Every finding on record at Crossview Care Center

Based on record review, staff interviews, and review of the facility policy titled Freedom of Abuse, Abuse Prevention: Fast Alerts, the facility failed to ensure that one of 18 sample residents (R) (R10) was free from misappropriation of trust account money.Findings include:Review of the facility policy titled Freedom of Abuse, Abuse Prevention: Fast Alert dated January 2025 documented Misappropriation of Resident Property as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent.Review of the electronic medical record (EMR) revealed R10 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, mild intellectual disabilities, brief psychotic disorder, paranoid personality disorder, and seizures.Review of R10's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was 09, indicating the resident's cognition was moderately impaired.Review of the Resident Fund Management Service form dated 03/26/2021 revealed the resident had a transferring (automatic transfer of care cost payments due to the facility) resident fund account set up with the facility.Review of the Facility Incident Report Form dated 02/06/2026 revealed the facility reported Exploitation/Misappropriation of Resident Property/Funds. The report indicated the resident did not authorize an online purchase for clothing on 11/25/2025. The resident reported to the [NAME] President of Operations on 02/06/2026 that he was unaware of the purchase and did not have knowledge of funds in his Resident Funds Management System.Review of the facility investigation and the undated follow up report indicated that on 02/06/2026, a facility employee reported the incident to the [NAME] President of Operations and an investigation was initiated. Review of the 02/05/2026 written statement by Licensed Practical Nurse (LPN) A revealed that around Christmas 2025, they received jumpsuits for residents on the [NAME] Wing. LPN A noted she had heard other staff voice concerns that the jumpsuits were paid for out of R11's personal funds. She further noted that on 02/04/2026, she went to the copy machine and noticed a receipt with the resident's name on it and an order in his name for jumpsuits totaling almost $5,000. The last page had an X as his mark and the previous Administrator's and receptionist's names. She noted she knew the resident would not be able to make an X that well. LPN A immediately notified the Regional Operations Manager and reported that other staff had told her the previous Administrator and former receptionist instructed staff not to tell the resident he had a substantial amount of money in his account.The [NAME] President of Operations interviewed the resident, who indicated he was not aware of the purchase, nor did he authorize the purchase of clothing items totaling $4,899.05. The previous Administrator and previous receptionist both signed and witnessed the invoice alleging the resident authorized the purchase. Both employees were placed on suspension pending investigation. The [NAME] President of Operations reviewed the invoices, validating the purchase of clothing in the amount of $4,899.05. The items were delivered to the facility, and the invoice had a mark indicated by the Administrator as being given by the resident authorizing the purchase. The resident stated he did not make the mark, or if he did, he was not aware of what it was for.A check in the amount of $4,899.05 was deposited into the resident's account to reimburse him. The Administrator and the receptionist were terminated from employment for not following policies for Resident Trust Funds.Review of the 11/25/2025 invoice from Resident Essentials revealed a total amount of $4,899.05 was spent purchasing 63 articles of clothing ranging in size from medium to 3X. Further review of the invoice revealed a perfectly marked X with the witnesses being the previous Administrator and the previous receptionist.Review of additional documents, such as a Check Cashing Authorization form dated 04/07/2026 and the Resident Shopping List/Spending Report signed/marked by the resident dated 03/04/2026, revealed the X mark made by the resident had very irregular lines.Review of the 02/06/2026 written statement from the previous Administrator revealed she noted she had ordered a large amount of clothing for the resident because he needed a spend down from his account. She ordered clothing in different sizes for him after asking if she could get him a new wardrobe, to which he agreed. She noted a large number of outfits arrived at the facility and he did not like them. She further noted she had known the resident for many years and felt she had a personal relationship with him that allowed her to do that. She also noted she did not tell him the exact amount of money in his account because he did not make good decisions regarding his money and would allow other residents-especially women-to manipulate him out of money. She further noted she had accidentally ordered the wrong sizes and had not sent the clothing back because she had not thought about it.Review of the Resident Statement Landscape form revealed that on 11/03/2025 the resident had a balance of $101,194; on 12/01/2025 the balance was $89,711; on 01/02/2026 the balance was $90,137; and on 02/02/2026 the balance was $88,742.Interview with the Interim Administrator and the Human Resources employee on 04/20/2026 at 10:55 AM, they stated the resident could not sign his name and was only able to make an X with very irregular lines. They both stated the resident would not be able to make a perfect X. They stated that when the clothing arrived, the resident did not like it, but the company would not refund the money. They stated the facility ended up reimbursing the resident.Interview with the Regional Operations Manager on 04/20/2026 at 11:06 AM, she stated LPN A called her on 02/04/2026 and reported she saw something suspicious on the copy machine regarding R11. LPN A reported the resident could not make a clear X for his mark/signature. She then reported it to the previous Administrator, corporate, and the corporate Resident Fund Management Service. The Regional [NAME] President then conducted the investigation in the facility.

Based on record review, staff interviews, and review of the policy titled Freedom of Abuse, Abuse Prevention: Fast Alerts, the facility failed to protect one of 18 sampled residents(R) (R10) from misappropriation of funds by not reporting to the state agency and law enforcement.Findings include:Review of the facility policy titled Freedom of Abuse, Abuse Prevention: Fast Alerts documented Reporting/Investigation/Response Policy - Any complaint, allegation, observation, or suspicion of resident abuse, mistreatment, or neglect-whether physical, verbal, mental, or sexual, involuntary or voluntary-was to be communicated to the Abuse Coordinator, thoroughly reported, investigated, and documented in a uniform manner as detailed below. Reporting. Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than two hours after the allegation was made if the events involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events did not involve abuse and did not result in serious bodily injury.Review of the 02/06/2026 Facility Incident Report Form revealed the facility reported an allegation of Exploitation/Misappropriation of Resident Property/Funds for R10. The report indicated the resident did not authorize an online purchase for clothing on 11/25/2025. Review of the facility investigation revealed no evidence the Sheriff's Department was notified.Interview on 04/21/2026 at 9:00 AM with the Interim Administrator revealed he called and spoke to an investigator with the Sheriff's Department, who told him there was no report found for the 02/06/2026 allegation.Review of an email correspondence dated 02/10/2026 revealed the previous [NAME] President of Operations had asked if the police had been by and was told no. However, there was no evidence that staff followed up with the Sheriff's Department.Interview on 04/21/2026 at 9:00 AM with the Interim Administrator revealed staff should have made a follow up call to the Sheriff's Department.

Based on resident and staff interviews, record review, and review of facility policy, the facility failed to ensure the timely availability of personal resident funds for four of four residents reviewed for access to personal funds out of a total sample of 20 residents (Resident (R) 14, R53, R25, and R29) of 20 sampled residents. Specifically, the facility's banking hours were limited to time when business office staff were in the facility and residents did not have access to their money after office hours, weekends, or holidays. If residents requested money for $99.00 or more the resident had to request it from the facility and then the facility had to request it from Central Office and then the resident would have to wait three working days before resident would get a check. The resident then had to find someone to cash their check. There was no bank in the town, and the facility had no transportation to take any residents to the bank. This failure had the potential to affect any resident for whom the facility kept personal funds. Findings include: Review of the facility's policy titled, RFMS (Resident Fund Money Services), most recently revised on 7/1/2025, read, in pertinent part, It is the policy of Residents' can withdrawal no more than $99 from the petty cash box (this allows for numerous residents to get funds daily) - Per tag F567 requests for money $99 or lower must be provided same day - only amount over $100 must be provided to residents within 3 business days. Residents requesting funds of $100 or more must sign a receipt - receipt is sent to CBO [Cash Balance Order] to complete a withdrawal within RFMS once RFMS approved check will be printed out in resident' name or (designated Name resident assigns) and given to resident. Residents/families or responsible for cashing check. Residents can withdrawal no more than $99 from the petty cash box (this allows for numerous residents to get funds daily) - Per tag F567 requests for money $99 or lower must be provided same day - only amount over $100 must be provided to residents within 3 business days. Residents requesting funds of $100 or more must sign a receipt - receipt is sent to CBO to complete a withdrawal within RFMS once RFMS approved check will be printed out in resident' name or (designated Name resident assigns) and given to resident. Residents/families or responsible for cashing check. 1.Review of R14's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/18/2024, revealed that the resident was cognitively intact, based on a Brief Interview for Mental Status (BIMS) score of 15 out of 15. During an interview with R14 on 12/3/2025 at 10:55 am, he indicated he had requested money back in November 2025 and had not received any as of this time (12/3/2025). Review of a Check Cashing Authorization note that he had requested money on 11/10/2025 for $200. R14 stated he could not go out of the facility to get his check. He stated that administration takes them to cash the check for him. When asked if he could get money in the evening or on weekends he stated, No just from the office. You have to get money from the office during the day, and I am not sure if they can [office open/money available] on the weekend. 2.During an interview on 12/3/2025 at 11:15 am, R53 voiced she had not received the money that she requested on 11/10/2025. She had wanted to take it with her to family for Thanksgiving. R53 expressed that she still had not yet received that money [as of 12/3/2025]. On 12/3/2025 at 3:45 pm, R53 stated that she could only get money during office hours. 3. On 12/3/2025 at 10:52 am, R25 stated she had not received any money that she had requested in November 2025. R25 stated that she had received checks before and her pastor had taken her checks to the bank and cashed them for her. R25 stated she was unable to go out of facility to cash her checks because she was in a wheelchair and the facility had no transportation to take her to get her check cashed. When asked if she could get money in the evening or on weekends she stated, No. 4). R29's quarterly MDS with an ARD of 7/22/2024, revealed that the resident was cognitively intact, based on a BIMS score of 15 out of 15. On 12/03/25 at 4:55 PM, R29 stated she had not received any money that she had requested in November. R29 stated that she had received checks before and the Administrator had taken her checks to the bank and cashed them for her. R29 stated she is unable to go out of facility to cash her checks facility had no transportation to take her to get her check cashed. When asked if she could get money in the evening or on weekends she stated, No. During an interview with the Administrator and the Corporate staff (C1) on 12/3/2025 at 2:33 pm, provided an e-mail that noted (RE: RFMS Issue) from Senior [NAME] President of Revenue (REV1) .@beaconhc.net> To: [C1] at .@altamahanh.com> Body of Email reads,We just located check requests on the following residents that was sent on 11/11/25 and miss filed .[R29] for $100[R14] for $200[R25] requested $300 only has $200All of these are being keyed in today (12-02-2025) and will be sent to facility by Thursday (12-04-2025) PS facility never sent an email following up on the request .Thanks[REV1]Sr [NAME] President of Revenue Cycle Management/Beacon Health Management/15310 [address]. During an interview with the Administrator and the C1 on 12/3/2025 at 2:33 pm, both confirmed the facility's cashier's office was open during office hours and there was no access to money during the evening hours or on weekends or holidays.

Based on record review, staff interviews, and facility policy review, the facility failed to enter a Do Not Resuscitate (DNR) status in the electronic medical record (EMR) and failed to obtain a corresponding physician's order for one of two residents (Resident (R) 30) reviewed for Advance Directives (AD) from a sample size of 20 residents. This failure had the potential to have R30's end-of-life wishes not honored. Findings include: Review of the facility's policy titled, Advanced Directives, dated January 2025, revealed: Policy: The facility must inform and provide written information to all residents concerning the right to accept or refuse medical or surgical treatment. Process: upon admission/readmission, the facility will upload a copy to the residents chart. the social worker, and or nursing will determine the residents decision making process capacity quarterly.during the care plan review to ensure the residents wishes. further review of the policy revealed Practitioner Orders for Life-Sustaining Treatment (POLST). Review of the facility's policy titled, Physician Service, dated January 2025, revealed, Physicians Services: .other orders to meet the specific needs of the resident.8. No medications, treatments, diet orders, therapy procedures of any kind. are to be administered to any resident without a physicians order. Procedure: the nurse who notes the order will transcribe the order onto the appropriate Medication Administration Record (MAR), .Treatment Administration (TAR) or any other records. Review of R30's Face Sheet, undated, revealed an admission date of 9/15/2025. Further review of the Face Sheet revealed code status was blank. Further review of the EMR Profile page revealed code status also was blank. Review of R30's EMR under the Orders, tab revealed no code status order was written on or around R30's admission date of 9/15/2025. However, an order for DNR was written on 12/2/2025 after the facility was made aware of the concern. Review of R30's Practitioners Orders for Life-Sustaining Treatment (POLST) dated 9/24/2025 located in the EMR under the tab Documents indicated allow natural death and do not attempt resuscitation. Interview with the Licensed Practical Nurse (LPN) 2 on 12/2/2025 at 1:29 pm, verified code status was to be documented in the EMR, Care Plan, the POLST and in the Red Book. LPN2 stated the Red Book was located at the nursing station and contained all the residents Advance Directives and code statuses. Review of the Red Book verified it contained the residents' face sheet, a POLST form and a purple or green sticker. The purple sticker indicated DNR and the green sticker full code. During this same interview LPN 2 verified R30 did not have a care plan that indicated the resident's code status. LPN2 also stated that a doctor's order should have been written the day of or shortly after the resident's admission of 9/15/2025. LPN2 verified that the Red Book was one of the first and most convenient places for the nursing staff to look in a time of emergency. Review of the Red Book verified that R30's POLST and purple sticker were included to indicate her DNR code status. Interview with the facility Administrator on 12/3/2025 at 10:07 am revealed the facility staff were to ensure there was a written doctor's order identifying all residents' end-of-life wishes upon admission to the facility.

Based on staff interview, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for one resident (Resident (R) 74) out of a total sample of 20 residents. This failure placed the residents at risk of having unmet care needs and services.Findings include:Review of the RAI Manual 3.0, dated 10/2019, revealed .If a Minimum Data Set (MDS) assessment is found to have errors that incorrectly reflect the resident's status, then that assessment must be corrected . Review of R74's medical face sheet found under the Clinical, tab of the electronic medical record (EMR), revealed R74 had diagnoses which included; candidal sepsis, anemia, hypertension, seizure disorder, anxiety disorder, depression, schizophrenia, anorexia, malignant neoplasm of overlapping colon, personal history of malignant neoplasm of the breast, and malignant neoplasm of bronchus.Review of R74's hospital notes located under the Document Manager tab revealed that R74 was hospitalized on [DATE] for surgical procedure to have an open hemicolectomy to remove a portion of the colon due to cancer, resident was then admitted due to complications and remained in the hospital until 10/22/2025.Review of R74's quarterly MDS assessment, located in the EMR under the MDS tab and with an Assessment Reference Date (ARD) of 11/3/2025, indicated R47 had an active diagnosis of candidal sepsis, anemia, hypertension, seizure disorder, anxiety disorder, depression, schizophrenia, anorexia. The MDS did not indicate cancer.During an interview on 12/3/2025 at 9:10 am, the facility's Director of Nurses (DON) reviewed R74's EMR and stated R74 was previously in the hospital for colon cancer on 7/21/2025. The DON stated that a diagnosis should be on the MDS. During an interview on 12/3/2025 at 9:25 am, the MDS Coordinator (MDSC) stated she completed the diagnosis section on R74's 11/3/2025 quarterly MDS. The MDSC reviewed R74's EMR and confirmed R74's quarterly MDS of 11/3/2025 was inaccurately coded for the diagnosis of cancer.

Based on resident and staff interviews and record reviews, the facility failed to ensure that three of nine residents (R) (R1, R2, R3) reviewed for ADL (Activities of Daily Living) received care and services according to their needs and preferences. Specifically, the facility failed to ensure shower/baths were given as scheduled for (R1, R2, and R3). Findings include: Record review for R1 revealed resident was admitted to the facility on [DATE], and had diagnoses of but not limited to aphasia, dysphagia, muscle weakness, need for assistance with personal care, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and contracture of right wrist. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed a Brief Interview for Mental Status (BIMS) score of 15 indicating little to no cognitive impairment. Review of the care plan, with a target date of 11/26/2024, revealed R1 had a self-care deficit r/t (related to) right wrist contracture, history of CVA (cerebral vascular accident-stroke), hemiplegia/hemiparesis (paralysis on one side or partial weakness), and seizures. The care plan also revealed he will refuse baths/showers at times. Interventions on 9/12/2024 included assisting with ADLs as needed and shower or bath per resident preference. A review of the grievances from June 2024 through December 2024 revealed a grievance filed on behalf of R1 on 9/2/2024 revealed resident complains he has only had bed baths, wants showers, and that he would prefer showers on days. Action to resolve documented that resident shower days were changed to Mondays, Wednesdays, and Fridays and he would be taken to the shower. Review of East Wing Baths list revealed that R1 was scheduled for baths on Mondays, Wednesdays, and Fridays. Review of the shower/bath sheets for September 2024 revealed R1 received five baths in September, on 9/2/2024, 9/11/2024, 9/16/2024, 9/18/2024, and 9/20/2024 (bed bath). Continued review revealed R1 refused a bath on 9/9/2024 and on 9/13/2024. Review of the shower/bath sheets for October 2024 revealed R1 received six shower/baths, on 10/2/2024, 10/11/2024, 10/16/2024, 10/21/2024, 10/27/2024, and 10/30/2024. The bath sheet for 10/7/2024 documented, refused, hip is hurting. Review of the shower/bath sheets for November 2024 revealed R1 received four shower/baths, on 11/8/2024, 11/13/2024, 11/21/2024, and 11/27/2024. Review of the shower/bath sheets for December 2024 revealed R1 received three shower/baths, on 12/6/2024, 12/11/2024, and 12/16/2024. During an interview on 12/19/2024 at 10:51 am, with family member of R1 revealed that she visited around Thanksgiving, R1 had not had a bath and was dirty. Family member stated that she filed a grievance with the facility. Review of the admission record for R2 revealed an admitted [DATE] and had diagnoses of but not limited to chronic obstructive pulmonary disease (COPD), type 2 diabetes with diabetic polyneuropathy, morbid (severe) obesity, hemiplegia/hemiparesis following cerebral infarction, chronic pain, bipolar disorder, and major depressive disorder. Review of the Admission MDS assessment dated [DATE] assessed R2 with a BIMS score of 15 indicating little to no cognitive impairment. Review of the care plan with a target date of 10/22/2024 revealed that R2 had a self-care/mobility deficit r/t COPD, obesity, heart failure, hemiplegia/hemiparesis, muscle weakness, difficulty in walking, chronic pain syndrome, spinal stenosis, and lumbar fractures. Interventions included assisting with ADLs as needed and shower or bath per resident's preference. A review of East Wing Bath list revealed that R2 was scheduled for baths on Tuesdays, Thursdays, and Saturdays. Review of the October 2024 grievances showed a grievance for R2 dated 10/9/2024 reporting he had not received a shower in a week. The resolution included the resident received a shower on 10/10/2024 and his shower days were moved to Tuesdays, Thursdays, and Saturdays. Review of the shower/bath sheets for October 2024 revealed R2 received a shower/bath on 10/10/2024 and 10/17/2024. Review of the shower/bath sheets for November 2024 revealed R2 received a shower/bath on 11/9/2024, 11/13/2024, 11/16/2024. On 11/19/2024 R2 refused, and on 11/23/2024 and 11/28/2024 R2 was out of facility. Review of the shower/bath sheets for December 2024 revealed R2 received a shower/bath on 12/3/2024 and 12/11/2024. An interview was attempted with R2 twice, but he was out of the facility. Review of the admission record revealed that R3 admitted to the facility on [DATE] with diagnoses of but not limited to cerebral infarction, muscle weakness, need for assistance with personal care, schizophrenia, bipolar disorder, chronic pain, fusion of spine, and repeated falls. Review of the Admission MDS assessment dated [DATE] for R3 assessed a BIMS score of 15 indicating little to no cognitive impairment. Review of the care plan with a target date of 10/23/2024 revealed R3 had a self-care/mobility deficit r/t CVA, weakness, and pain. She will refuse baths/showers. Interventions included assist with ADL's as needed and shower or bath per R3's preference. Review of the October 2024 grievances revealed that a grievance was filed by R3 on 10/29/2024 reporting a concern that she did not receive her shower/bath on the assigned days. The resolution was that residents' showers were moved to days from nights as it was her preference to receive her shower/bath during the day. A review of East Wing Bath list revealed R3 was scheduled for baths on Mondays, Wednesdays, and Fridays. Review of the shower/bath sheets for October 2024 for R3 revealed R3 received a shower/bath on 10/14/2024, 10/29/2024. On 10/24/2024 no shower/bath given due to no towels or rags, and on 10/31/2024, resident refused. Review of the shower/bath sheets for November 2024 revealed R3 received a shower/bath on 11/8/2024, 11/13/2024, and 11/18/2024. On 11/4/2024 and 11/27/2024 the resident refused. Review of the shower/bath sheets for December 2024 revealed R3 received a shower/bath on 12/11/2024 and 12/16/2024. On 12/6/2024 the resident refused. During an interview on 12/19/2024 at 1:33 pm with R3 revealed that staff would document that she refused her baths, but they could not give her a bath because they did not have towels, and she had not had a shower since Monday. During an interview on 12/19/2024 at 2:45 pm with Certified Nursing Assistant (CNA) AA revealed that there are times that baths cannot be given due to not having linens, sometimes we do not get linen until 3:00 pm, but we still try to get them done that shift. CNA AA stated that baths are not being able to be given because of linens happened as recent as last week or week before. During an interview 12/23/2024 at 3:23 pm with the Administrator revealed that if a resident wanted more showers than what was scheduled, then staff were expected to honor that. If resident wanted a shower at a different time than scheduled, staff were expected to update preference. Administrator revealed that there had not been any grievances for residents not receiving their baths due to no cloths available, and there was one complaint when she first started, and it was addressed right away with the family. During an interview on 12/26/2024 at 2:10 pm with the Director of Nursing (DON) revealed that staff were aware of how shower/baths were scheduled/preferences for residents by a list of the residents for the rooms, at the nurse's stations. She revealed that if the residents wanted something else, they could have it. The showers are listed in Point-Click -Care (PCC) and on the shower sheets. DON revealed that the shower sheets were accurate. She revealed that if showers were not documented, then they did not occur. The DON revealed that there had been an issue with no cloths for baths, and the last time was three weeks ago, which was the first week she worked at the facility. DON stated that housekeeping was responsible for ordering new linens and they have made a purchase for linens in the past month. During an interview on 12/26/2024 at 2:25 pm with the District Manager (DM), revealed that he was not aware of an issue with the facility not having clean linens, and there was an emergency supply in a nearby city. He revealed that he did not have any knowledge of laundry not being done timely. DM further revealed that wash cloths were ordered last month, linens are ordered once a month, and a stock load was put out on Christmas Eve. During an interview on 12/26/2024 at 4:39 pm with CNA KK revealed that sometimes residents were not able to be given a bath due to not having clean linens. CNA KK also revealed that clean linens come from laundry once a day. During a follow up interview on 12/26/2024 at 4:56 pm R3 revealed that it was three weeks before she received a shower after she was admitted to the facility. Resident revealed that the issue was still occurring and that she only gets a shower once a week and she has told staff that she would like a bath daily.

Based on observations, Staff interviews, record review, and review of the facility policy titled, Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, the facility failed to report an injury of unknown origin for one of six residents (R) (R6) to the State Agency within the allotted time frame. Findings include: Review of the facility's policy titled, Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, dated October 2023, under section labeled, Reporting revealed, - All employees are required to immediately notify the administrative or nursing supervisory staff that is on duty of any complaint, allegation, observation of suspicion of resident abuse, mistreatment, or neglect so that the resident's needs can be attended to immediately and investigation can be undertaken promptly, - Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Record review revealed R6 was admitted to the facility with diagnoses of but not limited to intellectual disabilities, Alzheimer's disease, dementia moderate with agitation, generalized anxiety disorder, major depressive disorder, dysphagia, and need for assistance with personal care. Review of R6's progress notes revealed that on 12/11/2024 and 12/18/2024 a bruise to the left eye of R6 was identified and it had not been evaluated. Observation on 12/19/2024 at 1:05 pm in the dining room, R6 was observed to have a bruise that was circular in shape that was on the top and bottom of her left eye. The bruise was at least three inches in diameter and was black. During an interview on 12/19/2024 at 1:06 pm with Certified Nursing Assistant (CNA) AA revealed that she was unsure of what happened to R6. Interview further revealed that R6's eye was like that when she came back off her cycle of days off. During an interview on 12/19/2024 at 1:07 pm with Licensed Practical Nurse (LPN) LL revealed she believed R6 had fallen. LPN LL looked in the computer to confirm statement but revealed that she could not find any information to confirm. During an interview on 12/23/2024 at 3:23 pm with the Administrator revealed she completed a report to the state the same day (12/19/2024) that writer inquired about R6. Administrator revealed that she was not sure of how the bruising happened and confirmed that no report of the injury had been completed.

Based on resident and staff interviews, record review, and review of the facility's policy titled, Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, the facility failed to investigate an injury of unknown origin for one of six residents (R) (R6). Findings include: Review of the facility's policy titled, Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, dated October 2023, under section labeled Reporting revealed, All employees are required to immediately notify the administrative or nursing supervisory staff that is on duty of any complaint, allegation, observation of suspicion of resident abuse, mistreatment, or neglect so that the resident's needs can be attended to immediately and investigation can be undertaken promptly, - While it may be necessary for a facility to make an initial evaluation as to whether on incident potentially meets one or more of the reporting criteria, a thorough investigation should be completed after reporting the allegation. For example, upon discovery of an injury, the facility must immediately take steps to evaluate whether the injury is an injury of unknown source, and if the injury meets the defined criteria, an immediate report is required. Record review revealed R6 was admitted to the facility with diagnoses of but not limited to intellectual disabilities, Alzheimer's disease, dementia moderate with agitation, generalized anxiety disorder, major depressive disorder, dysphagia, and need for assistance with personal care. Review of R6's progress notes revealed that on 12/11/2024 and 12/18/2024 a bruise to the left eye of R6 was identified and it had not been evaluated Review of the Facility Reported Incidents revealed no reports for the left eye bruising of R6. A request was made for incident report on 12/19/2024 for the incident involving the injury observed on R6, but none was given. During an interview on 12/19/2024 at 1:07 pm with Licensed Practical Nurse (LPN) LL revealed she believed R6 had fallen. LPN LL looked in the computer to confirm statement but revealed that she could not find any information to confirm. During an interview on 12/23/2024 at 3:23 pm with the Administrator revealed she was not sure of how the bruising happened and confirmed that no report of the injury had been completed. Administrator further stated that her expectations for when residents fall, nursing staff's reports are done and are completed according to procedures. Staff should have put everything in the incident report.

Based on staff interviews, record review, and review of the PBJ (Payroll Based Journal) [NAME] Report for the First Quarter (Q1) of Fiscal Year 2024, the facility failed to accurately report direct care staffing data to the Centers for Medicare and Medicaid (CMS). The facility census was 67 residents. Findings include: A review of the PBJ [NAME] Report for Q1 2024, October 1 through December 31, revealed the Staffing Data Report triggered for excessively low weekend staffing and a one-star staffing rating (Failure to submit PBJ data by the deadline, more than 4 days in the quarter without RN (Registered Nurse) Staffing hours, failure to respond to, submit documentation for, or failure to pass a CMS audit designed to discover discrepancies in PBJ data). A review of the facility's documents titled Daily Staff Posting, and PBJ Time, from October 2023 through December 2023, revealed discrepancies between the total number of hours nursing staff worked on the weekends and the total number of nursing hours worked reported to CMS. Interview with the Director of Nursing (DON) on 4/24/2024 at 2:30 pm, she reported being unable to explain the discrepancy. She has had to work weekends to ensure coverage and during the weekdays as a nurse on the floor to ensure coverage. She also reported her nursing staff and certified nursing assistant have worked hours over to ensure coverage. The discrepancy would have to have come from the prior DON and Administrator. Interview with the Administrator and Regional [NAME] President on 4/24/2024 at 10:42 am, the Administrator could not offer any explanation. She reported her hire date was after that period. Interview on 4/23/2024 at 3:00 pm, the Regional [NAME] President reported that the current Administrator is newly hired, and the former leadership (Administrator and DON) are no longer working. This would be hard to determine what happened in reference to the low staffing, and the accuracy of the PBJ reports submitted. It would be hard to determine the baseline and to determine the shortage of staff. She stated that the facility was currently in compliance with RN coverage and staffing. She acknowledged the one-star staffing rating and said that everyone was working hard to get staff into the facility.

Based on observations, staff interviews, and review of a job description titled, Laundry Worker, the facility failed to follow infection control practices by not having a clean and sanitary environment in the laundry department and a heavy buildup of dust, dirt, and grime to prevent cross contamination of dirty and clean laundry. The census was 67 residents. Findings Include: Review of undated job description titled, Laundry Worker revealed, Work Area Maintenance: cleans and sanitizes the work area including machines, worktables, and sorting area. Observation during tour of the laundry department on 4/25/2024 beginning at 9:42 am revealed the following: 1. Spider webs and a buildup of dust noted on walls, ceiling tiles and pipes, and behind the washing machines and dryers. 2. A heavy buildup of dust, dirt, and grime on the pipes, electrical cords, and floor behind the washing machines and dryers. 3. Heavily soiled and dusty cloths used as a filler surrounding the air condition unit in the clean sorting and folding area. 4. A pink bath pan under the handwashing sink filled with dark colored liquid (water). Water was leaking from under the sink into the pan and had been there long enough it had run over onto the floor, and unidentifiable black spots on the rim of the pan. Interview on 4/25/2024 at 9:20 am, Licensed Practical Nurse (LPN) KK revealed the facility was currently using agency staff for housekeeping and laundry. Interview on 4/25/2024 at 9:55 am with the Housekeeping Manager (HM) revealed she had been employed with the company for seven years. HM reported staff were to clean the laundry every day at the end of shift; staff were to sweep, clean lint traps, and make sure nothing was on the floor. She confirmed dust was on pipes, ceiling, on cloth/fabric filler around air conditioner (AC), around an old air unit that was sealed off with cardboard and blue tape, and the handwashing sink had been leaking. HM stated maintenance performed deep cleaning and it had been a while since deep cleaning was done. Interview on 4/25/2024 at 10:20 pm with the Maintenance Director (MD), and Corporate Maintenance (CM) revealed that housekeeping staff were responsible for cleaning in the laundry department. He was not aware of any cleaning or maintenance issues in the laundry department. CM and MD reviewed pictures, and confirmed the laundry department were unclean, unsanitary, and they would make immediate corrections as indicated. Interview on 4/25/24 at 12:57 pm the with Administrator revealed that her expectations were for the laundry department to be clean and sanitary. She stated that the folding/sorting room needed a new AC /heat unit and that she had to complete a capital expenditure request to corporate because the expense is over $500. She stated staff, she assumed, put towels and other materials under the window unit in the folding/sorting room, to block cold air from getting in since there have been cool temperatures in the mornings. She revealed her expectations were that staff clean daily and that maintenance clean the high, out of reach ceilings.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Medication Administration Guidelines, the facility failed to ensure four of 20 residents (R) (R3, R10, R22, and R27) did not have unsecured unauthorized medications stored at the bedside. This deficient practice had the potential to allow unauthorized access of medications to other residents and visitors in the facility. Finding include: Review of the facility policy titled, Medication Administration Guidelines (undated) under Purpose: The purpose of these guidelines is to promote the health and safety of the residents we serve by ensuring the safe assistance and administration of medications and treatments. Self-Administration: There may be occasions where a resident has been assessed to safely self-administer medications. In this case, the licensed nurse will assist the resident in maintaining the medications in a secure area and will be available for resource if the resident has questions regarding medication dosages side effects or effectiveness. 1. Record review of R3's clinical record revealed the following diagnoses but not limited to Type 2 diabetes mellitus, schizophrenia, Alzheimer, and hypertension, The Quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed a Brief Interview for Mental Status Score (BIMS) of 12 indicating resident had little to no cognitive impairment. Observation on 4/23/2024 at 9:01 am of R3's room revealed the following medicated cream Remedy Phyloplex (Antifungal and 'treatment ointment) and Remedy (Prevent Silicone Cream with zinc oxide) positioned on the bedside table within view. At the time of observation, R3 reported using the medicated cream (Remedy Prevent Silicone Cream with zinc oxide) daily on her sacral area. She stated that the nurse left the cream in the room. Review of R3's Self-Administration assessment dated [DATE] revealed that resident was not assessed to self-administer medications. 2. Record review of R10 's clinical record revealed the following diagnoses but not limited to gastro-esophageal reflux disease, mild cognitive impairment, and hypertension, The Annual MDS assessment dated [DATE] assessed a BIMS of 15 indicating resident had little to no cognitive impairment. Observation on 4/23/2024 at 10:56 am of R10's bathroom revealed peroxide and mupirocin 2% ointment cream in bathroom positioned on the sink. Resident stated that her wound nurse gave her the mupirocin ointment cream medication for her to self-apply to her vaginal area daily. Record review of R10's Physician Orders revealed an order for Mupirocin External Ointment 2 % (Mupirocin) Apply to skin boil on labia topically two times a day for skin boil start date 4/14/2024. Review of R10's Self-Administration assessment dated [DATE] revealed that resident was not assessed to self-administer medications. 3. Record review of R22 's clinical record revealed the following diagnoses but not limited to chronic obstructive pulmonary disease, mild cognitive impairment, and hypertension, The Annual MDS assessment dated [DATE] assessed a BIMS of 15 indicating resident had little to no cognitive impairment. Observation of R22 's room on 4/23/2024 at 10:51 am revealed a small bottle of oral tooth gel on resident 's bedside nightstand within view. Interview at the time of the observation, R22 reported that he uses tooth gel for pain in his mouth every now and then. He reported that his family helped him purchase the gel. Review of R22's Self Administration assessment dated [DATE] revealed that resident has not been assessed to self-administer medications. 4. Record review of R27 's clinical record revealed the following diagnoses but not limited to heart disease of native coronary artery, type 2 diabetes, hypertension, The Quarterly MDS assessment dated [DATE] assessed a BIMS of 15 indicating resident had little to no cognitive impairment. Observation on 4/2320/24 at 11:22 AM revealed the following items on the sink in R27 's bathroom a bottle of mouthwash with alcohol and a bottle of rubbing alcohol bottle within view. Resident shares the bathroom with two other residents in an adjoining room. Also, on the resident rolling bedside table was a small bottle of artificial tears within view. R27 reported that she uses the items alcohol and mouthwash without supervision for her own personal use but that the nurse will assist her with the artificial tears' meds. She stated that nurse left artificial tears in her room for her use. During an observation of rounds of R3, R10, R22, and R27's rooms on 4/23/2024 beginning at 1:11 pm and ending at 1:30 pm with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) BB all medications and antiseptic products were confirmed in the residents' room. Both staff reported being unaware of the medications and products. LPN BB reported that resident was not assigned to them but assigned to LPN AA who was at lunch. The DON reported that none of the residents were care planned or assessed to self-administered medications or antiseptic products. The DON removed the medication from the resident 's room. She reported that the R22 was receiving antibiotics for his gums. She thinks that the R22 's family brought the medication to him. R27 eyedrops should be kept at the nurse station. R3 using the antibiotic vaginal cream could be an infection control issue if the resident were applying it. She confirmed the muciprion was an on the residents' Electronic Medical record (EMR) but could not confirmed if the nurse left or gave the med to the resident. R10 's zinc ointment should have been placed in the bedside drawer and not in the opening. She stated that zinc ointment was okay to leave in the room as long as secured in the drawer. She reported that the facility has Angels Guardian Rounds, and this is to monitor and inspect rooms for any identified concerns and this should include unauthorized items in the resident 's room. DON reported that she had not been in the resident room lately and that she has other guardian angels monitoring these rooms, every day. Interview on 4/23/2024 at 1: 30 am, with LPN AA confirmed that the eyedrops were in R27 's room. She denied leaving eye drops in the room. She reported that R3 's zinc ointment should have been placed in a secure place and not left at the bedside. She stated that she and certified nursing assistant were educated to place the zinc ointment or any incontinent cream items in a secure place. She stated that her expectation is for the CNA to bring the zinc ointment to her after use so she can place it in a cabinet near the nurse station. She reported being unaware of R27 using the vaginal cream independently without supervision from a nurse. She stated that nurses would apply the vaginal cream with a Q-Tip for infection control and wash the perineal area before applying. She reported being unaware of R10 's oral gel.

Based on observations and staff interviews, the facility failed to ensure a safe/clean/comfortable/homelike environment for one of three hallways (100 Hall), four of 34 bedrooms and two of 17 bathrooms on the100 Hall. Specifically, the hallways had a loose handrail along the interior corridor, the frame on the exit door was jagged with rough edges at the bottom of the door, an old rusty inoperable heater was attached to the wall there were chips and scratches on the floor as residents entered the dining area. Additionally, residents' rooms and bathrooms contained black and sticky substances on the floors, basins uncovered, scraped and jagged closet doors, broken tiles, tiles pulled away from the wall, tiles with stains and dark brown sticky substance covering the floor and peeling paint. The facility census was 67 residents. Findings included: 1. Observation on 4/23/2024 at 8:49 am revealed a loose handrail along the interior corridor on unit 100 hallway. Observation on 4/24/2024 at 9:49 am revealed a loose handrail along interior corridor on unit 100 hallway. Observation dated 4/25/2024 at 11:00 am revealed a loose handrail along interior corridor on unit 100 hallway. Interview walking rounds on 4/25/2024 at 11:13 am with Administrator and the Maintenance Director (MD) confirmed that the handrail along interior corridor on 100 hallway needed repair. MD stated that the handrail was a quick fix. Observation dated 4/23/2024 at 11:45 am revealed the flooring on unit 100 by the dining room was noted to have chips and scratches. Observation dated 4/24/2024 at 10:10 am flooring on unit 100 by the dining room was noted to have chips and scratches. Observation dated 4/25/2024 at 1:30 pm revealed the flooring on unit 100 by the dining room was noted to have chips and scratches. An Interview walking rounds on 4/25/2024 at 1:45 pm with Maintenance Director confirmed that the flooring needs repairs. He stated that a rug was covering that area but when the rug was pulled up the repairs needed were noticed. He stated that this could be a quick fix, but approval needs to go through the corporate office. 36377 2. Observations were conducted daily on 100 Hall during the survey time period of 4/23/2024 through 4/25/2024 during hours of 8:00 AM through 5:00PM. The following environmental concerns were identified, confirmed, and addressed with the Administrator, Housekeeping Supervisor, and Maintenance Director on 4/25/2024 at 11:00 AM. 1. Observation of Room-13 missing peeling paint on floor exposing dirty tiles, scraped closet door and bathroom doors. 2. Observation of Room-10 's bathroom floor tiles stained with a dark brown sticky substance at the base of the toilet and bathroom door damaged that prevented closure. 3. Observation of Room-4 scraped closet doors and frame edge of one closet door with protruding sharp jagged edges. 4. Observation of Exit door frame edge damage with missing frame at the bottom causing jagged sharp edges. 5. Observation of a wall mounted heater near the exit door covered with brown rust-colored substances. The Maintenance Director identified substances as rust. 6.Observation of Room-8 bathroom revealed two basins on the floor uncovered with dirt and debris. Dark wet coffee colored stain substances observed coating the tiles near the commode. Interview on 4/25/2024 at 11:15 am, the Maintenance Director, Administrator, and Housekeeping Supervisor confirmed the environmental issues identified with each room. The Housekeeping Supervisor reported that her staff cleans the rooms daily and was unaware of the floor tile conditions in the bathrooms. The Administrator confirmed that the basin should not be on the floor and that the certified nursing assistant is responsible for sanitation of the basin. The Administrator reported that she was aware of the issues and the plan was to fix the identified items. She reported that the wall heater was not operable and can be removed.

