication) for nutrition. Review of a comprehensive care plan dated 12/11/2024, revealed Resident #1 received tube feeding as his primary source of nutrition and hydration and was at risk for complications including malnutrition, aspiration and dehydration. Continued review revealed Resident #1 received a mechanically altered texture pleasure diet. Review of a Medication Administration Record (MAR) for Resident #1 dated 1/1/2025, revealed .Diet .Tube Feeding .Glucerna 1.5 at 70 ML/HR .x 22 hours . Continued review revealed .Enteral Feed Order at bedtime. Change tubing, formula and syringe every 24 hours. The MAR revealed a check mark with Licensed Practical Nurse (LPN) A's initials in the 8:00 PM time box which indicated the task was completed. Review of a Nurse's Note (authored by LPN A) for Resident #1 dated 1/2/2025 at 6:32 AM, revealed .WENT INTO ROOM TO CHECK ON RESIDENT'S TUBE FEEDING .OSMOLITE 1.2 CAL [calorie] [tube feeding liquid nutrition] WAS NOTED TO BE HANGING [being administered through the tube feeding] .GLUCERNA 1.5 CAL PER MD [Medical Doctor] ORDERS .NO S/S [signs and symptoms] OF DISTRESS OR DISCOMFORT .NO N/V [nausea and vomiting] OR DIARRHEA .GLUCERNA 1.5 CAL IMMEDIATELY HUNG [administered]. DON [Director of Nursing] AND .[the Provider] WAS NOTIFIED . During an observation on 1/21/2025 at 1:00 PM, revealed Resident #1 had Glucerna 1.5 tube feeding formula infusing at 70 ML/HR. During an interview on 1/22/2025 at 11:45 AM, the Medical Director stated he was notified by the facility's nursing staff, the incorrect tube feeding formula was administered on 1/1/2025 (approximately 10 hours) to Resident #1. The Medical Director stated Resident #1 was monitored several days after the incident and did not exhibit any complications from being administered the incorrect tube feeding formula for the approximately 10 hours. Review of a Nutrition Progress Note for Resident #1 dated 1/22/2025 at 3:01 PM, revealed .On 1/ 2 [1/2/2025] [administration started on 1/1/2025 at 8:00 PM and ended on 1/2/2025 at 6:32 AM] .he [Resident #1] was given [administered] Osmalite [Osmolite] 1.5 .Error was discovered [by LPN A on 1/2/2025 at 6:32 AM] and feeding was changed to Glucerna 1.5 and resumed without incident .did not have signs .symptoms .distress .discomfort .GI side effects .Osmalite is a general tube feeding formula and does not contain components that would harm [Resident #1] upon administration . During an interview on 1/23/2025 at 10:30 AM, the Executive Director of Nursing stated it was her expectation the nurses administer the tube feeding formula as ordered by the physician. Multiple attempts for telephone interview of LPN A from 1/21/2025 - 1/23/2025 were unsuccessful.

Based on facility policy review, job description review, facility assessment review, Quality Assurance and Performance Improvement (QAPI) Plan review, QAPI Meeting Minutes review, facility documentation review, medical record review, observations, and interviews, the facility's QAPI program failed to ensure an effective, data-driven QAPI program that identified quality deficiencies, implement performance improvement activities to address quality concerns, and perform a root cause analysis related to infection control practices. The facility ' s QAPI committee failed to develop and implement effective processes or initiate action plans for performance improvement when the committee failed to recognize poor infection control practices of the facility and to ensure an effective infection control program to mitigate the spread of disease. The facility ' s QAPI program failed to recognize and provide to the staff the updated Centers for Disease Control Guidelines for the isolation and quarantine time of COVID-19 residents and employees, which allowed COVID-19 positive employees to work and provide care for vulnerable and COVID-19 negative residents of the facility, exposing the residents to the COVID-19 infection. The facility census was 99. The facility's failure to ensure an effective QAPI program, implement proper infection control practices, ensure physician ' s orders were followed related to vital sign monitoring for COVID-19 positive residents, and ensure medication administrations adhered to professional standard of practice resulted in an Immediate Jeopardy (IJ), (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) which had likelihood to impact all 99 residents of the facility. The Administrator, Director of Nursing (DON), [NAME] President of Operations (VPO), [NAME] President of Life Safety and Environmental Compliance (VPLSEC), and [NAME] President of Clinical Services (VPCS) (attended in person) and the [NAME] President of Regulatory Compliance (VPRC) and Chief Operating Officer (COO) with the Chief Regulatory Compliance Officer (CRCO) (attended by telephone) were notified of the IJs for F-880, F-835, F-837, F-867, F-684, and F-726 on 11/13/2024 at 9:42 PM in the Common Area/Recreation Area. The facility was cited Immediate Jeopardy at F-867 at a scope and severity of L. The facility was cited Immediate Jeopardy at F-684 at a scope and severity of K which is substandard quality of care. The facility was cited Immediate Jeopardy at F-726, F-835, F-837, F-880 at a scope and severity of L. An Extended survey was conducted onsite from 11/14/2024 through 11/15/2024. The IJ began on 8/9/2024 and is ongoing. The facility is required to submit a Plan of Correction (POC). The findings include: Review of the facility's undated policy titled, Quality Assurance and Performance Improvement (QAPI) Program, revealed .the facility shall develop, implement, and maintain an ongoing .data-driven QAPI program that is focused on indicators of the outcomes of care .objectives .provide a means to measure current and potential indicators for outcomes of care .establish and implement performance improvement projects to correct identified negative or problematic indicators .governing board (body) .is .responsible for the QAPI program .governing board [body] evaluates the effectiveness of its QAPI program at least annually . Review of a facility document titled, Regulatory Compliance and QAPI Program, dated 8/15/2023, revealed .infection prevention program expectations .surveillance .infection tracking and log .COVID [COVID-19] tracking staff and residents .testing .reporting .appropriate use of source control and PPE use during care .appropriate use of precautions .droplet .contact .enhanced barrier .QAPI participation .schedule monthly infection control meeting .separate from QAPI meetings .reporting of infection control meeting minutes during QAPI meetings .Ad-Hoc [as necessary] infection control meetings during outbreaks to discuss root cause analysis and facility actions . Review of a facility document (undated and untitled) revealed the QAPI committee meets one time monthly, and the Administrator is the committee contact. Review of the Administrator's Job Description signed and dated by the Administrator on 10/3/2022, revealed .plans, coordinates and manages all services and employees of [the] facility .responsible for .coordination and evaluation of all care and services provided .manages compliance with all policies and procedures .oversees and help develop education .ensure .outcomes .policies and procedures of Nursing services meet .regulations .services are provided in accordance with [the] resident ' s plan of care .drives .ongoing activities of the Quality Improvement Committee (QAPI) . Review of the DON ' s Job Description signed and dated by the DON on 7/10/2024, revealed .manages and directs the day-to-day functions of the Nursing Department in accordance with policies .that comply with federal, state, and local regulations .ensures .staff are qualified and trained .ensures that each patient ' s needs are assessed and .treatment plan is developed for nursing care .ensures that required documentation is complete . Review of the Medical Director Services Agreement and Description of Services dated 6/1/2021, revealed .Review resident cases .for quality of care .quality of life concerns .take steps to resolve situations .Participate in Facility staff meetings concerning infection control, pharmacy services .Review, approve, implement, and assist in the development of clinical, nursing .resident care policies .procedures .Review, consider .act upon consultant recommendations pertaining to .resident care .Attend Quality Assessment and Assurance meetings .Advise .direct quality improvement plans .Assist in identification .implementation of .staff educational needs .provide information to staff . Investigation revealed the facility had two COVID-19 outbreaks. Documentation revealed during the first outbreak on 8/9/2024 through 10/11/2024, revealed 28 residents and 15 employees tested positive for COVID-19. During the second outbreak on 10/19/202 through present, revealed 10 residents and 5 employees tested positive for COVID-19. The facility allowed 17 of the 20 total COVID-19 positive employees to return to work before the required isolation time frame recommended by CDC guidance, which increased the likelihood that contagious employees could spread the COVID-19 infection to all residents in the facility. The facility failed to accurately identify COVID-19 positive residents and residents who required EBP with appropriate signage and tracking of potentially infectious diseases. Further investigation revealed employees were non-compliant with PPE usage in the provisions of care for residents in Enhanced Barrier Precautions (EBP) rooms for 6 of 26 residents. Refer to F-880 Investigation revealed the facility failed to ensure the nursing staff were competent and fully understood isolation guidelines for EBP and COVID-19 and implemented appropriate use of PPE (Personal Protective Equipment) for residents in isolation to prevent and control the spread of COVID-19 and other infectious organisms. Refer to F-726 The facility failed to ensure that treatment and care provided met professional standards of quality and acceptable clinical practice for following physician ' s orders and administering medications. Refer to F-684 The facility Administration failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility Administration failed to ensure an effective QAPI Committee that identified noncompliance timely and used quality data to track and trend noncompliance. The facility Administration failed to ensure COVID-19 positive employees were excluded from work, failed to complete COVID-19 testing and tracking for residents and employees, failed to identify COVID-19 positive residents accurately, and failed to ensure the residents and employees with an active COVID-19 infection had completed the required isolation time frame recommended by the Centers of Disease Control (CDC) to control the exposure and spread of COVID-19. The facility Administration failed to ensure competent nursing staff who correctly identified all types of isolation precautions and implemented the correct PPE usage for those precautions. The facility Administration failed to identify deficient practice related to failure of staff to follow physician's orders and provide care according to professional standards of practice. Refer to F-835 The Governing Body failed to provide oversight to Administration to address in QAPI the facility ' s failure to identify all areas of non-compliance related to infection control, isolation and quarantine guidelines, PPE usage, competent staff, and acceptable standards of practice. The Governing Body failed to ensure Administration implement updated policies and procedures which aligned with the CDC guidelines and requirements for infection control. Refer to F-837 Review of the QAPI meeting minutes dated 11/2023-10/2024, revealed the QAPI committee and the Governing Body failed to identify infection control deficiencies related to unsafe infection control practices with accurate identification of COVID-19 positive residents to prevent the spread of COVID-19 which resulted in multiple COVID-19 outbreaks, non-compliance with isolation procedures, and the practice of allowing COVID-19 positive employees to provide care to Non-COVID-19 positive residents. The QAPI committee and the Governing Body failed to recognize the need to address staff competency related to infection control practices to address non-compliance with PPE usage for care provisions to residents who were potentially contagious. The QAPI committee and the Governing Body failed to implement corrective action to address the deficient practice of noncompliance with physician ' s orders related to vital sign monitoring and ensuring professional standards of care were followed for an unsafe practice of medication administration for a resident at risk for aspiration. During an interview on 11/6/2024 at 3:15 PM, the Medical Director stated he had voiced previous concerns to the facility administration in QAPI regarding staff PPE usage and infection control practices. The Medical Director stated the facility did not implement his professional recommendations in QAPI meetings for infection control practices and guidance during the outbreaks. During an interview on 11/13/2024 at 7:55 PM, the Administrator stated the facility had .some areas of improvement to address in QAPI to improve infection prevention and control practices . Further interview revealed the Administrator wanted to address in QAPI competent staffing and professional standards of care are met. Refer to F-684, F-726, F835, F837, F867, and F880

Based on facility policy review, review of the Centers for Disease Control and Prevention (CDC) recommendations and guidance, job description review, facility assessment review, and interviews, the Governing Body failed to provide oversight to Administration to ensure current CDC guidelines were utilized to prevent and control the spread of COVID-19 to the residents and employees. The Governing Body failed to provide oversight to Administration to ensure the staff were competent and knowledgeable on Enhanced Barrier Precautions (EBP) and COVID-19 isolation practices which included use of appropriate Personal Protective Equipment (PPE) for potentially contagious residents. The Governing Body failed to provide oversight to Administration to accurately identify residents with an active COVID-19 infection. The Governing Body failed to provide oversight to Administration to ensure COVID-19 testing of the staff was completed per CDC guidelines during the COVID-19 outbreaks from 8/2024-11/2024. The Governing Body failed to provide oversight to Administration to ensure COVID-19 positive employees and residents were quarantined for the required isolation time frame recommended by the CDC which resulted in COVID-19 positive employees provided care to COVID-19 negative residents. The Governing Body failed to provide oversight to Administration to ensure an effective, date-driven Quality Assurance and Performance Improvement (QAPI) program which reviewed systems and processes and failed to ensure the facility conducted ongoing tracking with monitoring of active COVID-19 infections in the facility. The Governing Body failed to provide oversight to Administration to ensure the QAPI Committee recognized repeated systemic failures to assess, identify, and implement the residents' need for isolation precautions related to COVID-19 that resulted in multiple COVID-19 outbreaks in the facility. The Governing Body failed to provide oversight to Administration to ensure the facility followed physician orders related to vital sign monitoring for 36 of 40 COVID-19 positive residents during a COVID-19 outbreak to ensure any acute clinical changes were addressed and monitored. The Governing Body failed to provide oversight to Administration to ensure treatment, care, and services related to medication administration for a resident at risk for aspiration were implemented in accordance with professional standards of practice. The failure of the Governing Body to provide oversight to the facility's Administration resulted in an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident), which had had the likelihood to affect all 99 residents in the facility. The Administrator, Director of Nursing (DON), [NAME] President of Operations (VPO), [NAME] President of Life Safety and Environmental Compliance (VPLSEC), [NAME] President of Clinical Services (VPCS) (attended in person) and the [NAME] President of Regulatory Compliance (VPRC) and Chief Operating Officer (COO) with the Chief Regulatory Compliance Officer (CRCO) (attended by telephone) were notified of the IJs for F-880, F-835, F-837, F-867, F-684, and F-726 on 11/13/2024 at 9:42 PM in the Common Area/Recreation Area. The facility was cited Immediate Jeopardy at F-837 at a scope and severity of L. The facility was cited Immediate Jeopardy at F-684 at a scope and severity of K which is substandard quality of care. The facility was cited Immediate Jeopardy at F-726, F-835, F867, and F-880 at a scope and severity of L. An Extended survey was conducted onsite from 11/14/2024 through 11/15/2024. The IJ began on 8/9/2024 and is ongoing. The facility is required to submit a Plan of Correction (POC). The findings include: Review of the facility's undated policy titled, Quality Assurance and Performance Improvement (QAPI) Program, revealed .the facility shall develop, implement, and maintain an ongoing .data-driven QAPI program that is focused on indicators of the outcomes of care .objectives .provide a means to measure current and potential indicators for outcomes of care .establish and implement performance improvement projects to correct identified negative or problematic indicators .governing board (body) .is .responsible for the QAPI program .governing board [body] evaluates the effectiveness of its QAPI program at least annually . Review of the facility's undated policy titled, Governing Body, revealed .the facility will have designated persons functioning as a governing body, that is .responsible for establishing and implementing policies .the governing body is responsible and accountable for the QAPI program .the governing body will have a process in place by which the administrator .reports .communication .how the governing body responds back to the administrator . Review of a facility's undated document titled, Governing Body Organizational Structure, revealed the governing body members were designated as the Medical Director, VPRC, VPCS, and the VPO. Review of a facility document titled, Regulatory Compliance and QAPI Program, dated 8/15/2023, revealed .infection prevention program expectations .surveillance .infection tracking and log .COVID [COVID-19] tracking staff and residents .testing .reporting .appropriate use of source control and PPE use during care .appropriate use of precautions .droplet .contact .enhanced barrier .QAPI participation .schedule monthly infection control meeting .separate from QAPI meetings .reporting of infection control meeting minutes during QAPI meetings .Ad-Hoc [as necessary] infection control meetings during outbreaks to discuss root cause analysis and facility actions . Review of the Administrator's Job Description signed and dated by the Administrator on 10/3/2022, revealed .plans, coordinates and manages all services and employees of [the] facility .responsible for .coordination and evaluation of all care and services provided .manages compliance with all policies and procedures .oversees and help develop education .ensure .outcomes .policies and procedures of Nursing services meet .regulations .services are provided in accordance with [the] resident's plan of care .drives .ongoing activities of the Quality Improvement Committee (QAPI) . Review of the Medical Director Services Agreement and Description of Services dated 6/1/2021, revealed .Review resident cases .for quality of care .quality of life concerns .take steps to resolve situations .Participate in Facility staff meetings concerning infection control, pharmacy services .Review, approve, implement, and assist in the development of clinical, nursing .resident care policies .procedures .Review, consider .act upon consultant recommendations pertaining to .resident care .Attend Quality Assessment and Assurance meetings .Advise .direct quality improvement plans .Assist in identification .implementation of .staff educational needs .provide information to staff . Further review revealed the Medical Director was not listed as a governing body designee in this contract. Review of a facility document (undated and untitled) revealed the QAPI committee meets one time monthly, and the Administrator was the committee contact. Investigation revealed the facility experienced two COVID-19 outbreaks. Documentation revealed during the first outbreak on 8/9/2024 through 10/11/2024, 28 residents and 15 employees tested positive for COVID-19. During the second outbreak on 10/19/2024 through present, revealed 10 residents and 5 employees tested positive for COVID-19. The facility allowed 17 of the 20 total COVID-19 positive employees to return to work before the required isolation time frame recommended by CDC guidance, which increased the likelihood that contagious employees could spread the COVID-19 infection to all residents in the facility. The facility failed to accurately identify COVID-19 positive residents and residents who required EBP with appropriate signage and tracking of potentially infectious diseases. Further investigation revealed employees were non-compliant with PPE usage in the provisions of care for residents in EBP rooms. Refer to F-880 The facility failed to ensure the nursing staff were knowledgeable and fully understood what EBP were, how to identify residents in EBP, and what PPE was required for residents in EBP and active COVID-19 rooms. The facility failed to ensure nursing staff implemented appropriate PPE usage for residents in EBP and droplet (for COVID-19) isolation to prevent and control the spread of COVID-19 and other infectious organisms. Refer to F-726 The facility failed to ensure that services provided met professional standards of quality and acceptable standards of clinical practice when staff failed to follow physician orders for obtaining vital signs on residents who tested positive for COVID-19 and failed to follow professional standards of practice for medication administration. Refer to F-684 The facility Administration failed to address in QAPI the facility's widespread problem of ensuring COVID-19 positive employees were excluded from work, failed to complete COVID-19 testing and tracking for employees, failed to accurately identify which residents were positive for COVID-19, and failed to ensure the residents and employees with an active COVID-19 infection had completed the required isolation time frame recommended by the Centers of Disease Control (CDC) to control the exposure and spread of COVID-19. The facility Administration failed to recognize the need to address staff competency related to infection control practices to address non-compliance with PPE usage for care provisions to residents that were potentially contagious. The facility Administration failed to recognize and address deficient practice related to following physician's orders and failed to ensure professional standards of care were followed related to medication administration. Refer to F-835 Review of the QAPI meeting minutes dated 11/2023 through 10/2024, revealed the QAPI committee and the Governing Body failed to identify infection control deficiencies related to unsafe infection control practices with accurate identification of COVID-19 positive residents to prevent the spread of COVID-19 which resulted in multiple COVID-19 outbreaks, non-compliance with isolation procedures, and the practice of allowing COVID-19 positive employees to provide care to Non-COVID-19 positive residents. The QAPI committee and the Governing Body failed to recognize the need to address staff competency related to infection control practices to address non-compliance with PPE usage for care provisions to residents that were potentially contagious. The QAPI committee and the Governing Body failed to implement corrective action to address the deficient practice with physician's orders compliance related to vital sign monitoring and ensuring professional standards of care were followed for an unsafe practice of medication administration for a resident at risk for aspiration. Refer to F-837 and F-867 During an interview on 11/6/2024 at 3:34 PM, the Administrator stated QAPI meetings are held monthly, and the required members are the Administrator, Medical Director, DON, and the Infection Preventionist. The Administrator stated the Governing Body members can attend the monthly QAPI meetings if desired, but it is not required for the Governing Body members to attend. The Administrator stated the primary mode of communication with the Governing Body designees was by email and there was no formal report or information required to send to the Governing Body members. The Administrator stated she did not know if the Governing Body had separate meeting to discuss facility problems or concerns. The Administrator could not identify the Governing Body members upon request. During an interview on 11/7/2024 at 10:03 AM, the Administrator stated at least one member of the Governing Body attended the monthly QAPI meetings and confirmed the Governing Body did not have a separate meeting to address facility problems or concerns. The Administrator stated she sent the Governing Body designees an invitation to attend the monthly QAPI meetings via (by way of) video teleconference. During an observation and interview on 11/7/2024 at 10:09 AM, revealed the Administrator entered the conference room and asked the surveyor to review the QAPI meeting signature logs provided to the surveyor on 11/5/2024. The Administrator skimmed through the monthly QAPI signature logs and proceeded to sign the signature of the VPRC on multiple signature logs (witnessed by the survey team). The Administrator stated the facility needed to review the QAPI meeting minutes and signature logs previously provided to the surveyor and stated the signature logs for the monthly QAPI meetings had been given in error. The Administrator took the monthly QAPI signature logs out of the conference room to review with the corporate team. During an observation and interview on 11/7/2024 at 10:45 AM, the Administrator returned to the conference room with the monthly QAPI meeting signature logs (11/2023 through 10/2024). Observation revealed the QAPI meeting signature logs had new signatures added from a member of the Governing Body on each of the QAPI meeting signature logs. The Administrator stated she had the Governing Body members to sign the QAPI meeting signature logs to verify their attendance to the meetings. The Administrator stated the Governing Body members failed to sign the signature logs of the QAPI meetings and stated the Governing Body members attended these meetings via video conference. (The Administrator failed to provide documentation of the video conference invitations with attendance to verify the presence of the Governing Body members in comparison to the addition of the new signatures.) Review of the QAPI meeting signature logs on 11/7/2024 at 10:50 AM, revealed the following discrepancies: 11/30/2023: addition of the name and signature of VPRC (name misspelled) 12/29/2023: addition of the name and signature of VPCS 1/25/2024: addition of the name and signature of VPO and VPRC (both names were misspelled) 2/22/2024: addition of the name and signature of VP of Administrator Leadership Education and QAPI (VPALEQ) 3/21/2024: addition of the name and signature of VPALEQ 4/18/2024: addition of the name and signature of VPCS 5/24/2024: addition of the name and signature of VPCS 6/27/2024: addition of the name and signature of VPCS 7/18/2024: addition of the name and signature of VPRC 8/30/2024: addition of the name and signature of VPCS 9/26/2024: addition of the name and signature of VPRC (name misspelled) 10/24/2024: addition of the name and signature of VPRC (name misspelled) During an interview in the recreation/ family visitation room on 11/8/2024 at 12:00 PM, with the VPRC and VPCS (Governing Body members), the VPRC stated she attended the monthly QAPI meetings via video teleconference or in-person. The VPRC and the VPCS stated they received the invitation for the QAPI meeting schedule via email (from the Administrator) and will attend. The VPRC stated the Governing Body designees did not conduct a separate meeting from the QAPI meetings to discuss facility problems or areas of concern. The VPRC stated the Governing Body communicated with each other via email or phone calls to discuss any action items recognized. The VPRC could not recall any specific conversation to the Governing Body designees regarding COVID-19 infection control issues, COVID-19 outbreaks, or CDC guideline updates. The VPCS stated the Governing Body had input and made suggestions during the QAPI meetings. The VPCS could not recall any specific suggestions or action plans during the QAPI meetings to address COVID-19 infection control issues, COVID-19 outbreaks, and CDC guideline updates.

Based on facility policy review, Centers for Disease Control and Prevention (CDC) recommendations and guidance review, job description review, facility assessment review, and interviews, the facility's Administration failed to ensure current CDC guidelines were utilized to prevent and control the spread of COVID-19 to the residents and employees. The facility's Administration failed to ensure the staff were competent and knowledgeable on Enhanced Barrier Precautions (EBP) and COVID-19 isolation practices which included use of appropriate Personal Protective Equipment (PPE) for potentially contagious residents. The facility's Administration failed to accurately identify residents with an active diagnosis of COVID-19. The facility's Administration failed to ensure the completion of COVID-19 testing of the staff during the COVID-19 outbreaks from 8/2024-11/2024. The facility's Administration failed to ensure COVID-19 positive employees and residents were quarantined for the required isolation time frame recommended by the CDC, and the facility's Administration allowed COVID-19 positive employees to provide care for COVID-19 negative residents. The facility's Administration failed to ensure an effective QAPI program which reviewed systems and processes with ongoing tracking and monitoring of active COVID-19 infections in the facility. The facility's Administration failed to recognize, in QAPI, repeated systemic failures to assess, identify, and implement the residents' need for isolation precautions related to COVID-19 that resulted in multiple COVID-19 outbreaks in the facility. The facility's Administration failed to ensure the facility carried out physician orders related to vital sign monitoring for 36 of 40 COVID-19 positive residents during a COVID-19 outbreak to ensure any acute clinical changes were addressed and monitored. The facility's Administration failed to ensure treatment, care, and services related to medication administration for a resident at risk for aspiration were implemented in accordance with professional standards of practice. These failures by the facility's Administration resulted in an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident), which had had the likelihood to affect all 99 residents in the facility. The Administrator, Director of Nursing (DON), [NAME] President of Operations (VPO), [NAME] President of Life Safety and Environmental Compliance (VPLSEC), and [NAME] President of Clinical Services (VPCS) (attended in person) and the [NAME] President of Regulatory Compliance (VPRC) and Chief Operating Officer (COO) with the Chief Regulatory Compliance Officer (CRCO) (attended by telephone) were notified of the IJs for F-684, F-726, F-835, F-837, F-867, and F-880, on 11/13/2024 at 9:42 PM in the Common Area/Recreation Area. The facility was cited Immediate Jeopardy at F-835 at a scope and severity of L. The facility was cited Immediate Jeopardy at F684 at a scope and severity of K which is substandard quality of care The facility was cited Immediate Jeopardy at F726, F-837, F867, F-880 at a scope and severity of L. An Extended survey was conducted onsite from 11/14/2024-11/15/2024. The IJ began on 8/9/2024 and is ongoing. The facility is required to submit a Plan of Correction (POC). The findings include: Review of the facility's policy titled, COVID-19 GENERAL TESTING POLICY,undated, revealed .Staff with symptoms or signs of COVID-19 .will be tested as soon as possible and will be restricted from the facility pending the results of COVID-19 testing .Residents who have signs and symptoms of COVID-19 .will be tested .be placed on transmission-based precautions (TBP) .DURING COVID-19 OUTBREAK .Facilities will investigate an outbreak using contact tracing or a broad-based approach .Broad-based approach .used if the facility is unable to conduct contract tracing .Broad-based approach includes testing every 3-[to] 7 days until no more positive cases identified for 14 days .if additional cases are identified after testing a unit, floor, or specific area .the facility will expand testing to facility-wide . Further review revealed the policy referenced the CDC guidance dated 5/25/2023. Review of the facility's policy titled, COVID-19 Management of Residents, undated, revealed .The facility will not have a dedicated COVID-19 unit unless the number of positive residents warrant .the facility will place a COVID-19 positive resident in a single room with appropriate isolation signage and staff wearing N95 respirator, eye protection, gown, and gloves upon entry to the room .dedicated staff, to care for residents with COVID-19 .the door will be kept closed .resident will be monitored every four hours for .symptoms, vital signs, oxygen saturation .and respiratory exam .residents will .wear source control until symptoms resolve . Further review revealed the policy referenced the CDC guidance dated 5/25/2023. Review of the CDC's guidance titled, Infection Control Guidance: SARS-CoV-2, dated 6/24/2024, revealed, .The recommendations in this guidance continue to apply after the expiration of the federal COVID-19 Public Health Emergency [5/11/2023] .To provide the greatest assurance that someone does not have SARS-CoV-2 infection .Establish a Process to Identify and Manage Individuals with Suspected or Confirmed SARS-CoV-2 Infection .Ensure everyone is aware of recommended IPC [infection prevention and control] practices in the facility . (The CDC published this recommendation on 6/24/2024 and was the guidance the facility should have followed from 6/24/2024 to present). Review of the CDC guidance titled, Viral Respiratory Pathogens Toolkit for Nursing Homes, dated 10/28/2024, revealed .Educate .Ensure everyone .including HCP [healthcare providers], are aware of recommended IPC [infection prevention and control] practices in the facility .When an acute respiratory infection is identified in a resident or HCP .take rapid action to prevent the spread to others in the facility .Apply appropriate Transmission-Based Precautions for symptomatic residents .HCP who enter the room of a resident with signs or symptoms of an unknown respiratory viral infection that is consistent with SARS-CoV-2 [COVID-19] infection should adhere to Standard Precautions .use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e. [example], goggles or a face shield that covers the front and sides of the face) .Develop sick leave policies for HCP .with public health guidance to discourage presenteeism .allow HCP with respiratory infection to stay home for the recommended duration of work restriction .Test anyone with respiratory illness signs or symptoms .Investigate for potential respiratory virus spread among residents and HCP .Perform active surveillance to identify any additional ill residents or HCP using symptom screening .evaluating potential exposures .testing of exposed individuals is recommended, even if they are asymptomatic .Make initial attempts to control limited spread .If SARS-CoV-2 transmission is occurring .Consider implementing broad-based testing as opposed to only testing close contacts to identify asymptomatic infection . Review of the Administrator's Job Description signed and dated by the Administrator on 10/3/2022, revealed .plans, coordinates and manages all services and employees of [the] facility .responsible for .coordination and evaluation of all care and services provided .manages compliance with all policies and procedures .oversees and help develop education .ensure .outcomes .policies and procedures of Nursing services meet .regulations .services are provided in accordance with [the] resident's plan of care .drives .ongoing activities of the Quality Improvement Committee (QAPI) . Review of the DON's Job Description signed and dated by the DON on 7/10/2024, revealed .manages and directs the day-to-day functions of the Nursing Department in accordance with policies .that comply with federal, state, and local regulations .ensures .staff are qualified and trained .ensures that each patient's needs are assessed and .treatment plan is developed for nursing care .ensures that required documentation is complete . Review of the facility's assessment dated [DATE], revealed .purpose of the assessment is to determine what resources are necessary to care for residents competently .use this assessment to make decisions about your direct care staff needs .capabilities to provide services to the residents .list the types of care that your resident population requires and that you provide for your resident population .infection prevention and control .identification and containment of infections .prevention of infections .staff training .infection control .isolation .use of personal protective equipment [PPE] .policies and procedures are established in compliance with state and federal regulations as well as CDC guidelines .issues identified facility or resident specific are made [as a multidimensional approach in] QAPI [Quality Assurance and Performance Improvement] . Investigation revealed the facility experienced two COVID-19 outbreaks. Documentation revealed during the first outbreak on 8/9/2024-10/11/2024 that 28 residents (Residents #96, #31, #45, #33, #11, #64, #609, #93, #15, #510, #611, #80, #612, #506, #615, #613, #614, #54, #68, #27, #53, #12, #95, #74, #30, #37, #3, and #89) and 15 employees tested positive for COVID-19. During the second outbreak which began on 10/19/2024 through present, revealed 10 residents (Residents #99, #617, #103, #72, #34, #618, #507, #508, #102, and #94) and 5 employees tested positive for COVID-19. The facility allowed 17 of the 20 total COVID-19 positive employees to return to work before the required isolation time frame recommended by CDC guidance, which increased the likelihood that contagious employees could spread the COVID-19 infection to all residents in the facility. The facility failed to accurately identify COVID-19 positive residents and residents who required EBP with appropriate signage and tracking of potentially infectious diseases. Further investigation revealed employees were non-compliant with PPE usage in the provisions of care for residents in Enhanced Barrier Precautions (EBP) rooms for 6 of 26 residents (Resident #13, #25, #56, #83, #24, #52). During an interview and facility policy review on 11/12/2024 at 10:12 AM, in the conference room, with the VPCS, VPRC, DON, and the Administrator, the facility identified they were not following the current CDC guidelines to prevent and control the spread of COVID-19. The ADM stated the facility had allowed COVID-19 positive employees to work in accordance with the CDC guidelines for contingency staffing and did not realize the emergency staffing waiver had ended. The Administrator stated the facility had re-educated all the managers on 11/11/2024 on the current CDC guidelines. Review of the education material used to re-educate the staff referenced the outdated 2023 CDC guidelines. During an interview and CDC guidelines review on 11/13/2024 at 3:32 PM, with the Administrator and VPCS, revealed the CRCO was responsible for updating the facility's COVID-19 policies and confirmed these outdated policies were used to re-educate staff. Further interview revealed the facility's new COVID-19 policies were revised (date unknown) referenced the outdated 2023 CDC guidelines. During an interview on 11/15/2024 at 3:00 PM, the Corporate Human Resources and VPRC verified and confirmed Licensed Practical Nurse (LPN) D, Registered Nurse (RN) B, LPN MM, Laundry NN, and LPN OO worked after testing positive for COVID-19 and were not quarantined for the recommend CDC guidance, which had the potential to cause or increase the 2 COVID-19 outbreaks. During an interview on 11/16/2024 at 7:56 PM, the DON confirmed the facility failed to perform facility wide employee testing and adhere to the recommended quarantine time during the COVID-19 outbreaks, failed to track and trend all facility COVID-19 cases, and confirmed the facility failed to ensure COVID-19 positive residents were quarantined according to CDC guidance. Refer to F-880 Investigation revealed the facility failed to ensure the nursing staff were knowledgeable and had a full understanding on the identification of residents on 3 of 4 hallways (200, 300, and 400 hallways) on EBP, active COVID-19 residents on 1 of 4 hallways (100 hallway) and implemented EBP, the appropriate use of (PPE) for isolation rooms to prevent and control the spread of COVID-19, and other infectious organisms. The facility failed to wear appropriate PPE for residents in EBP rooms for 6 of 26 residents (Resident #13, #25, #56, #83, #24, #52) reviewed for EBP. Refer to F-726 The facility failed to ensure that services provided met professional standards of quality and acceptable standards of clinical practice for not obtaining vital signs per physician orders for residents with an active COVID-19 diagnosis for 36 of 40 residents (Resident #96, #45, #31, #33, #11, #609, #64, #93, #15, #510, #612, #611, #80, #506, #613, #615, #54, #68, #27, #53, #12, #95, #74, #3, #30, #37, #617, #34, #618 #72, #103, #507, #102, #508, #619, and #509) of 40 residents reviewed and 1 of 6 residents (Resident #99) reviewed for medication administration. Refer to F-684 Review of the QAPI meeting minutes dated 11/2023-10/2024, revealed the QAPI committee and the Governing Body failed to identify infection control deficiencies related to unsafe infection control practices with accurate identification of COVID-19 positive residents to prevent the spread of COVID-19 which resulted in multiple COVID-19 outbreaks, non-compliance with isolation procedures, and the practice of allowing COVID-19 positive employees to provide care to Non-COVID-19 positive residents. The facility's Administration failed to recognize the need to address staff competency related to infection control practices to address non-compliance with PPE usage for care provisions to residents who were potentially contagious and failed to implement corrective actions to address the deficient practice with physician's orders compliance related to vital sign monitoring and ensuring professional standards of care were followed for an unsafe practice of medication administration for a resident at risk for aspiration. Refer to F-837 and F-867 During an interview on 11/6/2024 at 3:15 PM, the Medical Director stated he had voiced previous concerns to the facility administration regarding staff PPE usage and infection control practices. The Medical Director stated he was confused and would seek clarification from the staff prior to entering resident rooms because of the facility's inconsistent use and incorrect signage use for residents with transmissions-based precautions. The Medical Director stated he expected the facility to follow the CDC guidelines (current and updated) for the management of COVID-19 outbreaks. The Medical Director stated he had instructed the nurses to keep the doors closed for residents with COVID-19 infections and stated keeping the resident's door closed would mitigate the spread and control of COVID-19. The Medical Director stated the facility did not implement his professional recommendations in QAPI meetings for infection control practices and guidance during the outbreaks. During an interview on 11/13/2024 at 7:55 PM, the Administrator stated the facility had some areas of improvement to address in QAPI regarding infection prevention and control practices (to include the prevention and control of COVID-19 and adherence to isolation with PPE usage for the employees), competent staffing, and ensuring professional standards of care are met related to safety with medication administration and compliance with physician orders.