Based on observations, staff interviews, record review, and review of the facility policy titled, RAI/Care Planning Management, the facility failed to implement the care plan for one of five residents (R) R17. Specifically, the facility failed to ensure the plan of care was followed for R17 related to oxygen administration. Findings: Review of the facilities policy titled, RAI/ Care Planning Management, dated October 2023 revealed in the section Process for completing the MDS, CAAs, and Care plans, under Standard: It is the practice of this facility to conduct a comprehensive, accurate, state standardized, reproducible assessment of each resident's functional capacity. Under Objective number 1. To identify residents' individual needs and care requirements. Under section titled The Care Plan revealed care plans are to be accessible for clinical staff in order to facilitate care plan interventions or to update as indicated due to resident condition change. Review of the medical record for R17 revealed resident was admitted to the facility with a diagnosis of but not limited to chronic obstructive pulmonary disease (COPD) and shortness of breath. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed under section O (Special Treatments and Programs) indicated oxygen use for the assessment look back period. Review of R17 care plan revealed under focus: resident has COPD and requires supplemental oxygen, Goal: Resident will be free of signs and symptoms of respiratory infections through review date, Interventions: oxygen settings as ordered. During initial screening on 4/23/2024 at 9:50 am, Surveyor observed resident in bed with the oxygen on and the oxygen was set at 4.5 L/M. Second Observation on 4/23/2024 at 11:30 am revealed R17 oxygen level was still set at 4.5 L/M. Interview on 4/24/2024 at 4:15 pm with Director of Nursing (DON) revealed her expectations for nurses was to monitor and make sure the oxygen is set at the correct level per physician order for residents receiving oxygen therapy and for the staff to follow the residents plan of care. Interview on 4/25/2024 at 9:10 am with MDS Coordinator revealed that the care plan for R17 indicates her oxygen should be administered as ordered by the physician. Further interview also revealed that she expects the nurses to follow the physicians' orders and the residents plan of care.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Oxygen, Administration-Delivery Device , the facility failed to ensure oxygen was administered as ordered by the physician for one of five residents (R), R17. Findings include: Review of the facility policy titled, Oxygen, Administration-Delivery Device, dated August 2021 revealed under Purpose: To provide oxygen support when indicated via appropriate delivery device to achieve or maintain adequate oxygenation to the respiratory compromised resident. Further review under Guidelines number 3(a) Excessive levels of oxygen over a period may result in disorders associated with hyper-oxygenation. Review of the clinical record revealed R17 was admitted to the facility with the diagnoses of but not limited to chronic obstructive pulmonary disease, and shortness of breath. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed R17 had a Brief Interview for Mental Status (BIMS) score of 13, indicating little to no cognitive impairment. Review of Section O (Special Treatments and Programs) indicated oxygen use. Review of the Physician's Orders dated 4/11/2024 revealed O2 (oxygen) at 2 liters per minute (L/M) continuously via nasal canula every shift, change 02 tubing and water bottle weekly every night shift every Sun. During initial screening on 4/23/2024 at 9:50 am, Surveyor observed resident in bed with the oxygen on and the oxygen was set at 4.5 L/M. Second Observation on 4/23/2024 at 11:30 am revealed R17 oxygen level was still set at 4.5 L/M. Interview on 4/23/2024 at 11:39 with Licensed Practical Nurse (LPN) AA confirmed that the oxygen was set at 4.5 L/M. Surveyor asked what the ordered amount of oxygen for R17 was, she stated that she was not sure but will look at the physician order. After reviewing the physicians' orders for R17, LPN AA confirmed that the order is for oxygen at 2 L/M. Interview on 4/23/2024 at 11:50 am with LPN BB regarding residents' oxygen that is set at 4.5 L/M revealed that physician order was for oxygen at 2 L/M. She stated that she continues to check on R17 and did not know whether the resident changed the oxygen or not. Interview on 4/24/2024 at 11:30 am R17 stated that she is not a nurse and did not touch the oxygen tank to change the setting, and that she only puts the nasal canula in her nose. Interview on 4/24/2024 at 4:15 pm with Director of Nursing (DON) revealed her expectations for nurses was to monitor and make sure the oxygen is set at the correct level per physician order for residents receiving oxygen therapy. The surveyor asked if a resident will be at risk of adverse reaction when the oxygen level is higher than what the order says. DON revealed that the resident would be at risk of adverse reaction especially if the resident has COPD. Interview on 4/25/2024 at 9:10 am with MDS Coordinator revealed that the care plan for R17 indicates her oxygen should be administered as ordered by the physician. Further interview also revealed that she expects the nurses to follow the physicians' orders and the residents plan of care.

Based on observations, staff interviews, and review of the facility's housekeeping plan of correction, the facility failed to maintain an environment free from a build-up of dirt, debris, stains, smears, damaged baseboards, peeling/scuffed paint, missing bathroom fixtures, and supplies for three resident bathrooms, two shower rooms, and one dining room on one of three halls (West Hall secured unit). The deficient practice had the potential to affect all residents residing on the secured unit by not providing a clean, sanitary, and homelike environment and living space. Findings include: During an interview on 5/30/2023 at 11:30 a.m., with Project Crew members DD and EE revealed that the previous maintenance person had quit. They stated that they were part of a crew that traveled from facility to facility and had been at this facility for about a week and a half. Interview on 6/1/2023 at 4:30 p.m., with the Director of Nursing (DON) stated that the current Administrator and previous Administrator had identified concerns with housekeeping including the concerns on the secured unit. Interview on 6/1/2023 at 5:00 p.m. with the Administrator revealed that he had identified issues with housekeeping and that it was not up to his expectations. A review of the Client Survey/Facility Assessment-Plan of Correction form, with the contracted housekeeping company, revealed that an onsite visit was completed on 6/1/2023, and the plan of correction was initiated on 6/2/2023.The plan included the concerns of room cleanliness, resident room cleaning, resident rooms, and housekeeping staffing. The plan of correction included the housekeeping staff was provided with in-service education on 6/2/2023. The in-service education included a 5-Step daily patient room cleaning procedure and a 7-step daily washroom cleaning. The following observations were made on the [NAME] Hall secured unit: 1.During an observation on 5/15/2023 at 1:42 p.m. and on 6/5/2023 at 9:50 a.m., in the shared bathroom for rooms two and four, the toilet tank did not have a lid and the toilet seat was loose and askew. There was a stale urine odor. There was no toilet paper or toilet paper holder. During observations on 6/5/2023 at 9:50 a.m. and again on 6/6/2023 during environmental observations with the Administrator between 11:00 a.m. and 11:30 a.m. there was a pile of clothes in the corner near the sink. There were two spots of a thick brown substance on the floor along with two pieces of opened plastic packaging. There was no toilet paper or toilet paper holder, and the toilet tank did not have a lid. During the observation on 6/6/2023 with the Administrator, he stated that he was going to have to talk with housekeeping. 2. During an observation on 5/15/2023 at 1:45 p.m., in the shared bathroom for rooms five and seven, there were spots and smears of a dried brown substance on the wall and baseboard beside the toilet and on the bathroom door frame for the room seven entrance to the bathroom. During an observation on 6/5/2023 at 9:55 a.m., there were dried brown smears and stains on the wall beside the toilet. There was no toilet paper or toilet paper holder. There were no paper towels in the wall-mounted paper towel dispenser. The call light switch was missing the attached string. During environmental observations with the Administrator on 6/6/2023 between 11:00 a.m. to 11:30 a.m., there were dried brown smears and stains on the wall and the baseboard beside the toilet. There was no toilet paper or toilet paper holder. There were no paper towels in the paper towel dispenser, and the call light switch was missing the attached string. The Administrator stated that the cleaning needed to be more thorough. 3. During observations on 5/30/2023 at 10:35 a.m. and on 6/1/2023 at 3:10 p.m., in the shared bathroom for rooms [ROOM NUMBERS] the baseboard was partially detached from the wall behind the toilet and near the sink. There was no toilet paper, and the toilet paper holder did not have a spindle. During an observation on 6/5/2023 at 3:50 p.m., there were no paper towels in the wall-mounted paper towel dispenser. There was no toilet paper, and the toilet paper holder did not have a spindle. The baseboard behind the toilet and near the sink remained partially detached from the wall. During environmental observations with the Administrator on 6/6/2023 between 11:00 a.m. to 11:30 a.m., there were no paper towels in the paper towel dispenser. There was no toilet paper, and the toilet paper holder did not have a spindle. The baseboard behind the toilet and near the sink remained partially detached from the wall. 4. During observations on 6/5/2023 at 10:00 a.m., 1:05 p.m., 3:53 p.m., and on 6/6/2023 at 9:12 a.m., in the secured unit dining room, there were multiple dried white stains running down the large windows. There were also multiple random pieces of clear tape attached to the windows. There was a buildup and collection of dirt, debris, dried stains, scuffed and peeling paint to the lower portions of the walls, windowsills, and baseboards that wrapped around the dining room. During environmental observations with the Administrator on 6/6/2023 between 11:00 a.m. and 11:30 a.m., a staff member was cleaning and buffing the floor of the dining room. The build-up of dirt, debris, dried stains , scuffed and peeling paint remained on the lower portions of the walls, windowsills, and baseboards. There were multiple dried white stains and pieces of tape attached to the large windows. The Administrator stated that they were going to do some painting in the dining room.

Based on observations, resident and staff interviews, and review of pest control service records, the facility failed to maintain an environment free from flies on two of three halls (East and [NAME] Hall), in one of two dining rooms and for one of 15 resident's resident (R)(A). Findings include: A review of the facility fly control program contract revealed a fly control program has been in place since 6/8/2018. A review of pest control service records for 2023 revealed pest control services, including for flies, had been provided monthly on 1/18/2023, 2/20/2023, 3/20/2023, 4/19/2023, 5/19/2023, and 6/5/2023. However, flies were observed in the facility in the following areas: East Hall A review of the 5/19/2023 pest control service record revealed a notation from the service technician to please keep all ultraviolet light (UVL) fly equipment plugged in. However, during observations on 6/5/2023 at 11:23 a.m. and 2:03 p.m., the UVL mounted on the wall at the end of the East Hall was unplugged. During a medication pass task observation on 6/5/2023 at 11:41 a.m., on the East Hall, two flies were observed in room [ROOM NUMBER] crawling on (R) A's pillow, bed linens, overbed table, and his forehead. RA attempted to swat the flies away. During a subsequent observation on 6/5/2023 at 1:00 p.m., two flies were observed flying around RA while he was in bed eating lunch. The flies were observed crawling on the resident, the bed linens, and overbed table where his lunch tray was set up. RA, when asked if he usually had flies in his room, responded yes, every day. West Hall (secured unit) 1. During an observation of room four, on the [NAME] Hall (secured unit), on 5/15/2023 at 1:42 p.m., flies were observed flying around the room, near the closed bathroom door. When the bathroom door was opened multiple small insects, which were flying around the bathroom, flew out toward the door when it was opened. During an observation of room four on 6/5/2023 at 9:50 a.m., two flies were flying around the room. Flies were also observed flying around the room four bathroom. During environmental observation rounds with the Administrator on 6/6/2023 from 11:00 a.m. to 11:30 a.m., two flies were observed on the privacy curtain in room four, near the open bathroom door. 2. During an observation of room seven, on the [NAME] Hall (secured unit), on 6/5/2023 at 9:55 a.m., two flies were observed crawling on the first bed. During an environmental observation rounds with the Administrator on 6/6/2023 from 11:00 a.m. to 11:30 a.m., a fly was observed crawling on the first bed in room seven. Main Dining Room During observations on 6/5/2023 at 4:39 p.m. and 6/6/2023 at 8:05 a.m., multiple dead flies (more than 27) were observed on the windowsills underneath the line of windows in the main dining room. During environmental observation rounds with the Administrator on 6/6/2023 from 11:00 a.m. to 11:30 a.m., he confirmed that the pest control company was at the facility the day prior, on 6/5/2023, for their monthly service visit. The Administrator stated that he had spoken to the pest control service technician about flies, and they discussed adding additional UVL's in the facility.

Based on observation, resident and staff interviews, the facility failed to: maintain a safe, clean, comfortable, homelike environment on two of two Halls (East Hall and West Hall) free from stained, sagging, and holes in ceiling tiles, dusty, dirty ceiling vents and fans, stained, scratched toilets, missing baseboard, scuffed-up doors, one loose sink that needed caulking, one leaking sink; maintain a comfortable air temperature within range of 71 degrees Fahrenheit (F) to 81 degrees F; maintain a working women's shower free from disrepair, missing floor tiles, musky smell, with equipment stored in it; and ensure the smoking porch was free from dirty ceiling fans and spider webs. Findings include: Observation on 7/20/22 at 9:55 a.m., and interview at that time with resident (R) R#5 and R#41 revealed stained ceiling tiles and dead bugs in the fluorescent light fixture in resident room on East Hall. R#5 and R#41 reported the air did not work properly in odd numbered rooms on East Hall. Observation on 7/20/22 at 1:39 p.m. in room three on East Hall revealed a dusty box fan set up at the foot of bed b blowing on resident in bed because there was no air coming out of the floor vent. Observation in the bathroom revealed a busted ceiling tile, and dusty vent. Observation on 7/20/22 at 1:45 p.m. with the Maintenance Director, and interview at that time, revealed he was not aware the air was not working properly on East Hall, the unit was new, and he checked random rooms daily to ensure temperatures (temps) was between 72 to 76 degrees. Resident#73 presented with a Brief Interview of Mental status (BIMS) score 99, and R#48 presented with a BIMS of 00, indicating significant cognitive deficits. R#73 was in bed with cover up to his chin. Temperature check on 7/20/22 at 2:04 p.m. verified by the maintenance director using the facility calibrated thermometer, revealed a temp of 69 degrees in their room. Observation on 7/20/22 at 2:15 p.m. of a thermostat mounted on the East Hall, temp was set at 76 degrees. During random temperature checks with the maintenance director, using his calibrated thermometer, air temps in resident rooms on the East Hall were verified between 69 and 72 degrees Fahrenheit. Interview at that time with the maintenance Director revealed the problem is East Hall is very busy because smoke porch and laundry dept. are at the end, constant traffic in and out of the double doors causing warm temps in the hallway. The thermostat that regulates resident rooms was mounted in the hallway where it's warmer, keeps running trying to adjust to the temp set at, although it is much colder inside resident rooms. A temp check on East Hall revealed a temp of 79 degrees. His expectation was that the thermostat be moved from the hallway but that would have to be approved, and he would need help to get it done. Observation of R#40 in their room wearing grey sweatpants, tan long-sleeved pull-over shirt, a grey & white undershirt, grey non-skid socks, and grey hoodie cap. Interview at that time R#40 revealed to surveyor he was cold and said it's always cold. Air temp in the room, verified by the Maintenance Director, was 71 degrees. Temp was checked immediately in hallway outside the room and verified a temp of 79 degrees in hallway. During a walkthrough of the facility with the Maintenance Director on 7/21/22 between 2:00 p.m. and 2:30 p.m. the maintenance director verified the following on East and West Hall: Women's shower felt cold, damp, had musky smell, missing floor tiles, floor tiles in disrepair, and half of the shower was used for storage of equipment. Men's shower had bad floor and ceiling tiles, a hole in ceiling where sprinkler had been. Missing baseboard and very cold in room 14. Bad ceiling tiles and a hole in ceiling tile in bathroom of room seven. Dusty vent in bathroom, hole in ceiling, holes in bathroom wall tile, and no cable in room eight. Very dusty vent in bathroom of room six. Dusty vent and loose sink that was not caulked in room five. Dusty fan blowing on resident, air not running from vent, and light not working, dusty vent and broken ceiling tile in bathroom of room three. Dusty vent in bathroom, stained ceiling tiles and dead bugs in the ceiling light in room three. Dusty vent in bathroom and bad floor tiles in room two. Dirty ceiling fans and spider webs on smoking porch, one of three ceiling fans not working. Large hole in the wall in the laundry department, and several towels stuffed around another opening in wall. Stained or scratched toilet bowl in bathroom of room 16. Observation at that time the Maintenance Director confirmed large, formed stool in bathroom 16 toilet. Interview at that time with the Maintenance Director revealed he has to use the snake tool regularly to unstop the toilet because of the large stool, and he made a motion with his hands as if going in a circle around the toilet bowl. The consensus was that the inside of the toilet bowl was scratched from the tool instead of stained. Dripping faucet under bathroom sink in room two on West Hall. During an interview on 7/21/22 at 10:30 a.m. with CNA EE revealed she had worked here since 3/22/22. She confirmed orientation and training when she started and confirmed that if staff see something that needs cleaning or repairing, they should report it to housekeeping or maintenance. During an interview on 7/21/22 at 10:35 a.m. with CNA FF revealed she had worked here since 6/27/22. She confirmed receiving orientation and training when she started. Interview revealed if they see needed cleaning, maintenance or repairs they report it to housekeeping or maintenance. During an interview at 2:30 p.m. the Maintenance Director revealed he was the only person in Maintenance, he did not have any help, he did all maintenance and repairs by himself unless corporate comes, cleaning is contracted by Healthcare Services, and they do housekeeping/cleaning jobs. He revealed he did not have a work order log, there is a book at each nurse station that staff are supposed to use to report repairs and maintenance, but they don't use it, and staff inform him by word of mouth. He confirmed he cleaned the vents not long ago and could not believe they were so dusty. During an interview on 7/21/22 at 2:45 p.m. with the Administrator revealed housekeeping was contracted with Healthcare Services, they have a generalized policy for every building related to laundry, housekeeping and cleaning, and have only one maintenance staff, the director. The Administrator confirmed maintenance and repairs were needed, but supply and demand had caused a delay in getting supplies in rural areas. They utilized local retailers as much as possible but there is still a delay in getting what they need to complete repair and maintenance jobs. Her expectation was that the facility is in the best possible condition. Further interview confirmed there was only one door to the laundry department used for entering and exiting with dirty and clean laundry, and the laundry door is open to the smoking porch. The Administrator did not feel this was causing cross contamination because dirty laundry should be contained and transported in a covered container. Her expectation was the laundry door should be closed when residents are smoking on the porch, doors between the dirty and clean side should always be closed, laundry carts should not be parked on the smoking porch and should be stored in the laundry department. She confirmed there was a large hole in the wall, there were steps to get in and out of the laundry department, and that two staff could carry the laundry cart up and down the steps.

Based on observations, interviews, and record review of the policy entitled, Management of the Laundry, the facility failed to provide a separate delivery entrance into the Laundry Room to take soiled or dirty linen/clothes, use appropriate PPE including gloves and an apron when sorting linen, and keep soiled or dirty linen/clothes covered; this affected Residents who used the linen at the facility and had their clothes cleaned in the Laundry Room. The census was 75. Findings include: The policy entitled Management of the Laundry has these statements, It is very important to properly transport and store soiled linens to prevent the spread of infection. To do so, all soiled linen and clean linen must be covered during transportation and while being stored on unit or floors. Soiled linens brought down manually must have a separate delivery entrance and must be place into the soiled linen bins. As soiled linens are sorted into the proper wash classifications, employees must wear the proper personal protective equipment (PPE), which includes gloves and a protective apron. During an observation of the Laundry Department on 7/19/22 at 10:00 a.m. it was revealed there was uncovered dirty linen on the floor; there is only one door used to enter and exit the Laundry Department. The door to the clean area was open to the dirty side. During an interview with Laundry Worker (LW) AA, on 7/19/22 at 10:41 a.m. revealed the staff from the units bring dirty laundry in bags to the door of the laundry department and put the laundry on the floor; she uses gloves only to sort through the dirty laundry; clean clothes and linen are taken from the dryer to another room to fold and sort; clean clothes and linen are then put on a blue buggy outside of the laundry room and the laundry staff takes the clean linen and clothes to the unit. During an interview with LW BB on 7/20/22 at 09:00 a.m. revealed that the same door is used to take the dirty linen to the Laundry Department and take the clean linen from the Laundry Department to the units. During an Interview with LW BB on 7/20/22 at 12:15 p.m. revealed the smoking area is adjacent to the Laundry Department; the door to the Laundry Department is open most of the time; the clean clothes cart is kept out on the porch where Resident's smoke but she does not put clean clothes out there while smoking is going on; noted at this time there were three ceiling fans on the porch; all were dusty, one was not working. During an interview with Certified Nurse Assistant (CNA) DD on 7/21/22 at 9:00 a.m. revealed dirty linen is put in the Soiled Utility Room; they use gloves and put it in plastic bags; if leaking will double bag; the staff will take the dirty linen to the Laundry Department. They use gloves when transporting the linen. During interview and tour of Laundry Department with the Administrator on 7/21/22 at 9:30 a.m. revealed she is aware there is only one entrance for the Laundry Department; reviewed Laundry Policy with Administrator, Management of the Laundry which states; Soiled linens brought down manually must have a separate delivery entrance and must be placed into the soiled linen bins. Administrator states there is only one entrance for the Laundry Room. During an interview with LW BB on 7/21/22 at 1:30 p.m. revealed the door to the laundry is open at all times; clean linen is folded and sorted in a separate room; when ready to put linen on the cart she walks through dirty area and puts it on the cart on the porch area; the clean linen is not covered. During an interview on 7/21/22 at 2:45 p.m. with the Administrator it was revealed housekeeping services was contracted through Healthcare Services, and Healthcare Services has a generalized policy for every building related to laundry, housekeeping, and cleaning. The Administrator confirmed maintenance and repairs were needed but that supply and demand had caused a delay in getting supplies in rural areas and thus caused delays. They utilize local retailers as much as possible but there is still a delay in getting what they need to complete repair and maintenance jobs. Her expectation was that the facility is in the best possible condition. Further interview confirmed there was only one door to the laundry department, used for entering and exiting with dirty and clean laundry, and the laundry door is open to the smoking porch. She did not feel this was causing cross contamination because dirty laundry should be contained and transported in a covered container. Her expectation was the laundry door should be closed when residents are smoking on the porch, doors between the dirty and clean side should always be closed, laundry carts should not be parked on the smoking porch and should be stored in the laundry department. She confirmed there were steps to get in and out of the laundry department, and that two staff could carry the laundry cart up and down the steps.

Based on observations, record reviews, and staff interviews the facility failed to follow Physician's Order for one of four residents (R) (R#39) who received nutrition via gastric feeding tube. Findings include: A review of the clinical record revealed that R#39 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 7/20/22 9:36 a.m. revealed R#39 lying in bed low bed with head of bed elevated. Feeding pump was connected to G-tube, tube feeding formula Nepro 1.2 infusing at 60 cubic centimeters (cc) per hour (hr). A review of the physicians' order revealed note dated 5/23/22 that reads Nepro 1.2 60cc/hr for 22hrs via peg tube. Order was discontinued 7/21/22. During an Interview with DON on 7/21/22 at 9:20 a.m. it was revealed R#39 had been receiving the TF at 60cc/hr at 24 hours continuously, and the physician order should have reflected that the TF was infusing at 60 cc/hr for 24 hours continuously. During an interview with charge nurse on 7/21/22 at 1:35 p.m. it was revealed that she usually stops the tube feeding around 10:00 a.m. and resumes at 12 noon. Charge nurse confirmed she had no documentation for stopping and starting the tube feeding. A review of the Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review, staff interviews, and review of the facility policy titled, Change in Condition/Incident Reporting the facility failed to notify the responsible party of a fall for one of six residents (R) (R#1) reviewed for falls and failed to notify the physician of the fall and subsequent change in condition post fall for R#1. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on [DATE] at 4:42 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy is outlined as follows: A nursing Progress Note dated [DATE] revealed that Certified Nursing Assistant (CNA) UU observed R#1 laying on her side next to the bed at 6:00 a.m. and that R#1 had an unwitnessed fall. The Situation-Background-Assessment-Recommendation (SBAR) dated [DATE] revealed that the family was not notified, and that the physician was notified at 7:00 a.m. The 7:00 p.m. to 7:00 a.m. night shift nurse Licensed Practical Nurse (LPN) OO assessed R#1 on [DATE] at 7:00 a.m., after the residents fall, and the following vital signs were obtained: blood pressure (BP): ,d+[DATE], pulse (P): 84, respirations (R): 20, Temperature (Temp): 97.3 blood sugar: 140 and O2 saturation: 94% on 3 Liters of oxygen via nasal canula (normal greater than 92%). The 7:00 a.m. to 7:00 p.m. day shift nurse LPN RR completed a post fall evaluation on [DATE] at 1:10 p.m. and the resident's vital signs were obtained at 1:25 p.m. and revealed the following: BP: ,d+[DATE], Pulse: 71, R:20, and Temp: 96.6 the resident's O2 saturation was documented to be 86% on 3 Liters of oxygen via nasal canula. LPN RR documented that she rechecked R#1's O2 saturation on [DATE] at 1:34 p.m. and documented that the resident's O2 saturation level had dropped into the 80's. LPN RR noted the drop in the O2 saturation was because R#1 was removing her O2 nasal cannula. At 1:37 p.m., LPN RR documented that she checked the resident's O2 saturation continuously during the day and R#1's O2 saturation remained between 83% to 86%. The nurse noted that she called the physician at 1:54 p.m. LPN RR documented on [DATE] at 3:28 p.m. that the physician was notified that the resident kept removing her O2, however, there was not any evidence that LPN RR notified the physician of R#1's fall, earlier in the day, or that R#1's O2 level was dropping into the 80's, ranging from 83% to 86% throughout the day, after the residents fall. On [DATE] at 4:55 p.m. LPN RR entered the resident's room and found R#1 without a pulse and without respirations. LPN RR initiated Cardiopulmonary Resuscitation (CPR) and had staff call 911. When Emergency Medical Services (EMS) arrived at 5:20 p.m. R#1 was found to be in asystole (without a heart rate or rhythm) per an Electrocardiogram (EKG) strip and CPR was discontinued. Review of the Death Pronouncement form revealed R#1 was pronounced dead on [DATE] at 5:20 p.m. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at: F580 - Notification of Changes 483.10(g)(14)(i)(B), Scope/Severity: J; F600 - Freedom from Abuse, Neglect, and Exploitation 483.12, Scope/Severity: J; F655 - Baseline Care Plan 483.21(a)(1)-(3), Scope/Severity: J; F726 - Competent Nursing Staff 483.35 (a)(3)(4)(c), Scope/Severity J; F835 - Administration, 483.70 Scope/Severity: J; F867 - Quality Assessment and Assurance Improvement Activities 483.75(d)(1)(2)(e)(1)-(3)(g)(2), Scope/Severity: J. Additionally, Substandard Quality of Care was identified with the requirements at F600 Freedom from Abuse, Neglect, and Exploitation 483.12, Scope/Severity: J. Findings include: Review of facility policy titled, Change in Condition/Incident Reporting, dated [DATE], revealed the following: When a resident displays a change in condition, Licensed Nurse will complete an assessment to determine symptomology and clinical results. If there is an actual change in condition, the resident's physician is notified. Family/Responsible party notified. Record review revealed that R#1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the electronic Interact Change in Condition Evaluation dated [DATE] at 7:00 a.m. noted R#1 was observed lying on the floor next to the bed. The resident stated she rolled off the bed while dreaming. Review of the facility's Situation, Background, Assessment, and Recommendation (SBAR) Communication Form dated [DATE](Saturday) noted the resident had a fall. The Post Fall Evaluation form dated [DATE] at 1:10 p.m. noted an injury occurred as a result of the fall, however, there were no details of an injury documented on the form. Further documentation on the form noted the resident's O2 saturation level was abnormally low at 86%. The form indicated an abnormal O2 saturation level was less than 92%. Record review revealed a Progress Note dated [DATE] at 8:36 a.m. that documented R#1's family was notified earlier by her nurse about her rolling off bed. She had no injuries noted. Resident had stated to staff that she had been dreaming and rolled off the bed. However, further review revealed this Progress Note was documented on [DATE] at 4:03 p.m. two days after R#1 died . Review of Health Status Notes documented the following: [DATE] at 1:37 p.m. noted the resident's oxygen saturation level was checked continuously during the day and remained from 83% to 86%. [DATE] at 1:54 p.m., the physician was notified of the resident pulling the oxygen off and the nurse was waiting on a response from the physician. [DATE] at 3:28 p.m., physician returned call and spoke to staff about resident not keeping her oxygen nasal cannula on. The physician verbalized by phone to continue to monitor resident. No new orders received. Further review revealed that there was not any evidence that the nurse communicated to the physician that R#1's O2 level was dropping into the 80's and had ranged from 83% to 86% during the day. Review of a Progress Note dated [DATE] at 4:55 p.m. revealed that LPN RR entered R #1's room, and noticed the nasal cannula was laying on the floor. The resident did not respond to verbal or tactile stimulation and R#1 was without pulse or respiration. LPN RR initiated Cardiopulmonary Resuscitation (CPR) and had staff call 911. LPN RR documented that EMS arrived at 5:10 p.m. and ran an EKG strip. EMS stated that the resident was in full asystole (without a heartbeat) and called time of death. At 5:30 p.m. LPN RR noted that the Physician was called and notified of the resident expiring. During an interview with Physician WW on [DATE] at 11:43 a.m., he stated he was not aware that the resident had a fall, nor did he remember being notified of the fall. He stated that he also was unaware of the resident's O2 saturation being in the low 80's. He explained the information he received from the nurse was that the resident was taking off her oxygen and the O2 saturation would drop. When the oxygen was replaced, the level was adequate. He stated had he known that the resident's O2 saturation was in the low 80's he would have given orders for a chest x-ray, complete blood count and had her sent to the acute care hospital. During an interview with Licensed Practical Nurse OO on [DATE] at 12:25 p.m., she stated she did not call the physician about the resident's fall and that Registered Nurse (RN) NN faxed the fall notification to the physician. During an interview with RN NN on [DATE] at 12:26 p.m., she stated she had not spoken to the physician regarding the residents fall on [DATE]. She also stated that she was not sure if she texted or faxed the physician, but she did not get a response back from the physician. Interview on [DATE] at 3:57 p.m. Physician WW stated he did not find a fax regarding R#1's fall, and on [DATE] he called the facility at 5:47 p.m., 5:49 p.m. and 5:50 p.m. and based on his phone record the first call on his phone from the facility on [DATE] was at 5:54 p.m. During an interview on [DATE] at 1:16 p.m. the Administrator revealed that when a resident has an acute change in condition and the nurse cannot get in contact with the physician the nurses are to notify the DON. The nurses are not supposed to send residents to the hospital without a physician's order. If there is an emergency life or death situation, and resident is deteriorating, the nurses can send a resident to the hospital, and keep trying to notify the physician. Post survey interview on [DATE] at 11:43 a.m. with the Administrator revealed that RN NN faxed the Physician regarding R#1's fall on Saturday [DATE]. However, the fax number that RN NN utilized is for the Physician's office. The Administrator confirmed that the Physician's office is not opened on Saturdays. The Administrator revealed that for any change of condition, including falls and low oxygen saturation rates, the Physician should be called and should not be faxed. Cross refer F600

Based on record review, family and staff interviews, and review of the facility policy's titled Change in Condition/Incident Reporting, Accidents & Incidents Investigating and Reporting, Respiratory System Management Standard, Oxygen Therapy Protocol, the facility failed to address abnormally low oxygen (O2) saturation levels (normal is greater than 92%) for one of six residents (R), (R#1) after the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility neglected to send R#1 to the emergency room for evaluation and treatment after identifying that the resident was breathing slowly, and the resident's O2 saturation was dropping and ranged from 83% to 86% during the day on [DATE]. In addition, the facility failed to thoroughly assess and complete neurological monitoring for R#1 after the resident fell on [DATE], and subsequently died . The sample size was six residents. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on [DATE] at 4:42 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy is outlined as follows: A nursing progress note dated [DATE] revealed that Certified Nursing Assistant (CNA) UU observed R#1 laying on her side next to the bed at 6:00 a.m. and that R#1 had an unwitnessed fall. The Situation-Background-Assessment-Recommendation (SBAR) dated [DATE] revealed that the family was not notified, and that the physician was notified at 7:00 a.m. The 7:00 p.m. to 7:00 a.m. night shift nurse Licensed Practical Nurse (LPN) OO assessed R#1 on [DATE] at 7:00 a.m., after the residents fall, and the following vital signs were obtained: blood pressure (BP): ,d+[DATE], pulse (P): 84, respirations (R): 20, Temperature (Temp): 97.3 blood sugar: 140 and O2 saturation: 94% on 3 Liters of oxygen via nasal canula (normal greater than 92%). The 7:00 a.m. to 7:00 p.m. day shift nurse LPN RR completed a post fall evaluation on [DATE] at 1:10 p.m. and the resident's vital signs were obtained at 1:25 p.m. and revealed the following: BP: ,d+[DATE], Pulse: 71, R:20, and Temp: 96.6 the resident's O2 saturation was documented to be 86% on 3 Liters of oxygen via nasal canula. LPN RR documented that she rechecked R#1's O2 saturation on [DATE] at 1:34 p.m. and documented that the resident's O2 saturation level had dropped into the 80's. LPN RR noted the drop in the O2 saturation was because R#1 was removing her O2 nasal cannula. At 1:37 p.m., LPN RR documented that she checked the resident's oxygen saturation continuously during the day and R#1's O2 saturation remained between 83% to 86%. The nurse noted that she called the physician at 1:54 p.m. LPN RR documented on [DATE] at 3:28 p.m. that the physician was notified that the resident kept removing her O2; however, there was not any evidence that LPN RR notified the physician of R#1's fall, earlier in the day, or that R#1's O2 level was dropping into the 80's ranging from 83% to 86% throughout the day after the residents fall. On [DATE] at 4:55 p.m. LPN RR entered the resident's room and found R#1 without a pulse and without respirations. LPN RR initiated Cardiopulmonary Resuscitation (CPR) and had staff call 911. When Emergency Medical Services (EMS) arrived at 5:20 p.m. R#1 was found to be in asystole (without a heart rate or rhythm) per an Electrocardiogram (EKG) strip and CPR was discontinued. Review of the Death Pronouncement form revealed R#1 was pronounced dead on [DATE] at 5:20 p.m. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at: F580 - Notification of Changes 483.10(g)(14)(i)(B), Scope/Severity: J; F600 - Freedom from Abuse, Neglect, and Exploitation 483.12, Scope/Severity: J; F655 - Baseline Care Plan 483.21(a)(1)-(3), Scope/Severity: J; F726 - Competent Nursing Staff 483.35 (a)(3)(4)(c), Scope/Severity J; F835 - Administration, 483.70 Scope/Severity: J; F867 - Quality Assessment and Assurance Improvement Activities 483.75(d)(1)(2)(e)(1)-(3)(g)(2), Scope/Severity: J. Additionally, Substandard Quality of Care was identified with the requirements at F600 Freedom from Abuse, Neglect, and Exploitation 483.12, Scope/Severity: J. At the time of exit on [DATE]at 1:33 p.m. the IJ was ongoing. Findings include: Review of the facility policy titled; Change in Condition/Incident Reporting, dated [DATE], revealed as follows: Policy: When a resident exhibits a change in condition, action will be taken to coordinate appropriate care. 1. When a resident displays a change in condition, Licensed Nurse will complete an assessment to determine symptomology and clinical results. Review of the facility policy titled; Accidents & Incidents Investigating and Reporting, (revised [DATE]), revealed as follows: General Guidelines: Event management 1. Reporting of Accidents/Incidents 1f. Un-witnessed incidents with head injury should be sent to emergency room (ER) for Computed Tomography (CT) scan, per MD order. 3. Medical Attention 3c. if head injury suspected, send to ER for CT scan. Review of the Respiratory System Management Standard, Oxygen Therapy Protocol policy revealed indications for oxygen therapy include: 1. Documented hypoxemia - Oxygen saturation, saturation of peripheral oxygen (SpO2) of <90% in adults. Pulse Oximetry, Monitoring of residents. 6. Physician is to be notified if resident consistently shows a saturation less than the prescribed level with concurrent change in vital signs and respiratory status. Review of the clinical record revealed R#1 was a [AGE] year-old female who was admitted to the facility on [DATE] following a hospitalization on [DATE] through [DATE] for an acute kidney injury (resolved). R#1 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospital discharge summary dated [DATE] revealed at the time of discharge from the hospital R#1's O2 saturation was documented to be 100% on room air. R#1 was transferred from the hospital to the facility on [DATE] with admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on [DATE] at 10:24 a.m. with CNA UU revealed on [DATE] R#1 was sleeping and at approximately 6:00 a.m. CNA UU heard a loud noise. She went into the room and R#1 was laying on the floor. All available staff came to R#1's room and used a Hoyer lift to transfer R#1 back to bed. Review of the facility Progress Notes, dated [DATE] through [DATE], revealed an entry on [DATE] at 7:00 a.m. that CNA UU observed R#1 laying on her side next to the bed. Resident was noted as being asleep and rolled off the side of the bed. The resident denied pain and hitting her head. She had an unwitnessed fall. The night nurse LPN OO completed a head-to-toe assessment and vitals were obtained. The electronic Interact SBAR form dated [DATE] documented that the resident's vital signs were obtained at 6:52 a.m. and revealed the following: BP: ,d+[DATE], P: 84, R: 20, Temp of 97.3 (non-contact), O2 saturation: 94% (on oxygen at 3 Liters via nasal canula). R#1's blood sugar was obtained at 6:14 a.m. and the result was 140. Review of a Post Fall Evaluation Progress Note dated [DATE] at 1:10 p.m. that was completed by the day shift nurse (LPN RR) revealed the following vital signs were obtained at 1:25 p.m. BP: ,d+[DATE], P: 71, Temp: 96.6, O2 saturation: 86% (on oxygen at 3 Liters via nasal cannula). Blood glucose at 12:50 p.m. was 132. Section FDD. Injury, #10: Did injury occur as a result of the fall - Yes was selected as the answer. Section VAB. Abnormalities were checked for the following: 1. SPo2 (oxygen saturation) less than 92, 7. High blood pressure: Systolic greater than 140, 14. High blood glucose: greater than 130. Review of the Progress Note dated [DATE] at 1:34 p.m. revealed LPN RR documented that R#1 continuously had pulled off her O2 and caused her O2 saturation to drop into the 80's. At 1:37 p.m., LPN RR noted that she checked R#1's oxygen saturation continuously during the day and the O2 saturation ranged from 83% to 86%. At 3:28 p.m. LPN RR noted that the physician had returned the call and she informed the physician that R#1 was taking her oxygen off. There was no evidence that LPN RR communicated to the physician that R#1's oxygen saturation level had dropped into the 80's and had ranged from of 83% to 86% or that LPN RR communicated to the physician that R#1 was breathing slowly, or that her systolic blood pressure had been greater than 140. Further review revealed that R#1's O2 levels had been as low as 83%. There was no documentation that O2 levels for R#1 were obtained after 1:54 p.m. Further review revealed a Progress Note dated [DATE] at 1:52 p.m. that documented a follow up O2 saturation reading that had increased to 95 % and LPN RR would continue to check resident and make sure her O2 tubing was still in her nose. The Progress Note revealed when the O2 tubing was out of the resident's nose her O2 level dropped. Continued review revealed this Progress Note was a late entry, documented on [DATE], two days after R#1 died . Review of the Neuro Check Sheet for R#1 dated [DATE], revealed that on [DATE] after 1:45 p.m. there was no evidence that LPN RR assessed R#1 every hour to monitor the resident's level of consciousness, responsiveness, reaction to stimuli, strength of movement, or pupil reaction. Review of the Progress Note dated [DATE] at 4:55 p.m. documented that LPN RR entered R#1's room, and noticed the nasal cannula was laying on the floor. R#1 did not respond to verbal or tactile stimulation and the resident was without pulse or respiration. LPN RR initiated CPR and had staff call 911. LPN RR documented that EMS arrived at 5:10 p.m. and ran an EKG strip. EMS stated that R#1 was in full asystole (without a heartbeat) and called time of death. LPN RR documented that the physician was called and notified of the resident passing at 5:30 p.m. Review of the EMS Patient Care Report (PCR) dated [DATE] revealed EMS was contacted at 5:03 p.m. and arrived at the facility at 5:20 p.m. The report noted at 5:22 p.m. the paramedic and Emergency Medical Technician (EMT) were at the resident's bedside. The report noted that upon arrival the staff advised EMS they came in the patient room at 5:00 p.m. to find her unresponsive, not breathing and with no pulse. The [CONDITION(S)] was not witnessed and the last time the resident was seen alive was at 4:00 p.m. The EMS assessment revealed that the patient was cool to the touch and the cardiac rhythm was asystole. The EMS personnel did not initiate resuscitation as resident was dead at scene. There was no evidence that LPN RR communicated to the EMS that R#1 had an unwitnessed fall earlier in the day and did not communicate that R#1's oxygen saturation levels had ranged from 83% to 86% after the residents fall. There was no death certificate for R#1 available. Interview on [DATE] at 12:11 p.m. with the family of R#1 (F#1) revealed that R#1 told her family member that she had fallen out of her bed. F#1 revealed the facility never called her to tell her that the resident had fallen out of bed. F#1 stated that she missed a call from Registered Nurse (RN) NN on [DATE], and that it was after 5:00 p.m. when she missed the call. When she called back to the facility, RN NN told her that R#1 had coded, and the nurse had provided CPR. EMS had pronounced the resident. F#1 stated she had planned to come to the facility to visit R#1 but instead was told that R#1 was dead. An interview on [DATE] at 12:39 p.m. with another family member of R#1 (F#2) revealed that the last time he talked to R#1 was on [DATE] at 12:08 p.m. F#2 called the resident on her cell phone at 2:38 p.m., but she did not answer. He then called the facility at 2:38 p.m. and the nurse he was speaking to knocked on R#1' door and called R#1's name twice. The nurse told the family member that R#1 was asleep, and she would tell the resident that he had called. The resident's family member stated he kept trying to call the residents cell phone and R#1 never answered. The last time he tried to call R#1 was at 3:56 p.m. on [DATE]. An interview on [DATE] at 3:02 p.m. with RN NN revealed she was the weekend supervisor on [DATE] and that LPN OO informed her that R#1 had fallen out of the bed. RN NN stated that when she made her morning rounds, she had spoken with R#1. RN NN stated that LPN RR told her about R#1's low O2 saturation levels and that LPN RR had explained to her that she had to put the nasal cannula back in the R#1's nose. RN NN stated that she could not remember if R#1's oxygen saturations went back up. RN NN stated that she would have called the doctor for an order, if she had known R#1's oxygen saturation was 86%. RN NN stated she would have sent the resident to the hospital without a doctor's order and that she would have addressed the O2 saturation of 86% if she was aware of the oxygen saturation. A sequential interview on [DATE] at 12:26 p.m. RN NN revealed that she had not spoken to the doctor regarding the fall and she was not sure if she texted or faxed the doctor but she said she didn't get a response back from the doctor. An interview on [DATE] at 4:16 p.m. LPN OO revealed R#1 had a fall about 6:00 a.m. on [DATE]. The resident was laying on the floor next to her bed. She was alert and oriented. There was no abrasion. R#1 stated that she was sleeping. LPN OO did not call the family because there was not a number on her chart for the family. On [DATE] at 12:25 p.m. LPN OO revealed that she did not call the doctor about the fall and that RN NN had sent a fax to the physician to notify the physician of the fall. During an interview on [DATE] at 11:21 a.m. LPN RR revealed that [DATE] was the first day that she had taken care of R#1 and that the residents O2 saturation kept dropping into the 80's, ranging from 83% to 86% that day. LPN RR stated that 83% was the resident's lowest oxygen level. LPN RR also stated that the resident was breathing slowly and that she would take her nasal canula off. LPN RR stated that she would have sent R#1to the hospital, but the facility policy was to get a physician's order. LPN RR stated she had received in report that R#1 had rolled out of bed. LPN RR stated on the Post Fall Evaluation Progress Note that injury was marked as yes, indicating that R#1 had an injury. LPN RR stated that was error. LPN RR stated that at 4:55 p.m. she was going to give R#1 her medications and when she entered the room, she saw the resident was not responding. She stated she shook R#1 and did a sternal rub, and the resident did not respond. LPN RR stated she shouted for staff for assistance and for someone to call 911. Another nurse, and four CNAs came into the room. LPN RR stated she initiated CPR with R#1 in the bed. LPN RR stated she used a backboard when she performed CPR on R#1 while the resident was in the bed. LPN RR stated when EMS arrived about 5:15 p.m. they ran an EKG strip and said that R#1 was completely without a heart rate or rhythm. LPN RR stated EMS listened for breath sounds and wanted a copy of the resident's face sheet and left. LPN RR stated LPN VV told her to call the Administrator. LPN RR stated she called RN NN, the DON, and the Administrator. LPN RR again stated she knew she should have sent R#1 to the hospital but was afraid of the physician getting angry because she did not have an order. During an interview with Physician WW on [DATE] at 11:43 a.m., he revealed he was not aware that R#1 had fallen, nor did he remember being notified of the fall. He stated he also was unaware of the resident's oxygen saturation being in the low 80's. He explained the information he received from the nurse related to the resident taking he O2 off and the O2 saturation would drop. He was informed when the oxygen was replaced, the level was within normal limits. He stated had he known that the resident's O2 saturation was in the low 80's he would have given orders for a chest x-ray, complete blood count and had her sent to the acute care hospital. He continued to state that if he has not responded to a call within five minutes and the resident has an acute serious change in condition, the nurses can send the resident out without an order. An interview on [DATE] at 1:16 p.m. with the Administrator revealed when a resident has an acute change in condition and the nurse is unable to get in contact with the physician, the nurses are to notify the DON. The nurses are not supposed to send residents to the hospital without a physician's order. If it is an emergency life or death situation, and a resident's condition is deteriorating, the nurses can send the resident to the hospital and then call the physician. Post survey interview on [DATE] at 11:43 a.m. with the Administrator revealed that when a resident falls that staff are to complete a Post Fall Assessment. The Administrator also stated that considering R#1's fall and low oxygen saturation levels R#1 should have been sent out to the emergency room for evaluation and treatment.

Based on staff interviews, record reviews, and review of the facility policy titled, Care Pan Development the facility failed to develop a baseline care plan within 48 hours of admission for one of six residents (R#1). On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy on [DATE] at 4:42 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy is outlined as follows: A nursing progress note dated [DATE] revealed that CNA UU observed R#1 laying on her side next to the bed on [DATE] at 6:00 a.m. and that R#1 had an unwitnessed fall. The SBAR dated [DATE] revealed that the family was not notified, and that the physician was notified at 7:00 a.m. The 7:00 p.m. to 7:00 a.m. night shift nurse (LPN 00) assessed R#1 on [DATE] at 7:00 a.m., after the residents fall, and the following vital signs were obtained: blood pressure (BP): ,d+[DATE], pulse: 84, R: 20 Temperature (Temp): 97.3 blood sugar: 140 and Oxygen level (O2 sat): was 94% on 3 Liters of oxygen via nasal canula (normal greater than 92%). The 7:00 a.m. to 7:00 p.m. day shift nurse (LPN RR) completed a post fall evaluation on [DATE] at 1:10 p.m. and the resident's vital signs were obtained at 1:25 p.m. and revealed the following: BP: ,d+[DATE], Pulse: 71, R:20, and Temp: 96.6 the resident's oxygen saturation was documented to be 86% on 3 Liters of oxygen via nasal canula. LPN RR documented that she rechecked R#1's oxygen saturation on [DATE] at 1:34 p.m. and documented that the resident's oxygen saturation level had dropped into the 80's. LPN RR noted the drop in the oxygen saturation was because R#1 was taking off her oxygen. At 1:37 p.m., LPN RR documented that she checked the resident's oxygen saturation continuously during the day and R#1's oxygen saturation remained between 83% to 86%. The nurse noted that she called the Physician at 1:54 p.m. The nurse documented on [DATE] at 3:28 p.m. that the Physician was notified that the resident kept removing her oxygen; however, there was not any evidence that LPN RR notified the Physician of R#1's fall, earlier in the day, or that R#1's oxygen level was dropping into the 80's ranging from 83% to 86% throughout the day after the residents fall. On [DATE] at 4:55 p.m. LPN RR entered the resident's room and found R#1 without a pulse and without respirations. LPN RR initiated Cardiopulmonary Resuscitation (CPR) and had staff to call 911. When EMS arrived at 5:20 p.m. R#1 was found to be in asystole (without a heart rate) per an EKG strip and CPR was discontinued. Per the Death Pronouncement form R#1 was pronounced dead on [DATE] at 5:20 p.m. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at: F580 - Notification of Changes 483.10(g)(14)(i)(B), Scope/Severity: J; F600 - Freedom from Abuse, Neglect, and Exploitation 483.12, Scope/Severity: J; F655 - Baseline Care Plan 483.21(a)(1)-(3), Scope/Severity: J; F726 - Competent Nursing Staff 483.35 (a)(3)(4)(c), Scope/Severity J; F835 - Administration, 483.70 Scope/Severity: J; F867 - Quality assessment and assurance Improvement Activities 483.75(d)(1)(2)(e)(1)-(3)(g)(2), Scope/Severity: J. Additionally, Substandard Quality of Care was identified with the requirements at F600 Freedom from Abuse, Neglect, and Exploitation 483.12, Scope/Severity: J. At the time of exit on [DATE]at 1:33 p.m. the IJ was ongoing. Findings include: Review of the Care Plan Development 5.4 (,d+[DATE]). Procedure 1. An interim care plan will be developed within 24 hours of admission. To assure resident's immediate needs are met this care plan will be initiated by nursing or designees and developed further as needed until the comprehensive plan is completed. This may include but not limited to the following: risk for falls, pain, activities of daily needs or strengths, skin condition, incontinence, mood and/or behaviors. Review of the clinical record revealed R#1 was a [AGE] year-old female who was admitted to the facility on [DATE]with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the baseline care plan revealed that it was dated [DATE] and was signed on [DATE]. Further review revealed that RN BB Minimum Data Set (MDS) Coordinator had documented in the records that the baseline care plan was completed on the above dates ([DATE] and [DATE]). An interview on [DATE] at 12:30 p.m. RN BB revealed that R#1 was admitted to the facility on Thursday, [DATE]. RN BB stated that she did not complete the baseline care plan on [DATE] (as documented) and stated R#1's baseline care plan was not completed until [DATE]. RN BB stated that if she had not been on the medication cart, she would have completed R#1's baseline care plan on time and a family conference would have been scheduled for that Monday on [DATE]. An interview on [DATE] at 1:16 p.m. the Administrator revealed that the documentation in R#1's chart was reviewed with the nurses and the documentation was not up to par and that the nurses had went back and entered notes. (This was noted to be two days after R#1 died ). Post survey interview on [DATE] at 11:43 a.m. with the Administrator revealed that Baseline care plans should be developed within 48 hours of admission. Cross refer F600

Based on record review, staff interviews, and review of the Job Description for the Licensed Practical Nurse the facility failed to ensure staff thoroughly assessed and monitored for a change in condition after a fall for one of six residents (R#1) and failed to address abnormally low oxygen saturation levels and slow breathing for R#1. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy on [DATE] at 4:42 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy is outlined as follows: A nursing progress note dated [DATE] revealed that CNA UU observed R#1 laying on her side next to the bed on [DATE] at 6:00 a.m. and that R#1 had an unwitnessed fall. The SBAR dated [DATE] revealed that the family was not notified, and that the physician was notified at 7:00 a.m. The 7:00 p.m. to 7:00 a.m. night shift nurse (LPN 00) assessed R#1 on [DATE] at 7:00 a.m., after the residents fall, and the following vital signs were obtained: blood pressure (BP): ,d+[DATE], pulse: 84, R: 20 Temperature (Temp): 97.3 blood sugar: 140 and Oxygen level (O2 sat): was 94% on 3 Liters of oxygen via nasal canula (normal greater than 92%). The 7:00 a.m. to 7:00 p.m. day shift nurse (LPN RR) completed a post fall evaluation on [DATE] at 1:10 p.m. and the resident's vital signs were obtained at 1:25 p.m. and revealed the following: BP: ,d+[DATE], Pulse: 71, R:20, and Temp: 96.6 the resident's oxygen saturation was documented to be 86% on 3 Liters of oxygen via nasal canula. LPN RR documented that she rechecked R#1's oxygen saturation on [DATE] at 1:34 p.m. and documented that the resident's oxygen saturation level had dropped into the 80's. LPN RR noted the drop in the oxygen saturation was because R#1 was taking off her oxygen. At 1:37 p.m., LPN RR documented that she checked the resident's oxygen saturation continuously during the day and R#1's oxygen saturation remained between 83% to 86%. The nurse noted that she called the Physician at 1:54 p.m. The nurse documented on [DATE] at 3:28 p.m. that the Physician was notified that the resident kept removing her oxygen; however, there was not any evidence that LPN RR notified the Physician of R#1's fall, earlier in the day, or that R#1's oxygen level was dropping into the 80's ranging from 83% to 86% throughout the day after the residents fall. On [DATE] at 4:55 p.m. LPN RR entered the resident's room and found R#1 without a pulse and without respirations. LPN RR initiated Cardiopulmonary Resuscitation (CPR) and had staff to call 911. When EMS arrived at 5:20 p.m. R#1 was found to be in asystole (without a heart rate) per an EKG strip and CPR was discontinued. Per the Death Pronouncement form R#1 was pronounced dead on [DATE] at 5:20 p.m. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at: F580 - Notification of Changes 483.10(g)(14)(i)(B), Scope/Severity: J; F600 - Freedom from Abuse, Neglect, and Exploitation 483.12, Scope/Severity: J; F655 - Baseline Care Plan 483.21(a)(1)-(3), Scope/Severity: J; F726 - Competent Nursing Staff 483.35 (a)(3)(4)(c), Scope/Severity J; F835 - Administration, 483.70 Scope/Severity: J; F867 - Quality assessment and assurance Improvement Activities 483.75(d)(1)(2)(e)(1)-(3)(g)(2), Scope/Severity: J. Additionally, Substandard Quality of Care was identified with the requirements at F600 Freedom from Abuse, Neglect, and Exploitation 483.12, Scope/Severity: J. At the time of exit on [DATE]at 1:33 p.m. the IJ was ongoing. Review of the Job Description for the Licensed Practical Nurse revealed the following job summary: The primary purpose of the Licensed Practical Nurse position is to provide direct nursing care to residents as a member of an interdisciplinary team of care providers and to plan, supervise and evaluate the day-to-day nursing activities performed by nursing assistants. The Job Description also included the following job duties and responsibilities: 1. Implement and monitor compliance with all established policies and procedures. 2. Meet regularly with your assigned nursing staff and support personnel to plan and communicate appropriate care-related services and activities for your residents, communicate residents' concerns and needs and discuss other vital information related to resident care and facility practices. 3. Follow the facility's policies and procedures governing the provision of direct care to residents, including the administration of medications, treatments and/or other care in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Perform continual observation and evaluation of each resident's physical, mental, cognitive and emotional status and the Director of Nursing or designee, to the attending physician and to the resident's responsible party, according to facility policy and protocol. 5. Communicate timely with physicians and/or Nurse Practitioners related to the resident care needs and concerns. Be responsible to properly implement and communicate to other caregivers all physician and/or nurse practitioner orders. 6. Respond immediately to resident events, accidents, incidents, and/or allegations of abuse, neglect and/or misappropriation of property. Perform an assessment of the involved resident(s) and provide emergency intervention as required. Notify the Director of Nursing, the Administrator (as appropriate), the resident's attending physician and the resident's responsible party when the resident is involved in an accident/incident Record review revealed R#1 was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the electronic Interact Change in Condition Evaluation dated [DATE] at 7:00 a.m. noted the resident was observed lying on the floor next to bed. The resident stated she rolled off the bed while dreaming. Review of the SBAR Communication Form dated [DATE] noted the resident had a fall. The Post Fall Evaluation form dated [DATE] at 1:10 p.m., noted an injury occurred as a result of the fall however, there were no details of an injury documented on the form. Further documentation on the form noted the resident's oxygen saturation level was abnormally low at 86%. The form indicated an abnormal oxygen saturation level was an oxygen saturation level less than 92%. Review of the Health Status Note dated [DATE] at 1:37 p.m. revealed that R#1's oxygen saturation on [DATE] was checked continuously throughout the day and remained between 83% to 86%. Review of a Neuro Check Sheet dated [DATE] revealed that after 1:45 p.m. there was no evidence that LPN RR assessed R#1 every hour to assess the resident's level of consciousness, responsiveness, reaction to stimuli, strength of movement, or pupil reaction. During an interview with Physician WW on [DATE] at 11:43 a.m., he stated he was not aware that the resident had a fall, nor did he remember being notified of the fall. He stated that he also was unaware of the resident's oxygen saturation being in the low 80's. He continued to state that if he has not responded to a call within five minutes and a resident has an acute serious change in condition, the nurses can send the resident out without an order. During an interview with LPN RR on [DATE] at 11:21 a.m., she stated that [DATE] was the first day that she had taken care of the resident. She stated the resident's oxygen saturation kept dropping into the 80's and ranged between 83% and 86% and the resident had slow breathing. When she would go back into the resident's room the resident's oxygen nasal cannula would be off. LPN RR stated she would have sent the resident out (to the ER), but the facility policy was to get a doctor's order. LPN RR stated she knew R#1 should have been sent out to the emergency room . During an interview with RN NN on [DATE] at 3:02 p.m., she stated she was the weekend supervisor on [DATE]. She stated LPN RR did tell her the resident's oxygen saturation and would put the nasal cannula back in the resident's nose. She could not remember if the oxygen saturation went back up. She stated she would have called the physician for an order if she had known R#1's oxygen saturation was 86% and would have sent the resident out (to the emergency room ) without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Post survey interview on [DATE] at 11:43 a.m. with the Administrator revealed that when a resident falls that staff are to complete a Post Fall Assessment. The Administrator stated that staff completed a Post Fall Assessment; however, staff failed to complete thorough neuro checks after R#1 fell , failed to contact the Physician of R#1's fall, failed to communicate that R#1's oxygen saturation level was ranging from 83% to 86% after R#1 fell . Cross refer F600

Based on staff interviews, record review and review of job descriptions titled, Administrator and Director of Nursing Administration failed to ensure that the responsible party was notified of a fall for one of six residents (R#1) and failed to notify the Physician of a fall and the residents low oxygen saturation levels (below 92%) and slow breathing (decreased respirations) for one of six residents (R#1). Administration failed to ensure that R#1 was sent to the emergency room for timely evaluation and treatment. Administration failed to ensure that a baseline care plan was developed within 48 hours of admission for one of six residents (R#1). In addition, Administration failed to have an effective QAPI committee that ensured that residents that experienced a fall were monitored and received timely care. The facility census was 64 Residents. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy on [DATE] at 4:42 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy is outlined as follows: A nursing progress note dated [DATE] revealed that CNA UU observed R#1 laying on her side next to the bed on [DATE] at 6:00 a.m. and that R#1 had an unwitnessed fall. The SBAR dated [DATE] revealed that the family was not notified, and that the physician was notified at 7:00 a.m. The 7:00 p.m. to 7:00 a.m. night nurse (LPN 00) assessed R#1 on [DATE] at 7:00 a.m., after the residents fall, and the following vital signs were obtained: blood pressure (BP): ,d+[DATE], pulse: 84, R: 20 Temperature (Temp): 97.3 blood sugar: 140 and Oxygen level (O2 sat): was 94% on 3 Liters of oxygen via nasal canula (normal greater than 92%). The 7:00 a.m. to 7:00 p.m. day shift nurse (LPN RR) completed a post fall evaluation on [DATE] at 1:10 p.m. and the resident's vital signs were obtained at 1:25 p.m. and revealed the following: BP: ,d+[DATE], Pulse: 71, R:20, and Temp: 96.6 the resident's oxygen saturation was documented to be 86% on 3 Liters of oxygen via nasal canula. LPN RR documented that she rechecked R#1's oxygen saturation on [DATE] at 1:34 p.m. and documented that the resident's oxygen saturation level had dropped into the 80's. LPN RR noted the drop in the oxygen saturation was because R#1 was taking off her oxygen. At 1:37 p.m., LPN RR documented that she checked the resident's oxygen saturation continuously during the day and R#1's oxygen saturation remained between 83% to 86%. The nurse noted that she called the Physician at 1:54 p.m. The nurse documented on [DATE] at 3:28 p.m. that the Physician was notified that the resident kept removing her oxygen; however, there was not any evidence that LPN RR notified the Physician of R#1's fall, earlier in the day, or that R#1's oxygen level was dropping into the 80's ranging from 83% to 86% throughout the day after the residents fall. On [DATE] at 4:55 p.m. LPN RR entered the resident's room and found R#1 without a pulse and without respirations. LPN RR initiated Cardiopulmonary Resuscitation (CPR) and had staff to call 911. When EMS arrived at 5:20 p.m. R#1 was found to be in asystole (without a heart rate) per an EKG strip and CPR was discontinued. Per the Death Pronouncement form R#1 was pronounced dead on [DATE] at 5:20 p.m. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at: F580 - Notification of Changes 483.10(g)(14)(i)(B), Scope/Severity: J; F600 - Freedom from Abuse, Neglect, and Exploitation 483.12, Scope/Severity: J; F655 - Baseline Care Plan 483.21(a)(1)-(3), Scope/Severity: J; F726 - Competent Nursing Staff 483.35 (a)(3)(4)(c), Scope/Severity J; F835 - Administration, 483.70 Scope/Severity: J; F867 - Quality assessment and assurance Improvement Activities 483.75(d)(1)(2)(e)(1)-(3)(g)(2), Scope/Severity: J. Additionally, Substandard Quality of Care was identified with the requirements at F600 Freedom from Abuse, Neglect, and Exploitation 483.12, Scope/Severity: J. At the time of exit on [DATE]at 1:33 p.m. the IJ was ongoing. Findings include: The facility had a job description for the Administrator. The job description included a job summary job that the primary purpose of the Nursing Home Administrator position is to oversee the day-to-day operation of the facility and to review organizational performance. The job duty and responsibilities: Resident Care and Quality of Life to oversee that nursing services, social service programs, activity programs, food service programs and medical services are planned, implemented, and evaluated to meet resident needs to maximize resident quality of life and quality of care. The facility had a job description for the Director of Nursing. The job description included a job summary that the primary purpose of the Director of Nursing position is to plan, organize, develop, and direct the overall operation of the Nursing Department to ensure that the highest degree of quality care is maintained at all times. The job duties and responsibilities: Administrative functions job position was to develop methods for coordination of nursing services with other resident services to ensure the continuity of the resident's total regime of care. Review and ensure that charting documentation procedures for nursing are met according to Vanguard, state, and federal guidelines. The Nursing Care Functions inform nursing personnel of new admission's include all pertinent logistical information. Review nurse's note to ensure that they are informative, descriptive of the nursing care and consistent with therapy care being provided, that they reflect the resident's response to the care, and that such care is provided in accordance with the resident wishes. . Facility Administration, including the Administrator and DON, failed to effectively oversee clinical and nursing functions that were included in their job descriptions. 1. Administration failed to notify the responsible party of a fall for one of six residents (R#1) and failed to notify the Physician of a fall and the residents low oxygen saturation levels and slow breathing (decreased respirations) for one of six residents (R#1). Cross refer F580 2. Administration neglected to address abnormally low oxygen saturation (O2) levels (normal is greater than 92%) for one of six residents (R#1) after the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility neglected to send one of six residents (R#1) to the emergency room for evaluation and treatment after identifying that the resident was breathing slowly, and the resident's oxygen saturation was dropping and ranged from 83% to 86% throughout the day on [DATE]. In addition, the facility failed to thoroughly assess and complete neurochecks for one of six residents (R#1) after the resident fell on [DATE]. Cross refer F600 3. Administration failed to ensure that a baseline care plan was developed within 48 hours of admission for one of six residents (R#1). Cross refer F655 4. Administration failed to ensure staff thoroughly assessed and monitored for a change in condition after a fall for one of six resident (R#1) and failed to address abnormal low oxygen saturation levels and slow breathing for one of six residents (R#1). Cross refer F726 5. Administration failed to have an effective QAPI committee that ensured that residents that experienced a fall had complete and thorough neurochecks completed, failed to ensure that the Physician and Responsible Party were notified of the fall and the residents change in condition after sustaining a fall, and the facility failed to develop a Baseline care plan within 48 hours of admission. The facility census was 64 Residents. Cross refer F867 During an interview on [DATE] at 11:59 p.m. the DON revealed that she had received a call from LPN RR on [DATE]; however, she was not aware that the R#1 had a fall, nor did she know that R#1 had low oxygen saturations. The DON stated that she became aware of the acute changes in R#1's oxygen saturations (dropping into the 80's) after R#1 had been pronounced dead and she reviewed the medical records. During an interview on [DATE] at 1:16 p.m. the Administrator revealed that she normally does not get notified of a fall unless there is an injury. She became aware that R#1 had passed when the DON texted her. The Administrator stated when a resident has an acute change in condition and staff can't get in contact with the doctor. The nurses are to notify the DON. The nurses are not supposed to send residents out without a doctor's order. If it's an emergency life or death situation, and resident is going bad, the nurses can send the resident out, and keep calling the physician. Post survey interview on [DATE] at 11:43 a.m. with the Administrator revealed that the neurochecks for R#1 should have been completed thoroughly, that the Physician should have been notified regarding R#1's fall and change in condition via phone not by fax and that staff should have monitored R#1's oxygen more closely and that R#1 should have been sent out to the ER for evaluation and treatment. Cross refer F600, F680, F655, F726, F867

Based on staff interviews, record review and review of the facility's policy titled, Quality Assurance Performance Improvement (QAPI) Plan the QAPI Committee failed to have an effective QAPI committee that ensured that residents that experienced a fall had complete and thorough neurochecks completed, failed to ensure that the Physician and Responsible Party were notified of the fall and a residents change in condition after sustaining a fall, and the facility failed to develop a Baseline care plan within 48 hours of admission. The facility census was 64 Residents. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy on [DATE] at 4:42 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy is outlined as follows: A nursing progress note dated [DATE] revealed that CNA UU observed R#1 laying on her side next to the bed on [DATE] at 6:00 a.m. and that R#1 had an unwitnessed fall. The SBAR dated [DATE] revealed that the family was not notified, and that the physician was notified at 7:00 a.m. The 7:00 p.m. to 7:00 a.m. night shift nurse (LPN 00) assessed R#1 on [DATE] at 7:00 a.m., after the residents fall, and the following vital signs were obtained: blood pressure (BP): ,d+[DATE], pulse: 84, R: 20 Temperature (Temp): 97.3 blood sugar: 140 and Oxygen level (O2 sat): was 94% on 3 Liters of oxygen via nasal canula (normal greater than 92%). The 7:00 a.m. to 7:00 p.m. day shift nurse (LPN RR) completed a post fall evaluation on [DATE] at 1:10 p.m. and the resident's vital signs were obtained at 1:25 p.m. and revealed the following: BP: ,d+[DATE], Pulse: 71, R:20, and Temp: 96.6 the resident's oxygen saturation was documented to be 86% on 3 Liters of oxygen via nasal canula. LPN RR documented that she rechecked R#1's oxygen saturation on [DATE] at 1:34 p.m. and documented that the resident's oxygen saturation level had dropped into the 80's. LPN RR noted the drop in the oxygen saturation was because R#1 was taking off her oxygen. At 1:37 p.m., LPN RR documented that she checked the resident's oxygen saturation continuously during the day and R#1's oxygen saturation remained between 83% to 86%. The nurse noted that she called the Physician at 1:54 p.m. The nurse documented on [DATE] at 3:28 p.m. that the Physician was notified that the resident kept removing her oxygen; however, there was not any evidence that LPN RR notified the Physician of R#1's fall, earlier in the day, or that R#1's oxygen level was dropping into the 80's ranging from 83% to 86% throughout the day after the residents fall. On [DATE] at 4:55 p.m. LPN RR entered the resident's room and found R#1 without a pulse and without respirations. LPN RR initiated Cardiopulmonary Resuscitation (CPR) and had staff to call 911. When EMS arrived at 5:20 p.m. R#1 was found to be in asystole (without a heart rate) per an EKG strip and CPR was discontinued. Per the Death Pronouncement form R#1 was pronounced dead on [DATE] at 5:20 p.m. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at: F580 - Notification of Changes 483.10(g)(14)(i)(B), Scope/Severity: J; F600 - Freedom from Abuse, Neglect, and Exploitation 483.12, Scope/Severity: J; F655 - Baseline Care Plan 483.21(a)(1)-(3), Scope/Severity: J; F726 - Competent Nursing Staff 483.35 (a)(3)(4)(c), Scope/Severity J; F835 - Administration, 483.70 Scope/Severity: J; F867 - Quality assessment and assurance Improvement Activities 483.75(d)(1)(2)(e)(1)-(3)(g)(2), Scope/Severity: J. Additionally, Substandard Quality of Care was identified with the requirements at F600 Freedom from Abuse, Neglect, and Exploitation 483.12, Scope/Severity: J. At the time of exit on [DATE]at 1:33 p.m. the IJ was ongoing. Findings include: Quality Assurance Performance Improvement (QAPI) Plan/2021 ([DATE]). Purpose and Goals of the Committee; To monitor and evaluate the quality of care and service provided; to provide a means where negative outcomes related to resident care and services can be identified and resolved through an interdisciplinary approach. Acts as an advisory committee to the Administrator. Review of Quality Assurance Process Improvement (QAPI) Committee meeting notes dated [DATE] documented a Problem statement: 1. Identify residents who are at risk for falls. 2. Residents will be re-assessed for purpose of identifying residents who are at risk. 3. Care Plans and Kardex's are not updated with each incident and accident. Goal (Plan): To complete risk assessments audits for all residents in facility for purpose of identifying needs and implement interventions supporting those needs. Root causes: Failure to re-educate current and new staff on the Fall Clinical Standard. Failure to follow up on resident fall risk assessments, to implement fall protocols prior to fall, reassess resident post fall, update care plan after each fall with new interventions. Record review revealed that after the [DATE] QAPI meeting, the facility did not ensure that a fall was thoroughly monitored as indicated by incomplete Neuro- check form dated [DATE]. The family responsible party was not notified timely of the fall. The physician was not timely notified of the fall. And when the resident had an acute change in condition. The staff did not communicate to the physician the resident's low oxygen saturation, or the residents decreased respiratory rate. There was no baseline care plan within 48 hours per the MDS Coordinator. An Ad Hoc QAPI dated ,d+[DATE] revealed an identified concern: notifying resident's family and physician in a timely and proper manner with any falls and change of condition. Immediate corrective actions for those affected by the deficient practice was to educate staff on prompt communication, change in condition/incident report and proper notification. The measures put in place that to ensure the deficient practice does not reoccur. An ongoing education to nurses over proper notification for three months once per month. The unit manager s to ensure proper notification to be sent for resident with any change of conditions. Review of Quality Assurance Process Improvement (QAPI) Committee meeting notes dated [DATE] revealed a QAPI meeting was held. In attendance were the Administrator, Physician, DON, Social Services Director, Activities Director, MDS Coordinator, Admissions, Housekeeping supervisor, Maintenance Director, two Unit Managers and Business office manager. The meeting had a start time of 1:30 p.m. The Administrator QAPI committee report dated [DATE]. In the minutes, the number of falls were discussed. There was an inserted note that addressed notify families and physician in a timely manner with any falls and change of condition. This was referred to an Ad Hoc QAPI dated [DATE]. The note also stated that an in-service would cover prompt communications and notification, how to order medications, infection control, fall management, smoking safety, resident rights, and adding diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 11:30 a.m. the Administrator revealed that the QAPI committee met on [DATE] for an AD Hoc QAPI to discuss prompt notification, change of condition and falls. The Medical Director did not participate in the AD Hoc QAPI meeting. A corrective plan of action was put in place. Post survey interview on [DATE] at 11:43 a.m. with the Administrator revealed that since the [DATE] QAPI committee meeting regarding falls that the facility has seen improvement with falls in the facility; however, after R#1 fell on [DATE]staff failed to thoroughly conduct/complete neurochecks for R#1, failed to appropriately contact the Physician, and failed to contact the resident's Responsible Party. Cross Refer to F580, F600, F655, F726, F835

Based on observations, interviews, and record reviews, the facility failed to ensure that nutritional interventions were implemented for five residents (#3, #4, #6, #7, and #8), failed to implement laboratory test interventions for two residents (#3 and #7), failed to develop a care plan for weight loss for one resident (#5), failed to develop a comprehensive care plan timely for one resident (#9), and failed to implement behavioral interventions for one resident (#2) from a total sample of 35 residents. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Interim Administrator SS, Regional Vice President Clinical WW, and Licensed Practical Nurse GGG were informed of the Immediate Jeopardy on [DATE] at 3:13 p.m. The noncompliance related to the first Immediate Jeopardy was identified to have existed on [DATE]. The noncompliance related to the second Immediate Jeopardy was identified to have existed on [DATE]. Both Immediate Jeopardy's continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on [DATE]. 1.) The first Immediate Jeopardy is outlined as follows: Resident (R)#3 (R#3), a [AGE] year-old male, that had lab-work drawn on [DATE]. The lab results revealed R#3 had an abnormally high Sodium level of 158 (normal 136 - 145, critical level 160 or higher). Investigation revealed that the lab notified the facility of the abnormally high Sodium level on [DATE]. However, the facility did not address this abnormally high Sodium level until seven days later, on [DATE]. Physician ordered for R#3 to be sent to the emergency roiagnom on [DATE]. R#3 was admitted to the hospital with [REDACTED]. R#1 was admitted with profound [MEDICAL CONDITION] (critically high sodium level) and dehydration. R#3 subsequently died on [DATE]. There was also a repeated, systemic failure to implement pertinent interventions to address continued weight loss for seven residents (R#3, R#4, R#5, R#6, R#7, R#8, and R#9). There was also evidence of a complete systemic failure related to dietary services to ensure that Dietary Manager PP had the appropriate certification and skill sets to carry out the functions of the food and nutrition services in the facility. The Dietary Manager (DM) failed to ensure there was an adequate supply of nutritional supplements (Ready Shakes) available for residents who had Physician orders [REDACTED]. By not receiving these shakes it would put these nutritionally compromised residents at risk for additional weight loss or ongoing poor nutritional status. The DM also failed to routinely assess resident's likes and dislikes to meet the nutritional needs of the residents. 2.) The second Immediate Jeopardy is outlined as follows: R#11 was admitted to the facility on [DATE]. Two days later on [DATE] the resident started exhibiting threatening behaviors towards other residents and staff. As the behaviors continued, the facility failed to identify and address the ongoing escalating behaviors of R#11 who eventually fractured a nurses foot with a chair on [DATE] and lifted R#13 by his neck and threw him against the wall on [DATE]. After assaulting R#13 on [DATE], R#11 was placed on one to one observation. However, the resident was observed without one on one supervision on [DATE] at 10:59 a.m., 11:15 a.m., 12:47 p.m., 12:58 p.m., 1:00 p.m. and on [DATE] at 2:55 p.m., 2:58 p.m., 3:00 p.m. and 3:09 p.m. The care plan was not revised to reflect the one on one supervision until [DATE] after the resident was transferred to the hospital. The Immediate Jeopardy's were related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607, Scope/Severity: J); 42 C.F.R. 483.12(c), Reporting of Alleged Violations (F609, Scope/Severity: J); 42 C.F.R. 483.21(b)(1) Develop/Implement Comprehensive Care Plan (F656, Scope/Severity: K); 42 C.F.R. 483.25(g)(1)(2), Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K); 42 C.F.R. 483.50(a)(2)(i)(ii), Lab Services with Physician Order/Notify of Results (773, Scope/Severity: K); 42 C.F.R 483.60(a)(2), Qualified Dietary Staff (801, Scope/Severity: K); 42 C.F.R 483.60(a)(3), Sufficient Dietary Support Personnel (F802, Scope/Severity: K); 42 C.F.R. 483.60(c)(1)-(7), Menus and Nutritional Adequacy (F803, Scope/Severity: K); 42 C.F.R. 483.70, Administration (F835, Scope/Severity: K); 42 C.F.R. 483.75(g)(2), QAPI/QAA Improvement Activities (F867, Scope/Severity: K). Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607, Scope/Severity: J). 42 C.F.R. 483.12(c), Reporting of Alleged Violations (F609, Scope/Severity: J); and 42 C.F.R. 483.25(g)(1)(2), Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K). A Removal Plan (A Credible Allegation of Compliance) was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance while the facility continued management level staff oversight of residents for abuse and for nutrition. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's policy and procedures governing abuse and nutrition. In-service materials were reviewed to ensure appropriate training was giving to the staff. Resident records were reviewed to ensure care plans were developed and implemented with appropriate interventions. At the time of exiting the survey on [DATE] the Immediate Jeopardy was removed. Findings include: 1. R#3 had a care plan dated [DATE] for having potential nutritional problem related to being edentulous and prefers not to wear dentures or eat pureed food with interventions to obtain and monitor lab/diagnostic work as ordered and report results to the physician and follow up as indicated and monitor intake and record every meal. The resident also had a care plan dated [DATE] for being on diuretic therapy with an intervention to report lab results to physician (Especially hematocrit, sodium, and potassium). There was no care plan in place indicating the resident was at risk for dehydration. There was also a care plan dated [DATE] that the resident has [MEDICAL CONDITION] with a goal of the resident's electrolyte levels will be within normal. There were interventions to monitor lab work; potassium, sodium, BUN and creatinine and weight monitoring as ordered/indicated. Review of the clinical record revealed the physician visited the resident on [DATE] and wrote orders for routine labs to be done which included a Complete Blood Count, Basic Metabolic Profile, [MEDICATION NAME] aminotransferase (ALT) and Hemoglobin A1C (HGB A1C). Review of the laboratory results that were dated and reported to the facility on [DATE] at 1:29 p.m. revealed the following abnormal results: Sodium result of 158 (Reference range of ,[DATE] millimoles per liter(mmol/L) Chloride result of 115 (Reference range of ,[DATE] mmol/L) Glucose result of 282 (Reference range of ,[DATE] milligrams(mg)/deciliter(dl)) Urea Nitrogen result of 82 (Reference range of ,[DATE] mg/dl) Creatinine result of 2.8 (Reference range of 0XXX,[DATE].3 mg/dl) HGB A1C result of 9.0 (Reference range indicating diabetic >/=6.5) Further review of the clinical record revealed the facility did not attempt to notify the physician of the abnormal laboratory results until four days later on [DATE] when staff attempted to fax the results to the physician. However, there was no documentation the staff attempted to follow up with the physician to ensure he received the faxed laboratory results. The abnormal results were then emailed to the physician on [DATE]. The physician then gave orders on [DATE] to send the resident to the emergency room for evaluation and treatment of [REDACTED]. During an interview with Physician AAA on [DATE] at 1:00 p.m. he stated he did not receive the [DATE] lab results from the facility until [DATE]. He also stated labs with that degree of variation and that bad needed to be called to him on [DATE], not faxed or emailed. The resident had care plan for having potential nutritional problem related to being edentulous and prefers not to wear dentures or eat pureed food with an intervention to monitor intake and record every meal. Review of the Meal Intake Record for [DATE] was incomplete and there was not a May Intake Record. Cross Refer to F692 and F773. 2. R#4 had a care plan since [DATE] for alteration in nutrition due to being on a mechanically altered diet related to being edentulous status, side effects related to medications and [DIAGNOSES REDACTED]. The Meal Intake Records for April, May, July, and [DATE] were incomplete. During an interview with an Interim Director of Nursing NN on [DATE] at 1:30 p.m., she stated she was unable to locate the [DATE] meal intake record. There was also a [DATE] clarification order for house supplement is hi-calorie shake given by dietary with each meal. On [DATE] at 12:30 p.m., the resident was not served a shake with her lunch meal. After surveyor inquiry, DM PP documented on the [DATE] Diet History/Food Preference List that the dietary staff would send a tray and a sandwich to see which she will eat. The updated tray card indicated a sandwich would be sent with every meal. However, during the [DATE] at 12:50 p.m. lunch observation, the resident was not served a sandwich as indicated on the [DATE] Diet History/Food Preference List sheet and the updated tray card. Cross Refer to F692. 3. Review of the Weights and Vitals Summary sheet R#5 revealed the resident had a 11.1% weight loss from [DATE] (271 pounds) to [DATE] (240.9 pounds). There was not any documentation that weights were obtained in [DATE]. There was also no evidence a reweigh was done after the [DATE] weight loss and there were no weekly weights obtained in June and [DATE] as indicated in the policy and procedure. The resident continued to lose weight in [DATE]. On [DATE] he weighed 225.2 pounds which was a 16.9% loss in 5 months from [DATE] (271 pounds). The resident did not have a care plan for weight loss until [DATE] after surveyor inquiry. During an interview with the Senior Nurse Consultant HH on [DATE] at 2:45 p.m., she confirmed the resident did not have a care plan to address the resident's weight loss. 4. R#6 had a [DATE] care plan for potential nutritional problem related to severe dementia with a revision on [DATE] for weight loss and poor appetite. There were interventions to monitor intake and record every meal, supplements per physician orders [REDACTED]. Review of the clinical record revealed there were only two meal intake forms for 2020. One was for [DATE] and the other form was incomplete and not dated. During observations of the lunch meals on [DATE] at 12:53 p.m. and [DATE] at 1:15 p.m., the resident was not served a milk shake. There was also no evidence the Consultant Pharmacist had reviewed the resident's medication regimen. During an interview with the Pharmacy consultant on [DATE] at 11:30 a.m., he stated staff did not notify him to review the medications. 5. Resident (R)#7 had a care plan for a [DIAGNOSES REDACTED]. A Consultant Pharmacist Communication to the Physician form, dated February 2020, recommended for the physician to evaluate for laboratory orders for a complete metabolic panel (CMP), lipids panel, hemoglobin A1c, and [MEDICAL CONDITION] stimulating hormone (TSH) test. A note written on the communication form documented that the laboratory tests were completed on [DATE]. The physician signed and dated the pharmacist communication form as being in agreement with the recommendations on [DATE]. A review of the [DATE] laboratory results revealed that the TSH was elevated with a result of 6.11 from a range of 0.45- 5.33. The physician wrote on the laboratory results on [DATE] to increase R#7's [MEDICATION NAME] dose from 0.125 milligrams (mg) daily to 0.137 mg daily and to obtain a TSH and a Free [MEDICATION NAME] (FT4) laboratory tests in eight weeks. A review of the 2020 calendar revealed that eight weeks from [DATE] would be the week of [DATE]. However, there was no evidence in the clinical record that the TSH and FT4 laboratory tests were obtained as ordered by the physician and as care planned. During an interview on [DATE] at 3:45 p.m. Regional Nurse Consultant (RNC) HH confirmed that the laboratory tests were not obtained as ordered. Cross refer to F770 R#7 had a care plan dated [DATE] for being at risk for bleeding and bruising related to the use of anticoagulant medication (Eliquis). The care plan included an intervention for licensed nursing staff to monitor laboratory tests as ordered by the physician. A review of the clinical record revealed a [DATE] nurse's note that documented the Nurse Practitioner was notified that R#7 had brown blood in her brief when she was changed that morning. The nurse's note documented that new orders were received to complete a hemoccult test (a check for blood in the stool) three times and for a complete blood count (CBC) test to be obtained the following morning ([DATE]). physician's orders [REDACTED]. However, further review of the clinical record revealed no evidence that the CBC was obtained on [DATE] as ordered and care planned. The RNC did not provide evidence of CBC laboratory results from [DATE], after surveyor inquiry on [DATE]. During an interview on [DATE] at 3:20 p.m., the physician stated that he expected laboratory tests to be completed as ordered. Cross refer to F770 R#7 had care plan since [DATE] for being at risk of cardiac complications related to [DIAGNOSES REDACTED]. A review of the clinical record revealed [DATE] physician's orders [REDACTED]. A further review of the clinical record revealed no evidence that the laboratory tests were obtained as ordered. During an interview on [DATE] at 3:15 p.m., Regional Nurse Consultant (RNC) HH stated that the laboratory orders from [DATE] were from a telemedicine visit with a cardiovascular physician. She confirmed that the laboratory results were not included in the resident's clinical record, but they were completed (on [DATE]) as ordered. She obtained a copy from the laboratory and faxed it to the physician on [DATE]. There was no evidence that the [DATE] laboratory results were obtained and sent to the physician, as care planned, prior to surveyor inquiry on [DATE]. A review of the [DATE] laboratory report revealed the TSH to be elevated at 7.43 with a reference range of 0.45 to 5.33. During an interview on [DATE] at 3:20 p.m., the physician stated that he expected to be notified timely of laboratory results and that he would have acted on an elevated TSH level. Cross refer to F773 R#7 had a care plan for being for nutritional risk and significant weight loss. The care plan included interventions for nursing and dietary to provide supplements as ordered and for nursing to assist with meals as needed. However, R#7 was not provided with timely assistance during lunch on [DATE] as care planned. In addition, she was not provided with a nutritional supplement on [DATE] as ordered and care planned. During an observation of the lunch meal on [DATE] from 12:58 p.m. to 1:35 p.m. R#7 was observed seated at a table in the dining room with her lunch tray set up in front of her. After the resident finished drinking her cup of tea at 12:58 p.m. and picking up the cup of cherry dessert on her tray and licked it at 1:05 p.m., she made no further attempts to eat and was without staff assistance to eat for 20 minutes, until one of the two Certified Nursing Assistants (CNA's), who were already assisting two other residents at the time, finished and began assisting R#7 to eat. After staff assistance, R#7 consumed approximately 25% of the meal. Review of R#7's [DATE] physician's orders [REDACTED]. However, during an observation of lunch on [DATE] from 12:55 p.m. to 1:30 p.m., R#7 was not provided with a sugar free mighty shake. During an interview on [DATE] at 3:20 p.m., the physician stated he would expect the facility to provide supplements as ordered. Cross refer to F692 6. R#8 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident had a care plan for being at risk for nutritional decline and weight loss with interventions to monitor weights weekly, report 5% weight loss to the physician, and provide nutrition and hydration support. Review of the Monthly Weight Report for 2020 revealed that R#8 weighed 88.2 pounds in January, 96.4 pounds in February, 93.8 pounds in March, 97 pounds in June, 101.8 pounds in July and 92.8 pounds in August. Despite R#8 being identified as at risk for a nutritional decline with an intervention for weekly weights, there was no evidence in the clinical record or weight reports that weights were obtained weekly from January through [DATE] as care planned. In addition, no weight at all was obtained for two months (April and [DATE]). During an interview on [DATE] at 11:00 a.m., Regional Nurse Consultant (RNC) HH stated she could not locate any April or [DATE] weights for R#8. Further review of the weights documented on the Monthly Weight Report revealed that the weight change from 101.8 pounds in [DATE] to 92.8 pounds in [DATE] was a significant weight loss of nine pounds (8.8%) in one month. There was no evidence in the clinical record of interventions implemented to address the significant weight loss. The physician visited R#8 and wrote a progress note on [DATE]. However, there was no evidence that he was made aware of the significant weight loss as care planned. During an interview on [DATE] at 12:00 p.m., RNC HH stated that the interim Director of Nursing (DON) in place at the time would have been responsible for reviewing weights, calculating percentages and notifying the physician and responsible parties of weight loss. During an interview on [DATE] at 3:20 p.m. the physician could not recall if he was notified of R#8's significant weight loss but confirmed that he would expect the facility to address significant weight loss and attempt a new or different intervention. Review of the clinical record revealed that R#8 had a physician's orders [REDACTED]. However, the [DATE] physician's orders [REDACTED]. Cross refer to F692 7. The facility had a RAI/Care Planning/Management policy, dated [DATE]. The Care Plan section of the policy documented that the comprehensive care plan is completed within seven days after the Minimum Data Set (MDS) assessment is completed and at no time will this time frame exceed 21 days. The baseline care plan will be the guide for the comprehensive care plan. However, the facility failed to develop a comprehensive care plan for R#9. R#9 resided at the facility from [DATE] through [DATE] and had [DIAGNOSES REDACTED]. A review of the [DATE] Admission MDS assessment revealed that R#9 was assessed as having cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 10, needing assistance with Activities of Daily Living (ADL's), having occasional bladder incontinence, and using a wheelchair for mobility. A Baseline Care Plan was developed on [DATE] and included general information in the care areas of Initial Goals, Dietary Orders, Therapy Services, Safety, Social Services, ADL's, Bowel and Bladder, and Skin Concerns. Further review of the Baseline Care Plan revealed that a baseline care plan meeting was held on [DATE] via phone with R#9's family member. Despite completing an initial Baseline Care Plan on [DATE] and a [DATE] Admission MDS assessment, the facility failed to develop a comprehensive care plan during R#9's stay at the facility. A comprehensive care plan was not developed until [DATE], 16 days after the resident left the facility. During an interview and record review of the comprehensive care plan on [DATE] at 3:50 p.m., Regional Vice President (RVP) MM stated that the MDS coordinator who completed that comprehensive care plan no longer worked at the facility. RVP MM did not provide evidence that a comprehensive care plan was developed prior to [DATE] after surveyor inquiry on [DATE]. RNC NN did not provide evidence that a comprehensive care plan was developed prior to [DATE], for R#9, after surveyor inquiry on [DATE] at 12:07 p.m. 8. R#2 had a care plan for being verbally aggressive related to mental illness as evidence by yelling and cursing at others and being easily agitated and demanding. The care plan included an intervention for facility staff to intervene before agitation escalates when the resident becomes agitated; Guide the resident away from the source of distress; Engage calmly in conversation; If the response was aggressive, staff were to walk away and approach later. The care plan also included an intervention for facility staff to avoid arguing with the resident, speak in a calm level tone and encourage him to take some private time to calm down. However, Interim Administrator OO failed to implement appropriate interventions as care planned to address R#2's agitated behavior on [DATE]. A review of facility reported incidents revealed a Facility Incident Report Form, dated [DATE], that documented an incident of staff to resident abuse. The form included that the incident involved R#2 and Interim Administrator OO. Interim Administrator was listed as the alleged perpetrator. Further review of the form revealed the date of the incident as [DATE] and included that the Administrator spoke harshly to the resident when the resident was not staying in his room for quarantine. Further review of the facility's investigation revealed that they substantiated the allegation of verbal abuse and Interim Administrator OO was terminated. A review of the Worksite Employee Termination/Separation Form documented that Interim Administrator OO was terminated on [DATE]. The reason for the separation was listed as involuntary, misconduct, and detailed that a verbal abuse allegation was substantiated. Cross refer to F600 The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], a review of the facility Care Plan Policy was completed by the Senior Vice President of Operations and the Regional Vice President of Clinical Services with no revisions made. 2. R#9 was discharged from the facility on [DATE]. He was admitted to the hospital on [DATE]. R#9 did not return to the facility. 3. R#5 was identified with a significant weight loss on [DATE] by the Regional Vice President of Clinical Services. The Registered Dietician reviewed R#5 dietary needs on [DATE]. A comprehensive care plan was developed with appropriate interventions to assist with weight stabilization by the Regional Vice President of Clinical Services on [DATE]. 3. A. R#5 comprehensive weight loss care plan is reviewed weekly during the Care management meeting and updated with appropriate interventions by the MDS nurse, licensed nurse, and or Regional Vice President of Clinical Services. 4. R#3 was discharged from the facility on [DATE]. He was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. R#3 expired on [DATE]. 5. R#4 was identified on [DATE] with a significant weight loss by the Regional Vice President of Clinical Services. The Registered Dietician reviewed R#4 dietary needs on [DATE]. A comprehensive care plan was developed with appropriate interventions to assist with weight loss stabilization by the Regional Vice President of Clinical Services on [DATE]. A. R#4 comprehensive weight loss care plan is reviewed weekly during the Care Management meeting and updated with appropriate interventions by the MDS nurse, licensed nurse, or the Regional Vice President of Clinical Services. 6. R#6 was identified on [DATE] with a significant weight loss by the Regional Vice President of Clinical Services. The Registered Dietician reviewed R#6 dietary needs on [DATE]. A comprehensive care plan was developed with appropriate interventions to assist with weight loss stabilization by the Regional Vice President of Clinical Services on [DATE]. R#6 has anticipated weight loss due to his disease process. He is under the care of hospice services. A. R#6 comprehensive weight loss care plan is reviewed weekly during the Care Management meeting and updated with appropriate interventions by the MDS nurse or the Regional Vice President of Clinical Services. 7. R#8 was identified on [DATE] with a significant weight loss by the Regional Vice President of Clinical Services. The Registered Dietician reviewed R#8 dietary needs on [DATE]. A comprehensive care plan was developed with appropriate interventions to assist with weight loss stabilization by the Regional Vice President of Clinical Services on [DATE]. A. R#8 comprehensive weight loss care plan is reviewed weekly and updated with appropriate interventions by the MDS nurse or the Regional Vice President of Clinical Services. 8. R#7 was identified on [DATE] with a significant weight loss by the Regional Vice President of Clinical Services. The Registered Dietician reviewed R#7dietary needs on [DATE]. A comprehensive care plan was developed with appropriate interventions to assist with weight Joss stabilization by the Regional Vice President of Clinical Services on [DATE]. A. R#7 comprehensive weight loss care plan is reviewed weekly during the Care Management meeting and updated with appropriate interventions by the MOS nurse or the Regional Vice President of Clinical Services. 9. All current resident's (100%) comprehensive care plans were reviewed for potential risk for weight loss and or dehydration by the MDS nurse, licensed nurse, and or Regional Vice President of Clinical Services on [DATE]. A.12 residents were identified as being at potential risk for weight loss and or dehydration. The physician was notified of the identified residents at potential risk for weight loss and or dehydration. No new orders were received at this time. Responsible party and or family members were notified on [DATE] by the licensed nurse. B. The Registered Dietician evaluated each resident identified at potential risk for weight loss and or dehydration on [DATE]. 12 residents were identified with significant weight loss during the Registered Dietician evaluation with 3 residents identified as unavoidable weight loss due to their disease process. C. 66 of 66 resident's comprehensive care plans and Kardex's have been updated to include the potential risk for weight loss and dehydration. D. Resident identified at risk or with having weight loss comprehensive care plans will be monitored daily utilizing the Nutritional Weight monitoring tool that includes weekends to ensure appropriate interventions have been implemented and evaluated to the effectiveness of the interventions during morning meeting by the Interim Director of Nursing, and or MDS Coordinator. The RN Supervisor will monitor during weekends and holidays. E. The Interim Director of Nursing will monitor daily for appropriate interventions and the development of the comprehensive care plan related to altered nutrition. F. The RN Supervisor will monitor to ensure the appropriate interventions are effective and new interventions are implemented as needed during weekends and holidays. The Nutritional Weight Monitoring tool includes the following: the resident received the supplements as ordered, percentage consumed, likes and dislikes, and or labeled snacks. G. Kardex system (medical information system used by nursing staff as a way to communicate important information such as supplements ordered, labeled snacks, diet ordered, adaptative equipment, etc.) was reviewed and updated by the MDS nurse for Certified Nursing Assistants on [DATE]. H. The Interim Director of Nursing will utilize the Nutritional Weight monitoring tool daily during morning meeting for updates and accuracy. The Interim Director of Nursing and/ or MDS Coordinator to ensure interventions have been implemented and evaluated to ensure the effectiveness of interventions have been implemented during the morning meeting. During the morning meeting if the Interim Director of Nursing and or MDS Coordinator discovers the Care plan interventions are not appropriate, the interventions will be re-evaluated and or revised to ensure adequate nutrition and hydration is maintained. 10. In-service education regarding Comprehensive Care Plans, the failure to develop a person-centered care plan, and the failure to recognize the implantation of interventions to address the potential risk for weight loss and or dehydration on [DATE] by the Regional Vice President of Clinical Services. Care Plans will be updated and revised if the care plan interventions are not effective. 1 of 1 MOS LPN (100%) has been in-serviced by the Regional Vice President of Clinical Services on [DATE]. Additional educat ion regarding Kardex (medical information system used by nursing staff as a way to communicate important information such as supplements, adaptative equipment, diet orders, labeled snack, etc.) implementation was held on ,[DATE]/(TRUNCATED)