Based on facility policy review, job description reviews, review of the Centers for Disease (CDC) website for recommendations and guidance for Enhanced Barrier Precautions (EBP) and Coronavirus Disease 2019 (COVID-19), medical record reviews, observations, and interviews, the facility failed to ensure the nursing staff were knowledgeable and fully understood of 6 residents (Residents # 13, #24, #25, #52, #56, and #83) in EBP on 3 of 4 hallways (200, 300, and 400 hallways), of 4 residents (Residents #102, #507, #508, and #509) with active COVID-19 infection on 1 of 4 hallways (100 hallway), and implemented the appropriate use of Personal Protective Equipment (PPE) for isolation rooms to prevent and control the spread of COVID-19, and other infectious organisms. The facility's non-compliance placed the residents in Immediate Jeopardy (IJ) (A situation in which the providers noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator, Director of Nursing (DON), [NAME] President of Operations (VPO), [NAME] President of Life Safety and Environmental Compliance (VPLSEC), and [NAME] President of Clinical Services (VPCS) (attended in person) and the [NAME] President of Regulatory Compliance (VPRC) and Chief Operating Officer (COO) with the Chief Regulatory Compliance Officer (CRCO) (attended by telephone) were notified of the IJs for F-880, F-835, F-837, F-867, F-684, and F-726 on 11/13/2024 at 9:42 PM in the Common Area/Recreation Area. The facility was cited Immediate Jeopardy at F-726 at a scope and severity of L. An extended survey was conducted on 11/14/2024-11/15/2024. The Immediate Jeopardy began on 8/9/2024 and is ongoing. The facility is required to submit a Plan of Correction. The findings include: Review of the undated facility policy titled, Competent & [and] Sufficient Staff, revealed .to provide sufficient staff with appropriate competencies .skill sets to assure resident safety .attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident .Providing care includes, but is not limited to, assessing, evaluating, planning and implementing resident care plans and responding to resident's needs .The facility must ensure .nurse aides are able to demonstrate competency in skills .techniques necessary to care for residents' needs .The facility must ensure .licensed nurses have the specific competencies .skill sets necessary to care for resident's needs . Review of the undated facility policy titled, COVID-19 Management of Residents, which referenced the 5/25/2023 CDC guidelines revealed .The facility will not have a dedicated COVID-19 unit unless the number of positive residents warrant .the facility will place a COVID-19 positive resident in a single room with appropriate isolation signage and staff wearing N95 respirator, eye protection, gown, and gloves upon entry to the room .dedicated staff, to care for residents with COVID-19 .the door will be kept closed .resident will be monitored every four hours for .symptoms, vital signs, oxygen saturation .and respiratory exam .residents will .wear source control until symptoms resolve . Review of the facility's Director of Nursing job description revealed .The Director of Nursing manages and directs the day-to-day functions of the Nursing Department in accordance with established policies, procedures, and practices that comply with federal, state, and local regulations .ensures .that staff are qualified and trained . Review of the facility's ADON (Assistant Director of Nursing) Staff Development Coordinator job description revealed .Assisting DON in all aspects of resident care, nursing services, and directing personnel within the facility .Initiates the development of policies .procedures that govern nursing services .Responsible for staff performance .Designs, plans, and provides educational programs on all shifts .for all departments .Participates in the staff evaluation process .observation of employee performance .Provides general facility orientation to all new employees and ongoing in-service education .Audit documentation for errors or inconsistencies .Inventory, identify .monitor .supplies . Review of the facility's RN (Registered Nurse) Supervisor job description revealed .over-see .nurses and CNAs [Certified Nursing Assistant] are providing proper care to .residents . Review of the facility's Licensed Practical Nurse (LPN) Supervisor job description revealed .provides nursing services following the patient's treatment plan .physician's directions .supervises .nursing assistants on duty .Ensures quality .safe delivery of nursing services to patients .Uses equipment .supplies effectively .efficiently .Assist patients with personal hygiene .Provides nursing care following established nursing service objectives and standards. Ensures .all safety .infection control practices are followed . Review of the facility's Registered Nurse (RN) job description revealed .Ensures quality .safe delivery of nursing services to patients .Implements plan of care formulated by physicians .Uses equipment .supplies .effectively .efficiently .Ensuring all work areas .resident's rooms are maintained in accordance with safety and sanitation standards .Administering professional nursing practice services . Review of the facility's Certified Nursing Assistant (CNA) job description revealed .Assists .in provision of basic care for residents .Demonstrate performance .Demonstrate knowledge of disease entities .Ensure .asepsis is carried out during treatments .procedures . Review of the facility's Personal Care Aide job description revealed .has complete personal care training .competent to perform assigned functions of personal care to the client .Assists clients with personal hygiene .Assist clients in the use of toilet facilities .Meal preparation .feeding . Review of the facility's Facility Administrator job description revealed .plans, coordinates and manages all services and employees of facility .is responsible for the overall direction, coordination and evaluation of all care and services provided .Ensures .each employee working at the .facility has a Job Description, has read it, understands it, and complies with it in full .Assists with hiring .providing orientation/training .of sufficient .qualified staff to carry out all programs .services .Holds department leaders accountable .Oversees . helps develop education, in-services training .program development . Review of the Medical Director Services Agreement and Description of Services dated 6/1/2021, revealed .Review resident cases .for quality of care .quality of life concerns .take steps to resolve situations .Participate in Facility staff meetings concerning infection control, pharmacy services .Review, approve, implement, and assist in the development of clinical, nursing .resident care policies .procedures .Review, consider .act upon consultant recommendations pertaining to .resident care .Attend Quality Assessment and Assurance meetings .Advise .direct quality improvement plans .Assist in identification .implementation of .staff educational needs .provide information to staff . Review of the CDC guidance titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 4/2/2024, revealed .Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities .Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care .Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing .Bathing/showering .Transferring .Providing hygiene .Changing linens .Changing briefs or assisting with toileting .Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator .Wound care: any skin opening requiring a dressing .When implementing .Enhanced Barrier Precautions, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this .Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves) .Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves .Incorporate periodic monitoring .assessment of adherence to determine the need for additional training and education . Review of the CDC guidance titled, Viral Respiratory Pathogens Toolkit for Nursing Homes, dated 10/28/2024, revealed .HCP [Healthcare Personnel] who enter the room of a resident with sign and symptoms of SARS-CoC-2 [Covid-19] infection should use a NIOSH [National Institute for Occupational Safety and Health]-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection . Review of an undated and untitled document provided by the Infection Preventionist (IP) on 11/3/2024 revealed a list of residents in the facility who were in droplet isolation for COVID-19 included Residents #102, #507, #508, and #509. Review of the medical record revealed Resident #102 was admitted to the 100 Hallway on 10/2/2024 with diagnoses including Cerebral Infarction, Chronic Obstructive Pulmonary Disease, Hemiplegia and Hemiparesis Affecting Right Dominant Side, and Hypertension. Review of the Physician's Order for Resident #102 dated 10/28/2024, revealed .Isolation Droplet precautions .due to positive covid 19 [COVID-19] test. Mask, googles [goggles], gloves, gown, face shield . Review of the medical record revealed Resident #507 was admitted to the 100 Hallway on 10/11/2024 with diagnoses including Wedge Compression Fracture of the First Lumbar Vertebra, Osteoporosis, Dementia, Anxiety, and Hypothyroidism. Review of the Physician's Order for Resident #507 dated 10/25/2024, revealed .Isolation Droplet precautions .due to positive covid 19 test. Mask, googles, gloves, gown, face shield . Review of the medical record revealed Resident #508 was admitted to the 100 Hallway on 10/15/2024 with diagnoses including Cerebral Infarction, Congestive Heart Failure, and Major Depressive Disorder. Review of a Physician's Order for Resident #508 dated 10/28/2024, revealed .Isolation Droplet precautions .due to positive covid 19 test. Mask, googles, gloves, gown, face shield . Review of the medical record revealed Resident #509 was admitted to the 100 Hallway on 10/30/2024 with diagnoses including Fracture of Right Humerus, COVID 19, Anxiety, Pressure Ulcer of Sacral Region Stage 4, Chronic Respiratory Failure, and Adult Failure to Thrive. Review of the Physician's Order for Resident #509 dated 10/31/2024, revealed .Isolation Droplet precautions .due to positive covid 19 test. Mask, googles, gloves, gown, face shield . Review of a list of all residents on EBP provided by the facility during the survey dates 11/3/2024-11/15/2024, revealed 4 residents on the 100 Hallway, 12 residents on the 200 Hallway, 9 residents on the 300 Hallway, and 10 residents on the 400 Hallway. Review of an undated and untitled document provided by the IP on 11/3/2024 revealed a list of residents in the facility who were EBP: Resident #13- EBP for wound Resident #24- EBP for ESBL (Extended-Spectrum Beta-Lactamase- a type of bacterial infection that's resistant to many antibiotics) Resident #25- EBP for ESBL Resident #52- EBP for wound and ESBL Resident #56-EBP for indwelling urinary device Resident #83- EBP for wound, indwelling urinary device, and ESBL Review of the medical record revealed Resident #13 was admitted to facility on 5/13/2024 with diagnoses including Depression, Restless Leg Syndrome, and Anxiety.?? ? Review of a Physician's Order for Resident #13 dated 5/17/2024, revealed .resident in enhanced barrier precautions . for a wound.? Review of the comprehensive care plan for Resident #13 dated 5/17/2024, revealed .enhanced barrier precautions . for a wound. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including Unsteadiness on Feet, Epilepsy, and Dementia. Review of a Physician's Order for Resident #24 dated 8/19/2024, revealed resident inenhanced [in enhanced] barrier precautions . for ESBL of the urine. Review of the comprehensive care plan for Resident #24 dated 9/17/2024, revealed .enhanced barrier precautions . for ESBL of the urine. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including Difficulty Walking, Breast Cancer, and Hypertension. Review of a Physician's Order for Resident #25 dated 4/5/2024, revealed .Resident in Enhanced Barrier precautions . for ESBL in the urine. Review of the comprehensive care plan for Resident #25 revised 11/4/2024, revealed .enhanced barrier precautions .ESBL . Review of the medical record revealed Resident #52 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Intellectual Disabilities, Autistic Disorder, and Pain. Review of a Physician's Order for Resident #52 dated 7/12/2024, revealed .resident in enhanced barrier precautions . for a wound and ESBL of the urine. Review of the comprehensive care plan for Resident #52 dated 9/17/2024, revealed .enhanced barrier precautions . for a wound and ESBL of the urine. Review of the medical record revealed Resident #56 was admitted to the facility on [DATE] with diagnoses including Sepsis, Difficulty Walking, Arthritis, Gout, Cough, and Depression. Review of a Physician's Order for Resident #56 dated 7/12/2024, revealed .resident in enhanced barrier precautions . for an indwelling urinary catheter. Review of the medical record revealed Resident #83 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Lack of Coordination, Depression, Pain, and Anxiety. Review of a Physician's Order for Resident #83 dated 5/24/2024, revealed .Resident in Enhanced Barrier precautions . for a wound, an indwelling urinary catheter, and ESBL in the urine. Review of the comprehensive care plan for Resident #83 dated 11/10/2024, revealed .Enhanced barrier precautions . for a wound, an indwelling urinary catheter, and ESBL. During an observation on 11/3/2024 at 11:30 AM, Residents #13, #25, #56 and #83 had an 8 and half inch by 11-inch sign on their door which read ENHANCED BARRIER PRECAUTIONS (EBP) .EVERYONE MUST .Clean their hands, including before entering and leaving the room .PROVIDERS AND STAFF MUST ALSO .Wear gloves and gown for the following .Transferring .Changing Linens .Providing Hygiene .Do not wear the same gown and gloves for the care of more than one person . During a meal observation on 11/3/2024 at 12:10 PM, Patient Care Assistant (PCA) O removed a meal tray from a tray cart, entered Resident #13's room, adjusted the resident's belongings, delivered the meal tray, exited the room, returned to the tray cart, and removed an additional meal tray without performing hand hygiene. PCA O entered Resident #25's room, adjusted the resident's belongings on the bedside table, delivered the meal tray, exited the room, returned to the tray cart, and removed an additional meal tray without performing hand hygiene. PCA O entered Resident #56's room, adjusted the resident's belongings, delivered the meal tray, exited the room, returned to the tray cart and removed an additional meal tray without performing hand hygiene. PCA O entered Resident #83's room, adjusted the resident's belongings, delivered the meal tray, exited the room, and returned to the tray cart. PCA O did not perform hand hygiene prior to entering and prior to exiting the 4 residents' rooms. During an interview on 11/3/2024 at 12:32 PM, Resident #25 stated her hands were washed by PCA O with a washcloth prior to receiving her lunch tray. Resident #25 stated PCA O was not wearing a gown or gloves during hand hygiene. During an interview on 11/3/2024 at 12:35 PM, Resident #56 stated his hands were washed by PCA O with a washcloth prior to receiving his lunch tray. Resident #56 stated PCA O was not wearing a gown or gloves during hand hygiene. During an interview on 11/3/2024 at 12:40 PM, Resident #83 stated her hands were washed by PCA O with a washcloth prior to receiving her lunch tray. Resident #83 stated PCA O was not wearing a gown or gloves during hand hygiene. During a meal observation on 11/3/2024 at 12:42 PM, revealed Paid Feeding Assistant (PFA) DD delivered a meal tray to Resident #508 on the 100 Hallway, who was in droplet isolation precautions. PFA DD did not wear the appropriate PPE (N95 mask, gown, gloves, and eye/face shield protection) prior to entering the droplet isolation room. During an observation on 11/3/2024 at 12:45 PM, Risk Manager LPN M entered Resident #509's room on the 100 Hallway, who was in droplet isolation precautions, without wearing PPE prior to entering the room, adjusted the bedside table and spoke with the resident with the door open. Then Risk Manger LPN M exited the room, accessed the clean PPE supplies from the over the door PPE storage bin, donned (applied) an N95 mask, disposable shoe covers, and an isolation gown, reentered the room, and closed the door. During an interview on 11/3/2024 at 12:56 PM, PCA O stated the EBP sign was only for the CNAs. PCA O stated she did not have to wash her hands before entering and exiting rooms with EBP signage because she did not provide any care. PCA O confirmed she did not wear a gown or gloves when she provided hand hygiene to residents and restated the EBP signage is for CNAs. PCA O stated she did not have to wear a gown in any EBP rooms for any of her job duties which included meal tray deliveries and bed linen changes. PCA O also stated, .I would not know how to tell . which resident the EBP signage is for when a room has more than 1 resident. During an observation on 11/4/2024 at 7:52 AM, CNA Z entered Resident #509's (COVID-19 positive on admission 10/30/2024) room without wearing PPE and performed hand hygiene on the resident before the breakfast meal, then exited the room. During an observation on 11/4/2024 at 7:53 AM, CNA Z entered Resident #508's (COVID-19 positive 10/28/2024) room without wearing PPE and performed hand hygiene on the resident before the breakfast meal, then exited the room. During an interview on 11/4/2024 at 9:00 AM, LPN PP and CNA Z referred to the 100 Hallway as the facility's COVID-19 unit. LPN PP and CNA Z stated they looked for isolation barrels and signage on the resident's doors to identify residents on transmission-based precautions. LPN PP and CNA Z stated they were unaware residents in droplet isolation precautions required closed doors to prevent the transmission of respiratory infections and stated they had not been educated to keep the COVID-19 resident doors closed during a COVID outbreak. CNA Z stated they are required to complete education courses on the facility's computer-based learning system, they have meetings at the nurses' station where the nurses will hand staff a piece of paper and tell us to sign. LPN PP stated she was hired sometime in January 2024 and did not know how to log onto the computer-based learning system and had not completed any online education. During an interview on 11/4/2024 at 3:45 PM, the IP, with the ADON present, confirmed they were responsible for staff education, which was provided with new employee orientation, annual skills fair (last conducted 11/2023), re-education with updates, and an in-service book located at the nurses' station. The IP and ADON expressed staff are informed of which residents are in transmission-based precautions by department heads after daily huddle meetings. Continued interview with the IP revealed she stated the facility's policies for infection control were more stringent than the CDC guidelines, but she was unable to provide an example of how the facility's policies were more stringent than the CDC guidelines and acknowledged no changes to the facility's current policy had occurred. The IP stated the facility's infection control policies were provided to her through the corporate office and she had received updates from the local health department. The IP verified and confirmed the infection control policies the facility followed were dated 5/2023. The IP confirmed she was unaware of what the current CDC guidelines were and had not been to the CDC website. The IP stated staff are required to wear a gown, gloves, goggles, and N95 mask when entering a droplet isolation room with COVID-19 positive residents. The IP also stated staff are required to wear the appropriate PPE based on the type of isolation and signage posted on the door and she expected staff to change PPE and perform hand hygiene between resident care. The IP was informed of multiple observations and interviews with staff which revealed staff had no knowledge of transmission-based precautions, PPE, types of isolation, COVID-19 precautions, and how to identify residents in isolation. The IP confirmed that was deficient practice and stated employees of the facility should have knowledge of infection control practices prior to providing resident care. During an interview on 11/4/2024 at 5:45 PM, on the 300 hallway, LPN JJ was asked how she knew residents were in EBP. LPN JJ stated EBP was a sign on the resident's door used to alert staff that the resident needed barrier cream. When LPN JJ was asked if she knew what EBP was and what it meant to her she stated that is when a resident needs barrier cream applied to their peri area (an area of the pelvic cavity between the genitals and the anus). LPN JJ stated, .I would .look for a tube of barrier cream in the room .if the resident had a sign for EBP with no barrier cream in the room .then the resident did not need any barrier cream . The LPN stated EBP signage was not a communication tool used to alert staff for required PPE usage in the room for resident care. During an interview on 11/5/2024 at 10:43 AM, on the 300 hallway, PFA Q stated the EBP signage was only for nurses and CNAs. PFA Q stated she did not have to wear a gown in any EBP rooms for any of her job duties which included meal tray deliveries, assisting residents with their meals in their rooms, performing hand hygiene on residents, changing bed linens, and removing soiled linens and trash from rooms. During an interview on 11/5/2024 at 10:45 AM, on the 300 hallway, LPN R stated 11/5/2024 was her second day at the facility. LPN R stated she received education on infection control prior to starting and stated, .I can't remember what all they [Administration] said .they did not have a class .they gave me a bunch of papers to read .and I signed a paper saying that I received training . LPN R also stated she did not know what the requirements were for residents on EBP, stated both residents in a room were on EBP if an EBP sign was on the door and stated .since EBP is not really true isolation you could wear the same gown and gloves for both residents . During an interview on 11/5/2024 at 10:55 AM, on the 300 hallway, PFA S stated EBP signage was only for the CNAs, and she did not have to wear a gown or do hand hygiene before entering an EBP room. PFA S stated she did not have to wear a gown in any EBP rooms for any of her job duties which included meal tray deliveries, assisting residents with their meals in their rooms, performing hand hygiene on residents, changing bed linens, and removing soiled linens and trash from rooms. PFA S also stated she occasionally would help nurses bathe residents, empty urinals, and assist in turning residents. PFA S stated she could not remember a specific time but stated she routinely provided resident care for Resident #13, Resident #25, Resident #52, Resident #56, and Resident #53 without wearing a gown. During an interview and observation on 11/5/2024 at 2:52 PM, on the 300 hallway, CNA T stated she was trained on infection control recently and stated, .Enhance Barrier Precautions is a new word for me .I have not heard this before . CNA T observed an EBP sign at the 300-hall nurses' station and stated this signage meant CNAs and Nurses had to wash their hands, wear gloves, wear a gown when going in rooms and stated it [PPE] had to be discarded and hands washed before leaving the room. CNA T stated she had the entire 300-Hall and did not have any rooms on EBP. Further observation of the 300-Hallway revealed 7 rooms with EBP signage in place. During an interview on 11/6/2024 at 9:02 AM, Risk Manager LPN M confirmed he failed to follow infection control practices and don the appropriate PPE for droplet isolation when he entered Resident #509's room on the 100 Hallway on 11/3/2024. During an observation on 11/6/2024 at 2:10 PM, Housekeeper GG was in Resident #102's (COVID-19 positive 10/28/2024) room sweeping the floor. Housekeeper GG was observed wearing a surgical face mask only and did not wear any additional PPE. Continued observation revealed signage for Droplet Precautions posted to the wall beside the resident's door. During an interview on 11/6/2024 at 3:15 PM, the MD stated he had previously voiced concerns to the facility's administration regarding the staff's non-compliance with PPE usage on the 100 Hallway and stated the staff were .undermining their own safety . The MD stated the facility's response to his concern was to increase the supply of PPE to multiple resident rooms (including non-COVID positive rooms) which contributed to the staff confusion regarding the identification of residents on transmission- based precautions. The MD stated due to the incorrect and inconsistent transmission-based precaution signage posted outside resident rooms, he stated he was also confused and had to seek clarification from the staff prior to entering the rooms on the 100 Hallway. The MD stated, .one day I came to see a resident and he had 3 different signs on the door, and I thought to myself .what do I wear .and if I am a doctor and I don't know what to wear .how do the staff know what to wear . The MD also stated he had historically instructed the nurses to keep the doors closed for residents with COVID-19 infections to help mitigate the spread of the infection unless there was a safety concern. During an interview on 11/7/2024 at 10:00 AM, on the 400 hallway, PFA RR was unaware of what EBPs were and stated she had never been educated. PFA RR stated she would wear gloves and gown with those residents. During an interview and facility policy review on 11/12/2024 at 10:12 AM, in the conference room, with the VPCS, VPRC, DON, and the Administrator, revealed the facility identified they were not following the current CDC guidelines to prevent and control the spread of COVID-19. The Administrator stated the facility had allowed COVID-19 positive employees to work in accordance with the CDC guidelines for contingency staffing and did not realize the emergency staffing waiver had ended. The Administrator stated the facility had re-educated all the managers on 11/11/2024 on the current CDC guidelines. Review of the education material used to re-educate the staff referenced the outdated 2023 CDC guidelines. During an interview and CDC guidelines review on 11/13/2024 at 3:32 PM, with the Administrator and VPCS, revealed the CRCO is responsible for updating the facility's COVID-19 policies and confirmed these outdated policies were used to re-educate staff. Further interview revealed the facility's new COVID-19 policies were revised (date unknown) and referenced the outdated 2023 CDC guidelines. During an interview on 11/13/2024 at 7:55 PM, the Administrator confirmed the facility had some areas of improvement to address regarding infection prevention and control practices (to include the prevention and control of COVID-19 and adherence to isolation with PPE usage for the employees) and competent staffing. Refer to F-684, F-835, F-837, F-867, and F-880

Based on facility policy review, Centers for Disease Control and Prevention (CDC) recommendations and guidance review, medical record review, observations, and interviews, the facility failed to ensure current CDC guidelines dated 6/24/2024 and 10/28/2024 were followed to prevent and control the spread of COVID-19 to residents and staff, failed to identify and track residents with an active COVID-19 infection, failed to wear appropriate Personal Protective Equipment (PPE) in COVID-19 isolation rooms, and failed to perform facility wide employee testing and recommended quarantine time during the COVID-19 outbreaks. The facility failed to ensure COVID-19 positive residents were quarantined according to CDC guidance when Residents #608, #619, and #509 were admitted with COVID-19. The facility's first COVID-19 outbreak started 8/9/2024 through 10/11/2024, which resulted in 28 residents (Residents #96, #31, #45, #33, #11, #64, #609, #93, #15, #510, #611, #80, #612, #506, #615, #613, #614, #54, #68, #27, #53, #12, #95, #74, #30, #37, #3, and #89) and 15 employees testing positive. The facility's second COVID-19 outbreak started 10/19/2024 and was on going which resulted in 10 residents (Residents #99, #617, #103, #72, #34, #618, #507, #508, #102, and #94) and 5 employees testing positive. The facility failed to identify and track residents and staff with COVID-19 for 2 of 2 outbreaks. The facility failed to ensure staff wore the appropriate PPE and identified residents in Enhanced Barrier Precautions (EBP) for 6 of 26 residents (Resident #13, #25, #56, #83, #24, #52). The facility's noncompliance resulted in an Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The facility failed to follow infection control procedures during medication administration for 2 residents (Resident #52 and #99) of 6 residents observed for medication administration. The facility census was 99. The Administrator, Director of Nursing (DON), [NAME] President of Operations (VPO), [NAME] President of Life Safety and Environmental Compliance (VPLSEC), [NAME] President of Clinical Services (VPCS) (attended in person) and the [NAME] President of Regulatory Compliance (VPRC) and Chief Operating Officer (COO) with the Chief Regulatory Compliance Officer (CRCO) (attended by telephone) were notified of the IJs for F-880, F-835, F-837, F-867, F-684, and F-726 on 11/13/2024 at 9:42 PM in the Common Area/Recreation Area. The facility was cited Immediate Jeopardy at F-880 at a scope and severity of L. The facility was cited Immediate Jeopardy at F-684 at a scope and severity of K, which is substandard quality of care. The facility was cited Immediate Jeopardy at F-726, F-835, F-837, F-867 at a scope and severity of L. An Extended survey was conducted onsite from 11/14/2024 through 11/15/2024. The IJ began on 8/9/2024 and is ongoing. The facility is required to submit a Plan of Correction (POC). The findings include: 1) Review of the facility's undated policy titled, COVID-19 GENERAL TESTING POLICY, which referenced the 5/25/2023 CDC guidelines revealed .Staff with symptoms or signs of COVID-19 .will be tested as soon as possible and will be restricted from the facility pending the results of COVID-19 testing .Residents who have signs and symptoms of COVID-19 .will be tested .be placed on transmission-based precautions (TBP) .DURING COVID-19 OUTBREAK .Facilities will investigate an outbreak using contact tracing or a broad-based approach .testing every 3-[to] 7 days until no more positive cases identified for 14 days .if additional cases are identified after testing .the facility will expand testing to facility-wide if testing .implementation of infection control measures have failed .PCR [Polymerase chain reaction] [accurate and reliable test for diagnosing COVID-19] will be used .testing will occur on day 1, day 3, and day 5 . Review of the facility's undated policy titled, COVID-19 ADMISSIONS AND READMISSIONS, which referenced the 5/25/2023 CDC guidelines revealed .Due to risk of unrecognized COVID-19 infections among residents, facilities must conduct testing at the time of admission to the facility based on COVID-19 Hospital Admissions Levels .Empiric use of Transmission-Based Precautions is not necessary .unless .Resident is placed on a unit experiencing ongoing SARS-CoV-2 [COVID-19] transmission . Review of the facility's undated policy, COVID-19 Management of Residents, undated, which referenced the 5/25/2023 CDC guidelines revealed .The facility will not have a dedicated COVID-19 unit unless the number of positive residents warrant .the facility will place a COVID-19 positive resident in a single room with appropriate isolation signage and staff wearing N95 respirator, eye protection, gown, and gloves upon entry to the room .dedicated staff, to care for residents with COVID-19 .the door will be kept closed if safe to do so .resident will be monitored every four hours for .symptoms, vital signs, oxygen saturation .and respiratory exam .staff will wear full PPE (N95 respirator, gown, gloves, eye protection) when providing care . Review of the facility's undated policy titled, COVID-19 Positive Staff Member Work Restriction, which referenced the 5/25/2023 CDC guidelines revealed .HCP [Health Care Providers] should self-monitor for symptoms and seek re-evaluation .if symptoms recur .these HCP will be restricted form work .until they again meet the healthcare criteria .Staff who were ASYMPTOMSTATIC .will return to work .at least .7 .days have passed since the date of their first positive viral test if a negative viral test .is obtained .48 hours prior to returning to work or 10 days if testing is not performed .if using an antigen [rapid diagnostic test] test, staff should have a negative test obtained on day 5 and 48 hours later .Staff who are SYMPTOMATCIC can return to work .at least .7 .days have passed since symptoms first appeared, if a negative viral test .is obtained within 48 hours prior to returning to work, or 10 days if testing is not performed .at least 24 hours have passed since last fever without the use of fever-reducing medications .When Contingency staffing strategies are used, staff with SARS-CoV-2 infection will be well enough and willing to return to work .at least .5 .days have passed since symptoms first appeared (day 0) .at least 24 hours have passed since last fever without the use of fever-reducing medications .Symptoms .have improved .facility may choose to confirm resolution of infection with a PCR or a series of .2 .negative antigen tests taken 48 hours apart .Antigen tests typically have a more rapid turnaround time .are often less sensitive than PCR .Antigen testing is preferred . Review of the facility's undated policy titled, COVID-19 Transmission Based Precautions, which referenced the 5/25/2023 CDC guidelines revealed .Transmission-Based Precautions .If residents are placed in Transmission-Based Precautions .will be removed .after day 7 .and all viral testing .is negative .If viral testing is not performed, residents will be removed from Transmission-Based Precautions after day 10 .Duration of Transmission-Based Precautions for residents with COVID-19 .a minimum of 10 days since symptoms first appeared .fever free for 24 hours . Review of the facility's undated policy titled, COVID-19 GUIDELINES UNIVERSAL SCREENING, which referenced the 5/25/2023 CDC guidelines revealed .if the facility is in outbreak, all residents .will be evaluated at least daily for signs and symptoms of COVID-19 .if residents have a fever or symptoms .monitoring will be increased to every four hours .vital signs (temperature, pulse, respirations) .Oxygen saturation .Blood pressure . Review of the CDC's guidance titled, Infection Control Guidance: SARS-CoV-2, dated 6/24/2024, revealed, .The recommendations in this guidance continue to apply after the expiration of the federal COVID-19 Public Health Emergency [3/11/2023] .Establish a Process to Identify and Manage Individuals with Suspected or Confirmed SARS-CoV-2 Infection .Ensure everyone is aware of recommended IPC [infection prevention and control] practices in the facility .Source control is recommended for individuals in healthcare settings who: Have suspected or confirmed SARS-CoV-2 infection or other respiratory infection (e.g., those with runny nose, cough, sneeze); or Had close contact (patients and visitors) or a higher-risk exposure HCP with someone with SARS-CoV-2 infection, for 10 days after their exposure .Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible .To provide the greatest assurance that someone does not have SARS-CoV-2 infection, if using an antigen test .facilities should use 3 tests, spaced 48 hours apart .testing should be repeated every 3-7 days until no new cases are identified for at least 14 days .HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions .use a NIOSH [National Institute for Occupational Safety and Health] Approved particulate respirator with N95 filter .gown, gloves .eye protection .A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed .Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5 . Review of the CDC guidance titled, Viral Respiratory Pathogens Toolkit for Nursing Homes, dated 10/28/2024, revealed .Educate .Ensure everyone .including HCP, are aware of recommended IPC [infection prevention and control] practices in the facility .When an acute respiratory infection is identified in a resident or HCP .take rapid action to prevent the spread to others in the facility .Apply appropriate Transmission-Based Precautions for symptomatic residents .HCP who enter the room of a resident with signs or symptoms of an unknown respiratory viral infection that is consistent with SARS-CoV-2 [COVID-19] infection should adhere to Standard Precautions .use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e. [example], goggles or a face shield that covers the front and sides of the face) .Develop sick leave policies for HCP .with public health guidance to discourage presenteeism [lost productivity that occurs when employees are not fully functioning in the workplace because of an illness, injury, or other condition] .allow HCP with respiratory infection to stay home for the recommended 10 day duration of work restriction .Test anyone with respiratory illness signs or symptoms .Investigate for potential respiratory virus spread among residents and HCP .Perform active surveillance to identify any additional ill residents or HCP using symptom screening .evaluating potential exposures .testing of exposed individuals is recommended, even if they are asymptomatic .Make initial attempts to control limited spread .If SARS-CoV-2 transmission is occurring .Consider implementing broad-based testing as opposed to only testing close contacts to identify asymptomatic infection . The following 29 residents resided on the 100, 200, and 400 hallways. Resident #608 was admitted to the facility COVID-19 positive on 8/9/2024 and was identified as the start of the outbreak. An additional 28 residents tested positive for COVID-19 during the COVID-19 outbreak in the facility from 8/9/2024-10/11/2024 (Residents #96, #31, #45, #33, #11, #64, #609, #93, #15, #51, #611, #80, #612, #506, #615, #613, #614, #54, #68, #27, #53, #12, #95, #74, #30, #37, #3, and #89). The following COVID-19 positive employees were not excluded from work for the required isolation time frame recommended by the CDC guidance to prevent the exposure and spread of COVID-19 (Licensed Practical Nurse (LPN) Y, Physical Therapist (PT) CC, LPN BB, Housekeeper GG, Laundry HH, Physical Therapist Assistant (PTA) II, LPN JJ, Certified Nursing Assistant (CNA) KK, CNA Z, CNA AA, LPN C, and CNA LL) . 1a) Review of the medical record revealed Resident #608 was admitted to the facility on [DATE] with diagnoses including Myopathy, Hypertension, GERD (Gastroesophageal Reflux Disease), Osteoarthritis, Dementia, and COVID-19 (added on 8/9/2024). Review of the medical record revealed Resident #608 tested positive for COVID-19 on 8/7/2024 at the hospital and was admitted to the facility's 100 Hallway with an active COVID-19 infection on 8/9/2024. Further review revealed Resident #608 was identified as the start of the first COVID-19 outbreak. Review of a Physician's Order for Resident #608 dated 8/9/2024, revealed .isolation droplet precautions .[at] .all times due to positive covid 19 [COVID-19] test .mask .goggle [goggles] gloves, gown, face shield . The isolation order continued until 8/12/2024. (discontinued 5 days before the CDC recommended guidance) Review of the comprehensive care plan for Resident #608 dated 8/13/2024 (4 days after admission), revealed .Resident is positive for COVID-19 . Review of a 5-day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #608 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. 1b) Review of the medical record revealed Resident #96 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] on the 100 Hallway with diagnoses including Lung Disease, Heart Failure, COVID-19 (added on 8/14/2024), and Obstructive Sleep Apnea. Review of the laboratory result for Resident #96 dated 8/14/2024, revealed a COVID-19 test was flagged as an abnormal result which indicated the COVID-19 test was positive. Resident #96 tested positive for COVID-19 within 24 hours of admission. Review of the comprehensive care plan for Resident #96 initiated 8/14/2024, revealed no revisions made to care plan goals and interventions related to the new COVID-19 infection. Review of a Physician's Order for Resident #96 dated 8/14/2024, revealed .Isolation Droplet precautions @ [at] all times due to positive COVID-19 test. Mask, googles [goggles], gloves, gown, face shield . The isolation order continued until 8/24/2024. Review of an admission MDS assessment dated [DATE], revealed Resident #96 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. 1c) Review of the Medical record revealed Resident #31 was admitted to the facility on the 100 Hallway on 5/10/2024 with diagnoses including Dementia, Anemia, Diabetes, and COVID-19 (added on 8/21/2024). Review of a quarterly MDS assessment dated [DATE], revealed Resident #31 scored a 00 on the BIMS assessment which indicated the resident had severe cognitive impairment. Further review revealed staff were unable to complete the assessment. Review of the laboratory result for Resident #31 dated 8/21/2024, revealed a positive COVID-19 test. Review of a Physician's Order for Resident #31 dated 8/21/2024, revealed .Isolation Droplet precautions @ all times due to positive covid 19 test. Mask, googles, gloves, gown, face shield . The isolation continued until 8/31/2024. Review of the comprehensive care plan for Resident #31 dated 8/26/2024, revealed .Resident is positive for COVID-19 . 1d) Review of the medical record revealed Resident #45 was admitted to the facility on the 100 Hallway on 6/20/2024 with diagnoses including Cerebral Infarction (Stroke), Anxiety Disorder, Hypertension, Chronic Kidney Disease, and COVID-19 (added on 8/21/2024). Review of a Physician's Order for Resident #45 dated 8/21/2024, revealed .Isolation Droplet precautions @ all times due to positive covid 19 test. Mask, googles, gloves, gown, face shield . The isolation order continued until 8/31/2024. Review of the comprehensive care plan for Resident #45 dated 8/26/2024, revealed .Droplet precautions .Resident is positive for COVID-19 infection .Droplet isolation sign in place . Review of a significant change in status MDS assessment dated [DATE], revealed Resident #45 scored a 12 on the BIMS assessment which indicated the resident had moderate cognitive impairment. 1e) Review of the medical record revealed Resident #33 was admitted to the facility on the 100 Hallway on 8/13/2024 with diagnoses including COVID-19 (added on 8/22/2024), Congestive Heart Failure, Chronic Obstructive Pulmonary Disease (COPD), and Adult Failure to Thrive. Review of a 5-day admission MDS assessment dated [DATE], revealed Resident #33 scored a 7 on the BIMS assessment which indicated the resident had severe cognitive impairment. Review of the laboratory result for Resident #33 dated 8/23/2024, revealed the COVID-19 test result was positive. Review of a Physician's Order for Resident #33 dated 8/23/2024, revealed .Isolation Droplet precautions @ all times due to positive covid 19 test. Mask, googles, gloves, gown, face shield . The isolation order continued until 8/31/2024. Review of the comprehensive care plan for Resident #33 dated 8/23/2024, revealed the resident tested positive for COVID-19 and was placed under droplet precautions. During an interview on 11/12/2024 at 3:48 PM, the [NAME] President (VP) of Clinical Services stated according to the Nurse Practitioner (NP) note dated 8/26/2024 for Resident #33 the resident was evaluated for a positive COVID-19 diagnosis. Continued interview confirmed the COVID-19 test result was positive. 1f) Review of the medical record revealed Resident #11 was admitted to the facility on the 100 Hallway on 5/28/2024 with diagnoses including Hypertension, Diabetes, Depression, and COVID-19 (added on 8/22/2024). Review of the quarterly MDS assessment dated [DATE], revealed Resident #11 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of the laboratory result for Resident #11 dated 8/23/2024, revealed a positive COVID-19 test result. Review of a Physician's Order for Resident #11 dated 8/23/2024, revealed .Isolation Droplet precautions @ all times due to positive COVID-19 test. Mask, googles, gloves, gown, face shield . The isolation order continued until 9/1/2024. Review of the comprehensive care plan for Resident #11 dated 8/23/2024, revealed the resident had tested positive for COVID-19 and required droplet precautions. 1g) Review of the medical revealed Resident #64 was admitted to the facility on the 100 Hallway on 7/16/2024 with diagnoses including Diabetes, Primary Pulmonary Hypertension, and History of Lung Blood Clots. Further review revealed the diagnosis of COVID-19 was not added. Review of an admission MDS assessment dated [DATE], revealed Resident #64 scored a 7 on the BIMS assessment which indicated the resident had severe cognitive impairment. Review of a Physician's Order for Resident #64 dated 8/23/2024 (2 days prior to the COVID-19 test), revealed .Isolation Droplet precautions @ all times due to positive covid 19 test. Mask, googles, gloves, gown, face shield . The isolation order continued until 9/2/2024. Review of the laboratory result for Resident #64 dated 8/25/2024, revealed a positive COVID-19 test. Review of the comprehensive care plan for Resident #64 dated 8/26/2024, revealed .Droplet precautions .COVID-19 . 1h) Review of the medical record revealed Resident #609 was admitted to the facility on [DATE] and readmitted to the facility on the 100 Hallway on 9/25/2024 with diagnoses including Thyroid Cancer, Lung Cancer, Pneumonia, History of Lung Blood Clots, and COVID-19 (added on 9/4/2024). Review of the laboratory result for Resident #609 dated 8/23/2024, revealed a positive COVID-19 test. Review of a Physician's Order for Resident #609 dated 8/23/2024, revealed .Resident has an active infection on droplet precautions .COVID-19 . The isolation order continued until 9/2/2024. (discontinued 1 day before the CDC recommended guidance) Review of the comprehensive care plan for Resident #609 dated 8/26/2024, revealed .Resident is positive for COVID-19 . Review of an admission MDS assessment dated [DATE], revealed Resident #609 scored a 7 on the BIMS assessment which indicated the resident had severe cognitive impairment. 1i) Review of the medical record revealed Resident #93 was admitted to the facility on the 100 Hallway on 7/26/2024 with diagnoses including Pneumonia, Hypothyroidism, Difficulty Walking, and COVID-19 (added on 8/26/2024). Review of an admission MDS assessment dated [DATE], revealed Resident #93 scored an 8 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Review of the medical record for Resident #93 revealed no laboratory test for COVID-19 was available for review. Review of a Physician's Order for Resident #93 dated 8/23/2024, revealed .Isolation Droplet precautions @ all times due to positive COVID-19 test .Mask, googles, gloves, gown, face shield . The isolation order continued until 9/2/2024. Review of the comprehensive care plan for Resident #93 dated 8/26/2024, revealed .Droplet precautions .covid [COVID-19] . 1j) Review of the medical record revealed Resident #15 was admitted to the facility on the 100 Hallway on 7/30/2024 and was readmitted to the facility on [DATE] with diagnoses including Dementia, Acute Kidney Failure, Anxiety, and COVID-19 (added on 8/26/2024). Review of a quarterly MDS assessment dated [DATE], revealed Resident #15 scored a 9 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Review of the laboratory result for Resident #15 dated 8/23/2024, revealed a positive COVID-19 test result. Review of a NP's Progress Note for Resident #15 dated 8/23/2024, revealed the resident was evaluated due to the chief complaint of nausea and positive COVID-19 test result.Plan .Isolation precautions . Review of the comprehensive care plan for Resident #15 dated 8/26/2024, revealed .Resident is positive for COVID-19 . Review of a Physician's Order for Resident #15 dated 8/26/2024, revealed .Isolation Droplet precautions @ all times due to positive covid 19 test. Mask, googles, gloves, gown, face shield . The resident received the order for isolation 2 days after the positive COVID-19 test result. The isolation was discontinued on 9/1/2024 (discontinued 5 days before the CDC recommended guidance). 1k) Review of the medical record revealed Resident #510 was admitted to the facility on [DATE] and readmitted to the 100 hallway on 6/27/2024 with diagnoses including Heart Failure, Atrial Fibrillation, Chronic Kidney Disease, and COVID-19 (added on 8/26/2024). Review of a quarterly MDS assessment dated [DATE], revealed Resident #510 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. Review of a laboratory result for Resident #510 dated 8/24/2024, revealed the resident was positive for COVID-19. Review of a Physician's Order for Resident #510 dated 8/26/2024 (2 days after COVID-19 positive test), revealed .Isolation Droplet precautions @ all times due to positive COVID-19 test .Mask, googles, gloves, gown, face shield . The isolation orders continued until 9/2/2024. Review of the comprehensive care plan for Resident #510 dated 8/26/2024, revealed .Droplet precautions .COVID-19 . 1l) Review of the medical record revealed Resident #611 was admitted to the facility on [DATE] and readmitted to facility on the 100 Hallway on 8/15/2024 with diagnoses including Atrial Fibrillation, Congestive Heart Failure, and COVID-19 (added on 8/26/2024). Review of an admission MDS assessment dated [DATE], revealed Resident #611 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of the medical record for Resident #611, revealed no laboratory data for a positive COVID-19 test was available for review Review of a Physician's Order for Resident #611 dated 8/26/2024, revealed .Isolation Droplet precautions @ all times due to positive covid 19 test. Mask, googles, gloves, gown, face shield . The isolation order continued until 9/3/2024. Review of the comprehensive care plan for Resident #611 revised on 8/26/2024, revealed .positive for COVID-19 . Review of a NP's Progress Note for Resident #611 dated 8/28/2024, revealed the resident was evaluated due to follow up of positive COVID-19 test result .Plan . Isolation precautions . 1m) Review of the medical record revealed Resident #80 was admitted to the facility on [DATE] and readmitted to the 100 Hallway on 9/3/2024 with diagnoses including Fracture of the Right Femur, Diabetes, Heart Failure, and COVID-19 (added 8/26/2024). Review of an admission MDS assessment dated [DATE], revealed Resident #80 scored a 10 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Review of a NP's Progress note for Resident #80 dated 8/26/2024, revealed .Resident was seen today for a follow-up after recent positive COVID-19 swab . Review of a Physician's Order for Resident #80 dated 8/26/2024, revealed .Isolation Droplet precautions @ all times due to positive covid 19 test. Mask, googles, gloves, gown, face shield . The isolation order continued until 9/3/2024. Review of the comprehensive care plan for Resident #80 dated 8/26/2024, revealed .Droplet precautions .Baseline care plan .COVID-19 . 1n) Review of the medical record revealed Resident #612 was admitted to the facility on the 100 Hallway on 8/20/2024 with diagnoses including Chronic Respiratory Failure, Chronic Pulmonary Edema, Morbid Obesity, Emphysema, and COVID-19 (added 8/26/2024). Review of an admission MDS assessment dated [DATE], revealed Resident #612 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. Review of the laboratory result for Resident #612 dated 8/24/2024, revealed a positive COVID-19 test result. Review of a Physician's Order for Resident #612 dated 8/26/2024 (2 days after the positive COVID- 19 test result), revealed .Isolation Droplet precautions @ all times due to positive covid 19 test. Mask, googles, gloves, gown, face shield . The isolation order continued until 9/3/2024. Review of the comprehensive care plan for Resident #612, dated 8/26/2024, revealed .Resident is positive for COVID-19 . 1o) Review of the medical record revealed Resident #506 was admitted to the facility on the 100 Hallway on 7/10/2024 with diagnoses including Human Immunodeficiency Virus (HIV), Acute Respiratory Failure, and COVID-19 (added 8/27/2024). Review of the quarterly MDS assessment dated [DATE], revealed Resident #506 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. Review of the laboratory test for Resident #506 dated 8/26/2024, revealed a positive COVID-19 test result. Review of a NP's Progress Note for Resident #506 dated 8/27/2024, revealed .Chief Complaint .Follow-up COVID-19 .Isolation precautions . Review of a Physician's Order for Resident #506 dated 8/27/2024 (1 day after the positive COVID-19 test result), revealed .Isolation Droplet precautions @ all times due to positive covid 19 test. Mask, googles, gloves, gown, face shield . The isolation order continued until 9/5/2024. Review of the Comprehensive Care Plan for Resident #506 dated 9/5/2024, revealed the resident had a positive COVID-19 diagnosis and required isolation. 1p) Review of the Medical Record revealed Resident #615 was admitted to the facility on [DATE] with diagnoses including Cirrhosis of the Liver, Chronic Kidney Disease, and COVID-19 (added on 8/30/2024). Review of the medical record revealed Resident #615 tested positive for COVID-19 on 8/27/2024 at the hospital and was admitted to the facility's 100 Hallway with an active COVID-19 infection on 8/30/2024. Review of a Physician's Order for Resident #615 dated 8/30/2024, revealed .Isolation Droplet precautions @ all times due to positive COVID-19 test .Mask, googgles, gloves, gown, face shield. The isolation order continued until 9/6/2024. Review of an admission MDS assessment dated [DATE], revealed Resident #615 scored a 10 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Review of the comprehensive care plan for Resident #615 dated 9/4/2024, revealed .Droplet precautions .COVID-19 .Respiratory .follow facility infection control P&P [policy and procedures] for isolation .Check for proper PPE [personal protective equipment] .Droplet isolation sign in place . (baseline care plan was not developed within 48 hours of admission and the comprehensive care plan did not reflect the active COVID-19 diagnosis until 5 days after admission to capture COVID-19). 1q) Review of the medical record revealed Resident #613 was admitted to the facility on [DATE] and readmitted on the 100 Hallway on 8/14/2024 with diagnoses including Muscle Weakness, Diabetes, Heart Failure, and COVID-19 (added 8/28/2024). Review of a NP's Progress Note dated 8/28/2024 for Resident #613 revealed .Chief Complaint .COVID-19 positive .seen today due to testing positive for COVID-19 via nasal swab in the facility . Review of the comprehensive care plan for Resident #613 dated 8/28/2024, revealed .Resident is positive for COVID-19 . Review of a Physician's Order for Resident #613 dated 8/30/2024 (2 days after the positive COVID-19 test result), revealed .Isolation Droplet precautions @ all times due to positive COVID-19 test. Mask, googles, gloves, gown, face shield . The isolation order continued until 9/7/2024. (discontinued 2 days before the CDC recommended guidance) Review of a quarterly MDS assessment dated [DATE], revealed Resident #613 scored a 12 on the BIMS assessment which indicated the resident had moderate cognitive impairment. 1r) Review of the medical record revealed Resident #614 was admitted to the facility on the 100 Hallway on 8/19/2024 with diagnoses including Anxiety, Low Oxygen Blood Saturation, and COVID-19 (added 8/28/2024). Review of a discharge MDS dated [DATE], Resident #614 scored a 9 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Review of the laboratory result for Resident #614 dated 8/28/2024, revealed a positive COVID-19 test result. (9 days after admission into the facility) Review of the comprehensive care plan for Resident #614 dated 8/28/2024, revealed .Resident is positive for COVID-19 . Review of a NP's Progress Note dated 8/28/2024, revealed Resident #614 tested positive for COVID-19, the resident's family was concerned for further decline and initiated a discharge for Resident #614 to return home. The resident discharged home on 8/28/2024. 1s) Review of the medical record revealed Resident #54 was admitted to the facility on the 100 Hallway on 1/17/2024 with diagnoses including Brain Cancer, Asthma, Heart Attack,

Based on facility policy review, medical record review, and interview, the facility failed to ensure services were provided to meet professional standards of quality and acceptable standards of clinical practice by not obtaining vital signs per physician orders for residents with an active COVID-19 infection diagnosis for 36 of 40 residents (Resident #96, #45, #31, #33, #11, #609, #64, #93, #15, #510, #612, #611, #80, #506, #613, #615, #54, #68, #27, #53, #12, #95, #74, #3, #30, #37, #617, #34, #618, #72, #103, #507, #102, #508, #619, and #509) reviewed with active COVID-19 infection and 1 of 8 residents (Resident #99) reviewed for medication administration when nursing staff administered oral medication with a 60 milliliter (ml) syringe to Resident #99 who was at high risk for aspiration. The facility's failure to obtain vital signs per physician orders for residents with an active COVID-19 diagnosis and failure to ensure care was provided within the professional scope of practice for medication administration resulted in an Immediate Jeopardy (IJ), (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) which had the potential or likelihood to cause a serious adverse outcome for all 99 residents in the facility. The facility census was 99. The Administrator, Director of Nursing (DON), [NAME] President of Operations (VPO), [NAME] President of Life Safety and Environmental Compliance (VPLSEC), and [NAME] President of Clinical Services (VPCS) (attended in person) and the [NAME] President of Regulatory Compliance (VPRC) and Chief Operating Officer (COO) with the Chief Regulatory Compliance Officer (CRCO) (attended by telephone) were notified of the IJs for F-684, F-726, F-835, F-837, F-867, and F-880, and on 11/13/2024 at 9:42 PM in the Common Area/Recreation Area. The facility was cited Immediate Jeopardy at F-684 at a scope and severity of K, which is substandard quality of care. An Extended survey was conducted onsite from 11/14/2024 through 11/15/2024. The IJ began on 8/9/2024 and is ongoing. The facility is required to submit a Plan of Correction (POC). The findings include: Review of the facility's policy titled, Physician Orders, undated, revealed .A physician .nurse practitioner [NP] .must provide written .verbal orders for the residents' care and needs .order should allow facility staff .provide essential care .to .residents .orders .provide information .maintain or improve .resident's functional abilities . Review of the facility's policy titled, COVID-19 Management of Residents, undated, which referenced the 5/25/2023 Centers for Disease Control (CDC) guidelines revealed .The facility will not have a dedicated COVID-19 unit unless the number of positive residents warrant .the facility will place a COVID-19 positive resident in a single room with appropriate isolation signage and staff wearing N95 respirator [face mask], eye protection, gown, and gloves upon entry to the room .dedicated staff, to care for residents with COVID-19 .resident will be monitored every four hours for .symptoms, vital signs, oxygen saturation [O2 sat] .and respiratory exam [examination] .residents will .wear source control until symptoms resolve . Review of the facility's policy titled, Documentation in the Residents' Records Guidelines, undated, revealed .documentation shall be completed at the time of service, but no later than the shift the assessment .occurred .documentation .shall be .accurate .containing .details about the resident's care .and/or response to care . 1. The facility failed to obtain vital signs as ordered by the physician for 36 of 40 residents with an active COVID-19 infection. 1a. Review of the medical record revealed Resident #96 was admitted to the facility on [DATE] with diagnoses including Pulmonary Disease, Heart Failure, Depression, and Hypertension. The diagnosis of COVID-19 was added on 8/14/2024. Review of the laboratory result for Resident #96 dated 8/14/2024, revealed a positive COVID-19 test result. Review of a Physician's Order for Resident #96 dated 8/14/2024, revealed . Vital Signs monitoring for Covid [COVID-19] Positive every 4 hours throughout covid positive Isolation precautions . the isolation and vital signs continued until 8/24/2024. Review of the comprehensive care plan for Resident #96 dated 8/14/2024, revealed .Observe vital signs. Notify physician if abnormal . Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #96 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident was cognitively intact. Review of the Weights and Vitals Summary for Resident #96 dated 8/14/2024-8/24/2024, revealed the following lapses in obtaining the every 4-hour vital signs: On 8/14/2024, the facility obtained vital signs (VS), temperature, respirations, pulse, oxygen saturation (O2 sat), and blood pressure only 2 of 6 times as ordered. On 8/15/2024, the facility obtained VS only 3 of 6 times as ordered. On 8/16/2024, the facility obtained VS only 1 of 6 times as ordered. On 8/19/2024, the facility obtained the pulse and blood pressure only 1 of 6 times as ordered and no other VS were documented. On 8/20/2024, the facility obtained VS only 1 of 6 times as ordered. On 8/23/2024, the facility obtained the pulse and blood pressure only 1 of 6 times as ordered and no other VS were documented. The facility failed to obtain any VS on Resident #96 on 8/17/2024, 8/18/2024, 8/21/2024, 8/22/2024, and 8/24/2024. 1b. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Hypertension, Fibromyalgia, and Chronic Pain Syndrome. The diagnosis of COVID-19 was added on 8/21/2024. Review of the medical record for Resident #45 revealed no documentation of a positive COVID-19 test conducted from 8/20/2024-8/26/2024. Review of the NP Progress Notes for Resident #45 dated 8/21/2024, revealed .Resident was seen today due to positive result of COVID [COVID-19] swab in facility . Review of a Physician's Order for Resident #45 dated 8/23/2024, (2 days after positive test), revealed .Vital Signs monitoring for Covid Positive every 4 hours throughout covid positive Isolation precautions . the isolation and vital sign monitoring continued until 8/31/2024. Review of a comprehensive care plan for Resident #45 dated 8/26/2024, revealed the resident had tested positive for COVID-19 with interventions including .Observe vital signs. Notify physician if abnormal .Resident under droplet precautions . Review of the Weights and Vitals Summary, for Resident #45 dated 8/23/2024-8/31/2024, revealed the following lapses in obtaining the every 4-hour vital signs: On 8/23/2024, the facility obtained the pulse and blood pressure only 2 of 6 times as ordered and no other vital signs were documented. On 8/24/2024, 8/25/2024, and 8/26/2024, the facility obtained the pulse and blood pressure only 1 of 6 times as ordered and no other VS were documented. On 8/25/2024, the facility obtained the pulse and blood pressure only 1 of 6 times as ordered and no other VS were documented. On 8/26/2024, the facility obtained the pulse and blood pressure only 1 of 6 times as ordered and no other VS were documented. On 8/27/2024, the facility obtained VS only 1 of 6 times as ordered. On 8/29/2024, the facility obtained the pulse only 2 of 6 times as ordered, the blood pressure was obtained only 1 of 6 times as ordered, and no other VS were documented. On 8/30/2024, the facility obtained the pulse and blood pressure only 2 of 6 times as ordered and no other VS were documented. On 8/31/2024, the facility obtained the pulse and blood pressure only 1 of 6 times as ordered and no other VS were documented. The facility failed to obtain any VS on Resident #45 on 8/28/2024. Review of a significant change in status MDS assessment dated [DATE], revealed Resident #45 scored a 12 on the BIMS assessment, which indicated moderate cognitive impairment. 1c. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including Dementia, Type 2 Diabetes, Hypertension, and Anemia. The diagnosis of COVID-19 was added on 8/21/2024. Review of a quarterly MDS assessment dated [DATE], revealed Resident #31 scored a 99 on the BIMS assessment, which indicated the resident was unable to complete the interview. Review of the laboratory result for Resident #31 dated 8/21/2024, revealed a positive COVID-19 test result. Review of a Physician's Order for Resident #31 dated 8/23/2024 (2 days after the positive test), revealed .Vital Signs monitoring for Covid Positive every 4 hours throughout covid positive Isolation precautions . the isolation and vital sign monitoring continued until 8/31/2024. Review of a comprehensive care plan for Resident #31 dated 8/26/2024 (5 days after the positive test), revealed the resident had tested positive for COVID-19. Review of the Weights and Vitals Summary, for Resident #31 dated 8/21/2024-8/31/2024, revealed the following lapses in obtaining the every 4-hour vital signs: On 8/21/2024, the facility obtained the temperature, pulse, and blood pressure only 1 of 6 times as ordered and no other VS were documented. On 8/22/2024, 8/23/2024, 8/25/2024, 8/26/2024, 8/27/2024, and 8/29/2024, the facility obtained the pulse and blood pressure only 1 of 6 times as ordered and no other VS were documented. The facility failed to obtain VS on Resident #31 on 8/24/2024, 8/28/2024, 8/30/2024, and 8/31/2024. 1d. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including Generalized Arthritis, Hypertension, Chronic Pain, Heart Failure, and Difficulty Walking. The diagnosis of COVID-19 was added on 8/22/2024. Review of an admission MDS assessment dated [DATE], revealed Resident #33 scored a 7 on the BIMS assessment, which indicated severe cognitive impairment. Review of the laboratory result for Resident #33 dated 8/23/2024, revealed the COVID-19 test result was flagged as abnormal, which indicated the test was positive. Continued review of the laboratory result revealed the nursing staff had documented NEG [negative] in the notes field of the document, resulting in a conflicting result that indicated a negative COVID-19 test result. Review of a Physician's Order for Resident #33 dated 8/23/2024, revealed .Vital Signs monitoring for Covid Positive every 4 hours throughout covid positive Isolation precautions . the isolation and vital signs continued until 8/31/2024. Review of the comprehensive care plan for Resident #33 dated 8/23/2024, revealed the resident tested positive for COVID-19 and was placed under droplet precautions. Continued review revealed .Observe vital signs. Notify physician if abnormal .Observe/document breath sounds, document rate, rhythm, and the use of any accessory muscles .Notify MD if resident has low oxygen saturation or goes into respiratory distress . During an interview on 11/12/2024 at 3:48 PM, the [NAME] President (VP) of Clinical Services stated according to the NP visit note for Resident #33 dated 8/26/2024, the resident was evaluated for a positive COVID-19 diagnosis after testing positive for COVID-19 on 8/23/2024. Continued interview confirmed the COVID-19 test result documentation dated 8/23/2024 was inaccurately documented as NEG when the resident had an active COVID-19 diagnosis and positive test result. Review of the Weights and Vitals Summary, for Resident #33 dated 8/23/2024 through 9/1/2024, revealed the following lapses in obtaining the every 4-hour vital signs: On 8/23/2024, the temperature was only obtained 1 of 6 times as ordered, the respirations and O2 Sat were only obtained 2 of times as ordered, the pulse and blood pressure were only obtained 3 of 6 times as ordered, and no other VS were documented. On 8/26/2024 and 8/27/2024, the facility only obtained the VS 1 of 6 times as ordered and no other VS were documented. On 8/29/2024 and 8/30/2024, the facility obtained the pulse and blood pressure only 1 of 6 times as ordered and no other VS were documented. On 9/1/2024, the facility obtained the respirations, pulse, O2 Sat, and blood pressure only 1 of 6 times as ordered and no other VS were documented. The facility failed to obtain any VS on Resident #33 on 8/24/2024, 8/25/2024, 8/28/2024, and 8/31/2024. 1e. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including Hypertension, Diabetes, and Depression. The diagnosis of COVID-19 was added on 8/22/2024. Review of a quarterly MDS assessment dated [DATE], revealed Resident #11 scored a 15, which indicated the resident was cognitively intact. Review of the laboratory result for Resident #11 dated 8/23/2024, revealed a positive COVID-19 test result. Review of a Physician's Order for Resident #11 dated 8/23/2024, revealed .Vital Signs monitoring for Covid Positive every 4 hours throughout covid positive Isolation precautions . the isolation and vital signs continued until 9/1/2024. Review of a comprehensive care plan for Resident #11 dated 8/23/2024, revealed the resident had tested positive for COVID-19 with interventions including .Observe vital signs. Notify physician if abnormal . Review of the Weights and Vitals Summary, for Resident #11 dated 8/23/2024-9/1/2024, revealed the following lapses in obtaining the every 4-hour vital signs: On 8/23/2024, the facility obtained the pulse and blood pressure only 2 of 6 times as ordered and no other VS were documented. On 8/25/2024, 8/26/2024, 8/27/2024, and 8/28/2024, the facility obtained the pulse and blood pressure only 1 of 6 times as ordered and no other VS were documented. On 8/29/2024 and 8/30/2024, the facility obtained the pulse and blood pressure only 2 of 6 times as ordered and no other VS were documented. On 8/31/2024, the facility obtained the pulse and blood pressure only 1 of 6 times as ordered and no other VS were documented. On 9/1/2024, the facility obtained the respirations and O2 Sat only 1 of 6 times as ordered, pulse and blood pressure only 2 of 6 times as ordered, and no other VS were documented. The facility failed to obtain any VS on Resident #11 on 8/24/2024. 1f. Review of the medical record revealed Resident #609 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including Thyroid Cancer, Chronic Pain, Pneumonia, Diabetes, Anxiety, and History of Lung Blood Clots. The diagnosis of COVID-19 was added on 9/4/2024. Review of the laboratory result for Resident #609 dated 8/23/2024, revealed a positive COVID-19 test result. Review of a Physician's Order for Resident #609 dated 8/23/2024, revealed .Isolation Droplet precautions @ all times due to positive covid 19 test . The isolation continued until 9/2/2024. Continued review revealed no order for vital sign monitoring. Review of the admission MDS assessment dated [DATE], revealed Resident #609 scored a 7 on the BIMS assessment, which indicated severe cognitive impairment. Review of a Physician's Order for Resident #609 dated 8/26/2024 (3 days after positive COVID-19 test), revealed .Vital Signs monitoring for Covid Positive every 4 hours throughout covid positive Isolation precautions . the isolation and vital sign monitoring continued until 9/2/2024. Review of a comprehensive care plan for Resident #609 dated 8/26/2024, revealed the resident had tested positive for COVID-19 with interventions including .Observe vital signs. Notify physician if abnormal . Review of theWeights and Vitals Summary, for Resident #609 dated 8/23/2024-9/2/2024, revealed the following lapses in obtaining the every 4-hour vital signs: On 8/26/2024, the facility obtained the temperature, respirations, pulse, and blood pressure only 2 of 6 times as ordered, the O2 Sat only 3 of 6 times as ordered, and no other VS were documented. On 8/28/2024, the facility obtained the O2 Sat only 1 of 6 times as ordered and no other VS were documented. On 8/31/2024, the facility obtained the O2 Sat only 3 of 6 times as ordered and no other VS were documented. On 9/2/2024, the facility obtained the temperature 1 of 6 times as ordered and no other VS were documented. The facility to obtain any VS on Resident #609 on 8/27/2024, 8/29/2024, 8/30/2024, and 9/1/2024. 1g. Review of the medical record revealed Resident #64 was admitted to the facility on [DATE] with diagnoses including Diabetes, Heart Failure, and Hypertension. The diagnosis of COVID-19 was added on 8/25/2024. Review of an admission MDS assessment dated [DATE], revealed Resident #64 scored a 15 on the BIMS assessment, which indicated the resident was cognitively intact. Review of a Physician's Order for Resident #64 dated 8/23/2024 (2 days prior to the COVID-19 test), revealed .Vital Signs monitoring for Covid Positive every 4 hours throughout covid positive Isolation precautions . The isolation and vitals signs continued until 9/2/2024. Review of the laboratory result for Resident #64 dated 8/25/2024, revealed a positive COVID-19 test result. Review of a comprehensive care plan for Resident #64 dated 8/26/2024, revealed the resident had tested positive for COVID-19 with interventions including .Observe vital signs. Notify physician if abnormal .Resident under droplet precautions . Review of the Weights and Vitals Summary, for Resident #64 dated 8/23/2024-9/2/2024, revealed the following lapses in obtaining the every 4-hour vital signs: On 8/26/2024 and 8/27/2024, the facility obtained the VS only 1 of 6 times as ordered and no other VS were documented. The facility failed to obtain any VS for Resident #64 on 8/23/2024, 8/24/2024, 8/25/2024, 8/28/2024, 8/29/2024, 8/30/2024, 8/31/2024, 9/1/2024, and 9/2/2024. 1h. Review of the medical record revealed Resident #93 was admitted to the facility on [DATE] with diagnoses including Encephalopathy, Hypothyroidism, Hypertension, and Difficulty in Walking. The diagnosis of COVID-19 was added on 8/26/2024. Review of an admission MDS assessment dated [DATE], revealed Resident #93 scored an 8 on the BIMS assessment, which indicated moderate cognitive impairment. Review of the medical record revealed a positive COVID-19 test for Resident #93 was not available for review. Review of a NP Progress Notes for Resident #93 dated 8/23/2024, revealed .Resident was seen today due to testing positive for COVID-19 in the facility via nasal swab . Review of a Physician's Order for Resident #93 dated 8/23/2024, revealed .Vital Signs monitoring for Covid Positive every 4 hours throughout covid positive Isolation precautions . the isolation and vital sign monitoring continued until 9/2/2024. Review of a comprehensive care plan for Resident #93 dated 8/26/2024, revealed the resident tested positive for COVID-19 with interventions including .Observe vital signs. Notify physician if abnormal . Review of the Weights and Vitals Summary, for Resident #93 dated 8/23/2024-9/2/2024, revealed the following lapses in obtaining the every 4-hour vital signs: On 8/26/2024, the facility obtained the temperature only 2 of 6 times as ordered, obtained the respirations, pulse, O2 Sat, and blood pressure only 1 of 6 times as ordered, and no other VS were documented. On 8/27/2024, the facility obtained the VS only 1 of 6 times as ordered and no other VS were documented. On 8/28/2024, the facility obtained the temperature and blood pressure only 1 of 6 times as ordered and no other VS were documented. The facility failed to obtain any VS for Resident #93 on 8/23/2024, 8/24/2024, 8/25/2024, 8/29/2024, 8/30/2024, 8/31/2024, 9/1/2024, and 9/2/2024. 1i. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE], was discharged to the hospital, and readmitted to the facility on [DATE] with diagnoses including Mood Disorder, Vascular Dementia, Acute Kidney Failure, Pseudomonas, Non-Pressure Chronic Ulcer of Skin, Dysphagia, Venous Insufficiency, Anxiety Disorder, and Gastrointestinal Hemorrhage. The diagnosis of COVID-19 was added on 8/26/2024. Review of a quarterly MDS assessment dated [DATE], revealed Resident #15 scored a 9 on the BIMS assessment, which indicated moderate cognitive impairment. Review of the laboratory result for Resident #15 dated 8/23/2024, revealed a positive COVID-19 test result. Review of a Physician's Order for Resident #15 dated 8/26/2024 (3 days after the positive test result), revealed .Vital Signs monitoring for Covid Positive every 4 hours throughout covid positive Isolation precautions . the isolation and vital signs continued until 9/1/2024. Review of a comprehensive care plan for Resident #15 dated 8/26/2024, revealed the resident had tested positive for COVID-19 with interventions including .Observe vital signs. Notify physician if abnormal . Review of the Weights and Vitals Summary, for Resident #15 dated 8/26/2024-9/1/2024, revealed the following lapses in obtaining the every 4-hour vital signs: On 8/26/2024 and 8/27/2024, the facility obtained the VS only 1 of 6 times as ordered and no other VS were documented. On 8/29/2024, the facility obtained the respirations, pulse, and blood pressure only 1 of 6 times as ordered and no other VS were documented. On 9/1/2024, the facility obtained the respirations, pulse, O2 Sat, and blood pressure only 1 of 6 times as ordered and no other VS were obtained. The facility failed to obtain any VS for Resident #15 on 8/28/2024, 8/30/2024, and 8/31/2024. 1j. Review of the medical record revealed Resident #510 was admitted to the facility on [DATE], was discharged to the hospital, and readmitted to the facility on [DATE] with diagnoses including Heart Failure, Atrial Fibrillation, Hypertension, and Difficulty in Walking. The diagnosis of COVID-19 was added on 8/26/2024. Review of an admission MDS assessment dated [DATE], revealed Resident #510 scored a 13 on the BIMS assessment, which indicated the resident was cognitively intact. Review of the laboratory result for Resident #510 dated 8/24/2024, revealed a positive COVID-19 test result. Review of a Physician's Order for Resident #510 dated 8/26/2024 (2 days after the positive COVID-19 test result), revealed .Vital Signs monitoring for Covid Positive every 4 hours throughout covid positive Isolation precautions . the isolation and vital sign monitoring continued until 9/2/2024. Review of a comprehensive care plan for Resident #510 dated 8/26/2024, revealed the resident had tested positive for COVID-19 with interventions including .Observe vital signs. Notify physician if abnormal . Review of the Weights and Vitals Summary, for Resident #510 dated 8/26/2024-9/2/2024, revealed the following lapses in obtaining the every 4-hour vital signs: On 8/26/2024, the facility obtained the respirations, pulse, O2 Sat and blood pressure only 1 of 6 times as ordered and no other VS were documented. On 8/27/2024, the facility obtained the pulse, O2 Sat, and blood pressure only 1 of 6 times as ordered and no other VS were documented. On 8/28/2024, the facility obtained the blood pressure only 1 of 6 times as ordered and no other VS were documented. On 8/29/2024, the facility obtained the respirations, pulse and blood pressure only 1 of 6 times as ordered and no other VS were documented. On 8/30/2024, the facility obtained the pulse and blood pressure only 1 of 6 times as ordered and no other VS were documented. On 8/31/2024, the facility obtained the pulse only 1 of 6 times as ordered and no other VS were documented. On 9/1/2024, the facility obtained the respirations, pulse, O2 Sat, and blood pressure only 1 of 6 times as ordered and no other VS were documented. On 9/2/2024, the facility obtained the pulse and blood pressure only 1 of times as ordered, the O2 Sat only 2 of 6 times as ordered, and no other VS were documented. 1k. Review of the medical record revealed Resident #612 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Asthma, Heart Failure, and Depression. The diagnosis of COVID-19 was added on 8/26/2024. Review of the laboratory result for Resident #612 dated 8/24/2024, revealed a positive COVID-19 test result. Review of a Physician's Order for Resident #612 dated 8/26/2024 (2 days after the positive COVID-19 test result), revealed .Vital Signs monitoring for Covid Positive every 4 hours throughout covid positive Isolation precautions . the isolation and vital sign monitoring continued until 9/3/2024. Review of a comprehensive care plan for Resident #612 dated 8/26/2024, revealed the resident had tested positive for COVID-19 with interventions including .Observe vital signs. Notify physician if abnormal . Review of an admission MDS assessment dated [DATE], revealed Resident #612 scored a 14 on the BIMS assessment, which indicated the resident was cognitively intact. Review of the Weights and Vitals Summary, for Resident #612 dated 8/26/2024-9/3/2024, revealed the following lapses in obtaining the every 4-hour vital signs: On 8/26/2024 and 8/27/2024, the facility obtained the VS only 1 of 6 times as ordered and no other VS were documented. On 9/1/2024, the facility obtained the pulse only 1 of 6 times as ordered and no other VS were documented. The facility failed to obtain any VS for Resident #612 on 8/28/2024, 8/29/2024, 8/30/2024, 8/31/2024, 9/2/2024, and 9/3/2024. 1l. Review of the medical record revealed Resident #611 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Atrial Fibrillation, Hypertension, Heart Failure, and Difficulty in Walking. The diagnosis of COVID-19 was added on 8/26/2024. Review of an admission MDS assessment dated [DATE], revealed Resident #611 scored a 15 on the BIMS assessment, which indicated the resident was cognitively intact. Review of a Physician's Order for Resident #611 dated 8/26/2024, revealed .Vital Signs monitoring for Covid Positive every 4 hours throughout covid positive Isolation precautions . the isolation and vital sign monitoring continued until 9/3/2024. Review of a comprehensive care plan for Resident #611 dated 8/26/2024, revealed the resident had tested positive for COVID-19 with interventions including .Observe vital signs. Notify physician if abnormal . Review of the Weights and Vitals Summary, for Resident #611 dated 8/26/2024-9/3/2024, revealed the following lapses in obtaining every 4-hour vital signs: On 8/26/2024, the facility obtained the temperature, respirations, pulse and O2 Sat only 1 of 6 times as ordered, obtained the blood pressure only 2 of times as ordered, and no other VS were documented. On 8/27/2024, the facility obtained the temperature, respirations, pulse, and blood pressure only 1 of 6 times as ordered, the O2 Sat was obtained only 2 of 6 times as ordered, and no other VS were documented. On 8/28/2024, the facility obtained the blood pressure only 1 of 6 times as ordered, obtained the temperature, respirations, pulse, and O2 Sat only 2 of 6 times as ordered and no other VS were documented. On 8/29/2024, the facility obtained the O2 Sat only 1 of 6 times as ordered, temperature and respirations only 2 of 6 times as ordered, the blood pressure only 3 of 6 times as ordered, pulse only 4 of 6 times as ordered, and no other VS were documented. On 8/30/2024, the facility obtained the O2 Sat only 1 of 6 times as ordered, the pulse and blood pressure only 2 of 6 times as ordered, and no other VS were documented. On 8/31/2024, the facility obtained the pulse, O2 Sat and blood pressure only 1 of 6 times as ordered and no other VS were documented. On 9/1/2024, the facility obtained the respirations, pulse, O2 Sat, and blood pressure only 1 of 6 times as ordered and no other VS were documented. On 9/2/2024, the facility obtained the pulse, O2 Sat, and blood pressure only 2 of 6 times as ordered and no other VS were documented. On 9/3/2024, the facility obtained the pulse, O2 Sat, and blood pressure only 1 of 6 times as ordered and no other VS were documented. 1m. Review of the medical record revealed Resident #80 was admitted to the facility on [DATE], was discharged to the hospital, and readmitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease, Diabetes Mellitus, Hypertension, and Heart Failure. The diagnosis of COVID-19 was added on 8/26/2024. Review of an admission MDS assessment dated [DATE], revealed Resident #80 scored a 10 on the BIMS assessment, which indicated moderate cognitive impairment. Review of the medical record for Resident #80 revealed no documentation of a positive COVID-19 laboratory test result. Review of the NP Progress note for Resident #80 dated 8/26/2024, revealed .Resident was seen today for a follow-up after recent positive COVID-19 swab . Review of a Physician's Order for Resident #80 dated 8/26/2024, revealed .Vital Signs monitoring for Covid Positive every 4 hours throughout covid positive Isolation precautions . the isolation and vital sign monitoring continued until 9/3/2024. Review of a comprehensive care plan for Resident #80 dated 8/26/2024, revealed the resident tested positive for COVID-19 with interventions including .Observe vital signs. Notify physician if abnormal . Review of the Weights and Vitals Summary, for Resident #80 dated 8/26/2024-9/3/2024, revealed the following lapses in obtaining the every 4-hour vital signs: On 8/26/2024, the facility obtained the respirations, pulse, O2 Sat, and blood pressure only 1 of 6 times as ordered, temperature only 2 of 6 times as ordered, and no other VS were documented. On 8/27/2024, the VS were only obtained 1 of 6 times as ordered and no other VS were documented. On 8/28/2024, the facility obtained the temperature only 1 of 6 times as ordered and no other VS were documented. On 9/3/2024, the facility obtained the VS only 1 of 6 times as ordered and no other VS were documented. The failed to obtain any VS for Resident #80 on 8/29/2024, 8/30/2024, 8/31/2024, 9/1/2024, and 9/2/2024. 1n. Review of the medical record revealed Resident #506 was admitted to the facility on [DATE], was discharged to the hospital, and readmitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Chronic Pain Syndrome, and Muscle Weakness. The diagnosis of COVID-19 was added on 8/27/2024. Review of a quarterly MDS assessment dated [DATE], revealed Resident #506 scored a 14 on the BIMS assessment, which indicated the resident was cognitively intact. Review of the laboratory result for Resident #506 dated 8/26/2024, revealed a positive COVID-19 test result. Review of a Physician's Order for Resident #506 dated 8/27/2024 (1 day after the positive COVID-19 test result), revealed .Isolation Droplet precautions @ all times due to positive covid 19 test . The isolation continued until 9/5/2024. Continued review revealed no physician orders for vital sign monitoring. (The facility policy required vital signs (temperature, respirations, pulse, O2 Saturation, [TRUNCATED]

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure staff had the knowledge and skill set required to develop appropriate behavior health care plans and provide care to meet the behavioral health needs of 2 residents (#30 and #65) of 4 residents reviewed for behaviors. The facility's failure to have competent staff to implement appropriate behavioral interventions resulted in an altercation between Resident #30 and Resident #65 where Resident #65 suffered psychosocial harm. Resident #30's continued wandering behavior led to Resident #30 wandering into Resident #45's room and placing her hands-on Resident #45's neck and attempting to choke her. The facility's failure to ensure staff were knowledgeable and competent to provide services for residents with behavior care needs placed Resident #30 and Resident #65, and Resident #45 in Immediate Jeopardy (a situation in which the providers non-compliance with one or more requirements for participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) and had the potential to place all residents in Immediate Jeopardy. The Administrator was informed of the Immediate Jeopardy (IJ) in the conference room on 7/10/2021 at 12:50 PM. The Immediate Jeopardy was removed onsite 7/12/2021 and was effective 5/3/2021 - 7/11/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 7/12/2021 at 8:40 AM and the corrective actions were validated onsite by the surveyors on 7/12/2021 and 7/13/2021. The findings include: Review of the facility policy titled, Resident Centered Care Plans, dated 3/2019, showed .Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for caring [carrying] out the interventions, initially and when changes are made . Review of the facility policy titled, Behavior Management, dated 9/2019 revealed .the facility must have sufficient staff who provide direct services to residents with the appropriate competencies and skill sets to provide .services to assure resident safety .maintain the highest practicable physical, mental, and psychosocial well-being of each resident .Planning and implementing appropriate interventions into the resident's plan of care and evaluating the effectiveness of pharmacological and non-pharmacological interventions .Providing meaningful activities which promote engagement .between resident and staff .Meaningful activities are those that address the resident's customary routines, interests, preferences .and enhance the resident's well-being .Purpose to implement the most desirable and effective interventions that meet .needs of the residents, to change, modify, decrease or eliminate behaviors that are distressing to the resident and/or are decreasing or impacting on the resident's quality of life . Medical record review showed Resident #30 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #30's comprehensive care plan dated 4/13/2021, showed .elopement risk/wanderer AEB [as evidenced by] History of attempts to leave facility unattended .she becomes aggressive/combative with other residents at times, she goes in and out of residents rooms, needs frequent redirection .Distract her from wandering by offering pleasant diversions, structured activities, food, conversation, television, book .Document wandering behavior and attempted diversional interventions in behavior log . Review of Resident #30's Plan of Care Progress Note dated 4/14/2021, showed .Patient has been going in and out of other resident rooms .difficult to get vital signs .redirection . Review of Resident #30's admission Minimum Data Set (MDS) dated [DATE], showed the resident had severe cognitive impairment and had wandered 1-3 days during the assessment period. Resident #30 required supervision to walk in the room and hallways with no use of mobility devices. Review of Resident #30's care plan showed an update on 4/21/2021, .Requires assistance to participate in activities .we will continue to invite to activities & [and] 1'1 [one on one activities] as needed . The care plan had no individualized interventions for behaviors. Review of Resident #30's Physician Notification Progress Note dated 5/3/2021 at 5:16 PM, showed .Staff reported to this nurse a Resident to resident altercation. This Resident is [Resident #30], who was hitting [Resident #65] on the head and pulling her wheelchair back, [Resident #65] was screaming for Help . Review of Resident #30's Behavior Note/Anxiety Progress Note dated 5/5/2021, showed .Resident wandering through out facility this shift. Entering resident's room and nurse's station. Becomes agitated with redirection . Further review revealed no documentation of staff inventions to address the wandering behaviors. Review of Resident #30's Behavior Note/Anxiety Progress Note dated 5/20/2021, showed .Resident wanders the halls. Resident frequently goes into other Resident's rooms and takes belonging, drinks, food, etc. Resident had been involved in a couple of verbal arguments with other residents . Further review revealed staff had provided redirection out of the room and there was no documentation of staff inventions to address the wandering behaviors. Review of Resident #30's Social Service Progress Note dated 5/20/2021, showed .Resident exhibiting inappropriate behaviors .Discussed in team meeting this a.m. called and left a message with psych [psychiatric] NP [Nurse Practitioner] to assess for any needed medications . Further review revealed no documentation of staff inventions to address the wandering behaviors. Review of Resident #30's Social Service Progress Note dated 6/8/2021, showed .Resident displaying inappropriate behaviors, shopping in rooms, grabbing things out of residents hands, hard to redirect .Contacted psych NP to assess for any medication changes . Further review revealed no documentation of any non-pharmacological interventions attempted to distract the resident. Review of Resident #30's Behavior Note/Anxiety Progress Note dated 6/20/2021, showed .Resident continues to wander this shift. Resident wandering into other resident rooms and causing distress to other residents. Attempts to redirect are unsuccessful. Further review revealed no documentation of staff inventions to address the wandering behaviors. Medical record review showed Resident #65 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #65's comprehensive care plan dated 11/20/2020, showed .behavior problem .has attention seeking behaviors as evidenced by often becoming tearful for no particular reason .states she has a 'hole in her head' .intervene as necessary to protect the rights and safety of others .Divert Attention. Remove from situation and take to alternate location as needed . Further review showed no documentation of interventions to address crying and tearful behaviors. Review of Resident #65's quarterly MDS dated [DATE], showed the resident had moderately impaired cognitive status, the resident was independent for locomotion on the unit, and used a wheelchair for mobility. No behaviors were documented, and no wandering was documented. Review of Resident #65's Physician's Notification Progress Note dated 5/3/2021, showed .Resident to Resident altercation. This is [Resident #65] sitting in wheelchair while resident [Resident #30] was pushing wheelchair back and hitting [Resident #65] on top of head . Review of Resident #65's Psychotherapy Progress Note dated 5/6/2021, showed .The patient was quite distressed. She was hit recently by another patient and her room was moved. The patient approached the clinician stating she was distressed, and she asked if she could be sent to a psychiatric unit .the patient stating she is having hallucinations was significant this time, and having them directly after a significant stressor (being attacked by another patient) is highly consistent with the literature on [CONDITION(S)], as opposed to a manipulative quality. The patient was crying, and insistent on being considered for evaluation outside of the facility. The clinician discussed this with the staff, who stated that they would send her in the morning . Review of Resident #65's medical record showed she was sent to the hospital for psychiatric evaluation on 5/7/2021 and returned to the facility on [DATE]. Observation on 7/6/2021 at 12:15 PM, showed Resident #30 entered room [ROOM NUMBER]. A Certified Nursing Assistant (CNA) was in the room setting up a lunch tray and redirected the resident out of the room. No other intervention to address Resident #30's wandering was attempted. Observation on 7/6/2021 at 2:46 PM, showed Resident #30 entering room [ROOM NUMBER] while a CNA was in the room. The CNA redirected the resident to exit the room and no other intervention to address Resident #30's wandering was attempted. During an interview on 7/6/2021 at 2:55 PM, CNA #1 stated Resident #30 did wander frequently and did wander into other residents' rooms. She stated Resident #30 would take other residents' water pitchers. CNA #1 stated .there's not much we can do . CNA #1 stated she did not attempt any diversional activities or other interventions to address Resident #30's wandering. Observation on 7/6/2021 at 2:59 PM, showed Resident #30 wandering in the 400 hallway. She attempted to open the door to room [ROOM NUMBER] but did not go in. She then went to the 100 hallway and attempted to open the double doors into the hallway which is under construction. There was a cart blocking the door and she was unable to get onto the 100 hallway. She then wandered to the nurse's station, walked past a nurse seated at the nurse's station, opened the door to the Unit Secretary's office, and entered the office. She picked up a notebook from the Unit Secretary's desk, walked past the nurse seated at the nurse's station, and went down the 300 hallway. A staff member walked up to Resident #30 and took the notebook from her. No other intervention to address Resident #30's wandering was attempted. During an interview on 7/7/2021 at 2:07 PM, the Director of Social Services (DSS) stated Resident #30 had been in a resident-to-resident altercation with Resident #65. She stated Resident #30 used to work in a nursing facility and that Resident #65 had .psych issues . and .doesn't like to be touched . She stated after the altercation between Resident #30 and Resident #65, .became fearful .crying . The DSS stated Resident #30 goes in and out of resident rooms and .that's a problem .we pretty much let her wander and redirect her . She further stated the interventions staff took to prevent Resident #30's wandering behavior was .redirecting and put stop signs on some residents' rooms that she has a fondness to go into .the residents that complain . Further interview confirmed she was unaware of any other behavioral interventions, other than medication and redirection, to prevent Resident #30 from wandering into other residents' rooms. Medical record review showed Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #45's comprehensive care plan dated 3/23/2021, showed Resident #45 had a potential for impaired cognitive function related to confusion with an update on 7/9/2021 for .stop sign to doorway to prevent other residents from entering resident's room- Monitor Stop Sign every 15 minutes for placement . Review of Resident #45's 5-day MDS dated [DATE], showed the resident had moderate cognitive impairment, no behaviors noted, she was total dependence for bed mobility and transfers, did not walk, used a wheelchair for mobility, and used oxygen daily. Review of Resident #45's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #30] supervised the patient [Resident #45] while she was lying on her left resting .Resident [Resident #30] placed her right hand on the left side of the patient's [Resident #45] neck and held it .The patient [Resident #45] stated she turned and tried to push the arm [Resident #30's arm] away but it was very stiff .Ultimately she got the hand removed .Event was unprovoked . During a telephone interview on 7/8/2021 at 7:41 AM, Licensed Practical Nurse (LPN) #1 stated Resident #30 would wander frequently, and would wander into other resident's rooms. Resident #30's wandering .gets them [other residents] upset . The LPN stated at times Resident #30 would enter other resident rooms and the other residents would scream at her to get out. The LPN confirmed Resident #30 would pick up other resident's belongings from their rooms such as socks, toothbrushes, and decorations. LPN #1 stated when the staff hear the residents screaming, they go redirect her, but she is not easily redirectable. The LPN stated Resident #30 would often remove the stop signs placed on other residents' rooms and they would .disappear .we don't realize they are gone .we may find them on another hall or another nurses station . LPN #1 stated staff were unable to watch wandering residents at all times. During an interview on 7/8/2021 at 8:27 AM, LPN #2 confirmed Resident #30 had wandered into other residents' rooms, the staff try to redirect her and use stop signs on the doors of some residents, but she was unsure which residents were supposed to have stop signs. LPN #2 was not aware of any diversional activities to offer Resident #30 when she was wandering into other residents' rooms. During an interview on 7/8/2021 at 8:39 AM, Registered Nurse (RN) #1 stated Resident #30 would wander into other residents' rooms and would take things. RN #1 confirmed it was often difficult and required multiple attempts to redirect Resident #30, and she was unaware of any other interventions to prevent Resident #30 from wandering into other residents' rooms. During an interview on 7/8/2021 at 8:46 AM, the DSS confirmed the facility .would divert the resident as best they could .with demented patients [wandering] would occur . The DSS stated the stop signs on some resident doors had been attempted, but had been taken down, and they were effective at times. The DSS was unaware of which residents required stop signs and was unaware of how to obtain that information. She stated stop sign placement was determined when a resident had made a complaint about a wandering resident. During an interview on 7/8/2021 at 9:23 AM, LPN #3 stated Resident #30 would wander in and out of other residents' rooms, would take items from the other residents' rooms, and would drink everybody's drinks. LPN #3 stated the facility had placed stop signs on some of the resident's doors but Resident #30 would take them down and carry them around. LPN #3 stated Resident #30 is redirectable most of the time. She was unaware of any other interventions to prevent Resident #30 from wandering, including diversional activities. During an interview on 7/8/2021 at 9:32 AM, RN #2 confirmed Resident #30 would wander into other residents' rooms. RN #2 stated the facility had put stop signs up for the rooms .we find may be an issue . but she was not sure which residents were supposed to have stop signs on their doors. RN #2 stated the staff monitor Resident #30, and try to redirect, but was unaware of any other interventions to prevent Resident #30 from wandering, including diversional activities. During an interview on 7/8/2021 at 10:21 AM, CNA #2 stated that she had been at the nurse's station on 5/3/2021. Resident #30 was walking near Resident #65. Resident #65 did not want Resident #30 near her, and they had started to argue. CNA #2 then went to do .something . down the hallway without intervening. When she returned to the nurse's station, she was told Resident #30 had hit Resident #65. CNA #2 stated Resident #30 would wander into other residents' rooms and some residents did complain. CNA #2 stated Resident #65 had complained that Resident #30 would go into her room and go through her stuff. CNA #2 stated Resident #30 would wander into other residents' rooms and some residents did complain. CNA #2 stated there .really wasn't anything we could do . CNA #2 stated the staff would redirect the resident but was not aware of any other interventions, including diversional activities, to prevent wandering. During an interview on 7/8/2021 at 10:33 AM, CNA #3 stated Resident #30 would wander into other residents' rooms. CNA #3 stated she would provide redirection but no other interventions, including diversional activities, were used to prevent wandering. During a telephone interview on 7/8/2021 at 12:47 PM, RN #3 stated Resident #30 would wander .nonstop . into any room that was not locked, in and out of other residents' rooms, and would move/take other residents' belongings. RN #3 had witnessed Resident #30 remove a stop sign from a resident's door and had tried to explain to Resident #30 that she could not enter those rooms, but she was unable to understand. RN #3 was unsure which residents wanted a stop sign on their door and stated the information was passed on in shift report but not documented in the chart. RN #3 had reported Resident #30's wandering behavior to the Assistant Director of Nursing (ADON) and had been instructed to document the behaviors in the resident's chart, but no other interventions were utilized by staff. During an interview on 7/8/2021 at 1:31 PM, the ADON stated the facility had provided close monitoring of Resident #30, but she had the right to wander because the facility was her home. The ADON stated Resident #30's wandering had been discussed in IDT meetings. The ADON stated she had suggested Resident #30 may need placement in a locked unit, but the IDT had stated the facility was able to meet the resident's needs. During an interview on 7/9/2021 at 9:09 AM, the Activity Director stated she had not had a conversation with Resident #30's family to obtain her likes or interests, and the resident could not answer questions for the activity assessment. She stated .I went by what people told me to put down . The Activity Director stated she was aware of the resident's past occupation of working in a health care facility, then confirmed she had not taken that information into consideration when developing the resident's activity care plan. The Activity Director confirmed she was not aware of what person-centered care planning meant and was not aware that a care plan needed to be individualized to the resident's likes and interests. During an interview on 7/9/2021 at 10:10 AM, the MDS Coordinator stated Resident #30 had behaviors and had been seen grabbing stuffed animals from other residents and being aggressive. The MDS Coordinator was aware of the resident-to-resident abuse when Resident #30 hit Resident #65. She confirmed Resident #30 had gotten physically aggressive with residents. She stated Resident #30's wandering had been discussed with Administration, IDT (interdisciplinary team) team meetings, as well as in morning meetings. The MDS Coordinator stated after Resident #30 hit Resident #65, some members of the IDT had suggested Resident #30 needed one on one supervision, but Nursing Administration did not approve this. She confirmed Resident #30 had diversional activities listed on the care plan but was unsure how the facility had determined those activities and unsure of the effectiveness of the diversional activities. She stated she thought staff just get to know the residents and know what diversional activities she needs. She confirmed she had not had a conversation with the resident's family to obtain her likes or dislikes. She confirmed the facility had not developed diversional activities or interventions for behaviors for Resident #30. During an interview on 7/9/2021 at 12:51 PM, The DSS stated she had not developed any interventions for Resident #30's behaviors, including her wandering. She further stated she thought the MDS Coordinator had been adding behavioral interventions. She stated she had been aware of Resident #30 wandering into other residents' rooms from discussions in the facility's morning meetings. She stated Resident #30 needed interventions of redirection and medications for her behaviors .we can't tie her down .you can't restrict her in any manner . She stated Resident #30 had a wander guard (device used to alert staff when a resident is attempting to exit a door) placed on admission, but she had not assessed the resident for her wandering behaviors. She further stated Resident #30 had not been easily redirectable and had been more irritated lately. She stated she had not used the resident's past occupation to determine individualized interventions. She further stated Resident #65 had behaviors .she is tearful a lot .she has a history of abuse . She confirmed Resident #65 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DSS confirmed she was not aware of any intervention the staff had taken to address Resident #65's crying and tearful behaviors. During an interview on 7/9/2021 at 2:19 PM, the Medical Director stated that Resident #30 would wander into residents' rooms and take things. He confirmed the diversional activities the facility had attempted were not successful. He stated the resident-to-resident altercation that occurred between Resident #30 and Resident #65 .really set off [Resident #65's] anxiety .caused a significant amount of anxiety . He further confirmed the incident had caused Resident #65 to have psychosocial harm and there was a continued risk to other residents due to Resident #30's continued wandering. During an interview on 7/9/2021 at 3:20 PM, the Assistant Director of Nursing (ADON) confirmed Resident #30 exhibited aimless wandering. She stated the interventions used to prevent the wandering had been, close monitoring, a wander guard, psychological services, and activities. She confirmed Resident #30 needed closer monitoring and would not participate in activities. The ADON further confirmed the interventions the staff implemented had not been individualized and had been ineffective and Resident #30 had continued to wander into other resident's rooms. Refer to F-600, F-744 An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received 7/12/2021 at 8:40 AM, and the corrective actions were validated on-site by the surveyors on 7/12/2021 - 7/13/2021 through review of documents, review of facility policies, and staff interviews. The Removal Plan presented to the survey team by the facility documented the following immediate corrective actions implemented. On 7/10/2021 the Regional Director of Operations provided training to the Administrator, Assistant Director of Nursing, Nursing Educator, Unit Manager, MDS Coordinator, Medical Records, Social Services, Director of Rehab, Dietary, Admissions Liaison, and Human Resources. The training included: 1. the Abuse policy 2. types and reporting and investigating and prevention 3. process of identifying, preventing, and reporting abuse 4. how to recognize a potential behavior that is escalating, and to intervene 5. who is the Abuse Coordinator 6. suspected or observed abuse, all types, reported to the Administrator immediately All staff not working on 7/10/2021 were called and in-serviced. All residents with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interviewable residents were interviewed by the Social Service Director on any concerns related to abuse. Residents that were not interviewed had a skin assessment completed by the ADON and Unit Manager on 7/10/2021. The Regional Director of Clinical services reviewed the last 72 hours of nursing notes to identify any issues that needed to be investigated as an allegation with no issues identified. On 7/10/2021 the Nurse Educator, Director of Rehab, and Human Resources educated staff. The training included: 1. how to recognize potential behavior that is escalating and to intervene 2. who the abuse coordinator is- the Administrator 3. suspected or observed abuse 4. all types reported to the Administrator immediately All staff not working on 7/10/2021 were called and in-serviced. On 7/11/2021 all staff started competency tests on Hand-in-Hand Dementia module part 1 & 2, abuse prevention, reporting, and investigating test. Audits will be conducted by the Administrator and Director of Nursing (DON) of nursing notes for the past 24 hours to identify any potential reportable events. These audits will be performed 5 times per week for 4 weeks, 3 times per week for 4 weeks, and 2 times per week for 4 weeks. Five random residents will be interviewed daily to ensure no resident to resident and no incidents of other residents wandering into their rooms by Social Services. A Licensed Nurse will do 5 skin sweeps 5 times per week for 4 weeks, 3 times per week for 4 weeks, and 2 times per week for 4 weeks on residents who are not interviewable. The Regional Director of Clinical Services will monitor nursing notes written in the past 24 hours to identify any areas that potentially could be a reportable event 5 times per week for 4 weeks, 3 times per week for 4 weeks, and 2 times per week for 4 weeks. The Nurse Educator will track the interviews and skin sweeps, a reportable event log will be maintained in the Administrators office. Residents with behaviors/Dementia care plans were reviewed and updated on 7/10/2021 by the MDS Nurse and Social Services to reflect resident specific interventions for behaviors. Nursing staff were interviewed by the ADON and the Unit Manager to identify any new behaviors observed and/or exacerbations on 7/10/2021, no issues were identified. The Regional Director of Nursing reviewed the past 72 hours of nursing documentation for new and/or exacerbations of behaviors on 7/10/2021, no issues identified. On 7/10/2021 the Regional Director of Nursing Services re-inserviced the ADON, Unit Manager, Social Services, MDS Coordinator, and Activities Director on behavioral management policy including: 1.Making resident care plans specific to their behaviors with interventions 2. how to recognize potential behaviors that is escalating and to intervene On 7/10/2021 the Regional Director of Clinical Services re-inserviced the Administrator, ADON, Nursing Educator, Unit Manager, MDS Coordinator, Medical Records, Social Services, Director of Rehab, Dietary, Admission Liaison, and Human Resources on behavior management including : how to recognize a potential behavior that is escalating and to intervene All staff not present on 7/10/2021 were called and in-serviced by the Nurse Educator. No employee will work prior to being trained. Future employees will be educated on hire regarding behavioral management and care plan revisions as it relates to resident specific interventions and including how to recognize a potential behavior that is escalating and to intervene. Audits will be performed by the DON / designee of progress notes to identify any potential new or exacerbations of behaviors 5 times per week for 4 weeks, 3 times per week for 4 weeks, and 2 times per week for 4 weeks. The Nurse Educator will perform behavior management training monthly for 6 months using Hand-in-Hand. The Kardex's will be printed from Point Click Care and updated to reflect the behavioral interventions that are resident specific, on 7/11/2021 by the ADON and Unit manager. The Regional Director of Clinical Services will monitor nursing notes written in the past 24 hours to identify any areas that potentially could be exacerbated behaviors 5 times per week for 4 weeks, 3 times per week for 4 weeks, and 2 times per week for 4 weeks. Changes to a behavior care plan or development by the IDT team will be reviewed by the Administrator to ensure it is resident specific as updates occur. The comprehensive care plan development is overseen by the MDS Coordinator with input from Social Services, Activities, Dietary, and Rehab. Revisions to the behavioral care plan is the responsibility of the Social Services. Nursing Care plan updates are the responsibility of Licensed Nurses, Unit Manager, ADON, and the DON. The QAPI committee will meet weekly to analyze all events that may require investigation and reporting. Weekly updates will be provided by responsible members on the progress of each citation. The Regional Director of Nursing and /or the Regional Vice President of Operations will attend QAPI meetings in person or by phone. This will include input and review of data collected for the meeting. The Regional Director of Nursing and/or Regional Vice President of Operations will do facility visits to monitor compliance at a minimum weekly until substantial compliance is achieved and maintained. On 7/12/2021, Surveyors reviewed abuse policy, behavioral management policy, person-centered care plan policy. The Surveyors reviewed the education and sign in sheets which validated the corrective action plans onsite which was provided by the Administrator. The documentation showed all staff working on 7/12/2021 and 7/13/2021 had been provided the education on abuse, types of abuse, preventing, protecting, recognizing/identifying abuse/behaviors, reporting, and investigating abuse. The administrator was educated on abuse by the corporate nurse. Residents affected by the wandering residents were assessed and interviewed to determine if psychosocial harm had occurred. Twenty-two resident records were reviewed randomly to ensure care plans had been updated and Dementia care had been added to those with Dementia and behaviors. The records had been updated to include interventions on the 22 resident records reviewed. The surveyors validated all staff working on 7/12/2021 - 7/13/2021 had been educated and were knowledgeable about the new procedures related to abuse/behavior, Dementia Care, and person-centered care planning. On 7/12/2021, Surveyors validated the corrective actions onsite through interviews with the Administrator, DON, Nurse Educator, MDS Coordinator, Social Service Director, 4 RNs, 2 LPN's, 8 CNA's, 2 nurse aides in training, 2 therapists and 2 housekeepers. The interviews showed the staff were educated on how to prevent abuse, what to do when abuse occurs, reporting of abuse, investigating abuse, documentation and implementing person centered care plans for each resident with Dementia and behaviors. Staff verbalized knowledge of development of care plans for Dementia and behaviors and how to assess residents to determine person centered needs/interventions. The MDS Coordinator was provided education on person-centered care plans to address behaviors and how to update the care plans. The DSS had received education on behavioral interventions and updating the care plan for behavioral management interventions individualized to each resident. The Activity Director was educated on person centered care planning and updating the care plans with person centered interventions. Noncompliance at F-741 continues at a scope and severity of F for monitoring of the effectiveness of the corrective actions to ensure sustained compliance. The facility is required to submit a plan of correction. <b [TRUNCATED]

Based on facility policy review, medical record review, and interview, the facility failed to timely report to the State Survey Agency an allegation of abuse for 2 residents (Residents #65 and #45) and failed to timely report an allegation of abuse to Administration for 1 resident (Resident #45) of 16 residents reviewed for abuse. Resident #30 hit Resident #65 in the head. Resident #30 continued to display wandering and aggressive behavior and entered Resident #45's room and attempted to choke Resident #45. The facility's failure to ensure allegations of abuse were reported timely placed all residents in the facility in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements for participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was informed of the Immediate Jeopardy (IJ) in the conference room on 7/10/2021 at 12:50 PM. The facility was cited F-609 at a scope and severity of L which constitutes Substandard Quality of Care. The Immediate Jeopardy was removed 7/12/2021 and was effective 5/3/2021 - 7/11/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 7/12/2021 at 8:40 AM and the corrective actions were validated onsite by the surveyors on 7/12/2021 and 7/13/2021. The findings include: Review of the facility's policy titled, Freedom of Abuse, Neglect and Exploitation Standard, revised 11/2019, showed .All employees are required to immediately notify the administrative or nursing supervisory staff that is on duty of any complaint, allegation, observation or suspicion of resident abuse, mistreatment or neglect so that the resident's needs can be attended to immediately and investigation can be undertaken promptly .all violations involving abuse .are reported immediately, but not later than 2 hours after the allegation is made .The abuse coordinator will contact the State Agency and the local Ombudsman office to report the alleged abuse .Report the results of all investigations .to the State Survey Agency, within 5 working days of the incident . Medical record review showed Resident #30 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #30's comprehensive care plan dated 4/13/2021, showed .elopement risk/wanderer AEB [as evidenced by] History of attempts to leave facility unattended .she becomes aggressive/combative with other residents at times, she goes in and out of residents rooms . Review of Resident #30's admission Minimum Data Set (MDS) dated [DATE], showed the resident had severe cognitive impairment and had wandered 1-3 days during the assessment period. Review of Resident #30's Physician Notification Progress Note dated 5/3/2021 at 5:16 PM, showed Resident #30 had been in a resident to resident altercation with Resident #65 .This Resident .was hitting [Resident #65] on the head and pulling her wheelchair back, [Resident #65] was screaming for Help . Review of Resident #30's Physician's Progress Note dated 5/4/2021, showed .This person began hitting the other resident [Resident #65] on her head and pulling .wheelchair back .The other resident was screaming for help . Review of Resident #30's Psychiatric Evaluation dated 5/4/2021, showed .Evaluating mood and behaviors-patient having increased agitation, restlessness, aggression . Further review showed Resident #30 was having physical aggression and combativeness. Review of Resident #30's Behavior Note/Anxiety Progress Note dated 5/20/2021, showed .Resident frequently goes into other Resident's rooms and takes belonging, drinks, food, etc. Resident has been involved in a couple of verbal arguments with other residents . Review of Resident #30's Behavior Note/Anxiety Progress Note dated 6/4/2021, showed .Resident continues to wander the halls, but is increasingly more intrusive into other Resident rooms. Resident enters every room and takes items and hides them. Resident upsets other Residents with her actions. Resident also pushes other Residents in their wheelchair around the halls . Review of Resident #30's Behavioral Note/Anxiety Progress Note dated 7/5/2021, showed .Resident continues to wander this shift. Resident wandering into other resident rooms causing distress to other residents. Resident is also taking things from nurses station, med carts, and other residents rooms . Medical record review showed Resident #65 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #65's comprehensive care plan dated 11/20/2020, showed .often becoming tearful for no particular reason .states she has a 'hole in her head' .intervene as necessary to protect the rights and safety of others . Review of Resident #65's quarterly MDS dated [DATE], showed the resident had moderately impaired cognitive status, the resident was independent for locomotion on the unit, and used a wheelchair for mobility. Review of Resident #65's Physician's Notification Progress Note dated 5/3/2021, showed Resident #65 had been in a resident to resident altercation on 5/3/2021. Resident #30 was hitting Resident #65 in the head. Review of Resident #65's Psychiatric Evaluation dated 5/4/2021, showed .Evaluating mood and behaviors-patient was involved in an incident with [Resident #30] since that time she had increased anxiety and delusions . and the resident's medications had been increased. Review of Resident #65's Physician's Progress Note dated 5/4/2021, showed .The patient was a victim of the resident on resident violence earlier in the week .The patient's been very anxious since that time .The patient reports the other individual came up from behind her and grabbed and hit her right parietal [top of head] and temporal [side of head] area .This incident unfortunately set off exacerbation of patient's underlying anxiety disorder To become increasingly anxious and avoids individuals when moving about the community in her wheelchair . Review of Resident #65's Behavior Note/Anxiety Progress Note dated 5/5/2021, showed the resident was crying and did not want to return to her room and stated she was scared. The nurse moved her to a different room for the night. Review of Resident #65's Psychotherapy Progress Note dated 5/6/2021, showed .The patient was quite distressed. She was hit recently by another patient and her room was moved. The patient approached the clinician stating she was distressed, and she asked if she could be sent to a psychiatric unit .the patient stating she is having hallucinations was significant this time, and having them directly after a significant stressor (being attacked by another patient) is highly consistent with the literature on [CONDITION(S)], as opposed to a manipulative quality. The patient was crying, and insistent on being considered for evaluation outside of the facility . During an interview on 7/7/2021 at 2:34 PM, the Assistant Director of Nursing (ADON) confirmed the facility did not report resident to resident altercations to the State Survey Agency. She stated the facility would report allegations of abuse. The ADON stated the resident to resident altercation between Resident #30 and Resident #65 was considered to be behaviors and not abuse. During an interview on 7/7/2021 at 2:37 PM, the Administrator stated when a resident hits another resident, it would only be reported to the State Survey Agency depending on the situation. She stated the resident to resident altercation that occurred between Resident #30 and Resident #65 on 5/3/2021 was not considered to be abuse by the facility .those were behaviors . She stated both residents had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the IDT (Interdisciplinary Team) would discuss any resident to resident altercation and decide if they should be investigated as an abuse allegation or reported to the State Survey Agency. Medical record review showed Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #45's 5 day MDS dated [DATE], showed the resident had moderate cognitive impairment. Review of Resident #45's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #30] supervised the patient [Resident #45} while she was lying on her left resting .Resident [Resident #30] placed her right hand on the left side of the patient's [Resident #45] neck and held it .The patient [Resident #45] stated she turned and tried to push the arm away but it was very stiff .Ultimately she [Resident #45] got the hand removed .Event was unprovoked . Review of Resident #30's Physician's Progress Note dated 7/8/2021, showed .Yesterday this patient went into another resident's room [Resident #45] and placed her hand about the residents neck making the resident think she was being choked .Patient had wandered into the resident's room .Frequently up and about the building, restless .Eventually the patient is able to push the hand away from her neck .PLAN .Mental health consult .One-on-one observation if available . Review of a facility witness statement given by CNA #5, undated, showed .Resident [#45] stated she was sleeping, and thought was one of us shaking her awake. But it was [Resident #30] standing over her. She claimed [Resident #30] had her hands around her neck and told her she would hurt her/die . Review of facility documentation dated 7/8/2021, showed the resident to resident abuse between Resident #30 and Resident #45 that had been reported to the staff on 7/8/2021 at 6:00 AM, had not been reported to the State Survey Agency until 7/8/2021 at 12:01 PM (4 hours after the occurrence). During an interview on 7/8/2021 at 8:27 AM, Licensed Practical Nurse (LPN) #2 confirmed she had been assigned to Resident #30 and Resident #65 on the day of the altercation between the 2 residents on 5/3/2021. A CNA had reported the altercation to her. LPN #2 stated Resident #65 .was distraught and upset .crying .tearful . During an interview on 7/9/2021 at 1:40 PM, the Psychiatric (Psych) Nurse Practitioner (NP) stated she was aware of the resident to resident altercation between Resident #30 and Resident #65 that occurred on 5/3/2021. She confirmed she had added an antipsychotic medication for Resident #30 after the incident for delusions. She had also seen Resident #65 after the altercation and stated Resident #65 had delusions about the incident and thought the woman (Resident #30) was out to get her and out to kill her. The Psych NP confirmed the altercation did trigger some increased anxiety for Resident #65 which required medication changes. She confirmed the altercation did cause Resident #65 some significant distress and psychosocial harm. During an interview on 7/9/2021 at 2:19 PM, the Medical Director (MD) stated he was aware of Resident #30's wandering into other resident's rooms and stated .she has bumped into a few folks along the way . He stated the resident to resident altercation that occurred between Resident #30 and Resident #65 .really set off [Resident #65's] anxiety .caused a significant amount of anxiety . He further confirmed the incident had caused Resident #65 to have psychosocial harm and there was a continued risk to other residents due to Resident #30's continued wandering. Review of facility documentation dated 7/11/2021, showed the resident to resident abuse between Resident #30 and Resident #65 that occurred on 5/3/2021 was not reported to the State Survey Agency until 7/11/2021 (69 days after the occurrence). During an interview on 7/13/2021 at 10:40 AM, the Physical Therapy Assistant (PTA) stated he had assisted Resident #45 to therapy in the mid-morning of 7/8/2021. He had asked her how her morning had been and Resident #45 stated her morning had .gotten off to a rough start . Resident #45 stated to the PTA that someone came into the room and she thought at first it was a nurse. She had felt a hand on her upper chest but when she looked up it was another resident, not the nurse. Resident #30 said to Resident #45 .I'll kill you . The PTA told Resident #45 he would report the incident and she told him she had already reported the incident to a nurse. The PTA stated he went to LPN #2 and reported the incident. LPN #2 told him she had not been made aware of the incident, but she would report it. The PTA stated he also reported the incident to his supervisor about 1-1 ½ hours after he reported it to LPN #2. He stated his supervisor then immediately reported the incident to the ADON. During an interview on 7/13/2021 at 11:03 AM, LPN #2 stated the PTA had reported the incident between Resident #30 and Resident #45 to her on 7/8/2021 at about 10:00 AM. LPN #2 stated she reported the incident to her supervisor RN #1. LPN #2 stated the night shift staff had not reported the incident during shift report. During a telephone interview on 7/13/2021 at 11:30 AM, CNA #4 stated she had worked the night shift on 7/7/2021 into the morning of 7/8/2021. CNA #5 had worked the 300 hallway that night and CNA #4 had worked on all halls. CNA #5 reported to CNA #4 prior to them leaving their shift at 6:00 AM that Resident #45 (who resided on the 300 hallway) had reported the incident with Resident #30 to her. CNA #4 stated she did not report the incident because she assumed CNA #5 would report it. During an interview on 7/13/2021 at 1:11 PM, RN #1 stated she was the supervisor of the 300 hallway on 7/8/2021. LPN #2 reported to her at about 11:30 AM of an incident that occurred between Resident #30 and Resident #45. RN #1 went immediately to report to nurse management (RN #2) and was told by RN #2 that management was already aware. During an interview on 7/13/2021 at 1:27 PM, RN #2 confirmed she had been in the ADON's office on 7/8/2021 when the Rehabilitation Director had made her and the ADON aware of the resident to resident altercation between Resident #30 and Resident #45. She stated it was not long before lunch when they had been notified of the incident and they immediately reported it to the Administrator (approximately 4 ½ hours after incident occurred). During an interview on 7/13/2021 at 2:11 PM, while reviewing the video surveillance footage from 7/8/2021, the Administrator confirmed Resident #30 had entered Resident #45's room for a period of 34 seconds from 5:48:31 AM to 5:49:05 AM. She confirmed she had no way of knowing what happened in the room other than taking Resident #45's word. The Administrator stated Resident #45's roommate had not been in the room when Resident #30 had entered. She confirmed CNA #5 had reported the altercation to CNA #4 prior to them leaving their shift at 6:00 AM on 7/8/2021, but neither CNA had reported the incident to nursing or administration. She confirmed the facility should have reported the incident by 8:00 AM on 7/8/2021 to the State Survey Agency and confirmed the facility had not reported to any other entity such as the Ombudsman's office or Adult Protective Services. The Administrator further confirmed the facility had not followed their policy for reporting alleged abuse. Refer to F- 600 An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received 7/12/2021 at 8:40 AM, and the corrective actions were validated on-site by the surveyors on 7/12/2021-7/13/2021 through review of documents, review of facility policies, and staff interviews. The Removal Plan presented to the survey team by the facility documented the following immediate corrective actions implemented. On 7/10/2021 the Regional Director of Operations provided training to the Administrator, Assistant Director of Nursing, Nursing Educator, Unit Manager, MDS Coordinator, Medical Records, Social Services, Director of Rehab, Dietary, Admissions Liaison, and Human Resources. The training included: 1. the Abuse policy 2. types and reporting and investigating and prevention of abuse 3. process of identifying, preventing, and reporting abuse 4. how to recognize a potential behavior that is escalating, and to intervene 5. who is the Abuse Coordinator 6. suspected or observed abuse, all types, reported to the Administrator immediately All staff not working on 7/10/2021 were called and in-serviced. On 7/10/2021 the Administrator was in-serviced by the Regional Director of Operations on how to identify, report, and investigate potential allegations of abuse. All residents with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interviewable residents were interviewed by the Social Service Director on any concerns related to abuse. Residents that were not interviewed had a skin assessment completed by the ADON and Unit Manager on 7/10/2021. The Regional Director of Clinical services reviewed the last 72 hours of nursing notes to identify any issues that needed to be investigated as an allegation with no issues identified. On 7/10/2021 the Nurse Educator, Director of Rehab, and Human Resources educated staff. The training included: 1. how to recognize potential behavior that is escalating and to intervene 2. who the abuse coordinator is- the Administrator 3. suspected or observed abuse 4. all types reported to the Administrator immediately All staff not working on 7/10/2021 were called and in-serviced. On 7/11/2021 all staff started competency tests on Hand-in-Hand Dementia module part 1 & 2, abuse prevention, reporting, and investigating. Audits will be performed by the DON/designee of progress notes to identify any potential new or exacerbations of behaviors 5 times per week for 4 weeks, 3 times per week for 4 weeks, and 2 times per week for 4 weeks. The Nurse Educator will perform behavior management training monthly for 6 months using Hand-in-Hand. The Kardex's will be printed from Point Click Care and updated to reflect the behavioral interventions that are resident specific, on 7/11/2021 by the ADON and Unit manager. The Regional Director of Clinical Services will monitor nursing notes written in the past 24 hours to identify any areas that potentially could be exacerbated behaviors 5 times per week for 4 weeks, 3 times per week for 4 weeks, and 2 times per week for 4 weeks. Changes to a behavior care plan or development by the IDT team will be reviewed by the Administrator to ensure it is resident specific as updates occur. The comprehensive care plan development is overseen by the MDS Coordinator with input from Social Services, Activities, Dietary, and Rehab. Revisions to the behavioral care plan is the responsibility of the Social Services. Nursing Care plan updates are the responsibility of Licensed Nurses, Unit Manager, ADON, and the DON. The QAPI committee will meet weekly to analyze all events that may require investigation and reporting. Weekly updates will be provided by responsible members on the progress. The Regional Director of Nursing and/or the Regional Vice President of Operations will attend QAPI meetings in person or by phone. This will include input and review of data collected for the meeting. The Regional Director of Nursing and/or Regional Vice President of Operations will do facility visits to monitor compliance at a minimum weekly until substantial compliance is achieved and maintained. On 7/12/2021, Surveyors reviewed the education and sign in sheets which validated the corrective action plans. The documentation showed all staff working on 7/12/2021 and 7/13/2021 had been provided the education on abuse, types of abuse, preventing, protecting, recognizing/identifying abuse/behaviors, reporting, and investigating abuse. The Administrator was educated on abuse by the corporate nurse. Residents affected by the wandering residents were assessed and interviewed to determine if psychosocial harm had occurred. Twenty-two resident records were reviewed randomly to ensure care plans had been updated and Dementia care had been added to those with Dementia and behaviors. The records had been updated to include interventions on the 22 resident records reviewed. The surveyors validated all staff working on 7/12/2021-7/13/2021 had been educated and were knowledgeable about the new procedures related to abuse/behavior, Dementia Care, and person-centered care planning. On 7/12/2021, Surveyors validated the corrective actions onsite through interviews with the Administrator, DON, Nurse Educator, MDS Coordinator, Social Service Director, 4 RNs, 2 LPN's, 8 CNA's, 2 nurse aides in training, 2 therapists and 2 housekeepers. The interviews showed the staff were educated on how to prevent abuse, what to do when abuse occurs, reporting of all allegations of abuse to the Administrator immediately, investigating all allegations of abuse, documentation and implementing person centered care plans for each resident with Dementia and behaviors. Staff verbalized knowledge of development of care plans for Dementia and behaviors and how to assess residents to determine person centered needs/interventions. Administrator interview confirmed all allegations of abuse would be reported to the state agency within 2 hours of the allegation. Noncompliance at F-609 continues at a scope and severity of F for monitoring of the effectiveness of the corrective actions to ensure sustained compliance. The facility is required to submit a plan of correction.