Based on observations, record review, staff interview, and review of the facility's policy and procedure titled, Nutrition and Weight Management Standard and review of the facility policy section titled Weight Loss/Underweightthe facility failed to notify the physician of abnormal high laboratory results in a timely manner which resulted in a delay of care for one resident ( R#3) who was at risk for dehydration. As a result, the laboratory values increased to critical high values causing R#3 to be admitted to the hospital for profound [MEDICAL CONDITION] and dehydration and subsequently expired on [DATE]. There was also a repeated, systemic failure to implement pertinent interventions to address continued weight loss for seven residents (R#3, R#4, R#5, R#6, R#7, R#8 and R#9) who were a nutritional risk from a sample of 35 residents. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Interim Administrator SS, Regional Vice President Clinical WW, and Licensed Practical Nurse GGG were informed of the Immediate Jeopardy on [DATE] at 3:13 p.m. The noncompliance related to the first Immediate Jeopardy was identified to have existed on [DATE]. The noncompliance related to the second Immediate Jeopardy was identified to have existed on [DATE]. Both Immediate Jeopardy's continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on [DATE]. 1.) The first Immediate Jeopardy is outlined as follows: Resident (R)#3 (R#3), a [AGE] year-old male, that had lab-work drawn on [DATE]. The lab results revealed R#3 had an abnormally high Sodium level of 158 (normal 136 - 145, critical level 160 or higher). Investigation revealed that the lab notified the facility of the abnormally high Sodium level on [DATE]. However, the facility did not address this abnormally high Sodium level until seven days later, on [DATE]. Physician ordered for R#3 to be sent to the emergency roiagnom on [DATE]. R#3 was admitted to the hospital with [REDACTED]. R#1 was admitted with profound [MEDICAL CONDITION] (critically high sodium level) and dehydration. R#3 subsequently died on [DATE]. There was also a repeated, systemic failure to implement pertinent interventions to address continued weight loss for seven residents (R#3, R#4, R#5, R#6, R#7, R#8, and R#9). There was also evidence of a complete systemic failure related to dietary services to ensure that Dietary Manager PP had the appropriate certification and skill sets to carry out the functions of the food and nutrition services in the facility. The Dietary Manager (DM) failed to ensure there was an adequate supply of nutritional supplements (Ready Shakes) available for residents who had Physician orders for Ready Shake. These residents were to receive Ready Shakes because they were nutritionally compromised. By not receiving these shakes it would put these nutritionally compromised residents at risk for additional weight loss or ongoing poor nutritional status. The DM also failed to routinely assess resident's likes and dislikes to meet the nutritional needs of the residents. The Immediate Jeopardy's were related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607, Scope/Severity: J); 42 C.F.R. 483.12(c), Reporting of Alleged Violations (F609, Scope/Severity: J); 42 C.F.R. 483.21(b)(1) Develop/Implement Comprehensive Care Plan (F656, Scope/Severity: K); 42 C.F.R. 483.25(g)(1)(2), Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K); 42 C.F.R. 483.50(a)(2)(i)(ii), Lab Services with Physician Order/Notify of Results (773, Scope/Severity: K); 42 C.F.R 483.60(a)(2), Qualified Dietary Staff (801, Scope/Severity: K); 42 C.F.R 483.60(a)(3), Sufficient Dietary Support Personnel (F802, Scope/Severity: K); 42 C.F.R. 483.60(c)(1)-(7), Menus and Nutritional Adequacy (F803, Scope/Severity: K); 42 C.F.R. 483.70, Administration (F835, Scope/Severity: K); 42 C.F.R. 483.75(g)(2), QAPI/QAA Improvement Activities (F867, Scope/Severity: K). Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607, Scope/Severity: J). 42 C.F.R. 483.12(c), Reporting of Alleged Violations (F609, Scope/Severity: J); and 42 C.F.R. 483.25(g)(1)(2), Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K). A Removal Plan (A Credible Allegation of Compliance) was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance while the facility continued management level staff oversight of residents for abuse and for nutrition. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's policy and procedures governing abuse and nutrition. In-service materials were reviewed to ensure appropriate training was giving to the staff. Resident records were reviewed to ensure care plans were developed and implemented with appropriate interventions. At the time of exiting the survey on [DATE] the Immediate Jeopardy was removed. Findings include: Review of the facility's policy and procedure titled, Nutrition and Weight Management Standard dated [DATE] revealed the following under the section titled Weights: 1.If a discrepancy of five pounds or more is noted, the resident is reweighed to determine the accuracy of the first weight. Deviations of more than five pounds must be addressed. 2. Residents are weighed at least monthly by the weight team/person designated unless the need for more frequent weights is determined by the physician, nursing staff or dietary manager. The results of the weights are to be documented in the medical record within 24 hours of the weight being obtained. 3. Weekly weights should be done on the following residents: residents who have a 5% weight loss in 30 days, residents who have a 7.5% weight loss in 90 days, residents who have 10% weight loss in 180 days, residents with a physician order for [REDACTED]. Further review of the policy revealed the following under the section titled Weight Loss/Underweight: 1. Residents who have a significant, unchanged weight loss or who are 20% or more below their IBW or UBW are considered to be at risk. 2. Significant unchanged weight loss of more than 5% in one month, 7.5% in three months, or 10% in six months or underweight status of more than 20% below IBW or UBW should be addressed on the care plan. The following approaches should also be taken: The resident's physician and the consultant dietician are notified, the following lab work may be requested, if current values are not already available: Serum [MEDICATION NAME], Hemoglobin; Hematocrit. If appetite is poor, consider requesting a physician order for [REDACTED]. 1. R#3 was admitted to the facility on [DATE] and had the following [DIAGNOSES REDACTED]. The resident had a Quarterly Minimum Data Set (MDS) with an assessment reference date of [DATE]. The resident was assessed as having had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. The resident was also assessed as requiring extensive assistance with bed mobility, total dependence for transfers, independent with set up help only for eating, the resident was 66 inches tall and weighed 213 pounds. He was also assessed as not having weight loss. R#3 had a [DATE] care plan for having potential nutritional problem related to edentulous and prefers not to wear dentures or eat pureed food. The care plan interventions were as follows: Monitor/document/report as needed any signs and symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat and appears concerned during meals. Monitor/record/report to physician as needed signs and symptoms of malnutrition: Emaciation, muscle wasting, significant weight loss: three pounds in one week, greater than 5% in one month, greater than 7.5% in three months and greater than 10% in six months, Obtain and monitor lab/diagnostic work as ordered. Report results to physician and follow up as indicated, Occupational Therapy to screen and provide adaptive equipment for feeding as needed, Provide, serve diet as ordered, Monitor intake and record every meal, Registered Dietician (RD) to evaluate and make diet change recommendations as needed. The resident also had a care plan since [DATE] for being on diuretic therapy with an intervention to report lab results to physician (Especially hematocrit, sodium and potassium). There was no care plan in place indicating the resident was at risk for dehydration. There was also a [DATE] care plan for the resident has [MEDICAL CONDITION] with a goal of the resident's electrolyte levels will be within normal. There were interventions to monitor lab work; potassium, sodium, BUN and creatinine and weight monitoring as ordered/indicated. Per review of the [DATE] laboratory results, the resident was positive for [DIAGNOSES REDACTED]-CoV-2 (Coronavirus). Review of the Covid 19 Daily Progress Notes and the Nurse's Notes for R#3 revealed the following documentation: 1. [DATE] - loss of appetite. 2. [DATE]- appetite poor, has to be encouraged to drink fluids. At 12:05 p.m., spoke to physician's office regarding resident. Stated to push fluids by mouth. 3. [DATE] at 9:00 p.m., only took a couple of bites at supper. Appetite poor, pushing fluids by mouth. 4. [DATE] at 12:00 p.m., did not eat any lunch. At 5:00 p.m., did not eat supper. 5. [DATE] at 1:00 p.m., ate 25% of lunch and chocked on liquids 6. [DATE] - Speech therapy put resident on puree diet until Monday ([DATE]) and will reevaluate. 7. [DATE] at 9:00 p.m., Appetite poor per day shift nurse. Ensure offered, patient consumed almost half before refusing it. 8. [DATE] at 9:20 p.m., poor appetite, fluids encouraged. 9. [DATE], offered thickened Ensure, consumed two ounces. 10. [DATE]- resident's appetite poor, will drink Ensure. In bed, unable to sit in wheelchair at this time due to weakness. 11. [DATE] at 9:00 p.m., takes medications crushed with thickened liquids. 12. [DATE] 7P-7A- resident continues to show poor tolerance for chewing solids. Thickened liquids tolerated. 13. [DATE] at 7:30 a.m., resident in bed awake and responsive to tactile and verbal commands. Difficulty swallowing keeps food and liquid in mouth. 14. [DATE] at 2:45 p.m., order received from physician's office to transfer resident to the hospital for evaluation and treatment for [REDACTED]. 15. [DATE]- resident sent out on [DATE] related to increased confusion, difficulty swallowing, not consuming adequate amount of meal/fluid intake. Review of the Weights and Vitals Summary sheet revealed the resident also had severe significant weight loss of 37.3 pounds/17.1 percent in two months from [DATE] (217.3 pounds) to [DATE] (180 pounds) with no weight obtained in April while the resident was being treated for [REDACTED]. On [DATE] the physician visited the resident and wrote orders for routine labs for R#3 to be done which included a Complete Blood Count, Basic Metabolic Profile, [MEDICATION NAME] aminotransferase (ALT) and Hemoglobin A1C (HGB A1C). Review of the laboratory results that were dated and reported to the facility on [DATE] at 1:29 p.m. revealed the following abnormal results: Sodium result of 158 (Reference range of ,[DATE] millimoles per liter(mmol/L) Chloride result of 115 (Reference range of ,[DATE] mmol/L) Glucose result of 282 (Reference range of ,[DATE] milligrams(mg)/deciliter(dl)) Urea Nitrogen result of 82 (Reference range of ,[DATE] mg/dl) Creatinine result of 2.8 (Reference range of 0XXX,[DATE].3 mg/dl) HGB A1C result of 9.0 (Reference range indicating diabetic >/=6.5) Further review of the clinical record for R#3 revealed the facility did not attempt to notify the physician of the abnormal laboratory results until four days later on [DATE] when staff attempted to fax the results to the physician. However, there was no documentation the staff attempted to follow up with the physician to ensure he received the faxed laboratory results. The abnormal results were then emailed to the physician on [DATE]. The physician then gave orders to send the resident to the emergency room for evaluation and treatment of [REDACTED]. Review of the [DATE] emergency room laboratory results revealed a critical high Sodium of 161 (reference range of ,[DATE] mmol/L), Chloride of 127 (Reference range of ,[DATE] mmol/L), BUN critical high- 163 (Reference range of ,[DATE] mg/dl), Creatinine- 4.4 (Reference range of 0XXX,[DATE].2 mg/dl). The [DATE] Hospital Death Summary for R#3 noted the resident was admitted with a 14-liter free water deficit. He was hypotensive with poor renal function. It documented the patient was aggressively hydrated with free water and came down basically in accordance with guidelines. It also noted admission for hyperosmolar state with uremic [MEDICAL CONDITION]. The [DATE] hospital progress notes noted the resident remained in a metabolic coma. The death certificate noted the date of death as [DATE] listing the cause of death as aspiration pneumonia, [MEDICAL CONDITIONS] and dementia. During an interview with Physician AAA on [DATE] at 1:00 p.m. he stated he did not receive the [DATE] lab results from the facility until [DATE]. He also stated labs with that degree of variation and that bad needed to call to him on [DATE], not faxed or emailed. He stated those abnormal high lab results were close to critical high indicating acute renal injury needing to be treated with intravenous (IV) fluids. After reviewing the critical high emergency room lab results with the physician, he stated That was due to the delay, I am sorry to say so yes. When the surveyor asked the physician if the facility had notified him sooner would the outcome be different for the resident, he stated I would hope so. The facility's failure to notify the physician in a timely manner of abnormal high lab results resulted in delay of care for profound [MEDICAL CONDITION] and dehydration and subsequently expired on [DATE]. Regarding nutrition and weights for this resident, he also had a severe significant weight loss of 37.3 pounds/17.1% in two months from [DATE] (217.3#) to [DATE] (180#) with no weight obtained in April, when the resident was diagnosed with [REDACTED]. The resident had care plan for potential nutritional problem with intervention to monitor intake and record every meal. Review of the Meal Intake Record for [DATE] was incomplete and there was not a May Intake Record. Further of the record also revealed the Registered Dietician did not evaluate the resident until [DATE], four days after the resident had been admitted to the hospital. Review of the Nutritional Evaluation/Re-Evaluation form revealed the resident was last assessed by the Dietary Manager, who was not certified, on [DATE]. There was no assessment by the Dietary Manager in [DATE]. The [DATE] nurses note documented Speech Therapy put the resident on a puree diet until Monday [DATE] due to difficulty swallowing. However, there was no indication the physician was made aware. There was also a [DATE] Dietary Communication Form for puree diet and nectar thick liquids. However, there was no physician's order for the downgrade in the diet. There was also no documentation the physician was notified of the resident having difficulty swallowing. During an interview with the physician on [DATE] at 1:00 p.m., he stated that he was not directly notified of the resident having difficulty swallowing. He stated they usually just write the order for therapy and he signs the order later. During an interview with Registered Nurse VV on [DATE] at 2:46 p.m., she stated whenever she would offer the resident something to drink or eat, he would always say he did not want anything. She stated the resident just did not want anything to eat or drink towards the end. She could not remember when the resident started having problems with swallowing or losing weight. During an interview with the previous Interim Administrator OO on [DATE] at 11:30 a.m., she stated the previous Director of Nursing (DON) UU told her the weights were not done in April because the scale was not working for some time on the mechanical lift so residents could not get weighed by a mechanical lift in [DATE]. Review of an Invoice revealed one 500-pound capacity patient lift and one 600-pound digital scale lift had been purchased on [DATE]. During an interview on [DATE] at 10:00 a.m. with the Senior Nurse Consultant HH she stated she was unable to locate ,[DATE] and ,[DATE] meal intake forms. She also confirmed the resident was not weighed in [DATE] or re-weighed in [DATE] after the significant weight loss and confirmed the care plan was not revised for the actual weight loss. 2. R#4 had the following but not limited to Diagnoses: [REDACTED]. The resident had Quarterly MDS completed on [DATE] which revealed a BIMS of 10 indicating the resident had moderately impaired cognition, set up help only for eating and weight loss not on prescribed weight loss regimen. The resident had a care plan since [DATE] for alteration in nutrition due to being on a mechanically altered diet related to edentulous status, side effects related to medications and [DIAGNOSES REDACTED]. and dislikes, referral to RD or physician, vitamins and supplements as needed and supplements per physician orders. Review of the physician's orders revealed an order since at least ,[DATE] for Hi-Cal supplement. However, there was no amount specified to give to the resident until [DATE] when there was a clarification order for Hi-Cal supplement 120 militer (ml) twice a day with med pass. However, the clarification order was not transcribed to the Medication Administration Record [REDACTED]. However, the amount given was unknown. There was no June MAR indicated [REDACTED]. The Meal Intake Records for April, May, July, and [DATE] were incomplete. During an interview with an Interim Director of Nursing NN on [DATE] at 1:30 p.m., she stated she was unable to locate the [DATE] meal intake record and the [DATE] MAR. She also confirmed there was no amount specified for the Hi-Cal supplement that was given from [DATE] to [DATE]. There was also a [DATE] clarification order for house supplement is hi-calorie shake given by dietary with each meal. On [DATE] at 12:30 p.m., the resident was not served a shake with her lunch meal. During an observation in the kitchen on [DATE] at 2:45 p.m., there were no shakes (Ready Shakes) available. The only nutritional supplement was one case of sugar free Might Shakes. The Dietary Manager (DM) PP stated at that time, that they were out of Ready Shakes until some were delivered the next day. She further stated that the residents would receive the Mighty Shakes for supper that night. During an interview with the RVP of Operations MM on [DATE] at 3:56 p.m., she stated she called DM PP who told her the cook did not have enough Ready Shakes to serve the residents at lunch today. She also stated the DM PP was aware there were not enough Ready Shakes for lunch. On [DATE] at 12:45 p.m., the resident sitting side of bed looking the lunch tray and not eating. The resident was served goulash which consisted of noodles, peas, and ground beef, a roll, salad, a cookie, tea and a Ready Shake. The resident pointed to her tray and shook her head no. She then took a few sips of tea and put the lid on the plate without eating any of her lunch. The likes and dislikes section on the diet card was observed to be blank. On [DATE] at 12:50 p.m. the resident was sitting on edge of her bed for lunch. She was served chopped chicken, green beans, mashed potatoes, tea, cake with icing and a chocolate shake/supplement (Ready Shake). She was drinking her tea and supplement. After the surveyor pointed to the tray, she shook her no and then madly said I have asked them for a sandwich and why can't they bring me one! I just don't understand it! I drink my tea and I drink my milkshake! I guess I will continue to pray about it. The likes and dislikes section on the diet card remained blank. During an interview with the therapy department manager on [DATE] at 12:40 p.m., she stated the resident was a very picky eater. She stated before the COVID-19 pandemic, the resident would eat in the dining room and the CNA's knew the resident liked to eat either deli meat or a deli meat sandwich. She stated the kitchen would send the resident a meal tray and either deli meat or a deli meat sandwich with mustard. She also stated the resident would at times eat a plain mustard sandwich. She stated she did not know if the kitchen was still sending the sandwich/meat at lunch. During an interview with the Senior Nurse Consultant HH on [DATE] at 2:00 p.m., she stated the resident's likes and dislikes were never assessed by the DM. She stated she told the DM PP to assess the resident's likes and dislikes today and would include the resident likes sandwiches for lunch and supper. However, during the [DATE] at 12:50 p.m. lunch observation, the resident was not served a sandwich as indicated on the [DATE] Diet History/Food Preference List sheet and the updated tray card. DM PP documented on the [DATE] Diet History/Food Preference List that the dietary staff would send a tray and a sandwich to see which she will eat. The updated tray card indicated a sandwich would be sent with every meal. On [DATE] at 1:05 p.m., an observation was made of the resident's meal tray with Senior Nurse Consultant HH, she confirmed a sandwich was not served to the resident. She also confirmed the diet card had not been updated with the likes and dislikes with the DM PP plan to send a sandwich with the tray. She then went and got the resident a peanut butter and jelly sandwich. The resident told the regional nurse, At least I got my bread! The Senior Nurse Consultant HH stated there was no excuse and DM PP should have sent a sandwich and updated the diet card. Review of the Weights and Vitals Summary sheet indicated the resident had a significant weight loss from [DATE] (105.2 pounds) to [DATE] (94.6 pounds) indicating a 10%/10.6-pound weight loss in two months. There were no weights obtained in [DATE] and [DATE]. There was also no indication the resident was reweighed according to the facility policy and procedure after losing 10.6 pounds in two months. On [DATE] the resident's weight was 89.4 pounds which indicated a 15% weight loss since [DATE]. On [DATE] the resident weighed 86.8 pounds which indicated a total of 17.5% weight loss since in five months [DATE]. There were documentation weekly weights were done in [DATE] as specified in the policy and procedure. The resident had RD evaluations on [DATE], [DATE] and [DATE] with no recommendations given. On the [DATE] evaluation, the RD documented the resident's BMI as 18.1(underweight) but made no recommendations. She noted will continue to monitor weights, intakes and labs. Review of the resident's [DATE] laboratory results revealed the resident had a low total protein at 5.0 g/dl (Reference range of 6XXX,[DATE].2) and a low [MEDICATION NAME] level at 2.9 g/dl (Reference range of 3XXX,[DATE].7). 5. R#5 had [DIAGNOSES REDACTED]. The resident was also COVID-19 positive on [DATE]. He was hospitalized for [REDACTED]. He was started on ST on [DATE] for swallowing/chewing difficulties. He was also started on Occupational Therapy on [DATE] for the lack of ability to self-feed. Review of the Weights and Vitals Summary sheet revealed the resident had a 11.1% weight loss from ,[DATE] (271 pounds) to [DATE] (240.9 pounds). There was documentation weights were obtained in [DATE]. There was also no evidence a reweigh was done after the [DATE] weight loss and there were no weekly weights obtained in June and [DATE] as indicated in the policy and procedure. The resident continued to lose weight in [DATE]. On [DATE] he weighed 225.2 pounds which is a 16.9% loss in 5 months from ,[DATE] (271 pounds). The resident did not have a care plan for weight loss until [DATE] after surveyor inquiry. There was a Dietary Communication Form dated [DATE] for a Ready Shake with meals. During an observation of three lunch meals on [DATE] at 12:55 p.m., [DATE] at 12:35 p.m. and [DATE] at 1:20 p.m. the resident was not served the Ready Shake. The resident was evaluated by the RD on [DATE] who noted a 37-pound weight gain from May to [DATE] (278 pounds). However, the June weight that was recorded on the weight summary was incorrect which made the RD's evaluation inaccurate and recommended to discontinue all supplements. However, this recommendation was not acted on by the physician. 6. R#6 had [DIAGNOSES REDACTED]. Per review of the Nurse's Notes, the resident was in the hospital from [DATE]-[DATE] for COVID-19. The resident had a 26.2%/52.8# weight loss in 5 months from 200.8 pounds on [DATE] to 148 pounds on [DATE]. There were no [DATE] weight obtained. He also had a 20%/37.4-pound loss from [DATE](185.4 pounds) to [DATE] (148 pounds). There were no reweighs done after the significant weight loss and there no weekly weights done in [DATE] after a 5.27% loss in one month from [DATE] (200.8 pounds) and no weekly weights in June. The resident had a [DATE] care plan for potential nutritional problem related to severe dementia with a revision on [DATE] for weight loss and poor appetite. There were interventions to monitor intake and record every meal, supplements per physician orders and a pharmacy consult to review medications for possible cause weight loss. Review of the clinical record revealed there were only two meal intake forms for 2020. One was for [DATE] and the other form was incomplete and not dated. The resident had a dietary communication form dated [DATE] for milk shake three times a day. The tray card printed house shake for lunch and dinner. During observations of the lunch meals on [DATE] at 12:53 p.m. and [DATE] at 1:15 p.m., the resident was not served a milk shake. There was also no evidence the Consultant Pharmacist had reviewed the resident's medication regimen. During an interview with the Pharmacy consultant on [DATE] at 11:30 a.m., he stated staff did not notify him to review the medications. 5. During an observation [DATE] at 1:45 p.m. of the current supply of the supplement Hi-Cal RN VV, she stated she used the last bit in a bottle earlier. As she went to look for another bottle in the supply room and the medication room on the east wing, there was non available. An observation was then made on the west wing supply room and medication room where no bottles of the Hi-Cal supplement could be located. During an interview on [DATE] at 2:00 p.m. with the Central Supply Clerk CCC, she stated there was not any Hi-Cal available in the building. She stated the Administrator orders everything. She stated on Tuesday [DATE] when an order was submitted, Hi Cal was not on the order list. During an interview and review of the [DATE] Purchase Order with the Interim Administrator OO, she confirmed the Hi-Cal supplement was last ordered on [DATE]. She stated there were eight bottles of Hi-Cal in a case. Review of the Supplemental Audit Results revealed that four residents were receiving the supplement. 7. R#7 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the Weights and Vitals Exceptions report revealed that the resident had a height of 62 inches. A review of the Monthly Weight Report revealed that R#7 had a significant weight loss from [DATE] to [DATE]. She went from a weight of 82.2 pounds to 73.4 pounds, which is an 8.8-pound loss (10.7%) in one month. Record review of April and May Physician's Order Forms and Medication Administration Records (MAR's) revealed that at the time of the significant weight loss from April to [DATE], R#7 already had orders in place for 120 milliters (ml) of Hi-Cal nutritional supplement three times daily, a sugar free Might Shake with each meal, one multivitamin with minerals daily, one pack of Juven mixed with 8 to 10 ounces of juice or water twice daily, 500 milligrams (mg) of vitamin C daily and 220 mg of zinc daily (the vitamin C and zinc were discontinued on [DATE]). However, there was no evidence that additional interventions were implemented to address the significant weight loss. The physician acknowledged R#7's weight being in the 70's range in his [DATE] progress note and included that she was stable but remained fragile. Although the physician acknowledged the resident's weight, there was no evidence that the facility notified R#7's responsible party of the significant weight loss. During an interview on [DATE] at 2:14 p.m. Regional Nurse Consultant (RNC) HH stated she was unable to provide any additional information on what interventions were implemented to address R#7's significant weight loss or that the resident's responsible party was notified. During an interview on [DATE] at 3:20 p.m., the physician confirmed that he would exp(TRUNCATED)