Based on facility policy review, medical record review, and interview, the facility failed to investigate an allegation of abuse for 2 residents (Resident #30 and #65) of 16 residents reviewed for abuse when a Certified Nursing Assistant (CNA) failed to separate Resident #30 and Resident #65 when she overheard them arguing in the hallway, which resulted in a resident to resident altercation when Resident #30 hit Resident #65 in the head. This resulted in psychosocial harm for Resident #65. Resident #30's continued wandering led to Resident #30 entering Resident #45's room and attempting to choke Resident #45 and stating she would kill Resident #45. The facility's failure to recognize and investigate resident to resident abuse that occurred between Resident #30 and Resident #65 placed Resident #65 and Resident #45 in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements for participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The facility's failure to investigate an allegation of abuse perpetrated by Resident #30, and implement interventions based on the investigation to prevent further instances of abuse, had the potential to affect all residents in the facility . The Administrator was informed of the Immediate Jeopardy (IJ) in the conference room on 7/10/2021 at 12:50 PM. The facility was cited F-610 at a scope and severity of L which constitutes Substandard Quality of Care. The Immediate Jeopardy was removed onsite 7/12/2021 and was effective 5/3/2021-7/11/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 7/12/2021 at 8:40 AM and the corrective actions were validated onsite by the surveyors on 7/12/2021 and 7/13/2021. The findings include: Review of the facility's policy titled, Freedom Of Abuse, Neglect And Exploitation Standard, dated 11/2019, showed .The facility will consider factors indicating possible abuse .including .Resident, staff or family report of abuse .Physical abuse of a resident observed .The facility will implement policies and procedures to prevent and prohibit all types of abuse .When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted .All alleged violations involving mistreatment, abuse or neglect will be thoroughly investigated by the facility under the direction of the Administrator and in accordance with state and federal law .The Administrator, or his/her designee, will ensue that the investigation is completed within 48 to 72 hours . Medical record review showed Resident #30 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #30's comprehensive care plan dated 4/13/2021, showed .she becomes aggressive/combative with other residents at times, she goes in and out of residents rooms, needs frequent redirection . Review of Resident #30's admission Minimum Data Set (MDS) dated [DATE], showed the resident had severe cognitive impairment and had wandered 1-3 days during the assessment period. Resident #30 required supervision to walk in the room and hallways with no use of mobility devices. Review of Resident #30's Respiratory Evaluation Progress Note dated 4/15/2021, showed .Chronic disruptive behavior noted. Chronic wandering behavior noted . Review of Resident #30's QAPI (Quality Assurance and Performance Improvement)/Risk Meeting Progress Note dated 5/3/2021 at 1:52 PM, showed Resident #30 was a wandering risk with behaviors noted. Review of Resident #30's Risk Meeting Note dated 5/4/2021, showed .Resident to Resident [altercation] occurred on 05.03.21 @ [at] 1659 [4:59 PM]. This is Resident A [Resident #30] and the aggressor [Resident #30] was in a central location of hallway holding [Resident #65's] wheelchair and pulling the w/c [wheelchair] backwards with her [Resident #65] foot in the wheel of the chair. [Resident #30] hit [Resident #65] on top of the head several times. [Resident #65] started screaming for help .[Resident #65] stated 'I was just sitting in my chair when all of a sudden [Resident #30] started hitting me on top of the head and pulling my w/c backwards'. Called the psych [psychiatric] NP [Nurse Practitioner] and new orders received to send [Resident #30] to .ER [emergency room ] for psychiatric evaluation and treatment . Review of Resident #30's Physician's Progress Note dated 5/4/2021, showed Resident #30 .began hitting the other resident [Resident #65] on her head and pulling .wheelchair back .The other resident was screaming for help . Further review showed the Mental Health Nurse Practitioner (NP) was notified and had responded with an order to send Resident #30 to the emergency department for evaluation. Review of Resident #30's Behavior Note/Anxiety Progress Note dated 5/20/2021, showed Resident #30 would frequently wander into other resident rooms and take their belongings and had verbal arguments with other residents. Review of Resident #30's Behavior Note/Anxiety Progress Note dated 6/4/2021, showed Resident #30 continued to wander .but is increasingly more intrusive into other Resident rooms. Resident enters every room and takes items and hides them. Resident upsets other Residents with her actions. Resident also pushes other Residents in their wheelchair around the halls . Review of Resident #30's Social Service Progress Note dated 6/8/2021, showed Resident #30 had inappropriate behaviors and had been .shopping in rooms, grabbing things out of residents hands, hard to redirect . Review of a Behavior Note/Anxiety Progress Note dated 7/4/2021, showed .Resident wandering into other resident rooms, causing distress to other residents .taking things from .other residents rooms .Attempts to redirect unsuccessful . Review of Resident #30's Physician's Progress Note dated 7/8/2021, showed .Yesterday this patient went into another resident's room [Resident #45] and placed her hand about the resident's neck making the resident think she was being choked . Eventually the patient is able to push the hand away from her neck .One-on-one observation if available . Medical record review showed Resident #65 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #65's comprehensive care plan dated 11/20/2020, showed Resident #65 had a behavioral problem and often would become tearful for no particular reason. Further review showed .states she has a 'hole in her head' . Review of Resident #65's quarterly MDS dated [DATE], showed the resident had moderately impaired cognitive status with no behaviors documented. Review of Resident #65's Physician's Notification Progress Note dated 5/3/2021, showed Resident #65 was involved in a resident to resident altercation with Resident #30. Resident #65 had been sitting in a wheelchair while Resident #30 was pushing the wheelchair back and hitting resident #65 on top of the head. Review of Resident #65's Psychiatric Evaluation dated 5/4/2021, showed .patient was involved in an incident with another resident since that time she had increased anxiety and delusions. Increasing distress reasonable to restart as needed [MEDICATION(S)] [a medication used for anxiety] as well as increase [MEDICATION(S)] [an anti-psychotic medication] to target delusions . Review of Resident #65's Physician's Progress Note dated 5/4/2021, showed .The patient was a victim of the resident on the resident violence earlier in the week .The patient's been very anxious since that time . Further review showed Resident #30 had come up behind Resident #65 and hit her on the top and side of the head .This incident unfortunately set off exacerbation of patient's underlying anxiety disorder To become increasingly anxious and avoids individuals when moving about the community in her wheelchair . Review of Resident #65's Medication Administration Progress Note dated 5/4/2021, showed the resident was crying and stating I'm not going up there referring to her room. The resident was administered a dose of [MEDICATION(S)] 2mg. Review of Resident #65's Psychotherapy Progress Note dated 5/6/2021, showed Resident #65 was quite distressed. She had been hit by another resident .stating she was distressed, and she asked if she could be sent to a psychiatric unit .the patient stating she is having hallucinations was significant this time, and having them directly after a significant stressor (being attacked by another patient) is highly consistent with the literature on [CONDITION(S)], as opposed to a manipulative quality. The patient was crying, and insistent on being considered for evaluation outside of the facility . Further review showed her request was discussed with the staff and the resident was to be sent out for evaluation the next morning. Review of Resident #65's medical record showed she was sent out to a hospital on 5/7/2021 and returned to the facility on [DATE]. Medical record review showed Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #45's 5 day MDS dated [DATE], showed the resident had moderate cognitive impairment with no behaviors noted. Review of Resident #45's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .Resident [Resident #30] placed her right hand on the left side of the patient's [Resident #45] neck and held it .The patient [Resident #45] stated she turned and tried to push the arm away but it was very stiff .Ultimately she got the hand removed .Event was unprovoked . During an interview on 7/7/2021 at 2:34 PM, the Assistant Director of Nursing (ADON) confirmed there had been no investigation completed related to the resident to resident altercation between Resident #30 and Resident #65 that occurred on 5/3/2021. During an interview on 7/7/2021 at 2:37 PM, the Administrator stated the resident to resident altercation that occurred between Resident #30 and Resident #65 on 5/3/2021 was not considered to be abuse by the facility .those were behaviors . She stated both residents had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the IDT (Interdisciplinary Team) discusses any resident to resident altercations and decides if they should be investigated as an abuse allegation. She confirmed the facility felt this was not abuse but just a behavior and it had not been investigated. The Administrator stated the facility would only do a full abuse investigation if they decided it was abuse and not a behavior. During an interview on 7/8/2021 at 10:21 AM, CNA #2 stated she had been at the nurse's station on 5/3/2021. Resident #30 was walking near Resident #65 and they had started to argue. CNA #2 then went to do .something . down the hallway without intervening. When she returned to the nurse's station, CNA #3 reported to her that Resident #30 had hit Resident #65. During an interview on 7/8/2021 at 10:33 AM, CNA #3 stated on 5/3/2021 she was in a room on the 300 hallway when she heard Resident #65 .screaming bloody murder . She came out into the hallway and saw Resident #30 and Resident #65 close to the nurse's station and Resident #30 was .tapping . Resident #65 on the head. CNA #3 stated she separated the residents and Resident #30 then .wandered off . CNA #3 stated Resident #65 .freaks out .says she has water on the brain and that could hurt her . During an interview on 7/8/2021 at 1:31 PM, the ADON stated the facility considers abuse to be a purposeful and willful physical act toward another such as punching, hitting, kicking, and the resident must have the comprehension and knowledge of what they are doing. She stated the IDT team reviews resident to resident altercations and reviews the resident's history of behaviors, diagnoses, and the causative factors. She stated the facility's standard is if a resident had Brief Interview for Mental Status (BIMS) score of 8 (a score of 8-12 indicates moderately impaired cognitive status, a score of 13-15 indicates cognitively intact) or above, that they know what is going on and are able to make their own decisions. The ADON stated each resident to resident altercation depended on what the situation was and whether an incident would be investigated as abuse. The ADON stated staff are trained to report all incidents and then the IDT team would complete an Incident and Accident (I&A) report. The I&A report would be reviewed by the IDT team and a decision would be made as to whether an abuse investigation needed to be completed. She confirmed all resident to resident altercations would not be investigated as potential abuse. She stated Resident #65 had been having behaviors on 5/3/2021 and had been going through the hallway .crying and screaming . She stated it had been reported to her that Resident #30 approached Resident #65 and .it was more of a tap . She further stated both residents were .very behavioral . and the altercation had not been investigated as an allegation of abuse. The ADON confirmed Resident #30 had made willful physical contact with Resident #65 on 5/3/2021. During an interview on 7/9/2021 at 1:40 PM, the Psychiatric NP stated she was aware of the resident to resident altercation between Resident #30 and Resident #65 that occurred on 5/3/2021. The Psych NP confirmed the altercation did trigger some increased anxiety for Resident #65 and psychosocial harm. During an interview on 7/9/2021 at 2:19 PM, the Medical Director (MD) stated he was aware of Resident #30's wandering into other resident's rooms and stated .she has bumped into a few folks along the way . The MD confirmed Resident #30's continued wandering did increase the risk of another resident to resident altercation. He stated the resident to resident altercation that occurred between Resident #30 and Resident #65 .really set off [Resident #65's] anxiety .caused a significant amount of anxiety . He further confirmed the incident had caused Resident #65 to have psychosocial harm and there was a continued risk to other residents due to Resident #30's continued wandering. Refer to F-600 An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received 7/12/2021 at 8:40 AM, and the corrective actions were validated on-site by the surveyors on 7/12/2021-7/13/2021 through review of documents, review of facility policies, and staff interviews. The Removal Plan presented to the survey team by the facility documented the following immediate corrective actions implemented. On 7/10/2021 the Regional Director of Operations provided training to the Administrator, Assistant Director of Nursing, Nursing Educator, Unit Manager, MDS Coordinator, Medical Records, Social Services, Director of Rehab, Dietary, Admissions Liaison, and Human Resources. The training included: 1. the Abuse policy 2. types and reporting and investigating and prevention of abuse 3. process of identifying, preventing, and reporting abuse 4. how to recognize a potential behavior that is escalating, and to intervene 5. who is the Abuse Coordinator 6. suspected or observed abuse, all types, reported to the Administrator immediately All staff not working on 7/10/2021 were called and in-serviced. On 7/10/2021 the Administrator was in-serviced by the Regional Director of Operations on how to identify, report, and investigate potential allegations of abuse. All residents with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interviewable residents were interviewed by the Social Service Director on any concerns related to abuse. Residents that were not interviewed had a skin assessment completed by the ADON and Unit Manager on 7/10/2021. The Regional Director of Clinical services reviewed the last 72 hours of nursing notes to identify any issues that needed to be investigated as an allegation with no issues identified. On 7/10/2021 the Nurse Educator, Director of Rehab, and Human Resources educated staff. The training included: 1. how to recognize potential behavior that is escalating and to intervene 2. who the abuse coordinator is- the Administrator 3. suspected or observed abuse 4. all types reported to the Administrator immediately All staff not working on 7/10/2021 were called and in-serviced. On 7/11/2021 all staff started competency tests on Hand-in-Hand Dementia module part 1 & 2, abuse prevention, reporting, and investigating test. Audits will be conducted by the Administrator and Director of Nursing (DON) of nursing notes for the past 24 hours to identify any potential reportable events. These audits will be performed 5 times per week for 4 weeks, 3 times per week for 4 weeks, and 2 times per week for 4 weeks. Five random residents will be interviewed daily to ensure no resident to resident and no incidents of other residents wandering into their rooms by Social Services. A Licensed Nurse will do 5 skin sweeps 5 times per week for 4 weeks, 3 times per week for 4 weeks, and 2 times per week for 4 weeks on residents who are not interviewable. The Regional Director of Clinical Services will monitor nursing notes written in the past 24 hours to identify any areas that potentially could be a reportable event 5 times per week for 4 weeks, 3 times per week for 4 weeks, and 2 times per week for 4 weeks. The Nurse Educator will track the interviews and skin sweeps, a reportable event log will be maintained in the Administrators office. Residents with behaviors/Dementia care plans were reviewed and updated on 7/10/2021 by the MDS Nurse and Social Services to reflect resident specific interventions for behaviors. Nursing staff were interviewed by the ADON and the Unit Manager to identify any new behaviors observed and/or exacerbations on 7/10/2021, no issues were identified. The Regional Director of Nursing reviewed the past 72 hours of nursing documentation for new and/or exacerbations of behaviors on 7/10/2021, no issues identified. On 7/10/2021 the Regional Director of Nursing Services in-serviced the ADON, Unit Manager, Social Services, MDS Coordinator, and Activities Director on behavioral management policy including: 1. Making resident care plans specific to their behaviors with interventions 2. how to recognize potential behaviors that is escalating and to intervene On 7/10/2021 the Regional Director of Clinical Services in-serviced the Administrator, ADON, Nursing Educator, Unit Manager, MDS Coordinator, Medical Records, Social Services, Director of Rehab, Dietary, Admission Liaison, and Human Resources on behavior management including: how to recognize a potential behavior that is escalating and to intervene All staff not present on 7/10/2021 were called and in-serviced by the Nurse Educator. No employee will work prior to being trained. Future employees will be educated on hire regarding behavioral management and care plan revisions as it relates to resident specific interventions and including how to recognize a potential behavior that is escalating and to intervene. Audits will be performed by the DON/designee of progress notes to identify any potential new or exacerbations of behaviors 5 times per week for 4 weeks, 3 times per week for 4 weeks, and 2 times per week for 4 weeks. The Nurse Educator will perform behavior management training monthly for 6 months using Hand-in-Hand. The Kardex's will be printed from Point Click Care and updated to reflect the behavioral interventions that are resident specific, on 7/11/2021 by the ADON and Unit manager. The Regional Director of Clinical Services will monitor nursing notes written in the past 24 hours to identify any areas that potentially could be exacerbated behaviors 5 times per week for 4 weeks, 3 times per week for 4 weeks, and 2 times per week for 4 weeks. Changes to a behavior care plan or development by the IDT team will be reviewed by the Administrator to ensure it is resident specific as updates occur. The comprehensive care plan development is overseen by the MDS Coordinator with input from Social Services, Activities, Dietary, and Rehab. Revisions to the behavioral care plan is the responsibility of the Social Services. Nursing Care plan updates are the responsibility of Licensed Nurses, Unit Manager, ADON, and the DON. The QAPI committee will meet weekly to analyze all events that may require investigation and reporting. Weekly updates will be provided by responsible members on the progress of each citation. The Regional Director of Nursing and/or the Regional Vice President of Operations will attend QAPI meetings in person or by phone. This will include input and review of data collected for the meeting. The Regional Director of Nursing and/or Regional Vice President of Operations will do facility visits to monitor compliance at a minimum weekly until substantial compliance is achieved and maintained. On 7/12/2021, Surveyors reviewed the abuse policy which included investigating and reporting of abuse. The surveyors reviewed education and sign in sheets which validated the corrective action plans onsite which was provided by the Administrator. The documentation showed all staff working on 7/12/2021 and 7/13/2021 had been provided the education on abuse, types of abuse, preventing, protecting, recognizing/identifying abuse/behaviors, reporting, and investigating abuse. The Administrator was educated on abuse by the corporate nurse. Residents affected by the wandering residents were assessed and interviewed to determine if psychosocial harm had occurred. Twenty-two resident records were reviewed randomly to ensure care plans had been updated and Dementia care had been added to those with Dementia and behaviors. The records had been updated to include interventions on the 22 resident records reviewed. The surveyors validated all staff working on 7/12/2021-7/13/2021 had been educated and were knowledgeable about the new procedures related to abuse/behavior, Dementia Care, and person-centered care planning. On 7/12/2021, Surveyors validated the corrective actions onsite through interviews with the Administrator, DON, Nurse Educator, MDS Coordinator, Social Service Director, 4 RNs, 2 LPN's, 8 CNA's, 2 nurse aides in training, 2 therapists and 2 housekeepers. The interviews showed the staff were educated on how to prevent abuse, what to do when abuse occurs, reporting of abuse to the administrator immediately, investigating all allegations of abuse, documentation, and implementing person centered care plans for each resident with Dementia and behaviors. Staff verbalized knowledge of development of care plans for Dementia and behaviors and how to assess residents to determine person centered needs/interventions. Interview with the Administrator confirmed she would initiate and oversee the abuse investigations. Noncompliance at F-610 continues at a scope and severity of F for monitoring of the effectiveness of the corrective actions to ensure sustained compliance. The facility is required to submit a plan of correction.

Based on facility policy review, medical record review, observation, and interview, the facility failed to prevent and protect 2 residents (Resident #65 and #45) from abuse of 16 residents reviewed for abuse. The facility's failure to ensure interventions were implemented to prevent continued wandering of Resident #30 in and out of other residents' rooms and the failure of a Certified Nursing Assistant (CNA) to separate Resident #30 and Resident #65 when she overheard them arguing in the hallway, with Resident #30 hitting Resident #65 in the head, resulted in psychosocial harm to Resident #65. Resident #30 continued to wander throughout the facility, in and out of other residents' rooms, then entered Resident #45's room, attempted to choke her, and stated she would kill her. The facility's failure to prevent abuse by Resident #30 placed Resident #65 and Resident #45 in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements for participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The facility's failure to implement interventions to address Resident #30's wandering and aggressive behaviors had the potential to affect all residents in the facility. The Administrator was informed of the Immediate Jeopardy (IJ) in the conference room on 7/10/2021 at 12:50 PM. The facility was cited F-600 at a scope and severity of L which constitutes Substandard Quality of Care. The Immediate Jeopardy was removed onsite 7/12/2021 and was effective 5/3/2021-7/11/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 7/12/2021 at 8:40 AM and the corrective actions were validated onsite by the surveyors on 7/12/2021 and 7/13/2021. The findings include: Review of the facility's policy titled, Freedom of Abuse, Neglect and Exploitation Standard, revised 11/2019, showed .The purpose of this written Freedom of Abuse, Neglect, Exploitation Standard is to outline the prevention and action steps taken to reduce the potential for abuse, mistreatment and neglect of residents .and to review practices and omissions which if allowed to go unchecked, could lead to abuse .The scope of this program shall apply to the prevention of an abuse committed by anyone including .Residents .This facility shall not condone any acts of resident mistreatment .physical and/or mental abuse .by any .other residents .preventative steps will be taken to reduce the potential for such occurrences .Appropriate interventions to deal with aggressive reactions of residents .How CMS [Centers for Medicare and Medicaid Services] defines abuse .Identifying what constitutes abuse .Recognizing signs of abuse .Dementia Management .Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect such as .Aggressive and/or catastrophic reactions of residents .Wandering or elopement-type behaviors .Outburst or yelling out .Identifying, correcting and intervening in situations in which abuse .is more likely to occur .assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms .The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict .Train staff in appropriate interventions to deal with aggressive and/or catastrophic reactions by residents .Observe resident behaviors and their reaction to other residents .React to all allegations or questions of abuse by residents .Take appropriate actions when abuse .is suspected .Assess, monitor and develop appropriate plans of care for residents with needs and behaviors which might lead to conflict .such as residents with a history of aggressive behaviors, residents who have behaviors such as entering other resident's rooms . Medical record review showed Resident #30 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #30's comprehensive care plan dated 4/13/2021, showed .elopement risk/wanderer AEB [as evidenced by] History of attempts to leave facility unattended, she refuses to wear socks and shoes, she becomes aggressive/combative with other residents at times, she goes in and out of residents rooms, needs frequent redirection .Distract her from wandering by offering pleasant diversions, structured activities, food, conversation, television, book .Monitor location every shift. Document wandering behavior and attempted diversional interventions in behavior log . Review of Resident #30's Plan of Care Progress Note dated 4/14/2021, showed .Patient has been going in and out of other resident rooms .difficult to get vital signs, redirection . Review of Resident #30's Respiratory Evaluation Progress Note dated 4/15/2021, showed .Resident is currently experiencing unwanted behavior(s). Chronic disruptive behavior noted. Chronic wandering behavior noted. Resident wanders at night . Review of Resident #30's admission Minimum Data Set (MDS) dated [DATE], showed the resident had severe cognitive impairment and had wandered 1-3 days during the assessment period. Resident #30 required supervision to walk in the room and hallways with no use of mobility devices. Review of Resident #30's Care Plan showed an update on 4/21/2021, .Requires assistance to participate in activities .we will continue to invite to activities & [and] 1'1 [one on one activities] as needed . Review of Resident #30's QAPI (Quality Assurance and Performance Improvement)/Risk Meeting Progress Note dated 5/3/2021 at 1:52 PM, showed .Resident remains a wandering risk with behaviors present. Close monitoring provided by staff. IDT [Interdisciplinary Team] will continue to monitor for effective/appropriateness of interventions and intervene accordingly . Review of Resident #30's Physician Notification Progress Note dated 5/3/2021 at 5:16 PM, showed .Staff reported to this nurse an Resident to resident altercation. [Resident #30] who was hitting [Resident #65] on the head and pulling her wheelchair back, [Resident #65] was screaming for Help . Review of Resident #30's Medication Administration Progress Note dated 5/3/2021 at 9:05 PM, showed Resident #30 was sent to the hospital for evaluation after the incident .resident out of facility to hospital . Review of Resident #30's hospital documentation dated 5/3/2021, showed .PT [patient] SENT FROM [name of facility] AFTER HITTING A RESIDENT. PT SENT HER [here] FOR A MENTAL EVALUATION AND HAS A DX [diagnosis] OF DEMENTIA .sent here for mental eval [evaluation] as she apparently hit another resident at the nursing home today . Review of Resident #30's Risk Meeting Progress Note dated 5/4/2021, showed .IDT will continue to monitor for effective/appropriateness of interventions and intervene accordingly. IDT met, reviewed, discussed, and in agreement . Review showed no additional interventions were implemented after the resident-to-resident abuse on 5/3/2021. Review of Resident #30's Plan of Care Progress Note dated 5/4/2021 at 11:14 AM, showed .Resident returned to facility at 0630 [6:30 AM] via [by] stretcher with no new orders received . Review of Resident #30's Risk Meeting Note dated 5/4/2021, showed .Resident to Resident [altercation] occurred on 05.03.21 @ [at] 1659 [4:59 PM]. This is Resident [Resident #30] and the aggressor - [Resident #30] was in a central location of hallway holding resident [Resident #65's] wheelchair and pulling the w/c [wheelchair] backwards with [Resident #65's] foot in the wheel of the chair. [Resident #30] hit [Resident #65] on top of the head several times. [Resident #65] started screaming for help. [Resident #30] was redirected successfully. [Resident #30] was unable to give description. [Resident #65] stated 'I was just sitting in my chair when all of a sudden [Resident #30] started hitting me on top of the head and pulling my w/c [wheelchair] backwards'. Called the psych [psychiatric] NP [Nurse Practitioner] and new orders received to send [Resident #30] to .ER [emergency room ] for psychiatric evaluation and treatment .Monitor resident's location and activity q [every] 15 minutes and document x [for] 72 hours. Maintain personal space of comfort for other residents x 72 hours and then re-evaluate . Review of Resident #30's Physician's Progress Note dated 5/4/2021, showed .This person [Resident #30] began hitting the other resident [Resident #65] on her head and pulling .wheelchair back .The other resident was screaming for help .Mental health nurse practitioner was notified and responded with an order to send the patient [Resident #30] to the emergency department for evaluation . Review of Resident #30's Psychiatric Evaluation dated 5/4/2021, showed .Evaluating mood and behaviors-patient having increased agitation, restlessness, aggression. Was sent out to ER for emergency eval [evaluation] and was returned without medication changes. Patient having increased [CONDITION(S)] and delusions, reasonable to add [MEDICATION(S)] [an anti-psychotic medication] to target symptoms .Agitation: Physical aggression .Combativeness .Severe restlessness .Recommendations: [MEDICATION(S)] 25 mg [milligrams] bid [twice daily] delusions . Review of Resident #30's Behavior Note/Anxiety Progress Note dated 5/5/2021, showed .Resident wandering through out facility this shift. Entering residents' room and nurses' station. Becomes agitated with redirection, but generally will redirect . Review of Resident #30's Room Change Progress Note dated 5/5/2021, showed Resident #30 was involved in a .a resident to resident altercation . and the facility moved Resident #30 to a room on a different hall. Review of Resident #30's Behavior Note/Anxiety Progress Note dated 5/5/2021, showed .Resident continues to wander facility .Resident continues 15 minute checks . Review of Resident #30's Psychological Diagnostic Interview dated 5/6/2021, showed Resident #30 was referred by the Medical Director (MD) on 5/6/2021 to be seen by the Psychologist .Patient was shut down and even appeared angry .walked directly into another patient's room after leaving this area . patient is dismissive, has poor contract and seems angry . Review of Resident #30's Behavior Note/Anxiety Progress Note dated 5/20/2021, showed .Resident frequently walks throughout the building and goes into offices and just sits down. She tells other residents what to do. She shakes her head and gets upset when things don't go her way .Psych to be notified immediately per SS [social services] due to increased behaviors . Review of Resident #30's Behavior Note/Anxiety Progress Note dated 5/20/2021, showed .Resident wonders [wanders] the halls. Resident frequently goes into other Resident's [residents'] rooms and takes belonging, drinks, food, etc. Resident has been involved in a couple of verbal arguments with other residents . Review of Resident #30's Social Service Progress Note dated 5/20/2021, showed the Director of Social Services (DSS) documented .Resident exhibiting inappropriate behaviors .Discussed in team meeting this a.m. called and left a message with psych NP to assess for any needed medications . Further review showed no further recommendations or interventions were implemented. Review of Resident #30's Behavior Note/Anxiety Progress Note dated 5/21/2021, showed .entering other Residents [residents'] rooms taking items, food, etc. that doesn't belong to her. Resident tried to take a drink away from another Resident because she thought it was hers . Review of Resident #30's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #30's medical record showed no documentation the resident's location and activity had been monitored every 15 minutes for the dates of 5/4/2021-5/7/2021. Review of Resident #30's Behavior Note/Anxiety Progress Note dated 6/4/2021, showed .Resident continues to wander the halls, but is increasingly more intrusive into other Resident rooms. Resident enters every room and takes items and hides them. Resident upsets other Residents with her actions. Resident also pushes other Residents in their wheelchair around the halls. Resident takes a quite a bit of time to manage . Review of Resident #30's Social Service Progress Note dated 6/8/2021, showed .Resident displaying inappropriate behaviors, shopping in rooms, grabbing things out of residents hands, hard to redirect .Contacted psych NP to assess for any medication changes . Further review showed no additional recommendations or interventions were implemented. Review of Resident #30's Behavior Note/Anxiety Progress Note dated 6/30/2021, showed .Resident continues to wander this shift. Resident wandering into other resident rooms, causing distress to other residents. Resident also taking things from nurses [nurses'] station, and other residents .Attempts to redirect unsuccessful . Review of Resident #30's Behavioral Note/Anxiety Progress Note dated 7/5/2021, showed .Resident continues to wander this shift. Resident wandering into other resident rooms causing distress to other residents. Resident is also taking things from nurses [nurses'] station, med carts, and other residents rooms. PRN's [as needed medications] unsuccessful. Attempts to redirect are unsuccessful . Medical record review showed Resident #65 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #65's comprehensive care plan dated 11/20/2020, showed .behavior problem .has attention seeking behaviors as evidenced by often becoming tearful for no particular reason .states she has a 'hole in her head' .intervene as necessary to protect the rights and safety of others .Divert Attention. Remove from situation and take to alternate location as needed . Review of Resident #65's quarterly MDS dated [DATE], showed Resident #65 had moderately impaired cognitive status, the resident was independent for locomotion on the unit, and used a wheelchair for mobility. No behaviors were documented, and no wandering was documented. Review of Resident #65's Physician's Notification Progress Note dated 5/3/2021, showed .Resident to Resident altercation. This is [Resident #65] sitting in wheelchair while [Resident #30] was pushing wheelchair back and hitting [Resident #65] on top of head. Residents redirected with success . Review of Resident #65's Psychiatric Evaluation dated 5/4/2021, showed .Evaluating mood and behaviors-patient was involved in an incident with another resident since that time she had increased anxiety and delusions. Increasing distress reasonable to restart as needed [MEDICATION(S)] [a medication used for anxiety] as well as increase prn to target delusions . Review of Resident #65's Physician's Telephone Order dated 5/4/2021, showed .increase [MEDICATION(S)] 25 mg [milligrams] po [by mouth] BID [twice daily] .