Based on observation, record review and staff interview, the facility failed to ensure the Dietary Manager (DM) had the required certification and skill sets to carry out the functions of the food and nutrition service in the facility that included ensuring there was an adequate supply of nutritional supplements for four residents (R) (R#4, R#5, R#7 and R#8) and failed to assess one resident's (R#4) likes and dislikes from a sample of 35 residents . There were 66 residents that had oral diets. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Interim Administrator SS, Regional Vice President Clinical WW, and Licensed Practical Nurse GGG were informed of the Immediate Jeopardy on [DATE] at 3:13 p.m. The noncompliance related to the first Immediate Jeopardy was identified to have existed on [DATE]. The noncompliance related to the second Immediate Jeopardy was identified to have existed on [DATE]. Both Immediate Jeopardy's continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on [DATE]. 1.) The first Immediate Jeopardy is outlined as follows: Resident (R)#3 (R#3), a [AGE] year-old male, that had lab-work drawn on [DATE]. The lab results revealed R#3 had an abnormally high Sodium level of 158 (normal 136 - 145, critical level 160 or higher). Investigation revealed that the lab notified the facility of the abnormally high Sodium level on [DATE]. However, the facility did not address this abnormally high Sodium level until seven days later, on [DATE]. Physician ordered for R#3 to be sent to the emergency roiagnom on [DATE]. R#3 was admitted to the hospital with [REDACTED]. R#1 was admitted with profound [MEDICAL CONDITION] (critically high sodium level) and dehydration. R#3 subsequently died on [DATE]. There was also a repeated, systemic failure to implement pertinent interventions to address continued weight loss for seven residents (R#3, R#4, R#5, R#6, R#7, R#8, and R#9). There was also evidence of a complete systemic failure related to dietary services to ensure that Dietary Manager PP had the appropriate certification and skill sets to carry out the functions of the food and nutrition services in the facility. The Dietary Manager (DM) failed to ensure there was an adequate supply of nutritional supplements (Ready Shakes) available for residents who had Physician orders for Ready Shake. These residents were to receive Ready Shakes because they were nutritionally compromised. By not receiving these shakes it would put these nutritionally compromised residents at risk for additional weight loss or ongoing poor nutritional status. The DM also failed to routinely assess resident's likes and dislikes to meet the nutritional needs of the residents. The Immediate Jeopardy's were related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607, Scope/Severity: J); 42 C.F.R. 483.12(c), Reporting of Alleged Violations (F609, Scope/Severity: J); 42 C.F.R. 483.21(b)(1) Develop/Implement Comprehensive Care Plan (F656, Scope/Severity: K); 42 C.F.R. 483.25(g)(1)(2), Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K); 42 C.F.R. 483.50(a)(2)(i)(ii), Lab Services with Physician Order/Notify of Results (773, Scope/Severity: K); 42 C.F.R 483.60(a)(2), Qualified Dietary Staff (801, Scope/Severity: K); 42 C.F.R 483.60(a)(3), Sufficient Dietary Support Personnel (F802, Scope/Severity: K); 42 C.F.R. 483.60(c)(1)-(7), Menus and Nutritional Adequacy (F803, Scope/Severity: K); 42 C.F.R. 483.70, Administration (F835, Scope/Severity: K); 42 C.F.R. 483.75(g)(2), QAPI/QAA Improvement Activities (F867, Scope/Severity: K). Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607, Scope/Severity: J). 42 C.F.R. 483.12(c), Reporting of Alleged Violations (F609, Scope/Severity: J); and 42 C.F.R. 483.25(g)(1)(2), Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K). A Removal Plan (A Credible Allegation of Compliance) was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance while the facility continued management level staff oversight of residents for abuse and for nutrition. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's policy and procedures governing abuse and nutrition. In-service materials were reviewed to ensure appropriate training was giving to the staff. Resident records were reviewed to ensure care plans were developed and implemented with appropriate interventions. At the time of exiting the survey on [DATE] the Immediate Jeopardy was removed. Findings include: A review of the personnel file for the Dietary Services Supervisor PP revealed a date of hire of [DATE]. A further review of the file revealed an active ServSafe Certification since [DATE]. However, there was no evidence that the Dietary Services Supervisor had any additional dietary or food service certification or degree. Review of the Job Description for the Dietary Services Supervisor revealed the following position summary: Manage the operation of the Dietary Department to include staffing, food ordering and preparation, food delivery and clean-up in accordance with facility policies, physician orders, resident care plans and appropriate regulations. As directed by the Administrator, assures that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean, safe, and sanitary manner. Essential Duties and responsibilities included but were not limited to: 1. Interview residents or family members, as necessary, to obtain diet history and maintain records of resident food likes and dislikes. 2. Ensure the charted dietary progress notes are informative and descriptive of the services provided and of the resident's response to the service. 3. Visit residents periodically to evaluate the quality of meals served, likes and dislikes, etc. Equipment and Supply Functions: 1. Identify equipment and supply needs of the department. 2. Place orders for equipment and supplies as necessary or as may be required. 3. Ensure that stock levels of staple/non-staple food, supplies, equipment, etc. are maintained at adequate levels at all times. 4. Assist in the purchasing of food service supplies, equipment etc., as required. 1. Resident #4 had a [DATE] clarification order for house supplement is hi-calorie shake given by dietary with each meal. On [DATE] at 12:30 p.m., the resident was not served a Ready Shake with her lunch meal. Cross refer to F692 2. Resident #5 had a Dietary Communication Form dated [DATE] for a Ready Shake with meals. During an observation of three lunch meals on [DATE] at 12:55 p.m., [DATE] at 12:35 p.m. and [DATE] at 1:20 p.m. the resident was not served the Ready Shake. Cross refer to F692 3. Review of R#7's [DATE] Physician's Orders form revealed a current order for sugar free mighty shakes with each meal. However, during an observation of lunch on [DATE] from 12:55 p.m. to 1:30 p.m., R#7 was not provided with a sugar free mighty shake. Cross refer to F692 4. R#8 had a physician's order since [DATE] for a Ready shake supplement with meals. The [DATE] Physician's Orders form also included an order for [REDACTED]. Cross refer to F692 During an observation in the kitchen on [DATE] at 2:45 p.m., there were no shakes (Ready Shakes) available. The only nutritional supplement was one case of sugar free Mighty Shakes. The Dietary Manager (DM) PP stated at that time, that they were out of Ready Shakes until some were delivered the next day. She further stated that the residents would receive the Sugar Free Mighty Shakes for supper that night. During an interview with the RVP of Operations MM on [DATE] at 3:56 p.m., she stated she called DM PP who told her the cook did not have enough Ready Shakes to serve the residents at lunch today, [DATE]. She also stated the DM PP was aware there were not enough Ready Shakes for lunch. 5. Resident #4 had a care plan since [DATE] for alteration in nutrition with an intervention to offer substitutes and alternatives as needed per resident's likes and dislikes. On [DATE] at 12:50 p.m. the resident was sitting on edge of her bed for lunch. She was served chopped chicken, green beans, mashed potatoes, tea, cake with icing and a chocolate shake/supplement (Ready Shake). She was drinking her tea and supplement. After the surveyor pointed to the tray, she shook her no and then madly said I have asked them for a sandwich and why can't they bring me one! I just don't understand it! I drink my tea and I drink my milkshake! I guess I will continue to pray about it. The likes and dislikes section on the diet card remained blank. During an interview with the Senior Nurse Consultant HH on [DATE] at 2:00 p.m., she stated the resident's likes and dislikes were never assessed by the DM. She stated she told the DM PP to assess the resident's likes and dislikes today and would include the resident likes sandwiches for lunch and supper. However, during the [DATE] at 12:50 p.m. lunch observation, the resident was not served a sandwich as indicated on the [DATE] Diet History/Food Preference List sheet and the updated tray card. DM PP documented on the [DATE] Diet History/Food Preference List that the dietary staff would send a tray and a sandwich to see which she will eat. The updated tray card indicated a sandwich would be sent with every meal. During an interview on [DATE] at 1:00 p.m. with DM PP, stated the resident's diet card was updated this morning. She confirmed she did not assess the resident's likes/dislikes until last week. Stated she assessed residents likes/dislikes on admission, and no one has told her how often to do the likes/dislikes. She stated she was only told to do them on new admits. She stated she took the DM position [DATE] and was told she had two years to complete the Certified Dietary Manager course. She stated she finished a pre-certification course for the Certified Dietary Manager exam and was scheduled to take the test next week. Cross refer F692 The facility implemented the following actions to remove the Immediate Jeopardy: The facility has implemented the following corrective actions for the deficient practice regarding failure to ensure the Dietary Manager had the appropriate certification and skill set to carry out the functions of the food and nutrition service in the facility. The facility failed to ensure the facility an adequate supply of nutritional supplements (Ready Shakes) for those residents that had Physician orders for Ready Shakes. The Dietary Manager failed to routinely assess residents likes and dislikes to meet the nutritional needs of the residents. On [DATE], a review of the facility policy Nutritional and Weight Policy by the Senior Vice President of Operations and the Regional Vice President of Clinical Services. 1. The Dietary Manager was terminated on [DATE] by the Regional Vice President of Operation 2. Dietary support staff from sister facility will assist each day during the week including weekends and holidays with preparation of meals, ordering of food and nutritional supplements until Certified Dietary Manager is hired. 3. 100% (66 tot al) of all residents were audited for nutritional supplements on [DATE] by the Regional Nurse Consultant and licensed nurse. 4. The Regional Vice President of Operations placed an order with U.S. Foods on ,[DATE]/ 2020 for Mighty Shake and Magic Cup Supplements. The order from U.S. Foods was received on [DATE]. A. 9 of the 66 residents were identified who received Mighty Sha kes as indicated on the Physicians orders. Per record review, it was verified that nine of 66 resident had physician's orders for Mighty Shakes. B. 2 of the 66 residents were identified who received Magic Cup Supplements as indicated on the Physicians orders. C. All orders were discontinued for residents who received Ready Shake per the Physician order. The Registered Dietician recommended supplement changes during her visit on 09/ 23/ 2020 through [DATE]. The 2 residents identified who were discontinued from Ready Shake, received orders from Physician, for Med Pass o n [DATE] and [DATE]. 5. A 100% (66 total) of residents were assessed for likes and dislikes on 10/ 19/ 2020 by the Dietary Assistant and the Regional Vice President of Operations to ensure the nutritional needs of each resident is met. A. Tray cards were updated with likes and dislikes on [DATE] by the Licensed Nurse. 6. An Interim Certified Dietary Manager was identified on [DATE] by the Recruiting Manager. B. An offer of employment was extended to an Interim Certified Dietary Manager on 10/ 20/ 2020 by the Interim Administrator pending a satisfactory Georgia background check in accordance with the Georgia State Department of Health. The newly hired Interim Certified Dietary Manager started on 10/ 22/ 2020. C. The Certified Dietary Manager position is posted on multiple job advertisement websites that includes a four-thousand-dollar sign on bonus. The advertisement was posted on 10/ ,[DATE] by the Recruiting Manager. 7. The Registered Dietician visited the facility on [DATE] and reviewed 14 resident's charts to ensure nutritional requirements were met. 6 residents' received recommendations that included Med Pass Nutritional supplement, liberalized diet, double portion diet, appetite stimulant, ice cream BID (twice daily), Mighty shakes BID, vitamin supplements, and liquid protein. ,[DATE]/ 2020 from the Registered Dietician. The Physician was notified on ,[DATE]/ 2020 of the recommendations received by the licensed nurse. A. The Registered Dietician gave the dietary recommendations to the licensed nurse, who contacted the Physician and orders were received via phone on [DATE]. B. 6 of the 6 responsible parties were notified of the orders received. C. The Registered Dietician visited on [DATE] and reviewed 8 resident charts. No recommendations were received today [DATE] during her visit. D. On 10/ ,[DATE], 34 of the remaining residents' charts will be reviewed to ensure each Resident's nutritional and dietary needs are being met. All recommendations will be immediately addressed. 8. The Interim Administrator and or Regional Vice President of Operations will utilize the Dietary/Nutritional monitoring tool daily to ensure residents are receiving supplements, monitoring intake of the supplements, adequate supply of nutritional supplements, likes and dislikes are completed on new admission within 24 hours and updated as indicated on current residents 3 times per week to ensure th e facility has and adequate supply of supplements ordered by the Physician. The Dietary/Nutritional monitoring tool will include nutritional supplements on hand, order date of supplements needed, date supplements are received, new admission likes and dislikes form completed within 24 hours of admission, and likes and dislikes form updated as indicated on all current residents. 9. Education was provided regarding the facility's failure to employee a Dietary Manager with the appropriate certification and skill sets to carry out the functions of food and nutrition service for the facility and to ensure the facility has an adequate supply of nutritional supplements was provided to the Interim Administrator on [DATE] by the Regional Vice President of Operations. 10. In-service education was provided to the dietary staff members regarding having an adequate supply of nutritional supplements that are placed on residents' meal trays and likes and dislikes are honored as indicated on the tray cards by the Registered Dietician and the Regional Vice President of Operations on [DATE]. The dietary staff members will notify the Administrator and or Regional Vice President of Operations when the supply meets the necessary PAR level that would indicate an order is needed. The Interim Administrator and or Regional Vice President of Operations will place an order from U.S. Food once per week for needed nutritional supplements and on an as needed basis. 5 of 5 dietary staff was educated for a 100% of all dietary staff. 11. All Corrective actions were completed on [DATE]. 12. The immediacy of the IJ was removed on [DATE]. The State Survey Agency (SSA) validated the facility's written Immediate Jeopardy Removal Plan as follows: Verified via interview on [DATE] at 4:40 p.m. with RVP WW. 1. It was confirmed through review of the Worksite Employee Termination/Separation Form that Dietary Manager PP was terminated on [DATE] by the RVP of Operations. During an interview on [DATE] at 4:40 p.m. RVP JJJ confirmed that Dietary Manager PP was terminated by RVP MM. 2. It was confirmed through review of the dietary schedule from [DATE]-[DATE] and the sister facility timecards that sister facility staff were scheduled to assist each day during the week, including weekends and holidays with preparation of meals, ordering of food and nutritional supplements. 3. It was confirmed through record review that an audit was conducted on all 66 residents for nutritional supplements on [DATE] by the Regional Nurse Consultant (RNC) and licensed nurse. 4. It was confirmed through review of the invoice from dietary that two cases of Magic Cups were ordered on [DATE] and delivered to the facility on [DATE] and one case of Mighty Shakes was ordered on [DATE] and delivered on [DATE]. Also confirmed via interview on [DATE] at 4:40 p.m. with RVP JJJ. a. The list was then revised on [DATE] to include a total of 11 residents. b. Per record review, it was confirmed that two of 66 residents had physician's orders for Magic Cups. On [DATE] the list was revised to include only one resident. c. Per review of the 100% audit dated [DATE], all Ready Shake supplements were discontinued. 5. It was verified through record review that all 66 residents' likes and dislikes were assessed on [DATE] and all 66 residents' tray cards were updated on [DATE]. Also verified via interview on [DATE] at 4:40 p.m. with RVP WW. A. Verified via record review of dietary forms with likes and dislikes assessed cross compared to dietary cards. 6B.It was confirmed through record review of the Offer of Employment to Dietary Manager QQQ, dated [DATE], and signed by Dietary Manager QQQ on [DATE]. It was also confirmed that Interim Dietary Manager QQQ had a valid Certified Dietary Manager certificate. Also confirmed via observations of Certified Dietary Manager QQQ at the facility and working in the kitchen on [DATE], [DATE], and [DATE]. C. It was confirmed through record review that the Dietary Manager position was posted on three job advertisement websites that included a $4000 sign-on bonus. Also verified via interview on [DATE] at 3:32 p.m. with RVP WW and observation of her phone of the job position posted online. During an interview on [DATE] at 4:40 p.m. RVP JJJ stated that the facility was in the process of hiring a permanent Certified Dietary Manager, who was scheduled to start on [DATE], and the current Interim Certified Dietary Manager would remain until that time. 7. Review of the [DATE] RD progress notes confirmed she assessed 14 residents to ensure nutritional requirements were met. On [DATE] the RD made recommendations for six residents. A. Review of the [DATE] physician's orders confirmed the physician was notified and have orders based on the RD recommendations. B. Six of the six responsible parties were notified as verified by review of the Nurse's Notes. C. Through review of the [DATE] RD progress notes, it was verified that she reviewed eight residents' charts with recommendations made. D. Through review of the [DATE] RD progress notes, 46 additional residents were evaluated instead of 34 residents. 34 residents as stated in the AOC was a typographical error. 8. Review of the Dietary/Nutritional Monitoring Tool form revealed daily monitoring from [DATE]-[DATE] for adequate supplements on hand, order date of supplements needed, date supplements received, new admit likes and dislikes was completed and updated. Reviewed purchase orders dated [DATE] with a delivery date of [DATE] which included various supplies and supplements. Also verified via interviews on [DATE] at 4:40 p.m. with RVP JJJ and on [DATE] at 4:30 p.m. with Interim Administrator PPP. 9. Through review of the in-service sign in sheet, it was verified the Interim Administrator SS was educated regarding failure to employ a Certified Dietary Manager and skill sets to carry out the functions of food and nutrition service for the facility and the failure to ensure the facility had an adequate supply of nutritional supplements. Also verified via interview on [DATE] at 4:40 p.m. with RVP JJJ. 10. Confirmed through review of the in-service sign in sheet, education was provided on [DATE]-[DATE] for eight of eight dietary staff. Also confirmed via interviews on [DATE] at 4:40 p.m. with RVP JJJ and on [DATE] at 4:30 p.m. with Interim Administrator PPP. Interviews on [DATE] at 8:48 a.m. with dietary staff NNNN, [DATE] at 9:06 a.m. with dietary staff LLLL, [DATE] at 1:07 p.m. with dietary staff MMMM confirmed in-service education on supplement supply, and likes and dislikes honored. 11. Verified via observations, record reviews and interviews previously stated. 12. The immediacy of the IJ was removed on [DATE].

Based on observation, staff interview, and review of the facility policy titled, Dietary Staffing it was determined the facility failed to ensure there was adequate dietary support personnel to safely prepare and serve the breakfast meal on [DATE]. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Interim Administrator SS, Regional Vice President Clinical WW, and Licensed Practical Nurse GGG were informed of the Immediate Jeopardy on [DATE] at 3:13 p.m. The noncompliance related to the first Immediate Jeopardy was identified to have existed on [DATE]. The noncompliance related to the second Immediate Jeopardy was identified to have existed on [DATE]. Both Immediate Jeopardy's continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on [DATE]. 1.) The first Immediate Jeopardy is outlined as follows: Resident (R)#3 (R#3), a [AGE] year-old male, that had lab-work drawn on [DATE]. The lab results revealed R#3 had an abnormally high Sodium level of 158 (normal 136 - 145, critical level 160 or higher). Investigation revealed that the lab notified the facility of the abnormally high Sodium level on [DATE]. However, the facility did not address this abnormally high Sodium level until seven days later, on [DATE]. The Physician ordered for R#3 to be sent to the emergency roiagnom on [DATE]. R#3 was admitted to the hospital with [REDACTED]. R#1 was admitted with profound [MEDICAL CONDITION] (critically high sodium level) and dehydration. R#3 subsequently died on [DATE]. There was also a repeated, systemic failure to implement pertinent interventions to address continued weight loss for seven residents (R#3, R#4, R#5, R#6, R#7, R#8, and R#9). There was also evidence of a complete systemic failure related to dietary services to ensure that Dietary Manager PP had the appropriate certification and skill sets to carry out the functions of the food and nutrition services in the facility. The Dietary Manager (DM) failed to ensure there was an adequate supply of nutritional supplements (Ready Shakes) available for residents who had Physician orders for Ready Shake. These residents were to receive Ready Shakes because they were nutritionally compromised. By not receiving these shakes it would put these nutritionally compromised residents at risk for additional weight loss or ongoing poor nutritional status. The DM also failed to routinely assess resident's likes and dislikes to meet the nutritional needs of the residents. The Immediate Jeopardy's were related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607, Scope/Severity: J); 42 C.F.R. 483.12(c), Reporting of Alleged Violations (F609, Scope/Severity: J); 42 C.F.R. 483.21(b)(1) Develop/Implement Comprehensive Care Plan (F656, Scope/Severity: K); 42 C.F.R. 483.25(g)(1)(2), Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K); 42 C.F.R. 483.50(a)(2)(i)(ii), Lab Services with Physician Order/Notify of Results (773, Scope/Severity: K); 42 C.F.R 483.60(a)(2), Qualified Dietary Staff (801, Scope/Severity: K); 42 C.F.R 483.60(a)(3), Sufficient Dietary Support Personnel (F802, Scope/Severity: K); 42 C.F.R. 483.60(c)(1)-(7), Menus and Nutritional Adequacy (F803, Scope/Severity: K); 42 C.F.R. 483.70, Administration (F835, Scope/Severity: K); 42 C.F.R. 483.75(g)(2), QAPI/QAA Improvement Activities (F867, Scope/Severity: K). Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607, Scope/Severity: J). 42 C.F.R. 483.12(c), Reporting of Alleged Violations (F609, Scope/Severity: J); and 42 C.F.R. 483.25(g)(1)(2), Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K). A Removal Plan (A Credible Allegation of Compliance) was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance while the facility continued management level staff oversight of residents for abuse and for nutrition. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's policy and procedures governing abuse and nutrition. In-service materials were reviewed to ensure appropriate training was giving to the staff. Resident records were reviewed to ensure care plans were developed and implemented with appropriate interventions. At the time of exiting the survey on [DATE] the Immediate Jeopardy was removed. Findings include: Review of the policy titled Dietary Staffing dated 2016 indicated the following: 1. A staffing schedule will be developed each month by the Dietary Manager to ensure adequate staffing each shift of duty. 2. Staffing will be monitored by Dietary Manager to ensure proper number of staff to meet meal/dietary requirements. 3. Dietary staffing is correlated to resident census and nutritional needs. Note: (addendum [DATE]) In the event of a pandemic or a facility crisis, dietary staff will be scheduled as needed and in the event of limited staffing resources, the Dietary Manager will perform dietary duties as indicated and train staff for additional duties. On [DATE] 10:20 a.m. several Styrofoam to-go style plates were observed on the breakfast cart on the west wing/secured unit. During an interview with RN HHH at that time, she stated there were only two people in the kitchen that morning and they were trying to get breakfast out. She stated as far as she knew, the breakfast was not late. During an interview with dietary staff LLLL and MMMM on [DATE] at 10:35 a.m., they stated they both came in at 6:00 a.m. and it was just the two of them to prepare, cook and serve breakfast that morning. They stated that the grocery truck arrived at 5:30 a.m. that morning, so in addition to preparing, cooking and serving breakfast, they had to try and put up the groceries. They also stated that three dietary staff quit on [DATE]. They had to call in two additional dietary staff to come in and help. They stated those two arrived at 9:15 a.m. and 10:00 a.m. They stated they used Styrofoam plates that morning because they would not have to wash the dishes making that one less thing to do. They stated the last weekend it was just the two of them to prepare, cook and serve breakfast and they had to call in staff to come and help. They stated that they needed at least three people in the mornings and the evening to prepare the meals. They also stated that today they did not have tray cards or a menu to go by. Cross refer F692 The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], a review the facility Dietary Staffing Policy'' was reviewed by the Senior Vice President of Operations and the Regional Vice President of Operations. 2. The facility has implemented the following corrective actions for the deficient practice regarding failure to ensure there is adequate dietary support personnel to safely prepare and serve all meals. 3. The facility has had daily dietary support beginning on [DATE] from sister facilities for daily assistance to prepare and serve all meals to include weekends and holidays. 4. The facility will provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily needs nutritional and special dietary needs, taking into consideration the preference of each residents likes and dislikes. 5. The Interim Administrator and or Regional Vice President of Operations will monitor the dietary staffing schedule daily to ensure the facility has sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. The Dietary Staffing monitoring tool will include the dietary staffing schedule to include staff provide to from sister facilities. 6. On [DATE], 1 dietary staff member was hired by the Interim Administrator and on [DATE], 1 additional dietary staff member was hired by the Interim Administrator. 7. The Interim Administrator and or Regional Vice President of Operations will ensure meals are served timely and that there is not more than 14 hours between a substantial evening meal and breakfast meal the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day. 8.A 100% of all current residents likes and dislikes {preferences) form was completed on [DATE] by dietary support and or Regional Vice President of Operations. The Interim Certified Dietary Manager, Interim Administrator, and or Regional Vice President of Operations will ensure likes and dislikes are being honored on the tray cards and with each meal. The Nutrition and Weight monitoring tool will be utilized to monitor preferences. 9.The tray cards were updated with likes and dislikes on [DATE] by the Licensed nurse. 10. Menus were updated and provided to dietary support personnel on 09/ 23/ 2020 by the dietary manager of a sister facility. The Regional Vice President of Clinica l Services validated the dietary staff had proper menus and adequate food supplies to meet the requirements of the menu on 09/ ,[DATE]. 11.The Registered Dietician provided education on the proper scoop/ladle sizes and honoring preferences for each item on the menu on [DATE] to ensure nutritional needs were met. Weekly weights were re-implemented on residents who are identified with a significant weight loss by the Regional Vice President of Clinical Services. Monthly weights were obtained by the Certified Nursing assistant by the 10th of [DATE]. In-service education was also initiated on [DATE] by the Registered Dietician and completed by the Interim Administrator on [DATE] to include 5 of 5 dietary staff members to ensure there are adequate dietary support personnel to safely prepare and serve all meals, prepare food, cook, and wash dishes on all shifts. The education included meals times and to ensure meals are served timely, menus are available and followed, and correct portion sizes are served with the correct scoop or ladle size. 12. The Registered Dietician recommendations are being thoroughly completed and accurate by the Interim Director of Nursing after each visit. A. 15 out of 66 residents were identified with a significant weight loss on [DATE]. The Registered Dietician reviewed resident charts on [DATE], [DATE], and [DATE]. The Physician visited the facility on [DATE] and the 15 residents identified with significant weight loss was reviewed and orders received as indicated. B. 15 out of 66 residents were identified with a significant weight loss on [DATE] by the Regional Vice President of Clinical Services. The Medical Director was notified of the weights and orders received as indicated. C. 2 out of the 15 residents were discontinued from weekly weights due to stabilization on [DATE] by the Regional Vice President of Clinical Services. D. 13 out of 66 resident s were identified with significant weight loss on [DATE] by the Regional Vice President of Clinical Services. The Medical Director was notified of the identified resident's weekly weight and intervention implemented for each resident on [DATE] by the Regional Vice President of Clinical Services. E. 3 of the 13 residents were identified as having unavoidable weight loss due to their disease process and under the care and services of hospice by the Regional Vice President of Clinical Services on [DATE]. F. 1 of the 13 residents were discontinued from weekly weights due to weight stabilization on [DATE] by the Regional Vice President of Clinical Services. G.12 of 66 residents were identified with a significant weight loss on [DATE]. H. The Registered Dietician reviewed the 12 residents' charts on [DATE] that are being monitored weekly due to triggering for a significant weight loss to ensure the appropriate interventions are appropriate and effective. If the interventions are not effective the Registered Dietician will give recommendations to discuss with the Physician. I. The Certified Dietary Manager and or the Interim Administrator will monitor all meals daily to ensure resident are receiving nutritional supplements and proper serving size. The Nutritional/Supplement monitoring tool will include audit of proper portion of meal sizes are served, to ensure supplements are given as ordered, percentage consumed, and sufficient staffing each shift. 13. All corrective actions were completed on [DATE] 14. The immediacy of the IJ was removed on [DATE]. The State Survey Agency (SSA) validated the facility's written Immediate Jeopardy Removal Plan as follows: 1. Verified via review of statement documenting the Dietary Staffing Policy was reviewed by Senior VP LLL and RVP JJJ on [DATE] and review of the Dietary Staffing Policy, dated 2016. Also verified via interview on [DATE] at 4:40 p.m. with RVP JJJ. 2. Verified via review of the remaining AOC for this deficiency 3. Verified via review of the daily dietary staffing schedules from [DATE] through [DATE] for facility dietary staff and the name of the sister facility who was providing staff assistance for that specific date. Also verified via interview on [DATE] at 12:20 p.m. with RVP WW who stated that the sister facilities provide one to two additional dietary staff persons. Interviews on [DATE] at 8:48 a.m. with dietary staff NNNN, [DATE] at 9:06 a.m. with dietary staff LLLL, [DATE] at 1:07 p.m. with dietary staff MMMM, and on [DATE] at 5:10 p.m. with Certified Dietary Manager QQQ confirmed that they had received support staff from sister facilities. 4. Verified via review of Week-At-A-Glance planned menus (signed by a Registered Dietician). Also verified via observation of posted menus on the bulletin boards at the facility and compared to the planned menus on [DATE] at 2:55 p.m. and [DATE] at 12:45 p.m., to ensure they matched. During an observation of the lunch meal on [DATE] at 12:45 p.m. lunch tray carts were observed to be delivered to the halls and lunch served to the residents timely. Residents (R)#6, R#7, R#10, R#16, and R#21 were observed to have a lunch that matched their current diet and honored their likes/dislikes included on their tray cards. All were observed to be eating or receiving timely assistance. The food appeared appetizing. 5. Verified via review of October and [DATE] Dietary Staffing Monitoring Tool, initiated daily since [DATE]. Also verified via interviews on [DATE] at 4:40 p.m. with RVP JJJ and on [DATE] at 4:30 p.m. with Interim Administrator PPP. 6.Verified via review of the new hire package for dietary aide CCCCC with a date of hire of [DATE] and new hire package for dietary aide NNNN with date of hire of [DATE]. Also verified via review of the dietary staffing schedule which included both of the newly hired dietary staff on the schedule. 7.Verified via review of the meal serving schedule which included a breakfast range of 7:40 a.m. to 8:00 a.m., a lunch range of 12:10 p.m. to 12:30 p.m., and a supper range of 5:10 p.m. to 5:30 p.m. Snacks were listed as being served at 10 a.m., 2 p.m. and 8 p.m. Also verified via review of the lunch meal on [DATE] which was served in a timely manner. 8.During an interview on [DATE] at 3:55 p.m. RVP WW clarified that the mention of a Nutrition and Weight monitoring tool was an error; The tool as named Likes/Dislikes tool. Verified via review of the Likes/Dislikes Tool. 9.Verified via interview on [DATE] at 3:55 p.m. with RVP WW who confirmed that the tray cards were updated with likes and dislikes on [DATE]. 10.Verified via review of statement signed by the dietary manager of a sister facility and RVP WW that menus were updated and provided to dietary staff on [DATE] and that the RVP validated staff had proper menus and adequate food supply to meet menu requirements. Also verified via interview on [DATE] at 3:55 p.m. with RVP WW. 11.Verified via review of In-service/Training dated [DATE]-[DATE] with topic Dietary Staffing along with signature sheet of dietary staff receiving the in-service training, and review of the Steam Table Pan Setup form, dated [DATE] and signed by the Registered Dietician and dietary staff. A review of the [DATE] monthly weight report verified that all residents were weighed for October. In addition, a review of the QAPI Tool: Alteration in Nutrition forms for [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] revealed weekly weights were re-implemented. Also verified via interview on [DATE] at 4:40 p.m. with RVP WW. 12.Verified via interview on [DATE] at 4:40 p.m. with RVP JJJ and RVP WW. A. Verified via review of the QAPI Tool: Alteration in Nutrition for [DATE], week of [DATE] which includes 15 residents with nutritional recommendations B. Verified via review of the QAPI Tool: Alteration in Nutrition for the week of [DATE] which includes recommendations and or physician's orders and weight loss documentation. Also verified via interview on [DATE] at 4:40 p.m. with RVP WW. C. Verified via interview on [DATE] at 12:20 p.m. with RVP WW and review of the [DATE] through [DATE] QAPI Tools for alteration in nutrition. RVP WW stated that between ,[DATE] and [DATE] a total of three residents were discontinued from weekly weights due to stabilization. Those residents were identified as R#8, R#20 and R#21. D. Verified via review of the QAPI Tool: Alteration in Nutrition dated [DATE] and interview with RVP WW on [DATE]o at 4:40 p.m. E. Verified via review of the QAPI Tool: Alteration in Nutrition dated [DATE] includes three residents determined to have unavoidable weight loss. The three residents identified were R#6, R#22 and R#23, all of whom were receiving hospice services. Also verified via interview with RVP WW on [DATE] at 12:20 p.m. F. Verified via interview on [DATE] at 12:20 p.m. with RVP WW and review of the [DATE] through [DATE] QAPI Tools for alteration in nutrition. RVP WW stated that between [DATE] and [DATE] a total of three residents were discontinued from weekly weights due to stabilization. Those residents were identified as R#8, R#20 and R#21. G. Verified via QAPI Tool: Alteration in Nutrition form dated [DATE]. H. Per review of the RD progress notes dated [DATE], 12 residents were identified at risk for dehydration or has as a significant weight loss I. Verified via review of The Nutritional Supplement Monitoring Tool which includes monitoring for proper portion size, supplements given as ordered, percentage consumed, and sufficient staffing each shift which is signed daily since [DATE]. Also verified via observations of meal service and plating on [DATE] at 5:10 p.m. for the supper meal, on [DATE] at 12:15 p.m. for the lunch meal and on [DATE] at 12:40 p.m. for the lunch meal. 13. All corrective actions were completed on [DATE]. 14. The immediacy of the IJ was removed on [DATE].

Based on observations and staff interviews, and review of an undated policy titled, Menus and Portion Control the facility failed to ensure the dietary staff had menus and tray cards available to serve two meals and failed to ensure dietary staff were serving the correct portion size of pureed food according to the menu. There were 66 residents that had oral diets of which 50 residents were receiving a regular diet. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Interim Administrator SS, Regional Vice President Clinical WW, and Licensed Practical Nurse GGG were informed of the Immediate Jeopardy on [DATE] at 3:13 p.m. The noncompliance related to the first Immediate Jeopardy was identified to have existed on [DATE]. The noncompliance related to the second Immediate Jeopardy was identified to have existed on [DATE]. Both Immediate Jeopardy's continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on [DATE]. 1.) The first Immediate Jeopardy is outlined as follows: Resident (R)#3 (R#3), a [AGE] year-old male, that had lab-work drawn on [DATE]. The lab results revealed R#3 had an abnormally high Sodium level of 158 (normal 136 - 145, critical level 160 or higher). Investigation revealed that the lab notified the facility of the abnormally high Sodium level on [DATE]. However, the facility did not address this abnormally high Sodium level until seven days later, on [DATE]. The Physician ordered for R#3 to be sent to the emergency roiagnom on [DATE]. R#3 was admitted to the hospital with [REDACTED]. R#1 was admitted with profound [MEDICAL CONDITION] (critically high sodium level) and dehydration. R#3 subsequently died on [DATE]. There was also a repeated, systemic failure to implement pertinent interventions to address continued weight loss for seven residents (R#3, R#4, R#5, R#6, R#7, R#8, and R#9). There was also evidence of a complete systemic failure related to dietary services to ensure that Dietary Manager PP had the appropriate certification and skill sets to carry out the functions of the food and nutrition services in the facility. The Dietary Manager (DM) failed to ensure there was an adequate supply of nutritional supplements (Ready Shakes) available for residents who had Physician orders for Ready Shake. These residents were to receive Ready Shakes because they were nutritionally compromised. By not receiving these shakes it would put these nutritionally compromised residents at risk for additional weight loss or ongoing poor nutritional status. The DM also failed to routinely assess resident's likes and dislikes to meet the nutritional needs of the residents. The Immediate Jeopardy's were related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607, Scope/Severity: J); 42 C.F.R. 483.12(c), Reporting of Alleged Violations (F609, Scope/Severity: J); 42 C.F.R. 483.21(b)(1) Develop/Implement Comprehensive Care Plan (F656, Scope/Severity: K); 42 C.F.R. 483.25(g)(1)(2), Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K); 42 C.F.R. 483.50(a)(2)(i)(ii), Lab Services with Physician Order/Notify of Results (773, Scope/Severity: K); 42 C.F.R 483.60(a)(2), Qualified Dietary Staff (801, Scope/Severity: K); 42 C.F.R 483.60(a)(3), Sufficient Dietary Support Personnel (F802, Scope/Severity: K); 42 C.F.R. 483.60(c)(1)-(7), Menus and Nutritional Adequacy (F803, Scope/Severity: K); 42 C.F.R. 483.70, Administration (F835, Scope/Severity: K); 42 C.F.R. 483.75(g)(2), QAPI/QAA Improvement Activities (F867, Scope/Severity: K). Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607, Scope/Severity: J). 42 C.F.R. 483.12(c), Reporting of Alleged Violations (F609, Scope/Severity: J); and 42 C.F.R. 483.25(g)(1)(2), Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K). A Removal Plan (A Credible Allegation of Compliance) was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance while the facility continued management level staff oversight of residents for abuse and for nutrition. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's policy and procedures governing abuse and nutrition. In-service materials were reviewed to ensure appropriate training was giving to the staff. Resident records were reviewed to ensure care plans were developed and implemented with appropriate interventions. At the time of exiting the survey on [DATE] the Immediate Jeopardy was removed. Findings include: Review of an undated policy titled Menus and Portion Control revealed that scoop sizes are stated on the menus to show the portion that is served for each food item and noted to see menus for measurements and standard sizes for all serving sizes. Review of the planned menu for Monday, week four, documented that four ounces of pot roast with gravy, four ounces of red potatoes, four ounces of squash casserole and four ounces of Resident's Choice which was green beans were planned for residents receiving a pureed diet. Three ounces of pot roast with gravy was planned for residents receiving a regular diet. However, during an observation of the lunch meal service on [DATE] at 11:51 a.m., Dietary staff MMMM served two ounces of pot roast, three ounces of potatoes for pureed diets. There was not a pureed squash casserole as planned on the menu. Tongs were inappropriately used to plate the pot roast with gravy for regular diets. During the observation, staff were observed plating food from the steam table without a menu to reference to for the correct portion sizes. Dietary staff MMMM stated at that time that she did not have a menu to go by. When the surveyor asked her how she knew the portion sizes to be served, she stated they were just winging it because the Interim Administrator II never brought them the menu or current tray cards. She also stated they were using old tray cards from the previous week. She stated there were four residents currently on a puree diet. On [DATE] at 12:14 p.m., the Regional Vice President of Operations MM provided the dietary staff menus and tray cards after surveyor inquiry. She confirmed the dietary staff needed the menus to know the portion sizes to serve and they needed the tray cards to know each of the resident's diet. Cross refer F692 The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], a review of the facility policy Menu Development'' was completed by the Regional Vice President of Operations no revisions were made. 2. The facility has implemented the following corrective actions for the deficient practice regarding failure to ensure dietary staff have menus, tray cards available for all meals, and staff are using the correct ladle for service size for Puree food. 3. The Interim Administrator and or Regional Vice President of Operations will monitor dietary services daily to ensure dietary staff have menus and tray cards available for each meal. The monitoring tool will include the daily menu availability, tray cards, and correct ladle size for Puree foods to ensure residents are not at risk for nutritional compromise. The RN Supervisor will monitor during weekend and holidays. 4. 66 of 66 (100%} resident tray cards were reviewed and updated with likes and dislikes on [DATE] by the Licensed nurse. The Interim Certified Dietary Manager and or Interim Administrator will monitor daily to ensure residents receive likes and dislikes. The RN Supervisor will monitor during the weekend and holidays. 5. Menus were updated and provided to dietary support personnel on 09/ ,[DATE] by the dietary manager of a sister facility. The Regional Vice President of Clinical Services validated the dietary staff had proper menus and adequate food supplies to meet the requirements of the menu on [DATE]. 6. The Interim Administrator and or Certified Dietary Manager will monitor daily ensure menus are followed and posted daily to ensure the correct menu items are served. The RN Supervisor will monitor during the weekend and holidays. 7. The Registered Dietician provided education to dietary staff members (5 of 5) on the proper scoop/ ladle sizes for each item on the menu including puree foods on 10/ 06/ 2020 to ensure nutritional needs were met. Weekly weights were re-implemented on residents who are identified with a significant weight loss by the Regional Vice President of Clinical Services. Monthly weights were obtained by the Certified Nursing assistant by the 10th of [DATE] to include education regarding if a resident has a 5-pound weight loss or gain, the Certified Nursing Assistant will re-weighto ensure the weight is accurate. In-service education was initiated on [DATE] by the Registered Dietician and completed by the Interim Administrator on [DATE] to include 5 Of 5 dietary staff members to ensure there are daily menus available, tray cards, and proper ladle size utilize d for all meals including puree foods. A. 15 out of 66 residents were identified with a significant weight loss on [DATE]. The Registered Dietician reviewed resident charts on [DATE], 09/ 24/ 2020, and [DATE]. The Physician visit ed the facility on [DATE] and the 15 residents identified with significant weight loss was reviewed and orders received as indicated. B. Responsible parties were not previously notified but have been notified as of 10/ 20/ 2020. C. 15 out of 66 residents were identified with a significant weight loss on [DATE] by the Regional Vice President of Clinical Services. The Medical Director was notified of the weights and orders received as indicated. D. 2 out of the 15 residents were discontinued from weekly weights due to stabilization on [DATE] by the Regional Vice President of Clinical Services. 8. In-service education was initiated on [DATE] by the Registered Dietician and completed by the Interim Administrator on [DATE] to include all dietary staff members to ensure there are daily menus available, tray cards, likes and dislikes are honored, and proper ladle size utilized for all meals including puree foods. S of S dietary staff members were educated which is 100% of total dietary staff. 9. All Corrective actions were completed on [DATE]. 10. The immediacy of the IJ was removed on [DATE]. The State Survey Agency (SSA) validated the facility's written Immediate Jeopardy Removal Plan as follows: 1. Verified via review of statement signed by RVP JJJ that the Menu Development policy was reviewed with no revisions on [DATE] and via interview on [DATE] at 4:40 p.m. with RVP JJJ. Also verified via review of the Menu Development Policy, dated 2016. 2. Verified by the remainder of the #'s listed below. 3. Verified via review of the monitoring tool which included daily monitoring of the menus, tray cards for accuracy, correct ladle size which was signed daily since [DATE] by RVP JJJ. Also verified via interview with RVP JJJ on [DATE] at 4:40 p.m. 4. Verified via review of the dietary cards cross referenced with the forms which documented residents' likes and dislikes. 5. Verified via review of statement signed by the dietary manager of a sister facility and RVP WW that menus were updated and provided to dietary staff on [DATE] and that the RVP validated staff had proper menus and adequate food supply to meet menu requirements. Also verified via interview on [DATE] at 3:55 p.m. with RVP WW. 6. Verified via review of the monitoring tool that includes monitoring for daily menus followed, menus posted daily and correct food served on menu and is signed daily since [DATE] by RVP JJJ. 7. Verified via review of In-service/Training form dated [DATE]-[DATE] with topic of Dietary Staffing. Also verified via review of the October Monthly Weight Report and via review of email from the RD confirming she provided in-service education on [DATE]. Interviews on [DATE] at 8:48 a.m. with dietary staff NNNN, [DATE] at 9:06 a.m. with dietary staff LLLL, [DATE] at 1:07 p.m. with dietary staff MMMM confirmed in-service education was received and staff were knowledgeable about the information provided. A. Verified via review of the QAPI Tool: Alteration in Nutrition for [DATE], week of [DATE] which includes 15 residents with nutritional recommendations. Also verified via interview on [DATE] at 4:40 p.m. with RVP WW. B. Verified via interview on [DATE] at 12:20 p.m. with RVP WW who confirmed that responsible parties were notified via phone or in person during window/door visits with residents. C. Verified via review of the QAPI Tool: Alteration in Nutrition for the week of [DATE] which includes recommendations and or physician's orders and weight loss documentation. D. Verified via interview on [DATE] at 12:20 p.m. with RVP WW and review of the [DATE] through [DATE] QAPI Tools for alteration in nutrition. RVP WW stated that between ,[DATE] and [DATE] a total of three residents were discontinued from weekly weights due to stabilization. Those residents were identified as R#8, R#20 and R#21 8. Verified via review of In-service/Training form dated ,[DATE]-[DATE] with topic of Dietary Staffing. Also verified via interviews previously listed at #7. 9.Verified via above information 10.The immediacy of the IJ was removed on [DATE].