[MEDICATION(S)] 2 mg po BID PRN x [for] 14 days for anxiety . Review of Resident #65's Physician's Progress Note dated 5/4/2021, showed .The patient was a victim of the resident on the resident violence [with Resident #30] earlier in the week .The patient's been very anxious since that time .The patient reports the other individual [Resident #30] came up from behind her and grabbed and hit her right parietal [top of head] and temporal [side of head] area .This incident unfortunately set off exacerbation of patient's underlying anxiety disorder To become increasingly anxious and avoids individuals when moving about the community in her wheelchair . Review of Resident #65's Medication Administration Progress Note dated 5/4/2021, showed the resident had received a dose of [MEDICATION(S)] 2mg .Resident in hall crying, repeatedly saying 'I'm not going up there' referring to her room . Review of Resident #65's Behavior Note/Anxiety Progress Note dated 5/5/2021, showed .Earlier in shift, crying, stating 'I'm not going up there' pointing towards room. I'm scared'. Resident reassured, but still expressed some concern. PRN anti-anxiety administered, and resident transferred to room on another hall and is resting in bed with eyes closed . Review of Resident #65's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The [MEDICATION(S)] was administered 2 times on 5/4/2021 and 1 time on 5/5/2021. Review of Resident #65's Psychotherapy Progress Note dated 5/6/2021, showed .The patient was quite distressed. She was hit recently by another patient [Resident #30] and her room was moved. The patient approached the clinician stating she was distressed, and she asked if she could be sent to a psychiatric unit .the patient stating she is having hallucinations was significant this time, and having them directly after a significant stressor (being attacked by another patient) is highly consistent with the literature on [CONDITION(S)], as opposed to a manipulative quality. The patient was crying, and insistent on being considered for evaluation outside of the facility. The clinician discussed this with the staff, who stated that they would send her in the morning as resources would be more supportive . Review of Resident #65's Progress Note dated 5/7/2021, showed .Resident at [name of hospital] for screening before going to [name of hospital] for psych eval . Review of Resident #65's Admission Summary Progress Note dated 5/10/2021, showed .Resident readmitted . Observation on 7/6/2021 at 12:15 PM, showed Resident #30 entered room [ROOM NUMBER]. A CNA was in the room setting up a lunch tray and redirected the resident out of the room and she wandered down the hallway. Observation on 7/6/2021 at 2:46 PM, showed Resident #30 entering room [ROOM NUMBER] (another resident's room) while a CNA was in the room. The CNA redirected the resident to exit the room. During an interview on 7/6/2021 at 2:55 PM, CNA #1 stated Resident #30 did wander frequently and did go into other residents' rooms. She stated Resident #30 would take other residents' water pitchers. CNA #1 stated if Resident #30 was noticed in another room, the staff would cue her to come out of the room. She stated .there's not much we can do .I have suggested putting up stop signs on the doors but we would have to put them on every door because you never know which room she will go in . Observation on 7/6/2021 at 2:59 PM, showed Resident #30 wandering in the 400 hallway. She attempted to open the door to room [ROOM NUMBER] (another resident's room) but did not go in. She then went to the 100 hallway and attempted to open the double doors. Resident #30 then wandered to the nurse's station, walked past a nurse seated at the nurse's station, opened the door to the Unit Secretary's office, and entered the office. She picked up a notebook from the Unit Secretary's desk, walked past the nurse seated at the nurse's station, and went down the 300 hallway. During an interview on 7/7/2021 at 2:07 PM, the Director of Social Services (DSS) stated Resident #30 had been in a resident-to-resident altercation with Resident #65. She stated Resident #30 had been moved to a different room. She stated that Resident #65 had .psych issues . and .doesn't like to be touched . She stated after the incident on 5/3/2021, Resident #65 .became fearful .crying . The DSS stated Resident #30 goes in and out of resident rooms and .that's a problem .there is only so much medication you can mess with .we pretty much let her wander and redirect her . She further stated the interventions the facility had in place to prevent Resident #30's wandering behavior was .redirecting and put stop signs on some residents' rooms that she has a fondness to go into .the residents that complain . The DSS confirmed Resident #30 would wander into resident rooms, offices, and nurse's stations, and she had been informed that some residents had stated they had belongings that were missing. Medical record review showed Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #45's comprehensive care plan dated 3/23/2021, showed Resident #45 had a potential for impaired cognitive function related to confusion, with an update on 7/9/2021 for .stop sign to doorway to prevent other residents from entering resident's room- Monitor Stop Sign every 15 minutes for placement . Review of Resident #45's 5-day MDS dated [DATE], showed the resident had moderate cognitive impairment, no behaviors noted, she was totally dependent on staff for bed mobility and transfers, did not walk, used a wheelchair for mobility, and used oxygen daily. Review of Resident #45's Plan of Care Progress Note dated 7/7/2021, showed .Resident is A&O [alert and oriented] x 3 [person, place, time]. speech clear and able to make needs known . Review of Resident #45's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #30] supervised the patient [Resident #45] while she was lying on her left resting .Resident [Resident #30] placed her right hand on the left side of the patient's [Resident #45] neck and held it .The patient [Resident #45] stated she turned and tried to push the arm away but it was very stiff .Ultimately she got the hand removed .Event was unprovoked . Review of Resident #30's Physician's Progress Note dated 7/8/2021, showed .Yesterday this patient went into another resident's room [Resident #45] and placed her hand about the residents [resident's] neck making the resident [Resident #45] think she was being choked .Patient [Resident #30] had wandered into the residents [resident's] room [Resident #45] .Frequently up and about the building, restless .Eventually the patient [Resident #45] is able to push the hand away from her neck .PLAN .Mental health consult .One-on-one observation if available . Review of a facility witness statement given by Certified Nursing Assistant (CNA) #5, undated, showed .[Resident #45] stated she was sleeping, and thought was one of us shaking her awake. But it was [Resident #30] standing over her. She claimed [Resident #30] had her hands around her neck and told her she would hurt her/die . The facility's video surveillance footage for 7/8/2021 beginning at 5:46 AM was reviewed on 7/13/2021 at 1:49 PM, with the Administrator and the Plant Operations Manager present. The footage of the 300 hallway on 7/8/2021 showed Resident #30 at the end of the 300 hallway at 5:46:14 AM, she went to the linen cart at 5:47:24 AM. CNA #4 exited the shower room with another resident at 5:47:44 AM. Resident #30 walked past the other resident in the hallway who just came out of the shower room, and CNA #4 walked toward the nurses station away from the resident. Resident #30 stood by the shower room for several seconds then entered room [ROOM NUMBER] at 5:48:00 AM, and came back out of room [ROOM NUMBER] at 5:48:27 AM. Resident #30 then entered Resident #45's room at 5:48:31 AM. CNA #4 exited another resident's room at 5:48:42 AM. Resident #30 exited Resident #45's room at 5:49:05 AM. Resident #30 then entered another resident's room at 5:49:41 AM. Resident #45's roommate was seen walking in the hallway toward her room at 5:51:17 AM and entered the room at 5:51:39 AM (she had not been in the room while Resident #30 was in the room with Resident #45). Observation on 7/8/2021 at 7:45 AM, showed Resident #30 wandering on the 200 hallway, she entered another resident's room at the end of the 200 hallway. During an interview on 7/8/21 at 8:11 AM, Resident #40 stated Resident #30 would often wander into her room .we [Resident #40 and Resident #43] are afraid she will come in the middle of the night with a knife and stab us .you never know what someone might do .she [Resident #30] has tried to get in my roommate's bed . Resident #40 stated she had reported it to all the nurses and her roommate had made a complaint. During an interview on 7/8/2021 at 8:27 AM, Licensed Practical Nurse (LPN) #2 confirmed she had been assigned to Resident #30 and Resident #65 on 5/3/2021, the day of the altercation between the 2 residents. A CNA had reported the altercation to her. LPN #2 stated Resident #65 .was distraught and upset .crying .tearful . LPN #2 stated she tried to console her. LPN #2 stated both residents (#30 and #65) had rooms on the 300 hallway, but Resident #30 had been moved to the 400 hall after the altercation. LPN #2 confirmed Resident #30 had wandered into other residents' rooms prior to the incident, the staff try to redirect her, and use stop signs on the doors of some residents, but she was unsure which residents were supposed to have stop signs. Observation on 7/8/2021 at 8:30 AM, showed Resident #30 continued to wander on the 200 hallway. She entered another resident's room. Observation on 7/8/2021 at 8:45 AM, showed Resident #30 wandering by the nurse's station and started down the 300 hallway carrying a folded tablecloth. During an interview on 7/8/2021 at 9:13 AM, Resident #43 stated .that crazy one [Resident #30] comes in my room . Resident #43 stated she finally .ran crying to a nurse and she helped me file a grievance . During observation on 7/8/2021 at 9:22 AM, there was not a stop sign on Resident #43's door. During an interview on 7/8/2021 at 9:32 AM, Registered Nurse (RN) #2 stated a few days after Resident #30 was admitted to the facility, she had approached Resident #65 in the hallway as if she had recognized her saying .there you are . Resident #65 had told Resident #30 to get away from her because there was a pandemic. On 5/4/2021, after Resident #30 hit Resident #65 on the head and pulled her in the wheelchair on 5/3/2021, RN #2 was in the 300 hallway by the medication cart. Resident #65 approached her and stated she needed to go to the bathroom but was afraid to go in her room alone. The RN assisted her to the bathroom, got her a few outfits, and let her sleep in a different room for the night. RN #2 stated Resident #65 just spent the night in the other room to .ease her anxiety . RN #2 confirmed Resident #30 would wander into other residents' rooms. RN #2 stated the facility had put stop signs up for the rooms .we find may be an issue . but she was not sure which residents were supposed to have stop signs on their doors. RN #2 stated the staff monitor Resident #30 and try to redirect her but was unaware of any other interventions the facility had implemented to prevent Resident #30 from wandering. During an interview on 7/8/2021 at 10:21 AM, CNA #2 stated that she had been at the nurse's station on 5/3/2021. Resident #30 was walking near Resident #65. Resident #65 did not want Resident #30 near her, and they had started to argue. CNA #2 then went to do .something . down the hallway without intervening. When she returned to the nurse's station, CNA #3 reported to her that Resident #30 had hit Resident #65. CNA #2 stated Resident #30 would wander into other residents' rooms and some residents did complain. CNA #2 stated Resident #65 had complained that Resident #30 would go into her room and go through her stuff. CNA #2 stated she had reported the complaints to a nurse, there .really wasn't anything we could do . CNA #2 stated the staff would redirect the resident but was not made aware of any other interventions to prevent Resident #30 from wandering into other residents' rooms. During an interview on 7/8/2021 at 10:33 AM, CNA #3 stated on 5/3/2021, she was in a room on the 300 hallway when she heard Resident #65 .screaming bloody murder . She came out into the hallway and saw Resident #30 and Resident #65 close to the nurse's station and Resident #30 was .tapping . Resident #65 on the head. CNA #3 stated she separated the residents and Resident #30 then .wandered off . CNA #3 stated Resident #65 .freaks out .says she has water on the brain and that could hurt her . CNA #3 stated Resident #30 would wander into other residents' rooms. She stated Resident #41 had complained about her being in his room and Resident #46 had a stop sign on her door to prevent Resident #30 from going into her room. CNA #3 stated she would provide redirection but was unaware of any other interventions, including diversional activities, the staff were to use to prevent wandering. During an interview on 7/8/2021 at 11:04 AM, Resident #41 stated he turns his call light on when other residents wander into his room so staff will come remove them. He stated on one occasion, a resident had wandered into the room during a window visit with his family member. The resident .grabbed my wheelchair and pulled me backwards . He stated he was unable to reach his call light on that day and he had to yell out for help to come. During an interview on 7/8/2021 at 11:10 AM, Resident #46 stated in the past, she has had a woman come into her room and woke her up. Resident #46 stated that she did not know her name but said .she walks around the place all of the time . Resident #46 stated it made her feel uneasy because .you never know what she will do . During an interview on 7/8/2021 at 1:31 PM, the Assistant Director of Nursing (ADON) stated the facility considers abuse to be a purposeful and willful physical act toward another such as punching, hitting, kicking, and the resident must have the comprehension and knowledge of what they are doing. She stated the IDT (Interdisciplinary Team) team reviews resident to resident altercations and reviews the resident's history of behaviors, diagnoses, and the causative factors. She stated the facility's standard is if a resident had Brief Interview for Mental Status (BIMS) score of 8 (a score of 8-12 indicates moderately impaired cognitive status, a score of 13-15 indicates cognitively intact) or above, that the residents know what is going on and can make their own decisions. The ADON stated each resident-to-resident altercation depended on what the situation was and whether it was abuse. She stated Resident #65 had been having behaviors on 5/3/2021 and had been going through the hallway .crying and screaming . She stated it had been reported to her that Resident #30 approached Resident #65 and .it was more of a tap . She further stated both residents were .very behavioral . and the altercation had not been determined to be abuse by the facility. The ADON stated the facility had provided close monitoring of Resident #30, but she had the right to wander because the facility was her home. The ADON stated allegations of abuse would be reviewed by the IDT team and a decision would be made as to whether it met abuse. She stated all resident-to-resident altercations would not be determined to be abuse. The ADON confirmed it was her expectation for a staff member to intervene if 2 residents were seen/heard arguing and she had not been aware of the argument between Resident #30 and Resident #65 on 5/3/2021 that CNA #2 had witnessed prior to the altercation. The ADON confirmed Resident #30 had made willful physical contact with Resident #65 on 5/3/2021. The ADON confirmed Resident #30's wandering had been discussed in IDT meetings. The ADON stated she had suggested Resident #30 may need placement in a locked unit, but the IDT had stated the facility was able to meet the resi [TRUNCATED]

Based on review of facility policy, medical record review, and interview, the facility's Quality Assurance Performance Improvement (QAPI) program failed to identify a quality deficiency and implement interventions to address the root causes of a resident to resident altercation when Resident #30 hit Resident #65 in the head, which led to psychosocial harm to Resident #65.The facility's failure to investigate an instance of resident to resident abuse and to implement individualized, person-centered behavior interventions for Resident #30's continued wandering throughout the facility resulted in Resident #30 later entering Resident #45's room and placing her hands on the resident's neck and attempting to choke Resident #45. The facility's QAPI program's failure to identify, develop, and implement interventions to protect all residents from Resident #30's continued wandering and potential abuse placed all residents in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements for participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was informed of the Immediate Jeopardy (IJ) in the conference room on 7/10/2021 at 12:50 PM. The Immediate Jeopardy was removed onsite 7/12/2021 and was effective 5/3/2021 - 7/11/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 7/12/2021 at 8:40 AM and the corrective actions were validated onsite by the surveyors on 7/12/2021 and 7/13/2021. The findings include: Review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) dated 9/2019, revealed .Policy Explanation and Compliance Guidelines .Develop and implement appropriate plans of action to correct identified quality deficiencies. The facility will utilize Root Cause Analysis (RCA) and the Plan, Do, Study, Act (PDSA) cycle of improvement to improve existing processes. Chosen actions for change will be linked to the root causes and will be designed to effect change at the systems level . Medical record review showed Resident #30 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #30's admission Minimum Data Set (MDS) dated [DATE], showed the resident had severe cognitive impairment, and had wandered 1-3 days during the assessment period. Continued review showed Resident #30 required supervision to walk in the room and hallways with no use of mobility devices. Review of Resident #30's Physician Notification Progress Note dated 5/3/2021, revealed .Staff reported to this nurse an [a] Resident to resident altercation. This resident [Resident #30] who was hitting [Resident #65] on the head and pulling her wheelchair back .order to send to [local hospital] emergency room for psych eval [mental health evaluation] and treatment . Review of Resident #30's QAPI/Risk Meeting Progress Note dated 5/3/2021 at 1:52 PM, showed .Resident remains a wandering risk with behaviors present. Close monitoring provided by staff. IDT [Interdisciplinary Team] will continue to monitor for effective/appropriateness of interventions and intervene accordingly . Review of Resident #30's Risk Meeting Progress Note dated 5/4/2021, showed .IDT will continue to monitor for effective/appropriateness of interventions and intervene accordingly. IDT met, reviewed, discussed, and in agreement . Review showed no additional interventions were implemented after the resident-to-resident abuse on 5/3/2021. Medical record review of progress notes from 5/4/2021 - 7/5/2021 revealed Resident #30 wandered the facility daily, in and out of other resident rooms, and was frequently aggressive and combative with others. Review of Resident #30's Behavior Note/Anxiety Progress Note dated 7/5/2021 showed .Resident continues to wander this shift. Resident wandering into other resident rooms causing distress to other residents . Medical record review showed Resident #65 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #65's quarterly MDS dated [DATE], showed the resident had moderately impaired cognitive status, the resident was independent for locomotion on the unit, and used a wheelchair for mobility. No behaviors were documented, and no wandering was documented. Review of Resident #65's Physician's Progress Note dated 5/4/2021, showed .The patient was a victim of the resident on the resident violence earlier in the week .The patient's been very anxious since that time .The patient reports the other individual came up from behind her and grabbed and hit her right parietal and temporal area .This incident unfortunately set off exacerbation of patient's underlying anxiety disorder To become increasingly anxious and avoids individuals when moving about the community in her wheelchair . Medical record review showed Resident #65 experienced increased anxiety after the abuse by Resident #30 requiring medications to alleviate anxiety and an in-patient psychiatric stay from 5/7/2021 - 5/10/2021 to stabilize the resident. Medical record review showed Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of Resident #45's 5-day MDS dated [DATE], showed the resident had moderate cognitive impairment with no behaviors noted. She was total dependence for bed mobility and transfers, did not ambulate, used a wheelchair for mobility, and used oxygen daily. Review of Resident #45's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #30] supervised the patient [Resident #45] while she was lying on her left resting .Resident [Resident #30] placed her right hand on the left side of the patient's [Resident #45] neck and held it .The patient [Resident #45] stated she turned and tried to push the arm [Resident 30's arm] away but it was very stiff .Ultimately she got the hand removed .Event was unprovoked . Review of a facility witness statement given by Certified Nursing Assistant (CNA) #5, undated, showed .Resident stated she was sleeping, and thought was one of us shaking her awake. But it was [Resident #30] standing over her. She claimed [Resident #30] had her hands around her neck and told her she would hurt her/die . During an interview on 7/8/2021 at 2:11 PM, the Administrator stated the facility had not investigated the altercation between Resident #30 and Resident #65 as an abuse allegation. The Administrator stated she was unaware of the nurse's notes stating Resident #30 had wandered into other residents' rooms and caused distress to those residents. She further stated Resident #30 had .never harmed anyone .just wanders in the hallway . During an interview on 7/9/2021 at 5:12 PM, the Administrator stated the Interdisciplinary Team (IDT) reviewed the resident-to-resident altercation between Resident #30 and Resident #65 and stated the facility did not identify the altercation as abuse. She stated the resident-to-resident altercation was considered behaviors due to both residents' history and condition. She stated, I think we need more Dementia care training. The Administrator confirmed the resident-to-resident altercation was not identified as abuse, was not investigated as abuse, and was not reported to the State Agency. The Administrator stated there had been no other resident to resident altercations. The Administrator did not divulge any details for the incident of Resident #30 choking Resident #45. The QAPI committee had not identified the issue of resident wandering and how that led to the incidents of resident-to-resident abuse. Refer to F-600, F-609, F-610, F-741, and F-744 An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received 7/12/2021 at 8:40 AM, and the corrective actions were validated on-site by the surveyors on 7/12/2021-7/13/2021 through review of documents, review of facility policies, and staff interviews. The Removal Plan presented to the survey team by the facility documented the following immediate corrective actions implemented. On 7/10/2021 the Regional Director of Operations provided training to the Administrator, Assistant Director of Nursing, Nursing Educator, Unit Manager, MDS Coordinator, Medical Records, Social Services, Director of Rehab, Dietary, Admissions Liaison, and Human Resources. The training included: 1. the Abuse policy 2. types and reporting and investigating and prevention 3. process of identifying, preventing, and reporting abuse 4. how to recognize a potential behavior that is escalating, and to intervene 5. who is the Abuse Coordinator 6. suspected or observed abuse, all types, reported to the Administrator immediately All staff not working on 7/10/2021 were called and re-in-serviced. All residents with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interviewable residents were interviewed by the Social Service Director on any concerns related to abuse. Residents that were not interviewed had a skin assessment completed by the ADON and Unit Manager on 7/10/2021. The Regional Director of Clinical services reviewed the last 72 hours of nursing notes to identify any issues that needed to be investigated as an allegation with no issues identified. On 7/10/2021 the Nurse Educator, Director of Rehab, and Human Resources educated staff. The training included: 1. how to recognize potential behavior that is escalating and to intervene 2. who the abuse coordinator is- the Administrator 3. suspected or observed abuse 4. all types reported to the Administrator immediately All staff not working on 7/10/2021 were called and re-in-serviced. On 7/11/2021 all staff started competency tests on Hand-in-Hand Dementia module part 1 & 2, abuse prevention, reporting, and investigating test. Audits will be conducted by the Administrator and Director of Nursing (DON) of nursing notes for the past 24 hours to identify any potential reportable events. These audits will be performed 5x \week for 4 weeks, 3x\week for 4 weeks, and 2x\week for 4 weeks. 5 random residents will be interviewed daily to ensure no resident to resident and no incidents of other residents wandering into their rooms by Social Services. A Licensed Nurse will do 5 skin sweeps 5x\week for 4 weeks, 3x\week for 4 weeks, and 2x\week for 4 weeks on residents who are not interviewable. The Regional Director of Clinical Services will monitor nursing notes written in the past 24 hours to identify any areas that potentially could be a reportable event 5x\week for 4 weeks, 3x\week for 4 weeks, and 2x\week for 4 weeks. The Nurse Educator will track the interviews and skin sweeps, a reportable event log will be maintained in the Administrators office. Residents with behaviors/Dementia care plans were reviewed and updated on 7/10/2021 by the MDS Nurse and Social Services to reflect resident specific interventions for behaviors. Nursing staff were interviewed by the ADON and the Unit Manager to identify any new behaviors observed and/or exacerbations on 7/10/2021, no issues were identified. The Regional Director of Nursing reviewed the past 72 hours of nursing documentation for new and/or exacerbations of behaviors on 7/10/2021, no issues identified. On 7/10/2021 the Regional Director of Nursing Services re-inserviced the ADON, Unit Manager, Social Services, MDS Coordinator, and Activities Director on behavioral management policy including: 1.Making resident care plans specific to their behaviors with interventions 2. how to recognize potential behaviors that is escalating and to intervene On 7/10/2021 the Regional Director of Clinical Services re-inserviced the Administrator, ADON, Nursing Educator, Unit Manager, MDS Coordinator, Medical Records, Social Services, Director of Rehab, Dietary, Admission Liaison, and Human Resources on behavior management including : how to recognize a potential behavior that is escalating and to intervene All staff not present on 7/10/2021 were called and in-serviced by the Nurse Educator. No employee will work prior to being trained. Future employees will be educated on hire regarding behavioral management and care plan revisions as it relates to resident specific interventions and including how to recognize a potential behavior that is escalating and to intervene. Audits will be performed by the DON / designee of progress notes to identify any potential new or exacerbations of behaviors 5x/week x 4 weeks, 3x\week x4 weeks, and 2x\week x 4 weeks. The Nurse Educator will perform behavior management training monthly for 6 months using Hand-in-Hand. The Kardex's will be printed from Point Click Care and updated to reflect the behavioral interventions that are resident specific, on 7/11/2021 by the ADON and Unit manager. The Regional Director of Clinical Services will monitor nursing notes written in the past 24 hours to identify any areas that potentially could be exacerbated behaviors 5x/week x 4 weeks, 3x\week x4 weeks, and 2x\week x 4 weeks. Changes to a behavior care plan or development by the IDT team will be reviewed by the Administrator to ensure it is resident specific as updates occur. The comprehensive care plan development is overseen by the MDS Coordinator with input from Social Services, Activities, Dietary, and Rehab. Revisions to the behavioral care plan is the responsibility of the Social Services. Nursing Care plan updates are the responsibility of Licensed Nurses, Unit Manager, ADON, and the DON. The QAPI committee will meet weekly to analyze all events that may require investigation and reporting. Weekly updates will be provided by responsible members on the progress of each citation. The Regional Director of Nursing and /or the Regional Vice President of Operations will attend QAPI meetings in person or by phone. This will include input and review of data collected for the meeting. The Regional Director of Nursing and/or Regional Vice President of Operations will do facility visits to monitor compliance at a minimum weekly until substantial compliance is achieved and maintained. On 7/12/2021, Surveyors reviewed the education and sign in sheets which validated the corrective action plans onsite which was provided by the Administrator. The documentation showed all staff working on 7/12/2021 and 7/13/2021 had been provided the education on abuse, types of abuse, preventing, protecting, recognizing/identifying abuse/behaviors, reporting, and investigating abuse. The administrator was educated on abuse by the corporate nurse. Residents affected by the wandering residents were assessed and interviewed to determine if psychosocial harm had occurred. 22 resident records were reviewed randomly to ensure care plans had been updated and Dementia care had been added to those with Dementia and behaviors. The records had been updated to include interventions on the 22 resident records reviewed. The surveyors validated all staff working on 7/12/2021-7/13/2021 had been educated and were knowledgeable about the new procedures related to abuse/behavior, Dementia Care, and person-centered care planning. On 7/12/2021, Surveyors validated the corrective actions onsite through interviews with the Administrator, DON, Nurse Educator, MDS Coordinator, Social Service Director, 4 RNs, 2 LPN's, 8 CNA's, 2 nurse aides in training, 2 therapists and 2 housekeepers. The interviews showed the staff were educated on how to prevent abuse, what to do when abuse occurs, reporting of abuse, investigating abuse, documentation and implementing person centered care plans for each resident with Dementia and behaviors. Staff verbalized knowledge of development of care plans for Dementia and behaviors and how to assess residents to determine person centered needs/interventions. Noncompliance at F-867 continues at a scope and severity of L for monitoring of the effectiveness of the corrective actions to ensure sustained compliance. The facility is required to submit a plan of correction.

Based on facility policy review, medical record review, observation, and interview, the facility failed to develop and implement individualized care plan interventions to include and support each resident's Dementia care needs for 5 residents (Residents #30, #65, #41, #43, and #46) of 7 residents reviewed for Dementia care. The facility's failure to develop, implement and maintain individualized care plans for Dementia care needs resulted in a resident to resident altercation between Resident #30 and Resident #65 with Resident #30 hitting Resident #65 in the head resulting in psychosocial harm for Resident #65. Resident #30's continued wandering led to Resident #30 entering Resident #45's room, attempting to choke her, and stating she would kill her. The facility's failure to develop, implement and maintain an individualized, resident-centered care plan for Residents' #30, #65, #41, #43, and #46 placed Residents #30, #65, and #45 in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements for participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) and had the potential to effect all residents with dementia care needs. The Administrator was informed of the Immediate Jeopardy (IJ) in the conference room on 7/10/2021 at 12:50 PM. The facility was cited F-744 at a scope and severity of L which constitutes Substandard Quality of Care. The Immediate Jeopardy was removed onsite 7/12/2021 and was effective 5/3/2021-7/11/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 7/12/2021 at 8:40 AM and the corrective actions were validated onsite by the surveyors on 7/12/2021 and 7/13/2021. The findings include: Review of the facility policy titled, Dementia - Clinical Protocol, dated 11/2018, showed .For the individual with confirmed dementia, the IDT [Interdisciplinary Team] will identify a resident-centered care plan to maximize remaining function and quality of life .The IDT will adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia, development of new acute medical conditions or complications . Review of the facility's policy titled, Resident Centered Care Planning, dated 3/2019, showed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .to meet a resident's medical, nursing, and mental and psychosocial needs .'Person-centered care' means to focus on the resident as the locus of control .The care planning process will include an assessment of the resident's strengths and needs .The comprehensive care plan will describe .services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .The comprehensive care plan will be prepared by an interdisciplinary team that includes, but is not limited to .attending physician .registered nurse with responsibility for the resident .nurse aide with responsibility for the resident .The resident and the resident's representative . Review of the facility's policy titled, Behavior Management, dated 9/2019, revealed .the facility must have .staff who provide direct services to residents with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident determined by resident assessments and individual plans of care .Implementing non-pharmacological interventions .Planning and implementing appropriate interventions into the resident's plan of care and Evaluating the effectiveness of Pharmacological and non-pharmacological interventions .Providing meaningful activities which promote engagement and positive meaningful relationships between resident and staff, families, other residents and the community. Meaningful activities are those that address the resident's customary routines, interests, preferences, etc .and enhance the resident's well- being .Purpose to implement the most desirable and effective interventions that meet .needs of the residents, to change, modify, decrease or eliminate behaviors that are distressing to the resident and/or are decreasing or impacting on the resident's quality of life . Medical record review showed Resident #30 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #30's comprehensive care plan dated 4/13/2021 showed, .elopement risk/wanderer AEB [as evidenced by] History of attempts to leave facility unattended .she becomes aggressive/combative with other residents at times, she goes in and out of residents rooms, needs frequent redirection .Distract her from wandering by offering pleasant diversions, structured activities, food, conversation, television, book .Monitor location every shift. Document wandering behavior and attempted diversional interventions in behavior log . Review of Resident #30's Activity assessment dated [DATE], showed the resident had been interviewed to determine her interests. The review showed .Attention span .easily distracted . and it was not very important for the resident to have books, music, go outside, do things with groups of people, or attend religious services. The section titled, Previous Leisure Areas of Interest was not answered. The resident's activity goals were to .attend 1 out of room leisure activity 3-5 x's [times] per week for 3 months . Further review showed there was no documentation of her previous leisure areas of interest being assessed and there was no family involvement in completing the assessment. Review of Resident #30's Plan of Care Progress Note dated 4/14/2021, showed .going in and out of other resident rooms . and was difficult to redirect. Review of Resident #30's Respiratory Evaluation Progress Note dated 4/15/2021, showed Resident #30 was .experiencing unwanted behavior(s) .Chronic disruptive behavior noted. Chronic wandering behavior noted . Further review showed Resident #30 would wander at night. Review of Resident #30's admission Minimum Data Set (MDS) dated [DATE], showed the resident had severe cognitive impairment and had wandered 1-3 days during the assessment period. Her preferences for customary routine and activities showed having snacks between meals was very important and having pets was somewhat important to her. Books, music, going outside, and religious services were not important to her. Resident #30 required supervision to walk in the room and hallways with no use of mobility devices. Review of Resident #30's comprehensive care plan showed an update on 4/21/2021, .Requires assistance to participate in activities .we will continue to invite to activities & [and] 1'1 [one on one activities] as needed . The care plan did not include individualized, person-centered interventions to address the resident's dementia-related behaviors. Review of Resident #30's QAPI/Risk Meeting Progress Note dated 5/3/2021 at 1:52 PM, showed the resident remained a wandering risk with behaviors present, and staff were to provide close monitoring. The IDT (Interdisciplinary Team) would continue to monitor the interventions for .effective/appropriateness and intervene accordingly . Review of Resident #30's Physician Notification Progress Note dated 5/3/2021 at 5:16 PM, showed a resident to resident altercation between Resident #30 and Resident #65 had occurred. Resident #30 was hitting Resident #65 on the head and pulling her wheelchair back as Resident #65 was screaming for help. Review of Resident #30's Behavior Note dated 5/4/2021, showed .Resident to Resident occurred on 05.03.21 @ [at] 1659 [4:59 PM] .Monitor resident's location and activity q [every] 15 minutes and document x [for] 72 hours. Maintain personal space of comfort for other residents x 72 hours and then re-evaluate . Review of Resident #30's medical record showed no documentation the resident's location and activity had been monitored every 15 minutes for the dates of 5/4/2021-5/7/2021. Further review showed the resident's behaviors had not been documented every shift. Review of Resident #30's Risk Meeting Progress Note dated 5/4/2021, showed the IDT team would continue to monitor for effective/appropriateness of interventions .and intervene accordingly. IDT met, reviewed, discussed, and in agreement . Review revealed no individualized behavior interventions were implemented after the resident to resident abuse on 5/3/2021. Review of Resident #30's Psychiatric Evaluation dated 5/4/2021, showed .Evaluating mood and behaviors-patient having increased agitation, restlessness, aggression .Patient having increased [CONDITION(S)] and delusions, reasonable to add [MEDICATION(S)] [an anti-psychotic medication] to target symptoms .Agitation: Physical aggression .Combativeness .Severe restlessness .Recommendations: [MEDICATION(S)] 25 mg [milligrams] bid [twice daily] delusions . Further review showed no non-pharmacological behavioral interventions were recommended. Review of Resident #30's Behavior Note/Anxiety Progress Note dated 5/5/2021, showed .Resident wandering through out facility .Entering resident's room and nurses station. Becomes agitated with redirection . Review of Resident #30's Psychological Diagnostic Interview dated 5/6/2021, showed .Patient was shut down .appeared angry .walked directly into another patient's room after leaving this area .THIS PATIENT IS NOT A CANDIDATE FOR PSYCHOTHERAPY . Review of Resident #30's Behavior Note/Anxiety Progress Note dated 5/20/2021, showed .Resident frequently walks throughout the building .She tells other residents what to do. She shakes her head and gets upset when things don't go her way . Further review showed the Psychiatric NP would be notified due to increased behaviors. Review of Resident #30's Behavior Note/Anxiety Progress Note dated 5/20/2021, showed Resident #30 frequently wandered into other resident's rooms and would take their belongings. Further review showed .Resident has been involved in a couple of verbal arguments with other residents . Review of Resident #30's Social Service Progress Note dated 5/20/2021, showed .Resident exhibiting inappropriate behaviors . Further review showed the Psychiatric NP would assess the resident for needed medications. There was no documentation of any non-pharmacological behavioral interventions attempted. Review of Resident #30's Behavior Note/Anxiety Progress Note dated 5/21/2021, showed .entering other Residents rooms taking items, food, etc. that doesn't belong to her. Resident tried to take a drink away from another Resident because she thought it was hers . Review of Resident #30's Behavior Note/Anxiety Progress Note dated 6/4/2021, showed Resident #30 continued to wander .is increasingly more intrusive into other Resident rooms. Resident enters every room and takes items and hides them. Resident upsets other Residents with her actions. Resident also pushes other Residents in their wheelchair around the halls . Review of Resident #30's Social Service Progress Note dated 6/8/2021, showed Resident #30 was .displaying inappropriate behaviors, shopping in rooms, grabbing things out of residents hands . Continued review showed Resident #30 was hard to redirect and the Psychiatric NP would be notified to assess for medication changes. There was no documentation of any new non-pharmacological behavioral interventions to be attempted. Review of Resident #30's Behavior Note/Anxiety Progress Note dated 6/20/2021, showed the resident was .wandering into other resident rooms, causing distress to other residents . Resident was attempting to push other residents in their wheelchair and taking things from nurse's station and other residents. Staff were unable to redirect the resident. Documentation showed the Plan of Care would be continued. Review of Resident #30's Behavior Note/Anxiety Progress Note dated 6/30/2021, showed Resident #30 was wandering into other residents' rooms, causing distress to other residents. Resident was also taking things from nurse's station, and other residents. Attempts to redirect Resident #30 were unsuccessful. Review of Resident #30's Behavioral Note/Anxiety Progress Note dated 7/5/2021, showed the resident was wandering into other resident rooms causing distress to other residents. Resident #30 was taking things from the nurse's station, med carts, and other residents' rooms. Further review showed, .PRN's [as needed medications] unsuccessful. Attempts to redirect are unsuccessful . Review of the facility's video surveillance footage dated 7/8/2021 from the 300 hallway, reviewed on 7/13/2021 at 1:49 PM, with the Administrator and the Plant Operations Manager present. The video showed Resident #30 at the end of the 300 hallway at 5:46:14 AM, she went to the linen cart at 5:47:24 AM. CNA #4 exited the shower room with another resident at 5:47:44 AM. Resident #30 walked past the other resident in the hallway, who just came out of the shower room, and CNA #4 walked toward the nurses station away from the resident. Resident #30 stood by the shower room for several seconds then entered room [ROOM NUMBER] at 5:48:00 AM, and came back out of room [ROOM NUMBER] at 5:48:27 AM. Resident #30 then entered Resident #45's room at 5:48:31 AM. CNA #4 exited another resident's room at 5:48:42 AM. Resident #30 exited Resident #45's room at 5:49:05 AM. Resident #30 then entered another resident's room at 5:49:41 AM. Medical record review showed Resident #65 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #65's comprehensive care plan dated 11/20/2020, showed the resident had attention seeking behaviors as evidenced by often becoming tearful for no particular reason. She would state she had a hole in her head. Interventions in place included, .intervene as necessary to protect the rights and safety of others .Divert Attention. Remove from situation and take to alternate location as needed . Further review showed no individualized, resident-centered care plan with individualized interventions for dementia care had been developed for Resident #65. Review of Resident #65's quarterly MDS dated [DATE], showed the resident had moderately impaired cognitive status, the resident was independent for locomotion on the unit, and used a wheelchair for mobility. No behaviors were documented, and no wandering was documented. Review of Resident #65's Physician's Notification Progress Note dated 5/3/2021, showed a resident to resident altercation had occurred between Resident #30 and Resident #65. Resident #65 was sitting in her wheelchair while Resident #30 was pushing the wheelchair back and hitting Resident #65 on top of the head. Review of Resident #65's Psychiatric Evaluation dated 5/4/2021, showed Resident #65 was evaluated for mood and behaviors after the resident to resident abuse on 5/3/2021. Following the incident, Resident #65 had .increased anxiety and delusions . Further review showed Resident #65's [MEDICATION(S)] (anxiety medication) was restarted for her increasing distress and [MEDICATION(S)] (antipsychotic medication) was increased to target her delusions. Further review revealed no non-pharmacological interventions were recommended. Review of Resident #65's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The patient reported the other individual (Resident #30) .came up from behind her and grabbed and hit her right parietal [top of head] and temporal area [side of head] .The patient's been very anxious since that time .This incident unfortunately set off exacerbation of patient's underlying anxiety disorder . Further review showed she had become increasingly anxious and was avoiding individuals when moving about in her wheelchair. Review of Resident #65's Medication Administration Progress Note dated 5/4/2021, showed .Resident in hall crying, repeatedly saying 'I'm not going up there' referring to her room . Further review showed Resident #65 was administered an as needed (PRN) dose of [MEDICATION(S)]. Review of Resident #65's Behavior Note/Anxiety Progress Note dated 5/5/2021, showed Resident #65 continued to not want to go into her room after the resident to resident abuse .crying, stating 'I'm not going up there' pointing towards room. 'I'm scared'. Resident reassured, but still expressed some concern . Further review showed Resident #65 required a PRN dose of [MEDICATION(S)] to be administered and was transferred to another room for the night. Review of Resident #65's Psychotherapy Progress Note dated 5/6/2021, showed the resident was hit recently by another patient and thereafter relocated to a different room. The patient informed the clinician she was distressed and requested to be sent out to a psychiatric unit. Resident #65 stated she was having hallucinations. The clinician documented .having them [hallucinations] directly after a significant stressor (being attacked by another patient) is highly consistent with the literature on [CONDITION(S)], as opposed to a manipulative quality . Further review showed Resident #65 was crying, and insistent on being considered for evaluation outside of the facility. Review of Resident #65's medical record showed she was sent to the hospital for psychiatric evaluation on 5/7/2021 and returned to the facility on [DATE]. There was no individualized Dementia or behavioral plan developed after the resident's return from the hospital. Observation on 7/6/2021 at 12:15 PM, showed Resident #30 entered room [ROOM NUMBER]. A Certified Nursing Assistant (CNA) was in the room setting up a lunch tray and redirected the resident out of the room. No diversional activity was offered. Observation on 7/6/2021 at 2:46 PM, showed Resident #30 entering room [ROOM NUMBER] while a CNA was in the room. The CNA redirected the resident to exit the room with no diversional activity offered. During an interview on 7/6/2021 at 2:55 PM, CNA #1 stated Resident #30 did wander frequently and did go into other resident's rooms. She stated Resident #30 would take other residents' water pitchers. CNA #1 stated redirection was provided, and .there's not much we can do .I have suggested putting up stop signs on the doors but we would have to put them on every door because you never know which room she will go in . CNA #1 was unaware of any diversional activities that Resident #30 was to be offered. Observation on 7/6/2021 at 2:59 PM, showed Resident #30 wandering in the 400 hallway. She attempted to open the door to room [ROOM NUMBER] but did not go in. She then went to the 100 hallway and attempted to open the double doors. She then wandered to the nurse's station, walked past a nurse seated at the nurse's station, opened the door to the Unit Secretary's office, and entered the office. She picked up a notebook from the Unit Secretary's desk, walked past the nurse seated at the nurse's station, and went down the 300 hallway. A staff member walked up to Resident #30 and took the notebook from her. No diversional activity was offered. During an interview on 7/7/2021 at 2:07 PM, the Director of Social Services (DSS) stated Resident #30 had been in a resident to resident altercation with Resident #65. She stated Resident #30 had been moved to a different room. She stated Resident #30 used to work in a nursing facility and that Resident #65 had .psych issues . and .doesn't like to be touched . She stated after the incident, Resident #65 .became fearful .crying . The DSS confirmed Resident #30 wandered into other residents' rooms and .that's a problem .there is only so much medication you can mess with . we pretty much let her wander and redirect her . She further stated the interventions the facility had in place to prevent Resident #30's wandering behavior was .redirecting and put stop signs on some residents' rooms that she has a fondness to go into .the residents that complain . During a telephone interview on 7/8/2021 at 7:41 AM, Licensed Practical Nurse (LPN) #1 stated Resident #30 would wander frequently, and would wander into other residents' rooms. Resident #30's wandering .gets them [other residents] upset . The LPN stated at times Resident #30 would enter other resident rooms and the other residents would scream at her to get out. The LPN confirmed Resident #30 would pick up other resident's belongings from their rooms such as socks, toothbrushes, and decorations. LPN #1 stated when the staff hear the residents screaming, they go redirect her but she is not easily redirectable. Resident #30 is sometimes .a little mouthy . and does not want to come out of other residents' rooms. The LPN stated Resident #30 would often remove the stop signs placed on other residents' rooms and they would .disappear .we don't realize they are gone .we may find them on another hall or another nurses station . LPN #1 stated Resident #30's wandering and the complaints by other residents about her wandering had been reported by letter to the DSS and verbally to the dayshift nurse. LPN #1 stated staff were unable to watch wandering residents at all times. LPN #1 stated no new behavioral interventions had been communicated by the facility in regard to Resident #30's continued wandering into other residents' rooms. Observation on 7/8/2021 at 7:45 AM, showed Resident #30 wandering on the 200 hallway, she entered another resident's room at the end of the 200 hallway, a staff member redirected her back into the hallway without any diversional activities offered. During an interview on 7/8/2021 at 8:27 AM, LPN #2 confirmed Resident #30 had hit Resident #65 on the head during a resident to resident altercation, which caused Resident #65 to be upset and tearful. Resident #30 had been moved to another hallway after the altercation, but continued to wander throughout the facility, in and out of other residents' rooms. LPN #2 confirmed the staff try to redirect Resident #30 and use stop signs on the doors of some residents, but she was unsure which residents were supposed to have them. LPN #2 was not aware of any diversional activities the staff were to offer Resident #30 when she wandered into other residents' rooms. Observation on 7/8/2021 at 8:30 AM, showed Resident #30 continued to wander on the 200 hallway. She entered another resident's room and a staff member redirected her back into the hallway without any diversional activities offered. During an interview on 7/8/2021 at 8:39 AM, RN #1 stated Resident #30 would wander into other residents' rooms and would take things. RN #1 confirmed it was often difficult and required multiple attempts to redirect Resident #30, and she was unaware of any other interventions the facility had implemented to prevent Resident #30 from wandering into other residents' rooms. Observation on 7/8/2021 at 8:45 AM, showed Resident #30 wandering by the nurse's station and started down the 300 hallway carrying a folded tablecloth. A staff member took the tablecloth from her without offering any diversional activities. During an interview on 7/8/2021 at 8:46 AM, the DSS confirmed the facility .would divert the resident as best they could .with demented patients [wandering] would occur . The DSS stated the stop signs on some resident doors had been attempted but had been taken down and are effective at times. The DSS was unaware of which residents required stop signs and was unaware of how to obtain that information. She stated stop sign placement was determined when a resident had made a complaint about a wandering resident. During an interview on 7/8/2021 at 9:23 AM, LPN #3 stated Resident #30 would wander in and out of other residents' rooms, would take items from the other residents' rooms, and would drink everybody's drinks. LPN #3 stated the facility had placed stop signs on some of the residents' doors, but Resident #30 would take them down and carry them around. LPN #3 stated she had witnessed Resident #30 take the stop sign off other residents' doors. LPN #3 stated Resident #30 is redirectable .at times . but was unaware of any other interventions the facility had implemented to prevent Resident #30 from wandering, including diversional activities. During an interview on 7/8/2021 at 9:32 AM, RN #2 confirmed Resident #30 would wander into other residents' rooms. RN #2 stated the facility had put stop signs up for the rooms .we find may be an issue . but she was not sure which residents were supposed to have stop signs on their doors. RN #2 stated the staff monitor Resident #30 and try to redirect, but was unaware of any other interventions the facility had implemented to prevent Resident #30 from wandering, including diversional activities. During an interview on 7/8/2021 at 10:21 AM, CNA #2 stated Resident #30 would wander into other residents' rooms and some residents did complain. CNA #2 stated Resident #65 had complained that Resident #30 would go into her room and go through her stuff. CNA #2 stated she had reported the complaints to a nurse, there .really wasn't anything we could do . CNA #2 stated the staff would redirect the resident but was not made aware of any other interventions, including diversional activities, to prevent wandering. During an interview on 7/8/2021 at 10:33 AM, CNA #3 stated Resident #30 would wander into other residents' rooms and some residents had complained. CNA #3 stated she would provide redirection but was unaware of any other interventions, including diversional activities the staff were to use to prevent wandering. During a telephone interview on 7/8/2021 at 12:47 PM, RN #3 stated Resident #30 would wander .nonstop . into any room that was not locked, in and out of other residents' rooms, and would move/take other residents' belongings. RN #3 stated Resident #30 would get into the nurse's bags and once drank a nurse's drink. RN #3 stated the staff would look for other residents' belongings in her room and would sometimes find other residents' glasses, but most items she took were never located. RN #3 stated most residents were .not happy . with Resident #30 wandering into their rooms. RN #3 had witnessed Resident #30 remove a stop sign from a resident's door and had tried to explain to Resident #30 that she could not enter those rooms, but the resident was unable to understand. RN #3 was unsure which residents wanted a stop sign on their door and stated the information was passed on in shift report, but not documented in the chart. RN #3 had reported Resident #30's wandering behavior to the Assistant Director of Nursing (ADON) and had been instructed to document the behaviors in the resident's chart, but no further non-pharmacological behavioral interventions had been communicated. During an interview on 7/8/2021 at 1:31 PM, the ADON stated Resident #65 had been having behaviors on 5/3/2021 and had been going through the hallway .crying and screaming . She stated it had been reported to her that Resident #30 approached Resident #65 and .it was more of a tap . She further stated both residents were .very behavioral . The ADON stated the facility had provided close monitoring of Resident #30, but she had the right to wander because the facility was .her home . The ADON had been aware of another resident's complaint of Resident #30 wandering into her room. The ADON confirmed Resident #30's wandering behaviors had been discussed in the IDT meetings. The ADON confirmed Resident #30's medications were monitored by the Psychiatric NP and the facility staff monitor her wandering. No other interventions had been attempted. During an interview on 7/9/2021 at 12:51 PM, the DSS stated she had not developed any care plan interventions for Resident #30's behaviors, including her wandering. She further stated she thought the MDS Coordinator had been adding behavioral interventions into the care plans during the care plan meetings. She stated she had been aware of Resident #30 wandering into other residents' rooms from discussions in the facility's morning meetings. She stated Resident #30 needed interventions of redirection and medications for her behaviors .we can't tie her down .you can't restrict her in any manner . She was unaware of any other non-pharmacological behavioral interventions that had been developed for Resident #30's wandering behaviors. She stated Resident #30 had a wander guard (device used to alert staff when a resident is attempting to exit a door) placed on admission but she had not assessed the resident for her wandering behaviors. She further confirmed Resident #30 had not been easily redirectable and had been more irritated lately. She stated she had not incorporated the resident's past occupation in her care plan to determine individualized interventions. The DSS stated she believed she had been aware Resident #30 had been taking items from other residents. She stated she did feel the wandering into other residents' rooms and taking other residents' belongings did increase the susceptibility of Resident #30 to be involved in another resident to resident altercation. She further stated Resident #65 had behaviors .she is tearful a lot .she has a history of abuse . She stated Resident #65 believed she had a hole in her head and confirmed Resident #65's history of abuse and belief she had a hole in her head would have made her more susceptible to a negative outcome from someone hitting her in the head. The DSS confirmed she was not aware of any intervention the facility had taken to address Resident #65's behaviors. During an interview on 7/9/2021 at 1:40 PM, the Psychiatric NP stated she had evaluated Resident #30 and Resident #65 after the resident to resident altercation that occurred on 5/3/2021. She confirmed she had added an antipsychotic medication for Resident #30 after the incident for delusions. She confirmed Resident #65 had delusions about the incident and thought the woman (Resident #30) was out to get her and out to kill her. The Psychiatric NP confirmed the altercation triggered increased anxiety for Resident #65 which required medication changes and a hospitalization . She confirmed the altercation did cause Resident #65 some significant distress and psychosocial harm. The Psychiatric NP stated she would only provide medication recommendations to the facility and had not provided any recommendations of behavioral interventions. During an interview on 7/9/2021 at 2:19 PM, the Medical Director (MD) stated he was aware of Resident #30's wandering into other residents' rooms and stated .she has bumped into a few folks along the way . The MD stated that other residents had told him Resident #30 would wander into their rooms and would take things. He stated he had tried to encourage the other residents to not .take it personally . He confirmed the diversional activities the facility had attempted had been unsuccessful and a memory care unit might be more appropriate for Resident #30. The MD stated he had communicated informally with the facility staff, but he did not state if he made any recommendations to the facility to address the continued wandering. He stated the resident to resident altercation that occurred between Resident #30 and Resident #65 caused Resident #65 .a significant amount of anxiety . and caused Resident #65 to have psychosocial harm. The MD confirmed Resident #30's continued wandering did increase the risk of another resident to resident altercation. During an interview on 7/9/2021 at 3:20 PM, the ADON confirmed Resident #30 exhibited aimless wandering and was recently placed on one-on-one supervision. She confirmed [TRUNCATED]

Based on medical record review, review of facility investigation, review of facility policy, review of a personnel record, and interview, the facility failed to provide supervision and assistive devices to prevent a fall for one resident (#1) of six residents reviewed. The facility's failure to develop new interventions after repeated releasing of a self-release velcro seat belt and attempts to transfer unassisted by the resident resulted in a fracture of the femur (Harm) for resident #1. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Brief Interview for Mental Status (BIMS) dated February 6, 2013, revealed the resident was severely impaired cognitively. Review of a facility investigation dated November 9, 2012, revealed, "...6:30 p.m...resident noted sitting on floor in front of w/c (wheelchair) by day shift supervisor...resident stated 'was going for a walk' when...lost balance and fell ...no injury noted..." Continued review of the facility investigation revealed, "...dycem (non-skid) when in w/c for safety...instructed resident on safe use of assistive devices..." Continued review of the facility investigation and a fall assessment revealed, "...Poor recall, judgment, safety awareness...balance problem when standing...decreased muscular coordination...wandering...Total score 23...Resident at risk of falling..." Continued review of the facility investigation revealed, "...wedge cushion applied to wheelchair...will place res (resident) in restorative for ambulation 5x/wk (times per week)..." Medical record review of a Physical Therapy (PT) screen dated November 12, 2012, revealed, "...Upon investigation, resident was found to have appropriate alarms in place, attempted to rise independently and fell before staff could reach (resident). Continues to require assist of one for safe transfers and has had no recent change in functional abilities. Remains unable to follow directions due to advanced dementia..." Review of a facility investigation dated December 7, 2012, revealed, "...4:45 p.m...observed on floor...hallway...rock n go chair...stood up...attempted to walk without assist...no apparent injury...res attempted unassisted ambulation...unable to tell staff what (resident) was wanting to do...has alzheimer's and is unable to remember (resident) requires assist with transfers and ambulation...motion detector applied...continue reverse wedge...PT to screen for further recommendations..." Review of a facility investigation dated December 15, 2012, revealed, "...12:40 p.m., observed on the floor...staff responded to alarm and observed resident lying on the floor in the hallway. Resident had attempted to stand up from wheelchair unassisted and fell to the floor...no injuries noted...PT to screen and self-release velcro seat belt (alarming) applied..." Medical record review of a PT screen revealed, "...Motion detector is in place, no further recommendations at this time. PT is not appropriate for skilled therapy due to advanced dementia and inability to follow commands." Review of a facility investigation dated March 11, 2013, revealed, "...9:15 p.m...found in floor...rolled out of bed...bed alarm sounded...floor mat alarm was not sounding...full length side rails were up...concave mattress to be applied to bed...will continue bed alarm, d/c (discontinue) motion detector and floor pad alarm..." Medical record review of a Nurse's Note dated April 4, 2013, at 11:03 a.m., revealed, "...single assist rail for positioning, reverse foam wedge cushion, dycem to w/c, self-release Velcro seat belt (alarming), concave mattress...Requires two aides to transfer to lift the resident transfers...does not walk in room...does not walk in corridor...physically lifted or wheeled to move about unit...is physically lifted or wheeled to move off the unit...primary of locomotion is with a wheelchair...is wheeled by others..." Medical record review of a Nurse's Note dated April 10, 2013, at 1:20 p.m., revealed, "...Currently sitting up in w/c. Resident usually has poor posture and is hunched over (forward)...today is extending neck backwards, when nurse asked if (resident) neck was hurting...(resident) stated yes, prn (as needed) lortab (narcotic pain medication) administered. Resident has been drowsy today, sleeping more than usual..." Medical record review of a Nurse's Note dated April 10, 2013, at 5:10 p.m., revealed, "...CNA (Certified Nursing Assistant) staff alerted nurse that resident is having trouble transferring, unable to stand and seems to be in severe pain when being transferred. Resident is grabbing at...hips and moaning and groaning. Nurse ordered x-ray of bilateral hips. Will continue to monitor..." Medical record review of a Nurse's Note dated April 10, 2013, at 10:07 p.m., revealed, "...Physician notified Mobile x-ray showed fx (fracture) to femur. Notified family..." Continued medical record review revealed, "...ER (emergency room )/Acute care hospital (name) for eval (evaluation) per order of (name) physician." Medical record review of a Nurse's Note dated April 11, 2013, at 2:46 p.m., documented as a late entry for April 9, 2013, revealed "...Resident was sitting in w/c and leaned forward in w/c. When resident did (resident) fell out onto floor on...left side. (Nurse) assess resident to find no apparent injuries. Resident denies any pain at this time. Assisted resident back to chair..." Review of a facility investigation dated April 11, 2013, at 2:46 p.m., documented as a late entry for April 9, 2013, revealed, "...Resident was sitting in w/c and leaned forward in w/c. When resident did (resident) fell out onto floor on...left side...slid from chair...is chair/bed alarm used? Yes. Did staff verify it worked? Unknown. How long did it take to respond to the alarm? Unknown..." Continued review of the facility investigation revealed, "...Did fall result in a fracture? Yes, resident noted to have c/o (complaint of) pain on 4/10/13...x-ray obtained showing right intertrochanteric femur fx (fracture)..." Review of facility policy, Accidents and Incidents, revealed, "...all accidents or incidents occurring in the facility must be reported to the Team Leader, Director of Nursing, and Administrator to ensure proper documentation, assessment, and follow up on all incidents occurring to residents...Regardless of how minor an accident or incident may be, it must be reported to the Team Leader immediately." Review of the personnel record for Licensed Practical Nurse #1 revealed a Separation Notice of the termination dated April 12, 2013, for "...Misconduct - gross incompetence or negligence resulting in potential harm to residents or employees or financial harm to the company Interview with CNA #1, on April 22, 2013, at 1:45 p.m., in the conference room revealed CNA #1 was assigned to the resident the night of the fall and stated the resident "...did have the dycem in place in the chair and the self-release (alarming) seat belt on when placed in the hallway in the (rock n go) wheelchair...(resident) history of undoing the seat belt (Velcro) to pick at things on the floor...after placing the resident back in the chair after the fall the dycem and self-release (alarming) belt was reattached to the resident..." Interview with CNA #1 a second time on May 13, 2013, at 4:00 p.m., revealed after the fall on April 9, 2013, "...LPN #1 came to the resident's room I was working in told me to come with (LPN #1) and when I got to the hallway the alarm had already been silenced by (LPN #1)...(resident) would undo the (Velcro) seat belt at least 2-3 times a day when I worked...I would tell the nurse that (resident) removed the seat belt but the (LPN #1) would never chart anything about it...the belt was attached to the alarm in the chair when I got to it but I had been told by the nurse (LPN #1) silenced it before getting me to help put (resident) back in the chair..." Continued interview revealed when asked how often the resident take the self-release seat belt off CNA #1 stated "2 - 3 times a day." Interview with CNA #2 on May 13, 2013, at 12:00 p.m., revealed resident #1 would "occasionally undo the self-release belt when (resident) was in the chair...the alarm would sound and the staff would check on (resident) at that time..." Interview with CNA #3 on May 13, 2013, at 12:20 p.m., revealed, "...(resident) would always take...belt off (Velcro)...would see what (resident) needed and hook the belt back..." Interview with the Administrator, Director of Nursing, Assistant Director of Nursing on May 13, 2013, at 3:00 p.m., confirmed LPN #1 was terminated "...because LPN #1 failed to follow the facility's policy and procedure regarding the reporting of accidents. Further interview confirmed the expectation is that the CNA's will notify the Nurses if a resident is repeatedly removing a safety device." C/O #

Based on medical record review, review of a facility investigation, review of facility policy, review of a personnel record, and interview, the facility failed to provide the necessary care and service to maintain the highest practicable physical, mental, and psychosocial well-being for one resident (#1) of six residents reviewed. The facility's failure to ensure new interventions were developed to prevent falls, to ensure an appropriate assessment was completed after a fall, and facility policy was followed, resulted in a [MEDICAL CONDITION] (Harm) and a delay in treatment for [REDACTED]. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Brief Interview for Mental Status (BIMS) dated February 6, 2013, revealed the resident was severely impaired cognitively. Review of a facility investigation dated November 9, 2012, revealed, "...6:30 p.m...resident noted sitting on floor in front of w/c (wheelchair) by day shift supervisor...resident stated 'was going for a walk' when...lost balance and fell ...no injury noted..." Continued review of the facility investigation revealed "...dycem (non-skid) when in w/c for safety...instructed resident on safe use of assistive devices..." Continued review of the facility investigation and a fall assessment revealed, "...Poor recall, judgment, safety awareness...balance problem when standing...decreased muscular coordination...wandering...Total score 23...Resident at risk of falling..." Continued review of the facility investigation revealed, "...wedge cushion applied to wheelchair...will place res (resident) in restorative for ambulation 5x/wk (times per week)... Medical record review of a Physical Therapy (PT) screen dated November 12, 2012, revealed, "...Upon investigation, resident was found to have appropriate alarms in place, attempted to rise independently and fell before staff could reach (resident). Continues to require assist of one for safe transfers and has had no recent change in functional abilities. Remains unable to follow directions due to advanced dementia..." Review of a facility investigation dated December 7, 2012, revealed, "...4:45 p.m....observed on floor...hallway...rock n go chair...stood up...attempted to walk without assist...no apparent injury...res attempted unassisted ambulation...unable to tell staff what (resident) was wanting to do...has alzheimer's and is unable to remember (resident) requires assist with transfers and ambulation...motion detector applied...continue reverse wedge...PT to screen for further recommendations..." Review of a facility investigation dated December 15, 2012, revealed, "...12:40 p.m., observed on the floor...staff responded to alarm and observed resident lying on the floor in the hallway. Resident had attempted to stand up from wheelchair unassisted and fell to the floor...no injuries noted...PT to screen and self- release velcro seat belt (alarming) applied..." Medical record review of a PT screen revealed, "...Motion detector is in place, no further recommendations at this time. PT is not appropriate for skilled therapy due to advanced dementia and inability to follow commands." Review of a facility investigation dated March 11, 2013, revealed, "...9:15 p.m...found in floor...rolled out of bed...bed alarm sounded...floor mat alarm was not sounding...full length side rails were up...concave mattress to be applied to bed...will continue bed alarm, d/c (discontinue) motion detector and floor pad alarm..." Medical record review of a Nurse's Note dated April 4, 2013, at 11:03 a.m., revealed, "...single assist rail for positioning, reverse foam wedge cushion, dycem to w/c, self-release Velcro seat belt (alarming), concave mattress...Requires two aides to transfer to lift the resident transfers...does not walk in room...does not walk in corridor...physically lifted or wheeled to move about unit...is physically lifted or wheeled to move off the unit...primary of locomotion is with a wheelchair...is wheeled by others..." Medical record review of a Nurse's Note dated April 10, 2013, at 1:20 p.m., revealed, "...Currently sitting up in w/c. Resident usually has poor posture and is hunched over (forward)...today is extending neck backwards, when nurse asked if (resident) neck was hurting...(resident) stated yes, prn (as needed) [MEDICATION NAME] (narcotic pain medication) administered. Resident has been drowsy today, sleeping more than usual..." Medical record review of a Nurse's Note dated April 10, 2013, at 5:10 p.m., revealed, "...CNA (Certified Nursing Assistant) staff alerted nurse that resident is having trouble transferring, unable to stand and seems to be in severe pain when being transferred. Resident is grabbing at...hips and moaning and groaning. Nurse ordered x-ray of bilateral hips. Will continue to monitor..." Medical record review of a Nurse's Note dated April 10, 2013, at 10:07 p.m., revealed, "...Physician notified Mobile x-ray showed fx (fracture) to femur. Notified family..." Continued medical record review revealed, "...ER (emergency room )/Acute care hospital (name) for eval (evaluation) per order of (name) physician." Medical record review of a Nurse's Note dated April 11, 2013, at 2:46 p.m., documented as a late entry for April 9, 2013, revealed, "...Resident was sitting in w/c and leaned forward in w/c. When resident did (resident) fell out onto floor on...left side. (Nurse) assess resident to find no apparent injuries. Resident denies any pain at this time. Assisted resident back to chair..." Review of a facility investigation dated April 11, 2013, at 2:46 p.m., documented as a late entry for April 9, 2013, revealed, "...Resident was sitting in w/c and leaned forward in w/c. When resident did (resident) fell out onto floor on...left side...slid from chair...is chair/bed alarm used? Yes. Did staff verify it worked? Unknown. How long did it take to respond to the alarm? Unknown..." Continued review of the facility investigation revealed, "...Did fall result in a fracture? Yes, resident noted to have c/o (complaint of) pain on 4/10/13...x-ray obtained showing right intertrochanteric femur fx (fracture)..." Review of facility policy, Accidents and Incidents, revealed "...all accidents or incidents occurring in the facility must be reported to the Team Leader, Director of Nursing, and Administrator to ensure proper documentation, assessment, and follow up on all incidents occurring to residents...Regardless of how minor an accident or incident may be, it must be reported to the Team Leader immediately." Review of the personnel record for Licensed Practical Nurse (LPN #1) revealed a Separation Notice of the termination dated April 12, 2013, for "...Misconduct - gross incompetence or negligence resulting in potential harm to residents or employees or financial harm to the company Interview with CNA #1 on April 22, 2013, at 1:45 p.m., in the conference room revealed CNA #1 was assigned to the resident the night of the fall and stated the resident "...did have the dycem in place in the chair and the self-release (alarming) seat belt on when placed in the hallway in the (rock n go) wheelchair...(resident) history of undoing the seat belt (Velcro) to pick at things on the floor... after placing the resident back in the chair after the fall the dycem and self-release (alarming) belt was reattached to the resident..." Interview with CNA #1 a second time on May 13, 2013, at 4:00 p.m., revealed after the fall on April 9, 2013, "...(LPN #1) came to the resident's room I was working in told me to come with (LPN #1) and when I got to the hallway the alarm had already been silenced by (LPN #1)...(resident) would undo the (Velcro) seat belt at least 2-3 times a day when I worked...I would tell the nurse that (resident) removed the seat belt but the (LPN #1) would never chart anything about it...the belt was attached to the alarm in the chair when I got to it but I had been told by the nurse (LPN #1) silenced it before getting me to help put (resident) back in the chair..." Continued interview revealed when asked how often the resident take the self-release seat belt off CNA #1 stated "2 - 3 times a day." Interview with CNA #2 on May 13, 2013, at 12:00 p.m., revealed resident #1 would "occasionally undo the self-release belt when (resident) was in the chair...the alarm would sound and the staff would check on (resident) at that time..." Interview with CNA #3 on May 13, 2013, at 12:20 p.m., revealed, "...(resident) would always take...belt off (Velcro)...would see what (resident) needed and hook the belt back..." Interview with the Administrator, Director of Nursing, Assistant Director of Nursing on May 13, 2013, at 3:00 p.m., confirmed LPN #1 was terminated "...because LPN #1 failed to follow the facility's policy and procedure regarding the reporting of accidents. Further interview confirmed the expectation is that the CNA's will notify the Nurses if a resident is repeatedly removing a safety device." C/O #