Based on observations, staff interviews, and review of the Job Summary's for Nursing Home Administrator and Director of Nursing the facility failed to ensure administration was consistent with oversight in monitoring of nutrition such as: not monitoring weights, failure to provide supplements as ordered, failure to notify the Responsible Party and Physician of weight loss and critical labs, failed to address significant weight loss, failed to ensure that Registered Dietician assessments were complete and accurate for seven residents (R) (R#3, R#4, R#5, R#6, R#7, R#8 and R#9), and the facility also failed to ensure that three residents (R#1, R#2 and R#15) were free from abuse, failed to ensure staff were screened thoroughly before hire, and that allegations of abuse were reported timely from a total sample of 35 residents. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Interim Administrator SS, Regional Vice President Clinical WW, and Licensed Practical Nurse GGG were informed of the Immediate Jeopardy on [DATE] at 3:13 p.m. The noncompliance related to the first Immediate Jeopardy was identified to have existed on [DATE]. The noncompliance related to the second Immediate Jeopardy was identified to have existed on [DATE]. Both Immediate Jeopardy's continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on [DATE]. 1.) The first Immediate Jeopardy is outlined as follows: Resident (R)#3 (R#3), a [AGE] year-old male, that had lab-work drawn on [DATE]. The lab results revealed R#3 had an abnormally high Sodium level of 158 (normal 136 - 145, critical level 160 or higher). Investigation revealed that the lab notified the facility of the abnormally high Sodium level on [DATE]. However, the facility did not address this abnormally high Sodium level until seven days later, on [DATE]. Physician ordered for R#3 to be sent to the emergency roiagnom on [DATE]. R#3 was admitted to the hospital with [REDACTED]. R#1 was admitted with profound [MEDICAL CONDITION] (critically high sodium level) and dehydration. R#3 subsequently died on [DATE]. There was also a repeated, systemic failure to implement pertinent interventions to address continued weight loss for seven residents (R#3, R#4, R#5, R#6, R#7, R#8, and R#9). There was also evidence of a complete systemic failure related to dietary services to ensure that Dietary Manager PP had the appropriate certification and skill sets to carry out the functions of the food and nutrition services in the facility. The Dietary Manager (DM) failed to ensure there was an adequate supply of nutritional supplements (Ready Shakes) available for residents who had Physician orders [REDACTED]. By not receiving these shakes it would put these nutritionally compromised residents at risk for additional weight loss or ongoing poor nutritional status. The DM also failed to routinely assess resident's likes and dislikes to meet the nutritional needs of the residents. 2.) The second Immediate Jeopardy is outlined as follows: R#11 was admitted to the facility on [DATE]. Two days later on [DATE] the resident started exhibiting threatening behaviors towards other residents and staff. As the behaviors continued, the facility failed to identify and address the ongoing escalating behaviors of R#11 who eventually fractured a nurses foot with a chair on [DATE] and lifted R#13 by his neck and threw him against the wall on [DATE]. After assaulting R#13 on [DATE], R#11 was placed on one to one observation. However, the resident was observed without one on one supervision on [DATE] at 10:59 a.m., 11:15 a.m., 12:47 p.m., 12:58 p.m., 1:00 p.m. and on [DATE] at 2:55 p.m., 2:58 p.m., 3:00 p.m. and 3:09 p.m. The care plan was not revised to reflect the one on one supervision until [DATE] after the resident was transferred to the hospital. The Immediate Jeopardy's were related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607, Scope/Severity: J); 42 C.F.R. 483.12(c), Reporting of Alleged Violations (F609, Scope/Severity: J); 42 C.F.R. 483.21(b)(1) Develop/Implement Comprehensive Care Plan (F656, Scope/Severity: K); 42 C.F.R. 483.25(g)(1)(2), Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K); 42 C.F.R. 483.50(a)(2)(i)(ii), Lab Services with Physician Order/Notify of Results (773, Scope/Severity: K); 42 C.F.R 483.60(a)(2), Qualified Dietary Staff (801, Scope/Severity: K); 42 C.F.R 483.60(a)(3), Sufficient Dietary Support Personnel (F802, Scope/Severity: K); 42 C.F.R. 483.60(c)(1)-(7), Menus and Nutritional Adequacy (F803, Scope/Severity: K); 42 C.F.R. 483.70, Administration (F835, Scope/Severity: K); 42 C.F.R. 483.75(g)(2), QAPI/QAA Improvement Activities (F867, Scope/Severity: K). Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607, Scope/Severity: J). 42 C.F.R. 483.12(c), Reporting of Alleged Violations (F609, Scope/Severity: J); and 42 C.F.R. 483.25(g)(1)(2), Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K). A Removal Plan (A Credible Allegation of Compliance) was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance while the facility continued management level staff oversight of residents for abuse and for nutrition. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's policy and procedures governing abuse and nutrition. In-service materials were reviewed to ensure appropriate training was giving to the staff. Resident records were reviewed to ensure care plans were developed and implemented with appropriate interventions. At the time of exiting the survey on [DATE] the Immediate Jeopardy was removed. Findings include: The facility had a Job Summary for the Licensed Nursing Home Administrator. The job summary included that the primary purpose of the Nursing Home Administrator position was to oversee the day-to-day operation of the facility and to review organizational performance. The job duties and responsibilities included overseeing the areas of resident care and quality of life, human resources, finance, leadership and management, physical environment and safety, and working conditions. The facility also had a Job Summary for the Director of Nursing (DON). The job summary included that the primary purpose of the DON position was to plan, organize, develop and direct the overall operation of the Nursing Department to ensure that the highest degree of quality care is maintained at all times. The job duties and responsibilities included administrative functions, committee meeting functions, personnel functions, nursing care functions, safety and sanitation, equipment and supply functions, care plan and assessment functions, budgeting and planning functions, resident rights responsibilities, working conditions, and staff development functions. A review of the list of management changes at the facility revealed that the facility had seven different Administrators and eight different Director of Nurses (DON's) since [DATE]. The facility Administrators with their dates of service were as follows: Administrator QQ through [DATE], Administrator RR ([DATE]-[DATE]), Administrator OO ([DATE]-[DATE]), Regional Vice President (RVP) MM ([DATE]-[DATE]), Administrator II ([DATE]-[DATE]), Administrator SS ([DATE]-[DATE]), and Administrator PPP since [DATE]. The facility DON's with their dates of service were as follows: DON TT through [DATE], DON UU ([DATE]-[DATE]), DON NN ([DATE]-[DATE]), DON LL ([DATE]-[DATE]), Regional Nurse Consultant (RNC) HH ([DATE]-[DATE]), DON VV ([DATE]-[DATE]), RVP WW ([DATE]-[DATE]), and DON OOO since [DATE]. Facility Administration, including the Administrator and DON, failed to consistently and effectively oversee multiple areas of the facility that were included in their job descriptions. 1. Administration failed to ensure nursing staff notified the physician of abnormal high laboratory results in a timely manner which resulted in a delay of care for one resident (R#3) who was at risk for dehydration. As a result, the resident was admitted to the hospital for profound [MEDICAL CONDITION] and dehydration and subsequently expired on [DATE]. The Administrator also failed to ensure staff implemented pertinent interventions to address continued weight loss for seven residents (R#3, R#4, R#5, R#6, R#7, R#8 and R#9) who were a nutritional risk from a sample of 35 residents. Cross Refer to F656, F692, F773, F801, F802 and F803. 2. Administration failed to ensure three residents (R#1, R#2 and R#13) were free from abuse by other residents and staff. Specifically, failed to identify and address the ongoing escalating behaviors of R#11 who lifted R#13 by his neck and throwing him against the wall, failed to ensure two residents(R#1 and R#2) were free from abuse from staff as evidenced by a CNA throwing a roll of paper towels and yelling at R#1 and R#2 was yelled at by the Interim Administrator. Cross Refer to F600. 3. Administration failed to ensure staff followed the facility's Policy and Procedure for Abuse by not obtaining prior employment references for CNA BBB, hired on [DATE] who was found to have been abusive toward R#1 and failed to perform a thorough background check for Interim Administrator OO, hired on [DATE], who was found to be verbally abusive toward R#2. Cross Refer to F607. 4. Administration failed to ensure that all alleged violations involving abuse and neglect were reported timely for two residents (R#1 and R#2). During an interview on [DATE] at 3:10pm interview Regional Vice President (RVP) MM stated that there was a problem with consistency of staff and administration. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], the Regional Vice President of Operations re-educated the Interim Administrator on the Job description for the Licensed Nursing Home Administrator the duties include the following but not limited to resident care and quality of life, Human Resources, Finance, leadership and Management, Physical Environment and Safety, and Working conditions. 2. Administration failed to recognize the lack of consistent oversight in monitoring of nutrition such as: monitoring of weights, failure to provide supplements as ordered, failure to notify responsible party and Physician of weight loss and critical labs, failure to ensure labs are addressed timely , failure to ensure significant weight loss are addressed timely, failed to ensure the Registered Dietician assessments were competed and accurate, failure to recognize and address escalating behaviors, failure to ensure residents were free from abuse , failure to hire a Certified Dietary Manager, failure to ensure staff were screened thoroughly before hire, and that allegations of abuse were reported in a timely manner. A. The Interim Administrator and the Interim Director of Nursing was re-educated on ([DATE]) by the Regional Vice President of Clinical Services on the Freedom of Abuse Standard including all types of abuse, reporting abuse with 2 hour of incident to the Abuse Coordinator, Nutrition and Weight Management Standard, likes and dislikes, availability of supplements per Physician orders, notification of responsible party and Physician of weight loss and critical labs, labs are address timely, ensuring Care plans are developed and implemented timely, reviewing of Registered Dietician assessment to ensure they are complete and accurate after each visit , and new B. Education was provided to the Interim Administrator (Abuse Coordinator) and the Interim Director of Nursing by the Regional Vice President of Operations on 10/ 19/ 2020, in-regards to reporting all allegations of abuse immediately (within 2 hours) and will submit the 5 day investigation summary during dayshift , nightshift, weekend, and holidays. C. The Regional Vice President of Operations will visit the facility weekly times 8 weeks and then re-evaluate, and revise visitation as needed to provide Administrative oversight for the implementation of the plan in this document. D. The Administrator will have weekly calls with the Regional Vice President of Operations regarding process of the plan, identified concerns and non-compliance identified items. The weekly calls will include resident admissions, review of reported events and or escalating behaviors, and management of resident behaviors to meet resident needs, consistent oversight for the dietary department to include monitoring of weights, provide supplements as ordered, notifying the responsible party and Physician of weight loss and or critical labs, review of Registered Dietician assessments after each visit to the facility, and review new hire candidates prior to hire to ensure a thorough screen has been performed including a Georgia background check and references has been completed. E. The Regional Vice President of Operations will assist in monitoring of the facility progress or obstacles for compliance with weekly calls and visits. F. The Regional Nurse Consultant will visit the facility weekly to ensure compliance and identify any areas of concern including residents with aggressive behavior s, weight management, availability of supplements per Physician order, notification of responsible party and Physician with weight loss and or critical labs, review new hire candidates for nursing to ensure a thorough screening process has been completed prior to hire including a Georgia background check and two reference checks, and to ensure residents are free of abuse. Review of the findings will be placed on a weekly Trip Report by the Regional Nurse Consultant. 3. All Corrective actions were completed on [DATE]. 4.The immediacy of the IJ was removed on [DATE]. The State Survey Agency (SSA) validated the facility's written Immediate Jeopardy Removal Plan as follows: 1. Verified via review of the Licensed Nursing Home Administrator (LNHA) Job Summary signed by Interim Administrator SS. Also verified via interview on [DATE] at 4:15 p.m. with Interim Administrator SS. 2. Verified via review of the [DATE] In-service/Training form with topics: Freedom of Abuse Standard including abuse reporting in 2 hours and will submit the 5-day investigation summary during day shift, night shift, weekend and holidays; Reporting within two hours of incident to the abuse coordinator; Nutrition and weight management standard, likes and dislikes, availability of supplements per physician's orders [REDACTED]. The in-service education forms were signed by Interim Administrator SS and RVP WW (who was serving as interim DON). Also verified via interviews on [DATE] at 4:15 p.m. with Interim Administrator SS and on [DATE] at 4:40 p.m. with RVP WW and RVP JJJ. B. Verified via review of the [DATE] In-service/Training form with topics: Freedom of Abuse Standard including abuse reporting in 2 hours and will submit the 5-day investigation summary during day shift, night shift, weekend and holidays; Reporting within two hours of incident to the abuse coordinator. The in-service education forms were signed by Interim Administrator SS and RVP WW (who was serving as interim DON). Also verified via interview on [DATE] at 4;15 p.m. with Interim Administrator SS. C. Verified via review of the October and [DATE] calendar forms signed by RVP JJJ as being at the facility on [DATE], [DATE], [DATE] and [DATE]. Also verified via observations of RVP JJJ being at the facility on [DATE], [DATE] and [DATE]. Also verified via interview on [DATE] at 4:15 p.m. with Interim Administrator SS who stated that RVP JJJ had been at the facility on an almost daily basis. Also verified via interview with RVP JJJ on [DATE] at 4:40 p.m. D. Verified via review of October and [DATE] calendar forms signed by RVP JJJ and via interview with RVP JJJ on [DATE] at 4:40 p.m. E. Verified via interview on [DATE] at 4:40 p.m. with RVP JJJ that she would continue to oversee and assist the facility with corrective actions. F. Verified via interview on [DATE] at 3:15 p.m. with RVP WW who stated that RNC BBBBB would be the RNC for the facility and would start her visits the following week, but in her absence, RVP WW was serving as the RNC. 3. Verified via observations, record reviews and interviews previously stated. 4. The immediacy of the IJ was removed on [DATE].

Based on record review, staff interviews, and review of the facility's QAPI plans the facility failed to implement Quality Assessment and Performance Improvement Plans (QAPI) for identified concerns with leadership, the weight management process, residents not receiving physician ordered supplements, behavior management, and care plans. The facility QAPI process also failed to identify concerns related to laboratory tests and prompt reporting of results, failed to address significant weight loss, failed to ensure that RD assessments were complete and accurate, and failed to ensure staff were screened thoroughly before hire. In addition, F801 and F803 were previously cited on [DATE] during an Abbreviated/Partial Extended Survey. The facility census was 66 residents. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Interim Administrator SS, Regional Vice President Clinical WW, and Licensed Practical Nurse GGG were informed of the Immediate Jeopardy on [DATE] at 3:13 p.m. The noncompliance related to the first Immediate Jeopardy was identified to have existed on [DATE]. The noncompliance related to the second Immediate Jeopardy was identified to have existed on [DATE]. Both Immediate Jeopardy's continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on [DATE]. 1.) The first Immediate Jeopardy is outlined as follows: Resident (R)#3 (R#3), a [AGE] year-old male, that had lab-work drawn on [DATE]. The lab results revealed R#3 had an abnormally high Sodium level of 158 (normal 136 - 145, critical level 160 or higher). Investigation revealed that the lab notified the facility of the abnormally high Sodium level on [DATE]. However, the facility did not address this abnormally high Sodium level until seven days later, on [DATE]. Physician ordered for R#3 to be sent to the emergency roiagnom on [DATE]. R#3 was admitted to the hospital with [REDACTED]. R#1 was admitted with profound [MEDICAL CONDITION] (critically high sodium level) and dehydration. R#3 subsequently died on [DATE]. There was also a repeated, systemic failure to implement pertinent interventions to address continued weight loss for seven residents (R#3, R#4, R#5, R#6, R#7, R#8, and R#9). There was also evidence of a complete systemic failure related to dietary services to ensure that Dietary Manager PP had the appropriate certification and skill sets to carry out the functions of the food and nutrition services in the facility. The Dietary Manager (DM) failed to ensure there was an adequate supply of nutritional supplements (Ready Shakes) available for residents who had Physician orders for Ready Shake. These residents were to receive Ready Shakes because they were nutritionally compromised. By not receiving these shakes it would put these nutritionally compromised residents at risk for additional weight loss or ongoing poor nutritional status. The DM also failed to routinely assess resident's likes and dislikes to meet the nutritional needs of the residents. 2.) The second Immediate Jeopardy is outlined as follows: R#11 was admitted to the facility on [DATE]. Two days later on [DATE] the resident started exhibiting threatening behaviors towards other residents and staff. As the behaviors continued, the facility failed to identify and address the ongoing escalating behaviors of R#11 who eventually fractured a nurses foot with a chair on [DATE] and lifted R#13 by his neck and threw him against the wall on [DATE]. After assaulting R#13 on [DATE], R#11 was placed on one to one observation. However, the resident was observed without one on one supervision on [DATE] at 10:59 a.m., 11:15 a.m., 12:47 p.m., 12:58 p.m., 1:00 p.m. and on [DATE] at 2:55 p.m., 2:58 p.m., 3:00 p.m. and 3:09 p.m. The care plan was not revised to reflect the one on one supervision until [DATE] after the resident was transferred to the hospital. The Immediate Jeopardy's were related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607, Scope/Severity: J); 42 C.F.R. 483.12(c), Reporting of Alleged Violations (F609, Scope/Severity: J); 42 C.F.R. 483.21(b)(1) Develop/Implement Comprehensive Care Plan (F656, Scope/Severity: K); 42 C.F.R. 483.25(g)(1)(2), Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K); 42 C.F.R. 483.50(a)(2)(i)(ii), Lab Services with Physician Order/Notify of Results (773, Scope/Severity: K); 42 C.F.R 483.60(a)(2), Qualified Dietary Staff (801, Scope/Severity: K); 42 C.F.R 483.60(a)(3), Sufficient Dietary Support Personnel (F802, Scope/Severity: K); 42 C.F.R. 483.60(c)(1)-(7), Menus and Nutritional Adequacy (F803, Scope/Severity: K); 42 C.F.R. 483.70, Administration (F835, Scope/Severity: K); 42 C.F.R. 483.75(g)(2), QAPI/QAA Improvement Activities (F867, Scope/Severity: K). Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607, Scope/Severity: J). 42 C.F.R. 483.12(c), Reporting of Alleged Violations (F609, Scope/Severity: J); and 42 C.F.R. 483.25(g)(1)(2), Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K). A Removal Plan (A Credible Allegation of Compliance) was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance while the facility continued management level staff oversight of residents for abuse and for nutrition. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's policy and procedures governing abuse and nutrition. In-service materials were reviewed to ensure appropriate training was giving to the staff. Resident records were reviewed to ensure care plans were developed and implemented with appropriate interventions. At the time of exiting the survey on [DATE] the Immediate Jeopardy was removed. Findings include: 1. Review of the facility's QAPI plans dated [DATE] and [DATE], revealed the facility identified a problem with resident weights not obtained in a consistent and accurate manner following policy. The goal was to have accurate resident weights on a consistent basis following policy. The QAPI plan identified the following root causes: 1. Lack of consistent staff 2. Certified Nursing Assistant (CNA) positions vacant 3. Lack of monitoring of resident weights per clinical leadership. The barriers identified were; scales need calibrated and lack of monitoring/Director of Nursing (DON). The QAPI plan developed the following tasks: Calibration of scales, Education of staff regarding resident weight policy/consistent weights, Assignment of one staff CNA with backup for resident weights weekly and monthly, Monitoring of weekly weights during clinical meeting each week and during weekly care management meeting for residents with significant weight loss, Monitoring of monthly weights each month during Change Over process to ensure compliance, and Registered Dietician notes monthly with significant weight loss with recommendations/followed and implemented per clinical staff. The [DATE] and [DATE] QAPI plans had start dates of [DATE] and [DATE] respectively with an ongoing estimated completion date. During an interview [DATE] at 2:15 p.m. with the Senior Nurse Consultant HH and the Regional Vice President of Operations MM, they stated they were unable to find documentation where the scales were calibrated. The HH stated she calibrated the scale this morning and it was only off by 0.2 pounds. They stated they were not able to find the education that was supposed to be given to staff regarding the weight policy. They also confirmed the clinical meetings were not done as planned. They stated CNA's CC and DD started doing weights in August and they have done them about three times. They stated they were currently on their third DON, two of them were interim, and their second Interim Administrator. 2. Review of the facility's QAPI Plan dated [DATE], revealed the facility had a problem statement/plan for residents not receiving physician ordered supplements. The goal was to have physician ordered supplements in inventory to administer per physician's order. The plan was supplements will be available for administration as per physician's order. The plan identified the following root causes: 1. Lack of oversight by the Food Services Supervisor (FSF). 2. Lack of monitoring of supplemental inventory. 3. Lack of clinical oversight to ensure supplements are administered as ordered. The plan also identified the barriers as staff turnover and lack of DON/Nursing Home Administrator. The QAPI Plan had developed the following tasks: 1. Conduct audit of all physician's orders for supplements. 2. Review inventory of supplements and compare with orders and then contact vendor for new orders. 3. Education for clinical staff as to following physician's orders for supplements and administration/documentation of supplements. 4. Education of dietary staff as to ordering supplements for inventory. 5. FSD to audit/monitor supplements daily times four weeks to ensure administration and availability of product. 6. Results of audit to be brought to QAPI Committee for analysis for compliance. Further review of the QAPI Plan revealed the plan had a start date of [DATE] but did not include an estimated completion date. Although the facility had identified on the [DATE] and [DATE] QAPI plans a root cause as being lack of monitoring of resident weights per clinical leadership, a QAPI Plan was not developed until [DATE] to address the ineffective facility leadership. The facility had a Quality Assessment and Assurance Plan policy dated [DATE]. The policy documented that the purposes of the Quality Assessment and Assurance Plan included: 1. To provide a means to identify and resolve present and potential negative outcomes related to resident care and safety; 2. To reinforce and build upon effective systems of services and positive care measures; 3. To provide a structure and process to correct identified quality deficiencies. The policy also specified that the Quality Assessment and Assurance committee would meet monthly and the committee included the following individuals: committee chairperson, Administrator, Director of Nursing (DON), Medical Director, Dietary Representative, Pharmacy Representative, Social Services Representative, Environmental Services Representative, Infection Control Representative, Rehabilitative/Restorative Services Representative, Staff Development Representative, Safety Representative, and a Medical Records Representative. During an interview on [DATE] at 4:15 p.m. Interim Administrator SS, who had been at the facility since [DATE] confirmed that as Administrator, she was head of the Quality Assurance Committee A review of the Performance Improvement Plans (PIP) 2020 Book provided by Regional Vice President (RVP) MM revealed the following problems had been identified by the facility and Quality Assessment and Performance Improvement (QAPI) Plans had been developed: 1. Resident weights are not obtained in a consistent and accurate manner following policy. The start date was listed as [DATE] with a complete date listed as ongoing. 2. Care plans are not accurate for weight loss. The start date was listed as [DATE] with a completion date listed as ongoing. 3. Behavior management standard has not been implemented. the start date was listed as [DATE] with a completion date of ongoing. 4. Facility care plans are not current to resident condition and are not updated as condition changes. The start date was listed as [DATE] with a completion date of ongoing. 5. Resident weights are not obtained in a consistent an accurate manner following policy. The start date was listed as [DATE] with a completion date of ongoing. 6. Ad Hoc QAPI meeting identified concern of weight management process including weekly weights, physician and responsible party notification, documentation and follow through with recommendations. The Ad Hoc QAPI meeting date was [DATE] with a plan completion listed as [DATE]. Further review of the facility identified problems and plans revealed that the plans shared root cause of lack of leadership, lack of clinical leadership, and/or lack of Nursing Home Administrator or Director of Nursing oversight. During an interview on [DATE] at 3:10pm interview RVP MM stated that there was a problem with consistency of staff and administration. A review of the list of management changes at the facility revealed that the facility had seven different Administrators and eight different DON's since [DATE]. The facility Administrators with their dates of service were as follows: Administrator QQ through [DATE], Administrator RR ([DATE]-[DATE]), Administrator OO ([DATE]-[DATE]), Regional Vice President (RVP) MM ([DATE]-[DATE]), Administrator II ([DATE]-[DATE]), Administrator SS ([DATE]-[DATE]), and Administrator PPP since [DATE]. The facility DON's with their dates of service were as follows: DON TT through [DATE], DON UU ([DATE]-[DATE]), DON NN ([DATE]-[DATE]), DON LL ([DATE]-[DATE]), Regional Nurse Consultant (RNC) HH ([DATE]-[DATE]), DON VV ([DATE]-[DATE]), RVP WW ([DATE]-[DATE]), and DON OOO since [DATE]. As part of the Quality Assessment and Assurance committee, facility administration, including the Administrator and DON, failed to consistently and effectively implement QAPI plans for facility identified areas of concern for the weight management process, behavior management and care plans. In addition, the facility Quality Assessment and Assurance process and committee failed to identify concerns related to laboratory tests and prompt reporting of results and screening of employees and contributed to the following: 1. Nursing staff failed to notify the physician of abnormally high laboratory results in a timely manner which resulted in a delay of care for one resident (R#3) who was at risk for dehydration. As a result, the resident was admitted to the hospital for profound [MEDICAL CONDITION] and dehydration and subsequently expired on [DATE]. Facility staff failed to implement pertinent interventions to address continued weight loss for seven residents (R#3, R#4, R#5, R#6, R#7, R#8 and R#9) who were a nutritional risk from a sample of 35 residents. Cross refer to F656, F692, F773, F801, F802 and F803 2. The Quality Assessment and Assurance process and committee failed to ensure three residents (R#1, R#2, and R#13) were free from abuse by other residents and staff. Specifically, failed to identify and address the ongoing escalating behaviors of R#11 who lifted R#13 by his neck and throwing him against the wall, failed to ensure two residents(R#1 and R#2) were free from abuse from staff as evidenced by a CNA throwing a roll of paper towels and yelling at R#1 and R#2 was yelled at by the Interim Administrator. Cross refer to F600 3. The Quality Assessment and Assurance process and committee failed to ensure staff followed the facility's Policy and Procedure for Abuse by not obtaining prior employment references for CNA BBB, hired on [DATE] who was found to have been abusive toward R#1 and failed to perform a thorough background check for Interim Administrator OO, hired on [DATE], who was found to be verbally abusive toward R#2. Cross refer to F607 Further review revealed that the facility was cited F801 and F803 on [DATE]. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], a review of the facility policy Quality Assurance Performance Improvement Policy'' was completed by the Senior Vice President of Operations with no revision made. 2. The facility failed to have an effective QA process in place to recognize occurrences of abuse, failed to identify, address escalating behaviors, and to ensure the resident's safety and are free from abuse. The facility failed to implement a QA plan to identify and address abuse, Nutrition and Weight Management, development of comprehensive care plans, and to ensure the facility had adequate dietary staff, and failed to recognize that the Dietary M anager was not certified. Corrective action has been accomplished for the deficient practice regarding Quality Assurance Performance Improvement through education. All Department Managers (100 %) and members of the Quality Assurance and Perf orm ance Improvement Committee to include: Administrator, Interim Director of Nursing, MOS, Social Service Director, Activities Director, Certified Dietary Manager, Business Office Manager, Housekeeping Manager, M edical Director, Newly hired Interim Certified Dietary Manger, Licensed Nurse, Certified Nursing Assistant and Therapy Program Manager were in-serviced on Quality Assurance Performance Improvement Standard on [DATE] at 5 P.M. by the Regional Vice President of Operations. 3. An Ad-Hoc Quality Assurance meeting was held on [DATE] and a root cause analysis was initiated and conducted for deficiencies FG00, F607, F609, F656, F 692, F801, F802, F803, F835, and F867 and addressed the following. It was determined that employees needed education regarding the following areas: A. F600- Re-education was needed and provided on what is considered abuse and the types of abuse, how t o ident ify , provide supervision to protect resident s, to implement interventions to protect residents. Education was provided by the Interim Administrator on [DATE]. B. F607- Re-education and re-implementation was needed for the Personnel File Checklist prior to hire of each employee. To ensure backgrounds and references checks were in accordance with the Georgia State Department of Health screening regulations and that staff have appropriate License and certifications. Education was provided by the Senior Vice President of Human Resources on [DATE]. C. F609- Re-education was needed for reporting and immediately notifying the Interim Administrator on the timeframe in which to report all allegations of abuse within the 2 hour time frame, who to report the allegation to (Abuse Coordinator/Interim Administrator}, implement immediate interventions to ensure the residents safety, law enforcement, report to the Department of Community Health, responsible party, Physician notification and the 5 day follow up investigation summary. Any results of non-compliance will be communicated to the Quality Assurance Performance Improvement Commi tt ee as identified. D. F656-Re-education was needed and immediately provided for the MOS Coordinator on how to and when to develop a person centered comprehensive care plan with appropriate interventions to address all types of abuse include behaviors by the Interim Administrator on 10/ 22/ 2020. The facility will monitor (care plan monitoring tool) the care plan interventions related to behaviors, weight management, meal intake documentation, labs are reviewed and to ensure Physician is notified, and likes and dislikes are honored per the residents' request will be monitored daily during the morning meeting to evaluate the effectiveness of the interventions implemented by the MOS nurse and or Interim Director of Nursing. During the morning meeting if the Interim Director of Nursing and or MDS Nurse discovers the Care plan interventions are not appropriate, the interventions will be re¿ evaluated and revised based on resident needs. E. F692 Re-education was needed and provided by the Regional Vice President of Clinical Services for Nutrition and Weight management including resident who have a 5 pound weight gain or loss will re-weighed to ensure weights are accurate, likes and dislikes, and supplements are honored with each meal on [DATE] to ensure the facility recognizes, evaluates, and addresses the needs of every resident, including but not limited to, the residents risk or already experiencing impaired nutrition and or fluid volume loss and also provides a therapeutic diet that takes into account the resident's clinical condition and preferences when there is a nutritional indication. The Nutrition and Weight Management program will be reviewed weekly during Care Management meeting to ensure interventions implemented are effective. If during the care management meeting the Interim Director of Nursing discovers the interventions are not effective, the interventions will be re-evaluated and revised based on the resident needs. F. F773-Re-education was needed for promptly notifying the Physician will be notified promptly (with little or no delay) of critical labs results via phone, abnormal labs will be faxed to the Physician and or called within 24 hours, and all normal lab results will be faxed to the Physician with 24 hours of receipt of lab results by the licensed nurse. The Physician will give immediate orders for critical lab results via phone and abnormal/ normal lab results will be faxed back to the facility or a telephone order will be obtained within 24 hours of the Physician receiving lab results) by the Interim Director of Nursing and or licensed nurse. The Interim Director of Nursing and or the licensed nurse will monitor labs during the weekday during the morning meeting. The RN Supervisor will monitor during holidays and weekends. The monitoring tool will include residents name, lab result obtained, date and time of Physician notification, orders received, and Responsible party notification. Any non¿ compliance will be communicated to the Quality Assurance Performance Improvement Committee as identified. The Physician will give orders in a prompt manner (with little or no delay) for critical lab results via phone and abnormal/ normal lab results will be faxed back to the facility or a telephone order will be obtained within 24 hours of the Physician receiving lab results. The facility fax machine will be monitored (Receipt of lab results monitoring tool) by the Interim Administrator, Interim Director of Nursing and or Licensed nurse 8 times per day. The Interim Director of Nursing will utilize the Receipt of Lab results monitoring tool daily during the morning meeting to ensure receipt of lab results, timely notification of the Physician, and to ensure the facility receives timely responses from the Physician. The RN Supervisor will monitor during weekend and holidays. G. F801-Re-ducation was needed and provided by the Interim Administrator and Regional Vice President of Operations on [DATE] to ensure the Dietary Manager had the appropriate certification and skill set to carry out the functions of the food and nutrition service in the facility. A newly hired Interim Certified Dietary Manager started on [DATE]. Additional, education was provided the Dietary Staff to ensure the facility an adequate supply of nutritional supplements for those residents that had Physician orders by the Interim Administrator. The Dietary Manager rout inely assess residents likes and dislikes to meet the nutritional needs of the residents. The Dietary/Nutritional monitoring tool will include nutritional supplements on hand, order date of supplements needed, date supplements are received, new admission likes and dislikes form completed within 24 hours of admission, and likes and dislikes form updated as indicated on all current residents. Any non- compliance will be communicated to the Quality Assurance Performance Improvement Committee as identified. H. F802-Re-education was needed and provided by the Interim Administrator and Regional Vice President of Operations on 10/ ,[DATE]to ensure adequate dietary staffing daily to ensure the facility has sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. The Dietary Staffing monitoring tool will include the dietary staffing schedule to include daily dietary support staff provided from sister facilities. The Registered Dietician provided education on the proper scoop/ladle sizes for each item on the menu on ,[DATE]/ 2020 to ensure nutritional needs were met. Weekly weights were re-implemented on residents who are identified with a significant weight loss by the Regional Vice President of Clinical Services. Any non-compliance will be communicated to the Quality Assurance Performance Improvement Committee as identified. I. F803-Re-education was needed and provided by the Interim Administrator and Regional Vice President of Operations on [DATE] to ensure dietary staff have menus and tray cards available for each meal. The monitoring tool will include the daily menu availability, tray cards, likes and dislikes, correct ladle size for Puree foods to ensure residents are not at risk for nutritional compromise, meal consumption of meals, and nutritional supplements. The RN Supervisor will monitor during weekend and holidays. Any non-compliance will be communicated to the Quality Assurance Performance Improvement Committee as identified. J. F835-Re-education was needed and provided by the Regional Vice President of Operations to the Administrator on how to identify, how to address escalating behaviors, weights, abuse, protection of residents, and likes and dislikes. The Regional Vice President of Operations will visit weekly times 8 weeks and then re-evaluate, and revise visitation as needed to provide the Interim Administrator oversight for the implementation of the plan in this document. The Interim Administrator will have weekly calls with the Regional Vice President of Operations regarding process of the plan, identified concerns and non- compliance items. The weekly calls will include residents who have been identified with have an increased behaviors, review of reported events (abuse), dietary staffing needs, adequate supply of nutritional supplement needs, menus, tray cards, likes and dislikes, labs, and care plan development and implementation to meet resident needs. The Regional Vice President of Operations will assist in monitoring the facility of the facility progress or obstacles for compliance with weekly calls ad visits. The Regional Nurse Consultant will visit the facility weekly to ensure compliance and identify any areas of concern. Review of the findings will be placed on a weekly trip report by the Regional Nurse Consultant. 4. Newly hired Department Managers will be educated on the Quality Assurance Performance Improvement process by the Interim Administrator or Interim Director of Nursing during orientation and quarterly thereafter. Employees will not work until they have received the in¿ service. 5. Quality Assurance Performance Improvement minutes will be reviewed monthly by the Regional Vice president of Operations as well as the Regional Vice President of Clinical Services to provide guidance and opportunities for re-education on how to use the Quality Assurance Performance Improvement process for compliance to identify abuse patterns and or t rends. The Quality Assurance Performance Improvement committee will evaluate the effectiveness of the above interventions put in place. If not, effective new interventions will be implemented immediately. The Quality Assurance Performance Improvement meeting minutes were reviewed on [DATE] at 5 P.M., by the Regional Vice President of Operations in order to ensure all required components have been discussed and addressed with a plan according to this Allegation of Compliance. 6. All corrective actions were corrected on [DATE]. 7. The immediacy of the IJ was removed on [DATE]. The State Survey Agency (SSA) validated the facility's written Immediate Jeopardy Removal Plan as follows: 1. Verified via review of document which documented that on [DATE] a review of the facility policy Quality Assurance Performance Improvement Policy was completed and signed by the Senior VP of Operations (LLL) with no revisions 2. Verified via review of QAPI committee meeting attendance log, dated [DATE] with staff signatures of the committee members. Also verified via interviews with QAPI committee members on [DATE] at 4:40 p.m. with RVP JJJ and RVP WW, [DATE] at 4:15 p.m. with Interim Administrator SS, [DATE] at 1:40 p.m. with the Social Services Director, [DATE] at 3:30 p.m. with the Business Office Manager, [DATE] at 2:20 p.m. with the MDS Coordinator, [DATE] at 12:30 p.m. with the Admissions Coordinator, [DATE] at 2:02 p.m. with CNA DD, [DATE] at 12:52 p.m. with Therapy Manager KK, and on [DATE] at 1:54 p.m. with the maintenance supervisor. All confirmed that information regarding facility deficiencies and failures, facility corrective action plan and education were discussed in detail. 3. Verified via interview on [DATE] at 12:45 p.m. with RVP WW who confirmed that Ad Hoc forms were discussed in detail during the [DATE] QAPI meeting. She stated that all deficiencies were reviewed and root cause discussed. A. Verified via review of the Ad Hoc QAPI F600 and via interview on [DATE] at 4:15 p.m. with Interim Administrator SS. B. Verified via review of the Ad Hoc QAPI F607 and via interview on [DATE] at 4:40 p.m. with RVP WW who clarified that the education was provided on [DATE], not [DATE], which was a typographical error. Also verified via interview on [DATE] at 3:30 p.m. with the Business Office Manager. C. Verified via review of the Ad Hoc QAPI F609 and interview on [DATE] at 4:40 p.m. with RVP JJJ and RVP WW. D. Verified via review of the Ad Hoc QAPI F656. During an interview on [DATE] at 12:45 p.m. RVP WW stated that in addition to the MDS Coordinator receiving re-education at the facility, she received additional training by attending a meeting on [DATE] with the State MDS Coordinator. Also verified via interview on [DATE] at 2:20 p.m. with the MDS Coordinator. E. Verified via review of the Ad Hoc QAPI F692 and interview with RVP WW on [DATE] at 12:45 p.m. F. Verified via review of the Ad Hoc QAPI F773 G. Verified via review of the Ad Hoc QAPI F801 and via interview on [DATE] at 4:40 p.m. with RVP JJJ and RVP WW. H. Verified via review of the Ad Hoc QAPI F802 and via interviews on [DATE] at 4:40 p.m. with RVP JJJ and RVP WW and on [DATE] at 4:15 p.m. with Interim Administrator SS. I. Verified via review of the Ad Hoc QAPI F803. Also verified via interview on [DATE] at 10:13 a.m. with weekend supervisor, RN VV. J. Verified via review of the Ad Hoc QAPI F835 and interview on [DATE] at 4:40 p.m. with RVP JJJ and RVP WW. 3A through 3J also verified via interview with on [DATE] at 12:45 p.m. with RVP WW who confirmed that education was provided to the committee during the [DATE] QAPI meeting. 4. Confirmed via interview on [DATE] at 4:30 p.m. with Interim Administrator PPP and Interim Director of Nursing (DON) OOO. 5. Verified via review of the Quality Assurance Process Improvement Committee Meeting Agenda/Minutes which includes documentation under the section Regulatory Activity that the imme (TRUNCATED)

Based on observation, record review, staff and resident interviews, and review of the facility policies titled, Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts and Behavior Management Standard the facility failed to ensure that one of 35 residents (R) (R#13) was free from physical abuse and the facility failed to ensure two residents (R#1, R#2) of 35 residents were not abused by staff. On October 15, 2020, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Interim Administrator SS, Regional Vice President Clinical WW, and Licensed Practical Nurse GGG were informed of the Immediate Jeopardy on October 15, 2020 at 3:13 p.m. The noncompliance related to the first Immediate Jeopardy was identified to have existed on May 21, 2020. The noncompliance related to the second Immediate Jeopardy was identified to have existed on September 19, 2020. Both Immediate Jeopardy's continued through October 29, 2020 and was removed on October 30, 2020. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on October 30, 2020. This Immediate Jeopardy is outlined as follows: R#11 was admitted to the facility on [DATE]. Two days later on 7/4/20 the resident started exhibiting threatening behaviors towards other residents and staff. As the behaviors continued, the facility failed to identify and address the ongoing escalating behaviors of R#11 who eventually fractured a nurses foot with a chair on 8/30/20 and lifted R#13 by his neck and threw him against the wall on 9/19/20. After assaulting R#13 on 9/19/20, R#11 was placed on one to one observation. However, the resident was observed without one on one supervision on 9/21/20 at 10:59 a.m., 11:15 a.m., 12:47 p.m., 12:58 p.m., 1:00 p.m. and on 9/22/20 at 2:55 p.m., 2:58 p.m., 3:00 p.m. and 3:09 p.m. The care plan was not revised to reflect the one on one supervision until 9/29/20 after the resident was transferred to the hospital. The Immediate Jeopardy's were related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607, Scope/Severity: J); 42 C.F.R. 483.12(c), Reporting of Alleged Violations (F609, Scope/Severity: J); 42 C.F.R. 483.21(b)(1) Develop/Implement Comprehensive Care Plan (F656, Scope/Severity: K); 42 C.F.R. 483.25(g)(1)(2), Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K); 42 C.F.R. 483.50(a)(2)(i)(ii), Lab Services with Physician Order/Notify of Results (773, Scope/Severity: K); 42 C.F.R 483.60(a)(2), Qualified Dietary Staff (801, Scope/Severity: K); 42 C.F.R 483.60(a)(3), Sufficient Dietary Support Personnel (F802, Scope/Severity: K); 42 C.F.R. 483.60(c)(1)-(7), Menus and Nutritional Adequacy (F803, Scope/Severity: K); 42 C.F.R. 483.70, Administration (F835, Scope/Severity: K); 42 C.F.R. 483.75(g)(2), QAPI/QAA Improvement Activities (F867, Scope/Severity: K). Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607, Scope/Severity: J). 42 C.F.R. 483.12(c), Reporting of Alleged Violations (F609, Scope/Severity: J); and 42 C.F.R. 483.25(g)(1)(2), Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K). A Removal Plan (A Credible Allegation of Compliance) was received on October 30, 2020. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on October 30, 2020. The facility remained out of compliance while the facility continued management level staff oversight of residents for abuse and for nutrition. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's policy and procedures governing abuse and nutrition. In-service materials were reviewed to ensure appropriate training was giving to the staff. Resident records were reviewed to ensure care plans were developed and implemented with appropriate interventions. At the time of exiting the survey on November 9, 2020 the Immediate Jeopardy was removed. Findings include: Review of the facility policy titled, Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts with a revision date of September 2020, noted the following procedures under the section titled Resident to Resident Abuse Policy: 1. If a resident to resident altercation occurs, staff should intervene immediately. Separate the residents and take them to areas away from each other until the situation has diffused. 1:1 supervision may be needed if resident behaviors are harmful or considered inappropriate. 2. All incidents are to be documented in the resident's medical record with monitoring to continue for at least 72 hours. The resident's care plan and Kardex is to be updated to reflect immediate interventions and long-term interventions to reduce the risk of reoccurrence of this behavior and to protect resident safety. Review of the facility policy titled, Behavior Management Standard dated September 2020 noted the following under the section titled, Violent Behavior Management: Place the resident in a one to one situation with a staff member until the situation is resolved either through transfer to an acute setting or a psychiatric setting. Care planning should address the immediate interventions put into place as well as a long-term plan to address behavior management. 1. R#11 was admitted to the facility on [DATE] with the following but not limited to Diagnoses: [REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, delusions, verbal behaviors, and independent with transfers and ambulation in the room. Review of the October 16, 2019 Pre Admission Screening and Resident Review (PASRR) Level II, was completed prior to his admission to the facility, revealed the resident had been discharged from facilities due to his aggressive behaviors. It also noted he presented to the ER with agitation and aggression. The screening further noted presenting symptoms included feeling anxious/nervous, concentration difficulties and aggressive behavior. The resident had a care plan initiated on 7/20/20 for verbally aggressive behavior related to [MEDICAL CONDITION] and dementia with behaviors with the following interventions: Administer medications as ordered, monitor/document for side effects and effectiveness, give the resident as many choices as possible about care and activities, monitor behaviors each shift, document observed behavior and attempted interventions, psychiatric/psychogeriatric consult as needed and when the resident becomes agitated intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, if response is aggressive, staff to walk away and approach later. A care plan was initiated 7/20/20 for the resident having depression related [MEDICAL CONDITION] disorder with an intervention to monitor/record/report to physician as needed risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons. Record review of the Nurse's Notes for R#11 documented the following: 1. 7/3/20 at 2400, Resident is up at desk yelling and cursing and has been given medications. He keeps yelling at me to wake up, but I am talking and answering his questions. 2. 7/4/20 at 0650, resident was making verbal threats to the other residents. 3. 7/7/20, easily irritated with staff when trying to redirect, becomes verbally aggressive throughout day, yells at nurse and staff calling out curse words and racial slurs. 4. 7/11/20 at 4:00 p.m., resident is very aggressive verbally using curse words towards staff. 5. 7/11/20 at 5:30 p.m., resident continues to come out in hall yelling at nurse about clothes, already explained to resident that the clothes will be returned once cleaned. Continues to curse and yell out into hallway. 6. 7/15/20 at 5:00 a.m., Resident continues to come outside of room. On isolation protocol due to being a new admit. Resident is not easily redirected and becomes verbally aggressive when trying to do so. 7. 7/18/20 7P-7A, becomes verbally aggressive when other residents go outside to smoke, follows outside and gets another resident to give him the rest of cigarette. When asked to put down, gets aggressive with staff and nurse. Not easily redirected. 8. 7/21/20 at 2:45 p.m., resident walked out into hall, seen a resident sitting out in hall. Resident proceeded to make racial slurs regarding opposite race. Resident said Finally, someone other than a black SOB, I can talk to. 9. 7/24/20 at 8:00 a.m., resident received breakfast tray. While receiving breakfast tray, made a threat to Certified Nursing Assistant (CNA) stating he would use his fork and knife off his tray to stab someone. 10. 7/25/20, resident in halls cursing and yelling at staff. Not easily redirected. Continues to be aggressive towards staff. 11. 7/25/20, resident verbally abusive to staff, cursing and aggressive during shift. Demanding, states I come first in this facility. Attention and redirect resident to no avail. 12. 8/1/20 at 9:15 p.m., resident is alert, verbal, uncooperative. He is wandering, cursing and making sexual comments to writer. He went into his room and called 911. The Sheriff deputy said he called and claimed the nurse and CNA were selling drugs. 13. 8/7/20 at 11:00 p.m., resident sitting hallway in wheelchair. Interferes with residents' behaviors and instigates situations. Yells and curses at staff and other residents. Continue to monitor. 14. 8/18/20 at 6:45 p.m., resident sitting in hall near nurse's station instigating fights with another resident and making threats. Writer asked resident to calm down and leave residents alone. Uncooperative. 15. 8/19/20 at 6:20 p.m., resident sitting in doorway of resident #2121 picking at resident #2121 and malking (sic) her repeatedly. This writer asked resident to move away from her door. He refused. This writer attempted to remove resident from resident #2121 doorway. The resident refused to move and then began to curse, talk to and threaten this writer inappropriately. Redirection unsuccessful after numerous attempts. Resident then rolled himself to nurse's station threatening this writer and calling this writer inappropriate names. 16. 8/20/20 at 9:30 a.m., resident attempting to join smoke break. Resident does not have cigarettes to smoke per family request. CNA asked resident to move to the side so that the smokers could go outside. The resident began to curse at the aide and threatened to hit her in the face. This writer intervened and redirected resident. Resident then began to curse at this writer and threaten me. Resident got up out of wheelchair and continued to threaten this writer and the aide. Redirection unsuccessful after numerous attempts. This writer reported resident's behaviors to Social Services. 17. 8/20/20 at 10:15 a.m., resident went into his room and threw his full urinal into the hallway and said to the housekeeper, Colored girl, have you ever drank (sic) piss before? You can drink that. 18. 8/20/20 at 2200, resident was going back to his bedroom from the nurse's desk but stopped to see R#15. R#11 opened R#15's door without knocking and caught R#15 masturbating. R#11 got mad at R#15 for masturbating even though he entered R#15's room without knocking. R#15 came up to the nurse's desk and was talking to writer about the situation then sat down in the hallway. R#11 approached the nurse's desk and started telling the resident to behave and he shouldn't be touching his own self. He called R#15 a nigger dumb ass, mother[***] and queer. The writer asked R#15 to take a walk with her to the end of the other hall and sit down. R#11 stated, He wanted to kill the mother[***] and nurse for what happened. R#11 grabbed the pill crusher off the nurse's desk but couldn't pass by the two CNA's. R#15 grabbed a chair but dropped it and sat down. R#11 stayed in the hallway yelling, cursing and throwing objects like gloves, Germ X and cart at CNA's. CNA called 911 which an officer escorted R#11 back to his room. The DON and the Administrator were notified about the issue Review of the 8/20/20 Risk Management notes documented that R#11 was verbally abusive to staff and residents, has escalated to threats of physical abuse to staff and residents, Social Services scheduling care plan meeting to discuss options. Administrator speaking to resident about appropriate behaviors. However, review of the resident's care plan revealed no evidence the care plan interventions were re-evaluated to determine if the interventions were appropriate and/or effective to manage the ongoing escalating behaviors. 19. 8/21/20 at 11:50 a.m., resident is becoming more and more aggressive verbally and physically towards staff. 20. 8/22/20 at 6:30 p.m., resident up at nurses' station on phone with brother giving out other resident's name and fabricating made up stories about staff and residents. Instigates arguments between residents and is not compliant when trying to redirect. Becomes verbally aggressive with staff and other residents. 21. 8/23/20 at 4:45 p.m., resident came out in hall yelling racial slurs at CNA when asked for him to move his wheelchair from behind the room door due to a safety issue. Resident is noncompliant with rules. Becomes verbally aggressive when trying to redirect. Resident continues to stop in front of female residents' door and just sits there instigating arguments. Female resident asks for him to move from in front of her door. Residents continue to sit there and yell curse words at female resident as well as make threats. Resident does this throughout shift. Resident also stands over nursing station while trying to give report and document on charts. Resident will peek over desk and look or attempt to read notes. Nurse is unable to fully perform duties and charting due to resident invading privacy. Admin made aware. 22. 8/26/20 at 3:00 p.m., resident at nurses' station on phone fabricating stories of other residents and staff. Violating privacy rights of other residents nor compliant with nurse and refuses to be redirected. Becomes easily aggressive when trying to redirect. Director of Nursing (DON) and Administrator made aware of behaviors several times. 23. 8/23/20 at 10:00 p.m., writer visited resident to let him know his sister had called and wanted him to return her call. Resident accused writer of starting a fight with him. Writer attempted to explain to resident that his sister was concerned about him. Resident came at writer calling her a Fat ass [***] and all the nurses were going to hell. Resident continues to make verbal threats to writer. Writer attempted to redirect resident no avail. Gave report to charge nurse. 24. 8/30/20 at 7:00 p.m., resident became verbally and physically abusive towards staff when trying to redirect resident. Resident took a broom handle from the facility and when staff tried to remove broom handle from resident due to it being a safety issue for self and other residents, resident became verbally and physically abusive, yelling and cursing at staff calling staff Stupid mother[***] s and [***] es. Proceeded to pick up pill crusher from cart and throw it at staff behind nurses' station. Threatened us with more items including picking up and throwing water pitcher and hand sanitizer bottle at staff behind nursing station. Then picked up metal rolling chair with wheels tossing it at nurse behind station landing it (chair) on her foot and lower leg. Told both nurses on duty he would [***] you up and not[***]you can do about it because you are women. He put fists up in both nurses faces and proceeded to tap other nurse in face and arm. He then spit on her while saying You stupid [***] , [***] you! Both nurses tried to redirect resident calmly asking resident to please calm down and put items down. Resident refused to comply with nurses' attempts. Continues to storm around nurses' station until deputy showed up to assist with situation and walked resident back to room. 25. 8/30/20 at 2047, R#11 was walking with a broom handle and the nurses and CNA's asked for it back since it was a safety issue. He started cursing, yelling, throwing items at the nurses. He picked up a pill crusher and we safely removed it from R#11. R#11 saw Licensed Practical Nurse (LPN) AA and he picked up a brown chair and threw it at her which landed on her foot and lower leg. R#11 spit and hit LPN AA on her arm. I tried to notify the physician and the Nurse Practitioner, no answer. The Sheriff deputy was called and arrived at the scene. The deputy escorted the resident to his room. Review of the Daily Assignment Sheet for 8/30/20 revealed a section titled Special Assignment which indicated one to one (1:1) supervision for the resident. However, it did not specify if a specific staff person was assigned only for the 1:1 supervision. The 7-3 shift had two CNAs and one LPN assigned to the unit, the 3-11 shift had three CNAs and two LPNs splitting a shift and the 11-7 shift had one CNA and one LPN. There was no documentation the 1:1 supervision continued past 8/30/20 or had adequate staff to for 1:1 supervision on 8/30/20 for the 7-3 and 11-7 shift. During an interview on 9/23/20 at 9:45 a.m. with LPN AA she stated on 8/30/20 R#11 had a broom stick at the nurse's station. They told him to put the stick down and they would get therapy to look at him for possibly a cane because he stated he wanted a cane. They told him the broom was not safe for him or others. The other nurse went to get the broom and the resident became mad and started swinging the broom. She stated the resident became verbally aggressive and started throwing the water pitcher off the medication cart at them behind the nurse's station. He approached the nurses station trying to open the two doors to get into the nurse's station. She stated he was holding his fists up at the nurses. She stated she and the other two nurses were trying to keep the doors closed so he could not get behind the nurse's station. The resident then picked up a brown chair and threw it at her. The chair hit her leg and foot and broke her foot. He also spit on one of the other nurses and hit that nurse on the head and shoulder with his fist. He then walked off yelling and came back. The sheriff deputy arrived and took the resident to his room and calmed him down. She stated the next day the Administrator brought the resident a large stick that was brought in by the family. She stated the stick was approximately four feet tall. She stated the Administrator was well aware of the broomstick incident the day before but still gave the resident the stick. During an interview with CNA CC on 9/23/20 at 10:00 a.m., she stated after the resident was given the large stick, she went into his room to take him his tray. As she was leaving his room and closing his door, he threw the stick at her. She stated it was reported to the Interim Administrator OO. During an interview with the temporary Nurse Aide DDD on 9/22/20 at 3:11 p.m., she stated the resident used to have a cane/stick that he would try to hit you with, but they eventually took that away. Although the resident clearly had a care plan intervention to monitor/record/report to the physician as needed risk for harming others: possession of weapons or objects that could be used as weapons, the Interim Administrator OO continued to allow the resident to have a large stick in his possession after swinging a broomstick at staff on 8/30/20. Continued record review of the Nurse's Notes for R#11 documented the following: 26. 9/2/20 at 10:30 a.m., CNA went into resident's room to give him ice water. The resident began cursing at aide and threw his cane at the aide. He then began threatening aide repeatedly. 27. 9/2/20 at 10:40 a.m., writer contacted MD due to recent aggressive/violent behaviors. Writer received order to transfer resident to Behavioral Health Senior Center for stabilization. 1013 faxed to MD and it was filled out and signed by physician. 28. 9/2/20 at 10:50 a.m., resident ambulating in hallway with a wooden stick approximately 4.5-5 feet long. The stick had a bigger twisted handle and a rounded body. Resident using this stick as his cane that was brought to the facility by his mother and sister on Monday 8/31/20. Resident ambulating down hallway being verbally aggressive to staff. Redirection unsuccessful x3 attempts. 29. 9/3/20 late entry, on 9/2/20, in room with Administrator to inform of transfer to Behavioral Healthcare due to aggressive behavior. Administrator removed cane from room. 30. 9/13/20 7A-7P, resident constantly to nurse's station asking to use the phone. Resident has called writer multiple times a [***] , a dyke and states that writer told the office people lies about him. He states he hopes somebody kills me. Resident redirected and at times it's effective and at times it is not. He states the people here are going to get what's coming to them. He said he already got two nurses fired and he will do it again. Resident is very difficult to talk with due to hard of hearing. He continues to make threats about staff members jobs. 31. 9/16/20 at 11:00 a.m., resident at nurse's station yelling out loud at staff making threats and calling nurses [***] es. Stated He is tired of these stupid [***] es. On the phone with someone talking about calling FBI and law enforcement on the facility. After hanging up phone, wheeled off in wheelchair cussing out loud. 32. 9/17/20 at 10:00 a.m., On 9/16/20 resident stated to this nurse, I'm giving you a warning, the next time this happens I'm going to kill somebody. I asked him what he was referring to and he said people were lying about him and he said the nurse was the one that was lying. Informed the resident that the nurse no longer worked here, and he repeated what he said, I'm just warning you; I will kill somebody. I told him he couldn't say things like that, and he replied, Y'all are just trying to have me put in jail. I told him no we are not, but you can't say things like that. I asked the Regional Vice President to come talk with him. He stated, Then I retract that statement. This morning on rounds, he told me he did not mean what he said yesterday. The Nurse Practitioner is here today. Will have him evaluate. 33. 9/17/20- resident yelling and cursing at nurse. Stated I'm gonna beat the next one up that comes in my room. This nurse redirected resident. 34. 9/19/20 6:40 p.m., resident was seen yelling and cursing at another resident in the hallway. This resident had the other resident (R#13) lifted off the floor by his neck. Resident was told to stop, and resident threw another resident against the door. Resident then started threatening physical violence against staff members. Resident was making verbal threats to staff members and other residents. Resident returned to his room. Nursing Supervisor and law enforcement was (sic) notified. Law enforcement arrived at 6:50 p.m. and Nursing Supervisor arrived at 6:50 p.m. At 7:45 p.m., EMS here to transport resident to emergency room . On 9/19/20 at 9:30 p.m., called CHE Behavioral Services (Behavioral Health Service that provides psychiatric services to for the facility) regarding need for assistance to transfer resident to a behavioral facility. Informed of recent incident involving physical assault of another resident along with homicidal threat voiced to nursing staff. ER physician reluctant/refuse to complete 1013 process. Requested 1013 from CHE and agreed to complete 1013. 9/20/20 12:15 a.m., resident returned to facility via EMS and stretcher. No new orders. On 9/20/20 at 1:20 a.m., spoke to physician regarding aggressive and threatening behaviors. Resident is threatening staff with physical violence. Received orders for 10 milligrams [MEDICATION NAME] IM injection, one-time dose. 35. 9/21/20 at 4:20 p.m., resident up at nurse's station using the phone. He was speaking with his mother then slammed the phone down yelling that somebody better explain his money. He then went down the hallway slamming and hitting items in the hallway, the doors and trashcans. He then went to his room. 36. 9/21/20 at 6:00 p.m., resident up at nurse's station calling writer a dyke and lesbian. Calling fell ow nurse, a liar stating he hopes she dies. Resident unable to be redirected. 37. 9/22/20 at 11:50 a.m., resident making threats of self-harm while standing at nurses' station. Stated I'm gonna blow my brains out then proceeded to open side door pushing forcefully into a resident sitting in wheelchair on the other side of the door. Resident yelling loudly with another nurse about abuse from his mother. Nurse made attempts to calm resident down trying to verbally reason with resident regarding the situation. Resident and nurse went to resident's room to talk calmly with no success. Resident remains angry at this time. At 12 p.m., the physician and the Nurse Practitioner were notified of resident's behavior. Advised to have resident 1013 out of facility due to threats of self-harm. Resident on 1:1 until resident can be safely transferred from facility. At 2155 the resident left for Appling. During an interview with LPN BB on 9/23/20 at 10:10 a.m., she stated that on 9/19/20 at 6:40 p.m. she saw R#11 holding R#13 up by his neck with his feet off of the floor. When she yelled at R#11 to stop, he threw R#13 into the door. She stated R#13 had an abrasion to his right elbow and was sent to the ER. R#11 was also sent to the ER but returned to the facility later that evening. On 9/21/20 at 9:45 a.m., Central Supply staff CCC was observed sitting outside of the resident's room. She stated she was providing 1:1 observation with the resident because he had an altercation with another resident on 9/19/20. During a subsequent interview with Central Supply staff CCC on 9/21/20 at 1:00 p.m., she stated she guessed staff would have to do 1:1 supervision with the resident until the resident is transferred somewhere else. However, the resident was observed without 1:1 supervision as follows: 9/21/20 at 10:59 a.m., 11:15 a.m., 12:47 p.m., 12:58 p.m. and 1:00 p.m. and on 9/22/20 2:55 p.m., 3:00 p.m., 3:09 p.m. and at 3:11 p.m. During the observation on 9/21/20 at 10:59 a.m. while the resident was standing at the nurse's station unsupervised, a male CNA walked by the resident and stated I thought he was one to one. Where is she? The CNA continued to walk down the hall leaving the resident unsupervised. On 9/22/20 at 3:03 p.m., Temporary Nurse Aide (TNA) GG knocked on the resident's door, looked in the room, then closed the door. He then looked at the surveyor and said, You have to check on him because he will wander. The TNA then walked down the hall leaving the resident unsupervised with his roommate in the room and the door closed. At 3:11 p.m., TNA DDD arrived to the resident's room and told the resident she would be outside his room if he needed anything. TNA DDD then closed the door and sat in a chair in the hall outside of the door. On 9/23/20 at 5:05 p.m., the inconsistent 1:1 supervision and staff sitting outside the resident's room with the door closed was reported to the Regional Vice President (RVP) of Operations MM. She stated the staff were supposed to be with the resident at all times and they were not supposed to close the door and sit in the hallway while the resident was in his room. Review of the Daily Assignment Sheets revealed the following: Saturday 9/19/20, there were staff scheduled for 1:1 supervision. Sunday 9/20/20, there was one CNA assigned to supervise R#11 on the 3-11 shift. However, there was only one other CNA assigned to the west wing to care for the remaining residents. There was no staff assigned to supervise the resident on the 11-7 shift. Review of the Resident Safety Check form revealed on 9/21/20 and 9/22/20 the resident only had 15-minute checks done from 3:00 p.m.-10:45 p.m. each day. There was no indication staff was directly assigned for one to one supervision for R#11 for 3-11 shift on 9/21/20 and 9/22/20. During an interview with RVP MM on 10/6/20 at 10:15 a.m., she was unable to provide any additional documentation of one to one supervision for the resident. During an interview with the Regional Vice President of Clinical Services on 9/30/20 at 2:45 p.m., she stated with all of these behaviors the resident was having, staff should have notified the Regional Nurse Consultant so the consultant could tell them what to do and possibly complete every 15 minute checks or place the resident on 1:1 monitoring. She also stated with these types of behaviors, this resident should have been placed on 1:1 monitoring or every 15-minute checks due to his threatening behaviors. During an interview with the Minimum Data Set (MDS) Coordinator on 10/21/20 at 10:45 p.m., she stated staff told her the resident was placed on 1:1 supervision but she did not revise the care plan to reflect that. She further stated the 1:1 supervision should have been placed on the care plan, but she just did not think to revise the care plan with this information. The facility failed to identify and address the ongoing escalating behaviors of R#11 who had fractured a nurse's foot and lifted R#13 off the floor by the neck and throwing him against the wall. There was no indication there was ongoing re-evaluations/revisions of the care plan interventions to address the behaviors. R#11 had the potential to cause serious harm to vulnerable residents who reside on the Special Care Unit/West Wing due to his poor impulse control and threatening behaviors and the lack of consistent one to one supervision of the resident. 2. Review of the Nurse's notes for R#1 revealed documentation on 9/6/20 at 11:00 p.m. that the resident reported a grievance toward the CNA BBB. The resident stated she had given CNA BBB a list of things she requested from the store along with $16.00 cash for purchase. The resident stated CNA BBB did not return her change from the purchase. Writer inquired about claim with CNA BBB. The CNA immediately became agitated and defensive stating she gave the items to the resident and the resident always wants to tell lies on her. The writer asked the CNA to go with her to the resident's room. The CNA became verbally abusive towards the resident immediately upon entering the room then quickly grabbed a roll of paper towels and threw the roll at the resident and hit the resident in the face/chest area. Writer promptly directed the CNA to exit the room and wait at the nurse's station until otherwise advised. At 11:05 p.m. the employee to resident altercation was reported to the Interim Administrator OO. Review of the written statement by CNA BBB dated 9/8/20 revealed she admitted to raising her voice at the resident and throwing the paper towels at her. The CNA was terminated on 9/7/20. However, further review of CNA BBB's personnel file revealed she had previously been employed at the facility from 10/4/19 to 3/27/20. Review of the 3/31/20 Separation Notice revealed th(TRUNCATED)

Based on record review and staff interview, the facility failed to follow the policy titled, Freedom of Abuse, Neglect and Exploitation; Abuse Prevention by not obtaining prior employment references for one Certified Nursing Assistant (CNA) who was found to be abusive to one resident (R) (R#1) and failed to perform a thorough criminal background check for one Interim Administrator who was found to be verbally abusive to one resident (R#2) and failed to perform a thorough criminal background check for one of 35 Registered Nurses (RN's). On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Interim Administrator SS, Regional Vice President Clinical WW, and Licensed Practical Nurse GGG were informed of the Immediate Jeopardy on [DATE] at 3:13 p.m. The noncompliance related to the first Immediate Jeopardy was identified to have existed on [DATE]. The noncompliance related to the second Immediate Jeopardy was identified to have existed on [DATE]. Both Immediate Jeopardy's continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on [DATE]. This Immediate Jeopardy is outlined as follows: R#11 was admitted to the facility on [DATE]. Two days later on [DATE] the resident started exhibiting threatening behaviors towards other residents and staff. As the behaviors continued, the facility failed to identify and address the ongoing escalating behaviors of R#11 who eventually fractured a nurses foot with a chair on [DATE] and lifted R#13 by his neck and threw him against the wall on [DATE]. After assaulting R#13 on [DATE], R#11 was placed on one to one observation. However, the resident was observed without one on one supervision on [DATE] at 10:59 a.m., 11:15 a.m., 12:47 p.m., 12:58 p.m., 1:00 p.m. and on [DATE] at 2:55 p.m., 2:58 p.m., 3:00 p.m. and 3:09 p.m. The care plan was not revised to reflect the one on one supervision until [DATE] after the resident was transferred to the hospital. The Immediate Jeopardy's were related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607, Scope/Severity: J); 42 C.F.R. 483.12(c), Reporting of Alleged Violations (F609, Scope/Severity: J); 42 C.F.R. 483.21(b)(1) Develop/Implement Comprehensive Care Plan (F656, Scope/Severity: K); 42 C.F.R. 483.25(g)(1)(2), Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K); 42 C.F.R. 483.50(a)(2)(i)(ii), Lab Services with Physician Order/Notify of Results (773, Scope/Severity: K); 42 C.F.R 483.60(a)(2), Qualified Dietary Staff (801, Scope/Severity: K); 42 C.F.R 483.60(a)(3), Sufficient Dietary Support Personnel (F802, Scope/Severity: K); 42 C.F.R. 483.60(c)(1)-(7), Menus and Nutritional Adequacy (F803, Scope/Severity: K); 42 C.F.R. 483.70, Administration (F835, Scope/Severity: K); 42 C.F.R. 483.75(g)(2), QAPI/QAA Improvement Activities (F867, Scope/Severity: K). Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607, Scope/Severity: J). 42 C.F.R. 483.12(c), Reporting of Alleged Violations (F609, Scope/Severity: J); and 42 C.F.R. 483.25(g)(1)(2), Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K). A Removal Plan (A Credible Allegation of Compliance) was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance while the facility continued management level staff oversight of residents for abuse and for nutrition. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's policy and procedures governing abuse and nutrition. In-service materials were reviewed to ensure appropriate training was giving to the staff. Resident records were reviewed to ensure care plans were developed and implemented with appropriate interventions. At the time of exiting the survey on [DATE] the Immediate Jeopardy was removed. Findings include: Review of the facility policy titled, Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts with a revision date of [DATE], noted the following procedures under the section titled Pre-Employment Screening 1.) Criminal Background Check/Nurse Aid Registry Check- In states where Criminal Background Checks are required; all employment candidates are required to authorize the facility to conduct a background check for conviction of crimes. Refusal to grant authorization will eliminate the candidate from employment considerations. The facility will take all steps necessary to assure it does not hire individuals found guilty of abusing, neglecting or mistreating residents by a court of law or those having similar findings entered into the state nurse aide registry or appropriate licensing body. If the criminal background check discloses any misrepresentations or omissions on the application or a condition unsuitable for hire, the new hire will not continue to be employed 2.) Prior employment reference(s)- reference checks of the candidate's prior employment must be conducted by the department director, or designee, hiring the candidate. 1. Review of the personnel file for CNA BBB revealed a hire date of [DATE]. Further review of the record revealed no reference checks were done prior to hire and the CNA subsequently abused R#1 on [DATE]. Review of the Nurse's notes for R#1 revealed documentation on [DATE] at 11:00 p.m. that the resident reported a grievance toward the CNA BBB. The resident stated she had given CNA BBB a list of things she requested from the store along with $16.00 cash for purchase. The resident stated CNA BBB did not return her change from the purchase. Writer inquired about claim with CNA BBB. The CNA immediately became agitated and defensive stating she gave the items to the resident and the resident always wants to tell lies on her. The writer asked the CNA to go with her to the resident's room. The CNA became verbally abusive towards the resident immediately upon entering the room then quickly grabbed a roll of paper towels and threw the roll at the resident in the face/chest area. Cross refer to F600. 2. The facility's policy titled, Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts with a revision date of [DATE] included an employee screening section. The Pre-Employment Screening section included the steps that should be taken to assure that the applicant is suitable for hire. The steps included completing an employee application, verification of license/certification, criminal background check/nurse aid registry check, and prior employment references. However, the facility failed to complete the criminal background check step when hiring Interim Administrator OO. A review of the personnel file for Interim Administrator OO revealed that she was hired on [DATE]. A review of the list of management changes at the facility revealed that Interim Administrator worked at the facility from [DATE] through [DATE]. A review of facility reported incidents revealed a Facility Incident Report Form, dated [DATE], that documented an incident of staff to resident abuse. The form included that the incident involved R#2 and Interim Administrator OO. Interim Administrator was listed as the alleged perpetrator. Further review of the form revealed the date of the incident as [DATE] and included that the Administrator spoke harshly to the resident when the resident was not staying in his room for quarantine. The physician and responsible party were notified. The form documented additional steps taken by the facility included suspending Interim Administrator OO and providing immediate education on Freedom of Abuse to staff. The facility's accompanying investigation of the incident included an interview with R#2 staff written statements, Interim Administrator OO's personnel record information, in-service education information, social service progress notes, a summary of the investigation, and Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting notes. During an interview on [DATE] at 9:15 a.m. Regional Vice President of Operations (RVP) MM stated that the incident occurred on [DATE] and she was informed of the incident while visiting the facility on [DATE]. She stated that several staff reported it to her. She suspended Interim Administrator OO immediately. A review of the witness statements included in the facility's investigation revealed that Certified Occupational Therapy Assistant (COTA) KK documented on [DATE] that on [DATE] she overheard R#2 curse at Registered Nurse (RN) VV after she reminded him because he leaves the facility for [MEDICAL TREATMENT] he had to isolate on return to the facility. She overheard Interim Administrator OO and R#2 yelling at each other a few minutes later. Her statement included that Interim Administrator OO made statements that included You will not talk to my staff like that, get in your room. R#2 is documented as responding with I want to talk to your boss or corporate and the Interim Administrator responding with I am the boss and corporate and you will do what I say. During an interview on [DATE] at 2:15 p.m., COTA KK confirmed that she overheard the interaction between R#2 and Interim Administrator OO and stated that they were shouting at each other. Certified Nursing Assistant (CNA) CC documented on [DATE] that on [DATE] she heard loud voices coming from the hallway and it was Interim Administrator OO and R#2 arguing. The written statement included that the Interim Administrator told R#2 to go to his room with R#2 refusing and the interim administrator telling him to go or he would be forced to go. Dietary staff OOOO documented on [DATE] that on [DATE], while taking out the trash, she witnessed R#2 cursing at RN VV after she asked him to go back to his room because he was quarantined due to going to for [MEDICAL TREATMENT]. The dietary staff statement included that she also heard the Interim Administrator OO talking loud to R#2, and that she could hear them in the kitchen. The statement documented that the Interim Administrator told the resident to be quiet and that enough was enough. Interim Administrator OO also provided a written statement, dated [DATE]. She documented that R#2 had been asking staff to go out for food and was cursing at them; she told him he could not talk like that and to go to his room and calm down. He responded by using foul language and yelling at her. Her statement included that she felt he had gone to far and she got stern with him. A documented interview with R#2 on [DATE] at 10:00 p.m. included that R#2 stated he was not pleased with what Interim Administrator OO said to him. Further review of the facility's investigation of Interim Administrator OO revealed that the facility substantiated the allegation of verbal abuse and Interim Administrator OO was terminated. A review of the Worksite Employee Termination/Separation Form documented that Interim Administrator OO was terminated on [DATE] with the reason for the separation listed as involuntary, misconduct, and detailed that a verbal abuse allegation was substantiated. In reviewing the facility's investigation of the Facility Reported Incident (FRI) and Interim Administrator OO's personnel file, it was noted that prior to her being hired on [DATE], a background screening report was completed on [DATE]. The report included no reportable records found. However, the jurisdiction listed on the background check was Florida. There was no evidence that the background check included Georgia. During an interview on [DATE] at 12:50 p.m. RVP WW confirmed that a background check that included Georgia was not completed for Interim Administrator OO. Cross refer to F600 3. Review of the facility's list of newly hired employees revealed that Registered Nurse (RN) III was hired on [DATE]. A review of her personnel record revealed a background screening report was completed prior to hire on [DATE]. The report included no reportable records found. However, the jurisdiction listed on the background check was Texas. There was no evidence that the background check included Georgia. During an interview on [DATE] at 11:00 a.m., RVP WW confirmed that a background check that included Georgia was not completed for RN III. During an interview on [DATE] at 10:35 a.m., the Business Office Manager confirmed that the RN III was employed at the facility from [DATE] through [DATE], with her last day worked being [DATE]. The facility implemented the following actions to remove the Immediate Jeopardy: 1XXX[DATE], a review of the facility policy New Hire Employee Policy by the Senior Vice President of Human Resources and the Senior Vice President of Operations with no revisions made. 2. A. Employee CNA BBB was terminated on [DATE] due to a substantiated allegation of abuse (throwing paper towels at R#1) by the previous Interim Administrator. Certified Nursing Assistant certification expired on [DATE]. CNA BBB completed the temporary aide coarse and received a Temporary Nurse Aide certificate on [DATE]. B. On [DATE], the Certified Nursing Assistant was reported to the Georgia Nurse Aide Registry by the Regional Vice President of Operations for the substantiated abuse allegation. 3. A. The previous Interim Administrator was hired on [DATE] and a Florida background check was performed on [DATE]. No reportable records found on the background check. B. The previous Interim Administrator Georgia's background check was completed on [DATE]. No reportable records found on the background check. C. The previous Interim Administrator was terminated on [DATE] due to the substantiated allegation of abuse for R#2 by the Regional Vice President of Operations. D. On [DATE], the previous Interim Administrator was reported by the Senior Vice President of Clinical Services/ Corporate Compliance Officer to the Georgia State Board of Nursing Home Administrators for the substantiated allegation of abuse. 4. A. The current Interim Administrator and Human Resource employee were re-educated on the Personnel File Checklist by the Senior Vice President of Human Resource on [DATE]. The checklist will be completed prior to hire and will include but not limited to background checks, two reference checks, Photocopy of Professional License and or certificate, orientation/training checklist, and Georgia Criminal Background System. 5. A. 62 of 62 employees' files were audited on [DATE] by the Regional Vice President of Operations and or the Business Office Manager to ensure all licensed and or certified employees have valid certification or license. B. The audit revealed all current certified and or licensed employees have certification and or license on file. No discrepancies were found. 6. A. All current employees files will be audited to ensure a Georgia background check has been completed by the Regional Vice President of Operations and the Business Office Manager on [DATE] to ensure that there is no disqualifying offenses in accordance Georgia State Department of Health background screening regulations. B. The audit revealed all current employees had a Georgia background that did not include any disqualifying offenses in accordance with Georgia State Department of Health background screening regulations. No discrepancies were found. 7. A. The Interim Administrator and or Business Office Manager will monitor the new hire employee files daily during the morning meeting to ensure two reference checks have been obtained, Georgia Background check, and verification of certificates and license. The monitoring tool will include names of new employees, completion date of the Georgia background check, verification of two completed reference checks, verification of certificates or licensure. . B. The Interim Administrator and or Business Office Manager will monitor certification and licensure on current employees weekly to ensure certification and or licensure have not expired. 8. All Corrective actions were completed on [DATE]. 9. The immediacy of the IJ was removed on 10/ 30/ 2020. The State Survey Agency (SSA) validated the facility's written Immediate Jeopardy Removal Plan as follows: 1. Verified via review of the New Hire Policy, with documentation that it was reviewed by the Senior VP of Human Resources. During an interview on [DATE] at 1:50 p.m. RVP WW stated that the policy date was [DATE]. During an interview on [DATE] at 4:40 p.m. RVP WW and RVP JJJ confirmed that the New Hire Employee Policy was reviewed. RVP JJJ stated that currently the Business Office Manager (BOM) was also the Human Resources (HR) employee for the facility but they were in the process of hiring another person. 2. Verified via review of the Worksite Employee Separation Form for CNA BBB which document the last day worked as [DATE] and the separation effective date at [DATE]. The form included that CNA BBB was not eligible for rehire and detailed Resident founded physical abuse to resident as the cause. B . Verified via review of the Certificate of Completion for Temporary Nurse Aide, dated [DATE], for CNA BBB. C. Verified via review of a statement signed by RVP MM that includes that CNA BBB was reported to the Georgia Nurse Aide Registry on [DATE] and includes her certificate number. 3. A. Verified via review of the Pre-Screening Background Screening Report for Administrator OO, completed on [DATE], which lists the jurisdiction as Florida and includes no reportable records found. B. Verified via review of the Pre Screening Background Screening Report for Administrator OO, completed on [DATE], which lists the jurisdiction as Georgia and includes no reportable records found. C. Verified via review of the Worksite Employee Termination/Separation Form for Administrator OO which lists her last day worked as [DATE] and separation effective date as [DATE]. The form documents that a verbal abuse allegation was substantiated and that Administrator OO is not eligible for rehire. D. Verified via review of statement signed by RVP MM that documents that Administrator OO was reported to the Georgia Board of Nursing Home Administrators on [DATE] with her license number. 4. Verified via review of the in-service/Training form dated [DATE] with topic: Personnel file checklist, given by the Senior VP of Human Resources. The Business Office Manager and Interim Administrator SS signed as attending. Also verified via review of the Personnel File Checklist form. During an interview on [DATE] at 1:00 p.m., RVP WW stated that the checklist form was not a new form, but that it was being re-implemented. Since the re-implementation of the form, the facility had three new hires. RVP WW provided the personnel checklists for all three newly hired employees for verification that they were screened. During interviews on [DATE] at 4:15 p.m. with Interim Administrator SS and on [DATE] at 3:30 p.m. with the Business Office Manager, both confirmed re-education on the Personnel File Checklist. 5. A. Verified via review of Human Resources audit tools for employee files checking for background checks, license and references. The audit completion dates were listed as [DATE] and [DATE]. Also verified via interviews on [DATE] at 4:40 p.m. with RVP JJJ and on [DATE] at 3:30 p.m. with the Business Office Manager. B. Verified via review of the Human Resources audit tools for employee files dated [DATE] and [DATE] with no abnormal findings documented. Also verified via interview s on [DATE] at 4:40 p.m. with RVP JJJ and on [DATE] at 3:30 p.m. with the Business Office Manager. Both confirmed no discrepancies were found. 6. A. Verified via review of [DATE] note signed by RVP JJJ that the files were audited no disqualifying offenses were identified from the audits. Also confirmed via interviews on [DATE] at 4:40 p.m. with RVP JJJ and on [DATE] at 3:30 p.m. with the Business Office Manager. Both confirmed that no disqualifying offenses were found. B. Verified via review of [DATE] statement signed by RVP JJJ that no disqualifying offenses were identified from the audits. Also confirmed via interviews on [DATE] at 4:40 p.m. with RVP JJJ and on [DATE] at 3:30 p.m. with the Business Office Manager. Both confirmed that no disqualifying offenses were found. 7. A. Verified via review of the [DATE] and [DATE] Human Resources Audit monitoring tool- signed as being reviewed daily since [DATE]. The audit tool includes three newly hired staff and evidence the audit tool was completed on each one with no adverse findings. Verified via interviews on [DATE] at 3:30 p.m. with the Business Office Manager and on [DATE] at 4:30 p.m. with Interim Administrator PPP. B. Verified via interview on [DATE] at 1:00 p.m. with RVP WW, who stated that the monitoring was actually being completed daily. During an interview on [DATE] at 4:30 p.m. Interim Administrator PPP confirmed that she was aware of and would monitor files of newly hired employees. 8. Verified via interviews and record reviews previously listed. 9. The immediacy of the IJ was removed on 10/ 30/ 2020.

Based on record review and staff interviews, the facility failed to report allegations of abuse of two of 35 sampled residents (R#1 and R#2) by facility staff to the State Survey Agency (SSA) in a timely manner. On October 15, 2020, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Interim Administrator SS, Regional Vice President Clinical WW, and Licensed Practical Nurse GGG were informed of the Immediate Jeopardy on October 15, 2020 at 3:13 p.m. The noncompliance related to the first Immediate Jeopardy was identified to have existed on May 21, 2020. The noncompliance related to the second Immediate Jeopardy was identified to have existed on September 19, 2020. Both Immediate Jeopardy's continued through October 29, 2020 and was removed on October 30, 2020. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on October 30, 2020. This Immediate Jeopardy is outlined as follows: R#11 was admitted to the facility on [DATE]. Two days later on 7/4/20 the resident started exhibiting threatening behaviors towards other residents and staff. As the behaviors continued, the facility failed to identify and address the ongoing escalating behaviors of R#11 who eventually fractured a nurses foot with a chair on 8/30/20 and lifted R#13 by his neck and threw him against the wall on 9/19/20. After assaulting R#13 on 9/19/20, R#11 was placed on one to one observation. However, the resident was observed without one on one supervision on 9/21/20 at 10:59 a.m., 11:15 a.m., 12:47 p.m., 12:58 p.m., 1:00 p.m. and on 9/22/20 at 2:55 p.m., 2:58 p.m., 3:00 p.m. and 3:09 p.m. The care plan was not revised to reflect the one on one supervision until 9/29/20 after the resident was transferred to the hospital. The Immediate Jeopardy's were related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607, Scope/Severity: J); 42 C.F.R. 483.12(c), Reporting of Alleged Violations (F609, Scope/Severity: J); 42 C.F.R. 483.21(b)(1) Develop/Implement Comprehensive Care Plan (F656, Scope/Severity: K); 42 C.F.R. 483.25(g)(1)(2), Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K); 42 C.F.R. 483.50(a)(2)(i)(ii), Lab Services with Physician Order/Notify of Results (773, Scope/Severity: K); 42 C.F.R 483.60(a)(2), Qualified Dietary Staff (801, Scope/Severity: K); 42 C.F.R 483.60(a)(3), Sufficient Dietary Support Personnel (F802, Scope/Severity: K); 42 C.F.R. 483.60(c)(1)-(7), Menus and Nutritional Adequacy (F803, Scope/Severity: K); 42 C.F.R. 483.70, Administration (F835, Scope/Severity: K); 42 C.F.R. 483.75(g)(2), QAPI/QAA Improvement Activities (F867, Scope/Severity: K). Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607, Scope/Severity: J). 42 C.F.R. 483.12(c), Reporting of Alleged Violations (F609, Scope/Severity: J); and 42 C.F.R. 483.25(g)(1)(2), Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K). A Removal Plan (A Credible Allegation of Compliance) was received on October 30, 2020. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on October 30, 2020. The facility remained out of compliance while the facility continued management level staff oversight of residents for abuse and for nutrition. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's policy and procedures governing abuse and nutrition. In-service materials were reviewed to ensure appropriate training was giving to the staff. Resident records were reviewed to ensure care plans were developed and implemented with appropriate interventions. At the time of exiting the survey on November 9, 2020 the Immediate Jeopardy was removed. Findings include: Review of the facility policy titled, Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts with a revision date of September 2020, noted the following procedures titled Reporting/Investigation/Response Policy; Reporting- 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. Ensure that all alleged violations involving abuse, neglect, exploitation of resident property are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. In the section titled Discipline it noted the following: 1.) Any employee suspected of abuse, neglect or mistreatment must be suspended as soon as the incident is reported, pending outcome of the investigation. 2.) The employee will not be permitted to enter the facility or grounds unless at the direction and direct supervision of the Administrator or Director of Nursing. 1. Review of the Facility Incident Report Form revealed an allegation by Resident #1 that Certified Nursing Assistant (CNA) BBB did not give her money back from the store. The CNA denied the claim and raised her voice to the resident and threw a paper towel roll at the resident's chest. The form indicated the date and time of the incident as 9/6/20 at 11:05 p.m. Although the form was dated 9/7/2020 there was no documentation of when the form was actually sent to the State Survey Agency. During an interview with the Regional Vice President of Operations MM on 10/1/20 at 9:40 a.m., she stated she was unable to determine when or if the 9/7/20 Facility Incident Report Form was sent in by the former Interim Administrator OO. It was determined that the State Survey Agency Complaint Intake had a creation date of 9/8/20 for the 9/6/20 incident making it two days late. 3. The facility's policy titled, Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts with a revision date of September 2020 included a Reporting/Investigation/Response Policy section. The section documented that all employees are required to immediately notify administrative or nursing supervisory staff of any allegation of resident abuse so that the resident's needs can be attended to immediately and an investigation can be undertaken promptly. However, facility staff did not report an allegation of verbal abuse that occurred on 9/7/20 until 9/8/20. A review of facility reported incidents revealed a Facility Incident Report Form, dated 9/8/20, that documented an incident of staff to resident abuse. The form included that the incident involved R#2 and Interim Administrator OO. Interim Administrator was listed as the alleged perpetrator. Further review of the form revealed the date of the incident as 9/7/20 and included that the Administrator spoke harshly to the resident when the resident was not staying in his room for quarantine. The physician and responsible party were notified. The form documented additional steps taken by the facility included suspending Interim Administrator OO and providing immediate education on Freedom of Abuse to staff. The facility's accompanying investigation of the incident included an interview with R#2, staff written statements, Interim Administrator OO's personnel record information, in-service education information, social service progress notes, a summary of the investigation, and Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting notes. A review of the witness statements included in the facility's investigation revealed that Certified Occupational Therapy Assistant (COTA) KK documented on 9/8/20 that on 9/7/20 she overheard R#2 curse at Registered Nurse (RN) VV after she reminded him that he was on isolation due to going out for [MEDICAL TREATMENT] treatments. A few minutes later, she overheard Interim Administrator OO and R#2 yelling at each other. Her statement included that Interim Administrator OO made statements that included You will not talk to my staff like that, get in your room. R#2 is documented as responding with I want to talk to your boss or corporate and the Interim Administrator responding with I am the boss and corporate and you will do what I say. During an interview on 10/8/20 at 2:15 p.m., COTA KK confirmed that she overheard the interaction between R#2 and Interim Administrator OO and stated that they were yelling at each other and that she felt that it was more inappropriate than abusive. COTA KK stated that Interim Administrator OO was yelling at R#2 and he was yelling at her and getting mad at her, that was the way R#2 was. COTA KK also stated that that was the way Interim Administrator OO was, that she was aggressive in the way she talked to people; she talked down to people and she (COTA KK) had not liked the way Interim Administrator OO had talked to her before either. COTA KK stated that if she felt that Interim Administrator OO was being abusive, she would have called RVP MM. Certified Nursing Assistant (CNA) CC documented on 9/8/20 that on 9/7/20 she heard loud voices coming from the hallway and it was Interim Administrator OO and R#2 arguing. The written statement included that the interim administrator told R#2 to go to his room with R#2 refusing and the interim administrator telling him to go or he would be forced to go. Dietary staff OOOO documented on 9/8/20 that on 9/7/20, while taking out the trash, she witnessed R#2 cursing at RN VV after she asked him to go back to his room because he was quarantined due to going to for [MEDICAL TREATMENT]. The dietary staff statement included that she also heard Interim Administrator OO talking loud to R#2, and that she could hear them in the kitchen. The statement documented that the interim administrator told the resident to be quiet and that enough was enough. Interim Administrator OO also provided a written statement, dated 9/8/20. She documented that R#2 had been asking staff to go out for food and was cursing at them; she told him he could not talk like that and to go to his room and calm down. He responded by using foul language and yelling at her. Her statement included that she felt he had gone too far, and she got stern with him. A documented interview with R#2 on 9/9/20 at 10:00 p.m. included that R#2 stated he was not pleased with what Interim Administrator OO said to him. During an interview on 10/1/20 at 9:15 a.m. Regional Vice President of Operations (RVP) MM stated that the incident occurred on 9/7/20 and she became aware of it while visiting the facility on 9/8/20. She stated that several staff reported it to her (on 9/8/20). She immediately suspended Interim Administrator OO on 9/8/20. RVP MM confirmed that the allegation was should have been reported on the day that it was witnessed, 9/7/20 by calling the Director of Nursing or herself (RVP MM). Further review of the facility's investigation revealed that they substantiated the allegation of verbal abuse and Interim Administrator OO was terminated. A review of the Worksite Employee Termination/Separation Form documented that Interim Administrator OO was terminated on 9/10/20 with the reason for the separation listed as involuntary, misconduct, and that a verbal abuse allegation was substantiated. Cross refer to F600. The facility implemented the following actions to remove the Immediate Jeopardy: 1.On 10/17/2020, a review of the facility policy Freedom of Abuse was completed by the Senior Vice President of Operations and the Regional Vice President of Clinical Services with no revisions made. 2.In-service education regarding abuse reporting was started on October 17, 2020 at 11:00 a.m. and completed on 10/19/2020 by the Regional Vice President of Operations, licensed nurse, and Regional Nurse Consultant to 60 of 63 staff which included agency, PRN and part time employees, 4 of 5 RN's, 11 of 12 LPN's, 12 of 15 Certified Nursing Assistant, 8 of 8 Temporary Nursing Assistants, 5 of 5 Dietary Staff, 6 of 6 Housekeeping, 7 of 7 Therapy Staff, 1 of 1 Maintenance, 1 of 1 Business Office Manager, 1 of 1 MDS, 1 of 1 Social Services Director and 1 of 1 Activities Director have been in-serviced which is 90% of total staff. The education included the process in which the Certified Nurses Assistants reports all allegations of abuse to their immediate supervisors (charge nurses). Then the charge nurse will then report the allegation of abuse to the Administrator and or Director of Nursing immediately on all shifts including days, nights, weekends, and holidays. The Interim Administrator will report all allegations of abuse within 2 hours to the State Agency and or Law Enforcement, Physician, and the Responsible Party. A.On 10/17/2020, 17 of 17 residents who are cognitively intact (Cognitively intact residents are identified as having a BIMS of 13-15) were educated by the Regional Nurse Consultant on types of abuse, how and to whom to report abuse (resident reports to nurse and the nurse reports immediately to the Abuse Coordinator (Interim Administrator), 15 of 15 residents who are moderately impaired ( Moderately impaired residents have a BIMS of 8-12} were educated by Regional Nurse Consultant on types of abuse, how and to whom to report abuse, and 34 of 34 residents who are severely cognitively impaired (Severe impairment defined as a BlMS of 7 or less) received a positing of the letter in their room by the Regional Nurse Consultant related to whom the Abuse Coordinator is, types of abuse, and to contact the Abuse Coordinator immediately. All allegations of abuse will be reported immediately by the Abuse Coordinator and education was provided with the State Compliance Hotline telephone number by the Regional Vice President of Operations on 10/22/2020. Responsible parties were provided with a copy of the Elder Justice Act via U.S. mail on 10/23/2020 by the RegionaI Vice President of Operations. B. On 10/22/2020, a 100% of current residents (66) received a skin assessment on 10/22/2020 by the Regional Nurse Consultant and or Licensed nurse. No concerns were identified. 3. The Administrator and or Director of Nursing will immediately report all allegations of abuse, neglect, exploitation, and mistreatment per facility Freedom of Abuse Policy. Abuse Coordinator (Administrator) signage is posted in the lobby, dining room, West and East hall nurses station, West and East hall and includes the Administrators name and direct phone number, along with Georgia Department of Health and Human Services hotline number. 4. In-service education included that all allegations of abuse should be reported immediately to the Abuse Coordinator who will then report to law enforcement and Department of Community health within 2 for allegations of abuse, was held 10/17/2020 at 11:00 A.M. and was completed on 10/20/2020. In-service education includes the Freedom of Abuse Standard and the seven components of abuse: identification, screening, reporting (including timely reporting to the Department of Community Health and law enforcement), protection, prevention, investigation, education. The education mentioned above also included the Elder Justice Act facility phone number, local law enforcement name and number, and the State Agency Survey number. Education was provided by the Regional Director of Clinical Services to 59 of 62 staff which included agency, PRN and full time employees, 4 of 4 RN's, 11 of 12 LPN's, 12 of 15 Certified Nursing Assistant, 8 of 8 Temporary Nursing Assistants, 5 of 5 Dietary Staff, 6 of 6 Housekeeping, 7 of 7 Therapy Staff , 1 of 1 Maintenance, 1 of 1 Business Office Manager, 1 of 1 MOS, 1 of 1 Social Services Director and 1 of 1 Activities Director have been in-serviced which is 90% of tot al staff. 5. The responsible parties and or family members (66 of 66 resident's} have received education on the Freedom of Abuse including the seven components, types of abuse including sexual , to contact the Abuse Coordinator immediately and was provided with the State Compliance Hotline telephone number [PHONE NUMBER] or [PHONE NUMBER] via United States Postal Service, Certified Mail on 10/23/2020. 6. The same education {as noted above in #4) will be provided for all current staff not previously in-serviced, newly hired staff, PRN and Agency staff. No staff will be allowed to work until education has been completed. 7. All corrective actions were completed on October 29, 2020. 8. The immediacy of the IJ was removed on October 30, 2020. The State Survey Agency (SSA) validated the facility's written Immediate Jeopardy Removal Plan as follows: 1. Verified via review of the Freedom of Abuse standard and review of a signed statement from Senior VP LLL and RVP WW that it was reviewed. Also verified via interview on 11/6/20 at 1:40 p.m. with RVP WW. 2. Verified via review of In-Service/Training forms dated 10/16-10/20/20 with topics: Freedom of Abuse; Abuse Coordinator, the accompanying education materials, employee lists by department and signatures of staff receiving the in-service education. During an interview on 11/3/20 at 4:15 p.m. Interim Administrator SS confirmed she was the abuse coordinator and would report all allegations timely. During an interview on 11/9/20 at 4:30 p.m. Interim Administrator PPP confirmed that she was the Abuse Coordinator and would report any allegations of abuse timely. Interviews conducted on 11/5/20 at 4:57 p.m. with Registered Nurse (RN) QQQQ, 11/7/20 at 10:13 a.m. with RN VV, 11/9/20 at 12:59 p.m. with RN PPPP, 11/5/20 at 11:43 a.m. with Licensed Practical Nurse (LPN) ZZ, 11/5/20 at 12:45 p.m. with LPN RRRR, 11/5/20 at 3:57 p.m. with LPN BB, 11/6/20 at 9:57 a.m. with LPN TTTT, 11/6/20 at 10:14 a.m. with LPN AA, 11/6/20 at 2:02 p.m. with agency LPN HHHH, 11/6/20 at 2:28 p.m. with agency LPN FFFF, 11/9/20 at 10:33 a.m. with LPN unit manager UUUU, 11/5/20 at 11:18 a.m. with Certified Nursing Assistant (CNA) RRR, 11/5/20 at 1:10 p.m. with CNA UUU, 11/5/20 at 2:02 p.m. with CNA DD, 11/5/20 at 3:43 p.m. with CNA CC, 11/5/20 at 4:47 p.m. with CNA TTT, 11/6/20 at 11:26 a.m. with CNA [MEDICAL CONDITION], 11/6/20 at 1:43 p.m. with CNA CCCC, 11/6/20 at 3:38 p.m. with CNA ZZZ, 11/7/20 at 10:20 a.m. with agency CNA DDDD, 11/9/20 at 10:49 a.m. with agency CNA EEEE, 11/5/20 at 10:59 a.m. with Temporary Nurse Aide (TNA) SSS, 11/5/20 at 1:27 p.m. with TNA AAAA, 11/5/20 at 4:33 p.m. with TNA YYY, 11/6/20 at 2:52 p.m. with TNA BBBB, 11/6/20 at 3:26 p.m. with TNA DDD, 11/6/20 at 3:27 p.m. with TNA WWW,11/6/20 at 8:48 a.m. with dietary staff NNNN, 11/6/20 at 9:06 a.m. with dietary staff LLLL, 11/6/20 at 1:07 p.m. with dietary staff MMMM, 11/5/20 at 1:52 p.m. with housekeeping staff EEE, 11/6/20 at 9:28 a.m. with housekeeping staff IIII, 11/6/20 at 9:37 a.m. with housekeeping staff KKKK, 11/6/20 at 9:44 a.m. with housekeeping staff JJJJ, 11/5/20 at 12:16 p.m. with therapy staff JJ, 11/6/20 at 11:36 a.m. with therapy staff WWWW, 11/9/20 at 9:47 a.m. with therapy staff VVVV, 11/6/20 at 12:52 p.m. with the therapy manager, 11/9/20 at 1:54 p.m. with the maintenance supervisor, 11/5/20 at 12:30 p.m. with the Admissions Coordinator and on 11/9/20 at 1:26 p.m. with the Activity Coordinator revealed that staff received in-service education and were knowledgeable about the abuse policy and components, the Elder Justice Act, addressing behaviors in residents and reporting timeframes. Interviews were conducted with the Housekeeping Manager on 11/5/20 at 2:45 p.m., the Social Services Director on 11/6/20 at 1:40 p.m. and Minimum Data Set (MDS) Coordinator HHH on 11/6/20 at 2:20 p.m. confirming they received in-service education and were knowledgeable of the information. A. Verified via review of the Brief Interview for Mental Status (BIMS) forms completed, review of the resident questionnaire forms and evidence that letters were mailed to the responsible parties. Also verified via interview on 11/2/20 at 2:50 p.m. with RVP WW. During an interview on 11/6/20 at 1:40 p.m. the Social Services Director confirmed that BIMS assessments were completed on each resident, residents were educated on abuse and responsible parties were mailed information. B. Verified via review of body audit forms completed on all residents. 3. Verified via observation on 10/31/20 at 11:03 a.m. and 11/4/20 at 5:00 p.m. of signage posted throughout the facility. During an interview on 11/9/20 at 4:30 p.m. Interim Administrator PPP and Director of Nursing (DON) OOO confirmed that they would report any allegations of abuse or mistreatment immediately. Administrator PPP confirmed that her contact information was posted throughout the facility. 4. Verified via review of In-service/Training forms, the accompanying education materials, employee lists by department, and signatures of staff receiving the in-service education. Also verified via interviews previously listed at #2. 5. Verified via review of the letter and information mailed to the responsible parties, certified mail receipts and postage receipts. During an interview on 11/6/20 at 1:40 p.m. the Social Services Director confirmed that responsible parties were mailed information on abuse and that she had had some of them phone the facility to inquire about the information once received, which she explained to them. 6. Verified via interview on 11/2/20 at 11:50 a.m. with RVP WW, who confirmed that any prn or agency staff would be in-serviced prior to working again. Also verified via review of list of employees who needed education which included three newly hired employees with education documented as being completed on them also. 7. Verified via interviews and record reviews previously listed. 8.The immediacy of the IJ was removed on October 30, 2020.

Based on record review, staff interviews, and review of the facility policy titled, Lab Procedures and Other Services the facility failed to notify the physician in a timely manner of abnormal laboratory results for two residents (#3 and #7) from a total sample of 35 residents. The failure to notify the physician of abnormally high laboratory values for Resident (R) #3 resulted in a delay in care. The laboratory values increased to a critical high-level causing R#3 to be hospitalized and subsequently expired on [DATE]. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Interim Administrator SS, Regional Vice President Clinical WW, and Licensed Practical Nurse GGG were informed of the Immediate Jeopardy on [DATE] at 3:13 p.m. The noncompliance related to the first Immediate Jeopardy was identified to have existed on [DATE]. The noncompliance related to the second Immediate Jeopardy was identified to have existed on [DATE]. Both Immediate Jeopardy's continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on [DATE]. 1.) The first Immediate Jeopardy is outlined as follows: Resident (R)#3 (R#3), a [AGE] year-old male, that had lab-work drawn on [DATE]. The lab results revealed R#3 had an abnormally high Sodium level of 158 (normal 136 - 145, critical level 160 or higher). Investigation revealed that the lab notified the facility of the abnormally high Sodium level on [DATE]. However, the facility did not address this abnormally high Sodium level until seven days later, on [DATE]. Physician ordered for R#3 to be sent to the emergency roiagnom on [DATE]. R#3 was admitted to the hospital with [REDACTED]. R#1 was admitted with profound [MEDICAL CONDITION] (critically high sodium level) and dehydration. R#3 subsequently died on [DATE]. There was also a repeated, systemic failure to implement pertinent interventions to address continued weight loss for seven residents (R#3, R#4, R#5, R#6, R#7, R#8, and R#9). There was also evidence of a complete systemic failure related to dietary services to ensure that Dietary Manager PP had the appropriate certification and skill sets to carry out the functions of the food and nutrition services in the facility. The Dietary Manager (DM) failed to ensure there was an adequate supply of nutritional supplements (Ready Shakes) available for residents who had Physician orders for Ready Shake. These residents were to receive Ready Shakes because they were nutritionally compromised. By not receiving these shakes it would put these nutritionally compromised residents at risk for additional weight loss or ongoing poor nutritional status. The DM also failed to routinely assess resident's likes and dislikes to meet the nutritional needs of the residents. The Immediate Jeopardy's were related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607, Scope/Severity: J); 42 C.F.R. 483.12(c), Reporting of Alleged Violations (F609, Scope/Severity: J); 42 C.F.R. 483.21(b)(1) Develop/Implement Comprehensive Care Plan (F656, Scope/Severity: K); 42 C.F.R. 483.25(g)(1)(2), Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K); 42 C.F.R. 483.50(a)(2)(i)(ii), Lab Services with Physician Order/Notify of Results (773, Scope/Severity: K); 42 C.F.R 483.60(a)(2), Qualified Dietary Staff (801, Scope/Severity: K); 42 C.F.R 483.60(a)(3), Sufficient Dietary Support Personnel (F802, Scope/Severity: K); 42 C.F.R. 483.60(c)(1)-(7), Menus and Nutritional Adequacy (F803, Scope/Severity: K); 42 C.F.R. 483.70, Administration (F835, Scope/Severity: K); 42 C.F.R. 483.75(g)(2), QAPI/QAA Improvement Activities (F867, Scope/Severity: K). Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607, Scope/Severity: J). 42 C.F.R. 483.12(c), Reporting of Alleged Violations (F609, Scope/Severity: J); and 42 C.F.R. 483.25(g)(1)(2), Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K). A Removal Plan (A Credible Allegation of Compliance) was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance while the facility continued management level staff oversight of residents for abuse and for nutrition. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's policy and procedures governing abuse and nutrition. In-service materials were reviewed to ensure appropriate training was giving to the staff. Resident records were reviewed to ensure care plans were developed and implemented with appropriate interventions. At the time of exiting the survey on [DATE] the Immediate Jeopardy was removed. Findings include: The facility had a Lab Procedures and Other Services standard, dated [DATE]. The general guidelines section documented that the Licensed Nurse communicates laboratory results to the physician when received. During an interview on [DATE] at 9:45am interview with Licensed Practical Nurse (LPN) AA regarding the facility's process for obtaining laboratory tests and reporting the results to the physician, she stated that when they get an order for [REDACTED]. Lpn AA also stated that someone from the front office usually had already sent the results to the physician and written on the laboratory report that it was sent (via facsimile) by the time they brought it to the nurse. Lpn AA stated that the previous front office manager used to do that, and that the office manager would also follow up on laboratory tests, such as when the physician would send back the laboratory copy (via facsimile) with questions or orders. Lpn AA stated however, that front office manager was no longer at the facility (she left a few months ago) and since she was not there anymore, there really was no set way that laboratory tests results were handled. 1. Resident #3 had a [DATE] care plan for having potential nutritional problem with interventions to obtain and monitor lab/diagnostic work as ordered, and report results to physician and follow up as indicated. On [DATE] the physician visited the resident and wrote orders for routine labs to be done which included a Complete Blood Count, Basic Metabolic Profile, [MEDICATION NAME] aminotransferase (ALT) and Hemoglobin A1C (HGB A1C). Review of the laboratory results that were dated and reported to the facility on [DATE] at 1:29 p.m. revealed the following abnormal results: Sodium result of 158 (Reference range of ,[DATE] millimoles per liter(mmol/L) Chloride result of 115 (Reference range of ,[DATE] mmol/L) Glucose result of 282 (Reference range of ,[DATE] milligrams(mg)/deciliter(dl)) Urea Nitrogen result of 82 (Reference range of ,[DATE] mg/dl) Creatinine result of 2.8 (Reference range of 0XXX,[DATE].3 mg/dl) HGB A1C result of 9.0 (Reference range indicating diabetic >/=6.5) Further review of the clinical record revealed the facility did not attempt to notify the physician of the abnormal laboratory results until four days later on [DATE] when staff attempted to fax the results to the physician. However, there was no documentation the staff attempted to follow up with the physician to ensure he received the faxed laboratory results. The abnormal results were then emailed to the physician on [DATE]. The physician then gave orders to send the resident to the emergency room for evaluation and treatment of [REDACTED]. Review of the [DATE] emergency room laboratory results revealed a critical high Sodium of 161 (reference range of ,[DATE] mmol/L), Chloride of 127 (Reference range of ,[DATE] mmol/L), BUN critical high- 163 (Reference range of ,[DATE] mg/dl), Creatinine- 4.4 (Reference range of 0XXX,[DATE].2 mg/dl). The [DATE] Hospital Death Summary noted the resident was admitted with a 14-liter free water deficit. He was hypotensive with poor renal function. It documented the patient was aggressively hydrated with free water and came down basically in accordance with guidelines. It also noted admission for hyperosmolar state with uremic [MEDICAL CONDITION]. The [DATE] hospital progress notes noted the resident remained in a metabolic coma. The death certificate noted the date of death as [DATE] listing the cause of death as aspiration pneumonia, [MEDICAL CONDITIONS] and dementia. During an interview with the physician on [DATE] at he stated he did not receive the [DATE] lab results from the facility until [DATE]. He also stated labs with that degree of variation and that bad needed to call to him on [DATE], not faxed or emailed. He stated those abnormal high lab results were close to critical high indicating acute renal injury needing to be treated with intravenous (IV) fluids. After reviewing the critical high emergency room lab results with the physician, he stated That was due to the delay, I am sorry to say so yes. When the surveyor asked the physician if the facility had notified him sooner would the outcome be different for the resident, he stated I would hope so. 2. R#7 had a care plan for the use of anticoagulant medication (Eliquis) with an intervention to monitor laboratory tests as ordered by the physician. A review of the clinical record revealed that R#7 had been receiving Eliquis since [DATE] for [MEDICAL CONDITIONS]. A [DATE] 7:15 nurse's note that documented that the Nurse Practitioner was notified that R#7 had brown blood in her brief when she was changed that morning. The nurse's note documented that new orders were received to complete a hemoccult test three times (a check for blood in the stool) and for a complete blood count (CBC) test to be obtained the following morning ([DATE]). Physician's orders were written for a hemoccult test to be completed three times and for a CBC to be obtained on [DATE] due to blood in stool. The hemoccult test was documented on the [DATE] Medication Administration Record [REDACTED]. The [DATE] entry includes that the test was positive (for blood) on [DATE] at 2:20 p.m. However, there was no evidence in the clinical record that the physician was notified of the positive hemoccult test results from [DATE]. During an interview on [DATE] at 3:20 p.m., the physician stated that he would have expected to be notified of a positive hemoccult stool result. R#7 also had care plan for the [DIAGNOSES REDACTED]. A review of the clinical record revealed [DATE] physician's orders from a cardiovascular physician to obtain laboratory tests that included a hemoglobin A1c, [MEDICAL CONDITION] Stimulating Hormone (TSH), and Basic Metabolic Panel (BMP). A further review of the clinical record revealed no evidence that the laboratory tests were obtained as ordered. During an interview on [DATE] at 3:15 p.m., Regional Nurse Consultant (RNC) HH stated that the laboratory orders from [DATE] were from a telemedicine visit with a cardiovascular physician. She confirmed that the laboratory results were not included in the resident's clinical record, but they were completed (on [DATE]) as ordered. She obtained a copy from the laboratory and faxed it to the physician on [DATE]. There was no evidence that the [DATE] laboratory results were obtained and sent to the physician prior to surveyor inquiry on [DATE]. A review of the [DATE] laboratory report revealed the TSH to be elevated at 7.43 with a reference range of 0.45 to 5.33. During an interview on [DATE] at 3:20 p.m., the physician stated that he expected to be notified timely of laboratory results and that he would have acted on an elevated TSH level. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], a review of the facility policy Laboratory Policy was reviewed by the Senior Vice President of Operations and the Regional Vice President of Clinical Services with no revisions made 2. R#3 lab results were received on [DATE]. The results were communicated to the Physician on 05/ ,[DATE]. R#3 was sent to the emergency room for evaluation on 05/ 28/ 2020 where he was admitted with a [DIAGNOSES REDACTED]. 3. On [DATE], 66 current resident' s (100%) lab orders and or lab results were reviewed to ensure abnormal lab results have been communicated with the Physician in a timely manner by the licensed nurse, Interim Director of Nursing, and or Regional Vice President of Clinical Services. 4. The process for lab orders include the following: orders received from the Physician, CLS (Clinical laboratory Services) requisite completed and placed in lab binder for CLS to obtain blood sample, responsible party notified of order, lab results are obtained via fax and or by phone with critic al results from CLS, Physician notified of results by Licensed nurse, and responsible part y notified of lab results by the licensed nurse and any recommendations from the Physician. The Physician will be notified promptly (with little to no delay) of critical labs results via phone, abnormal labs will be faxed to the Physician and or called within 24 hours, and all normal lab results will be faxed to the Physician with 24 hours of receipt of lab results by the licensed nurse. The Physician will give immediate orders for critical lab results via phone and abnormal/ normal lab results will be faxed back to the facility or a telephone order will be obtained within 24 hours of the Physician receiving lab results by the Interim Director of Nursing and or licensed nurse. A. 1 resident was identified as having critical abnormal lab results. The Physician was notified of identified abnormal lab results on 10/ 19/ 2020 by the licensed nurse. 1 order a TSH ([MEDICAL CONDITION] stimulating hormone) level was received at this time. Responsible party and family members were notified on [DATE] by the licensed nurse. B. Lab results will be monitored daily to include weekends and holidays to ensure the Physician is notified in a timely manner. The RN Supervisor will monitor during holidays and weekends. The lab monitoring tool will include residents name, lab result obtained, date and time of Physician notification, orders received, and Responsible party notification. The facility faxmachine will be monitored (Receipt of lab results monitoring tool) by the Interim Administrator, Interim Director of Nursing and or licensed nurse 8 times per day. The Interim Director of Nursing will utilize the Receipt of lab results monitoring tool daily during the morning meeting to ensure receipt of lab results, timely notification of the Physician, and to ensure the facility receives timely responses from the Physician. The RN Supervisor will monitor during weekend and holidays. 5. On 10/ 19/ 2020, In-service education regarding timely notification to the Physician and responsible party for abnormal lab results was completed by the Interim Director of Nursing, licensed nurse, and or Regional Vice President of Clinical Services. 4 of 4 RN's and 11 of 12 LPN's were educated. Education was provided to agency and PRN staff as well as full time members. 6. All corrective actions were completed on [DATE]. 7. The immediacy of the IJ was removed on [DATE]. The State Survey Agency (SSA) validated the facility's written Immediate Jeopardy Removal Plan as follows: 1. Per review of the Laboratory Policy it was confirmed the policy was reviewed and signed by the Senior Vice President of Operations and the Regional Vice President of Clinical Services on [DATE]. Also confirmed via interview on [DATE] at 4:40 p.m. with RVP WW 2. Verified per record review R#3's lab results were received on [DATE] and communicated to the physician on [DATE]. The resident was sent to the emergency roiagnom on [DATE] where he was admitted with a [DIAGNOSES REDACTED]. 3. Per record review, all 66 residents' labs and or results were reviewed, and new orders were written for residents who needed labs to monitor medications. Verified via interview on [DATE] at 4:40 p.m. with RVP WW. 4. The process for lab orders was reviewed and verified. During an observation on [DATE] at 1:00 p.m., copies of the lab process were posted at the facsimile machine and at each nurses' station. Also verified via interview on [DATE] at 4:40 p.m. with RVP WW who stated that the nurses and the Director of Nursing (DON) have been checking the fax machine often and getting into that routine. She also stated that the facility would be getting two additional lines run (one to each nursing station) so that faxes could be received at the nursing stations (not just the front office). A. The resident identified as having critical lab results was identified and reviewed. The results were reported to the physician timely an the responsible party. B. Per review of the Receipt of Lab Results Monitoring Tool lab results have been logged daily to ensure the physician is notified in a timely manner. The log did include monitoring of the fax machine of lab results at least eight times daily. The lab monitoring tool that included lab results obtained, date and time of physician notification, orders received and responsible party notification was not implemented until after surveyor inquiry on [DATE]. However, the facility was utilizing the receipt of results lab monitoring tool and all labs reviewed since [DATE] revealed the system of receiving labs and notifying the physician was being implemented timely and correctly, including critical lab results for one resident (R#12). During an interview on [DATE] at 10:13 a.m. the weekend supervisor, RN VV confirmed monitoring on the weekends. 5. Per Review of the [DATE] in-service education, it was confirmed that four of four RN's and 12 of 12 LPN's received education regarding timely notification to the physician and responsible party for abnormal lab results. Interviews conducted on [DATE] at 4:57 p.m. with Registered Nurse (RN) QQQQ, [DATE] at 10:13 a.m. with RN VV, [DATE] at 12:59 p.m. with RN PPPP, [DATE] at 11:43 a.m. with Licensed Practical Nurse (LPN) ZZ, [DATE] at 12:45 p.m. with LPN RRRR, [DATE] at 3:57 p.m. with LPN BB, [DATE] at 9:57 a.m. with LPN TTTT, [DATE] at 10:14 a.m. with LPN AA, [DATE] at 2:02 p.m. with agency LPN HHHH, [DATE] at 2:28 p.m. with agency LPN FFFF, and on [DATE] at 10:33 a.m. with LPN unit manager UUUU confirmed that licensed nursing staff were knowledgeable of the lab process and reporting results to the physician timely. 6. Verified via observations, interviews and record reviews previously listed. 7. The immediacy of the IJ was removed on [DATE].

Based on record review, interview and review of facility policies, the facility failed to notify the physician regarding significant changes in condition of diabetic residents per physician's order [REDACTED].#5 and R#27) of the fifty-four (54) sampled residents. On March 18, 2015. a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ) on March 18, 2015. The noncompliance related to the IJ was identified to have existed on March 01, 2015, the date that R#5's physician ordered that Finger Stick Blood Sugars (FSBS) greater than (>) four-hundred (400) or less than (<) sixty (60) were to be called to the physician. Review of the medical record for R#5 revealed that on March 4, 2015 at 11:00 a.m. the BS result was 440, at 4:00 p.m. the blood sugar was 499, and at 9:00 p.m. the blood sugar was 528. Interview with the physician on 3/19/15 at 9:40 a.m. revealed the physician would be expect the staff to have notified him of the blood sugar results and for sliding scale insulin to be administered per the protocol. Cross reference to F 309 Findings include: 1. Review of the medical record for R #5 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Observation and interview on 3/18/15 at 11:05 a.m. revealed that R #5 FSBS results to be 433 milligrams per deciliter (mg/dl). Interview with Licensed Practical Nurse (LPN) #63, revealed that no action would be taken related to the FSBS of 433 mg/dl. Continued interview with LPN #63 acknowledged the physician order [REDACTED].>) four-hundred (400) or less than (<) sixty (60), however LPN #63 stated, We don ' t do that. Review of March 2015 physician orders [REDACTED].> 400 or < 60. Review of the protocol developed by the facility and dated 2005, titled FSBS and Sliding Scale Insulin Protocol revealed the following: 1) Sliding scale insulin coverage (SSIC) Blood glucose (BG = FSBS) < 200 No Insulin BG 201-250 - 2 units Regular insulin Sub Q (subcutaneous) BG 251-300 - 4 units Regular insulin Sub Q BG 301-350 - 6 units Regular insulin Sub Q BG 351-400 - 8 units Regular insulin Sub Q BG 401-450 -12 units Regular insulin Sub Q BG >450 - 15 units Regular insulin Sub Q and repeat accu-check (FSBS) in 2 hours and repeat sliding scale insulin. BG <60 - Give 4 ounces of orange juice or 4 ounces of non-diet cola/ 8 ounces of skim milk/ or glucose agent. Repeat FSBS in 15-30 minutes. (If unresponsive give [MEDICATION NAME] one (1) milligram (mg) and call MD) 2) Please contact the Medical Doctor (MD) for FSBS > 450 or < 60 on two (2) consecutive occasions. Review of R #5 ' s Medication Administration Record [REDACTED]> 400 with no evidence of physician notification; in August 2014 a total of four (4) episodes of > 400; in September 2014 a total of six (6) episodes of > 400, including two (2) episodes of > than 500; in October 2014 a total of eight (8) episodes of > than 400 and one (1) of greater than 500; in November 2014 a total of six (6) episodes of > 400; in December 2014 a total of seven (7) episodes > 400 and three (3) > than 500; in January 2015 a total of nine (9) episodes > 400 and 3 > than 500; in February 2015 a total of eight (8) > than 400 and 3 > than 500, and; in March 2015, a total of seven (7) episodes > than 400 with two (2) > than 500. Further review of the medical record for R #5, revealed that although the protocol for SSIC called for the physician to be notified of an FSBS of >450, R #5 had a specific physician's order [REDACTED].> 400 (not 450). Review of the March MAR indicated [REDACTED]> 400 revealed a total of three (3) episodes on March 18, 2015. Review of the medical record revealed that on 3/1/15, at 10:30 p.m. R#5 was lethargic and had decreased responsiveness. R #5 was slumped over in the wheelchair and had a FSBS of 508. The facility transferred R#5 to the emergency room at 12:20 a.m. Review of the documentation revealed that the physician had not been notified on 3/1/15 when R #5 became lethargic, had decreased responsiveness and was slumped over in the wheelchair at 10:30 p.m. Review of the record revealed the facility failed to notify the physician of the total of forty-seven (47) episodes of blood sugars > 400 and the thirteen (14) episodes of > than 500. The facility failed to follow their protocol when they failed to notify the physician regarding R #5 FSBS, prior to the March 1, 2015 specific physician order, then after a hospital evaluation, the facility continued not follow the physician orders [REDACTED].#5. Interview on 3/19/15 at 9:40 a.m. with the attending physician for R #5, confirmed an expectation from the facility when R #5 FSBS was > 400 on two (2) consecutive readings. The physician confirmed that the facility failed to notify him. Interview on 3/19/15 at 4:40 p.m. with the DON related to R #5 FSBS confirmed knowledge that the repeated elevated FSBS should have reported to the physician immediately. The DON verified the staff failed to follow the protocol, failed to notify the physician and failed to follow the sliding scale insulin protocol for R #5, and then failed to follow the March 1, 2015 physican order. 2. Review of the medical record for R #27 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the March [DATE] for R #27 revealed the following March FSBS results: On 3/02/15 at 8:00 p.m. FSBS was 420 with no evidence that the facility administered sliding scale insulin per protocol; per the protocol, 12 units of regular insulin should have been given. In addition, the physician was not notified that R#27 did not receive the sliding scale insulin or that FSBS was elevated to 420. On 3/04/15 at 6:00 a.m. FSBS was 454 per protocol R #27 should have received 15 units of regular insulin. However there was no written documentation that R #27 received the sliding scale insulin or that the physician was notified. A recheck per protocol was to be completed in two hours, there is no evidence the recheck was completed per protocol. On 3/07/15, R #27 ' s FSBS was 452 and R #27 should have been given 15 units of regular insulin and a recheck of the FSBS in two hours per the facility insulin sliding scale protocol. The physician was not notified and the follow up FSBS was not completed. The physician was not notified that the sliding scale insulin was not given. Interview on LPN 29 on 5/20/15 at 11:30 a.m. with Licensed Practical Nurse (LPN) 29 confirmed that R 27 ' s FSBS was 420 on 3/2/15 at 8:00 p.m., FSBS was 454 on 3/4/15 at 6:00 a.m. and FSBS was 452 on 3/7/15. LPN 29 verified that the nurse's notes on 3/2/15, 3/4/15 and 3/7/15 did not include documented evidence of notifying the physician. Review of the MAR indicated [REDACTED]. LPN 29 verified that there was no written documentation that the physician was notified that R 27 ' s did not receive the sliding scale insulin per protocol. An Credible Allegation of Jeopardy Removal (CAJR) was received on March 18, 2015. The allegation included that on March 19, 2015, included the following: · Clarify insulin orders versus physician resident specific insulin orders · Review the policy and procedure related to insulin · Review the sliding scale insulin protocol · Educated the licensed staff An allegation of jeopardy removal was received on March 18, 2015. The allegation included that on March 19, 2015, included the following: · Clarify insulin orders versus physician resident specific insulin orders · Review the policy and procedure related to insulin · Review the sliding scale insulin protocol · Educated the licensed staff Duaring this extended survey, the State Survey Agency reviewed the corrective actions implenmneted by the facility as reflected in the Credible Allegation of Jeopardy Removal (CAJR) with findings as follows: -On May 20, 2015, during the extended survey the sample was expanded to include three (3) additional diabetes residents. The physician orders [REDACTED].#1 of the CAJR. -On May 20, 2015, the Insulin Therapy protocol was reviewed and verified to be in place and followed through record review and interview with the Director of Nursing by the surveyors at 9:45 a.m., in accordance with Step #2 of the CAJR. -On May 20, 2015 review of the sliding scale insulin protocol was reviewed and verified to be in place in the medical records of diabetic residents and followed through record review and interview with the Director of Nursing at 9:45 a.m., in accordance with Step #3 of the CAJR. -On May 20, 2015 an inservice record was reviewed dated March 19, 2015 which revealed a total of eight (8) licensed nurses were educated on the sliding scale insulin orders out of the eighteen (18) licensed staff, in accordance with Step #4 of the CAJR. During the extended survey of May 19, 2015 through May 21, 2015, the insulin dependent sample was expanded without further deficient practices related to FSBS. Based on the corrective plans which had been developed and implemented by the facility on March 19, 2015, the immediacy of the deficient practice was determined to have been removed on May 21, 2015, and the facility remained out of compliance at a lower scope and severity of E while the facility continued management level staff oversight of diabetic resident care to ensure the protocols are in place. This oversight process includes facility staff conformance to the protocol, policy and procedures, monitoring of diabetic residents insulin coverage and reporting to the QAA Committee. Resident records were reviewed to ensure that resident care and treatment, including physician orders [REDACTED]. Interviews were conducted to verify complaince with the above.

Based on observation, interview, and record review the facility failed to implement measures to protect four (4) residents (R#5, R #62, R #15 and R #54 ) of the fifty-four (54) sampled residents from abuse. On May 20, 2015 at 2:00 p.m. a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, DON, Regional Administrator and owner were informed of the IJ on May 20, 2015 at 2:30 p.m. The noncompliance related to the IJ was identified to have existed on January 22, 2015, the date that R#5 was abused by R#23. R#23 was known by the facility to have a domestic violence in relationship to a demented wife prior to admission to the facility. The facility was aware that R#23 did not tolerate demented residents, had impulse control behaviors, depression and anger issues. R #23 was being treated for [REDACTED]. R #23 admitted to being abuse to R #62 on 7/18/2014. The facility failed to implement protective measures for the other residents in the facility, then on January 22, 2015, R#23 harmed R#5. A Credible Allegation of Jeopardy Removal was received on May 21, 2015. Based on the corrective plans which had been developed and implemented by the facility via this Credible Allegation of Jeopardy Removal on May 21, 2015, the immediacy of the deficient practice was determined to have been removed on May 21, 2015. The facility remained out of compliance at a lower scope and severity of E while the facility continued management level of staff oversight of abuse procedures to ensure the safety of residents. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures governing the abuse free environment, behavior management of residents and abuse prevention by staff. In-service materials and records were reviewed related to the newly-implemented and/or routine process of protecting residents from abuse continues. Findings include: 1. Interview on 3/16/15 at 4:45 p.m. with R #23 revealed that residents that smoke will come to the door right next to his room which leads outside to the smoking area when they want to smoke. There is scheduled smoking times so they will knock on the door and yell that they want to smoke. R #23 stated one day that resident, R #5, was banging on the door and yelling for a cigarette. R #23 stated he went out and proceeded to yell at R #5 and slapped her in the face. R #23 stated some people just need it. Record review of R #23 medical record revealed a nursing note dated 1/22/15, Resident #5 was at R #23 door knocking on the door. Resident # 23 came out and was yelling at R #5, then R # 23 hit R #5 on left (L) side of face. Scratches were observed to the right (R) arm and a finger on (L) hand bleeding of R #5. Resident # 23 was cursing during statement, the nurse requested that R #23, not to talk like that because of visitors in the hall. R #23 stated, if they don't like it they could get their ass out. Review of the medical record revealed that R #23 was admitted to this facility on 7/22/11 with [DIAGNOSES REDACTED]. Interview with R #23 on 3/16/15 at 12:01 p.m. revealed that prior to his admission to the facility he lived with his wife; who had a [DIAGNOSES REDACTED]. He stated that a friend saw the bruises on his wife and reported it to the authorities. The authorities removed his wife from the home. R #23 stated that he was told that he could spend up to five (5) years in prison as a result of his abuse against his wife, so he attempted suicide. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed that R #23 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of 15, which assessed R #23 had no cognition concerns and the ability to form willful intent. Record review of behavioral health progress note dated 1/28/15 for R #23 confirmed that on 1/22/15 R #5 was knocking on the door of R #23. Continued review revealed that R #23 went out of the room and yelled at R #5 who was waiting to go outside and smoke. R #23 reported hitting R #5 on the left side of the face, and displayed no remorse for the incident. A review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was completed for R #5 with a score of ten (10) out of 15, revealing a moderately impaired cognition. Interview on 3/18/15 at about 10 a.m. with the Director of Nursing (DON) and the Minimum Data Set (MDS) Coordinator confirmed there were no interventions developed or implemented to protect other residents in the facility from being abused by R #23. 2. Interview on 3/16/15 at 12:01 p.m. with R #23 revealed that he had a roommate (R #62) a few months back. R #23 stated the roommate had dementia and would moan and yell out. R #23 stated I finally could not take it any longer and I rolled over in my wheel chair to the other bed and twisted the nose of R #62 nose until I drew blood. Interview on 3/16/15 at 4:45 p.m. R #23 revealed the name (R #62) of the prior roommate whom he had abused. Record review for R #62 revealed a nurse's note dated 7/18/14, Resident #62 was lying in bed hollering so his roommate (R #23) propelled to the bedside and squeezed the nose of R #62. Assessment of the nose of R #62 revealed a 0.1 centimeter (cm) scratch under his right eye from altercation, no signs of pain or distress noted this shift. Call light within reach will continue to monitor. Review of a MDS dated [DATE] revealed section I-4800 for R #62 with a [DIAGNOSES REDACTED]. Observation on 3/16/15 at 12:01 p.m. revealed the room in which R #23 resided, to be the last room at the end of the hall farthest away from the nurses station. Interview on 5/20/2015 at 12:45 a.m. with the Regional Administrator who confirmed that R #62 shared a room with R #23. The Regional Administrator confirmed that R #62 had a [DIAGNOSES REDACTED].#62) was placed in a room of R #23, with a known intolerance of demented residents. Review of the Abuse Summary of Investigation Report dated 8/2/14, which was fifteen (15) days after the altercation revealed the following information: Summary of Incident Nurse overheard R #62 verbalizing loudly in his room. The nurse entered the room to find R #62 yelling. Resident #62 is unable to verbalize what is wrong secondary to Dementia. The nurse interviewed the roommate, R #23, who stated he became annoyed at the noise level, rolled over in his wheel chair to R #62 low bed, leaned down in what he states was an attempt to tell R #62 to shut up. While leaning down, R #23 stated he accidentally scratched the face of R #62 with his outstretched hand . Although review of the Summary of incident revealed that R #23 accidentally scratched R #62, the interview with R #23 on 3/16/15 at 12:01 p.m. suggested that R #23 intentionally hurt R #62 because he was annoyed at the noise. An interview on 5/20/15 at 12:45 a.m. conducted during the extended survey with the Regional Administrator confirmed that R #62 had a [DIAGNOSES REDACTED].# 23. The Regional Administrator stated the inability to understand why a demented resident would be permitted to be the roommate of R#23 with the known history of intolerance and history of abusive behaviors toward people with dementia. The interview continued and included the Director of Nursing (DON) and facility Administrator who confirmed that both residents, R #62 and R #5 had a [DIAGNOSES REDACTED].# 23 lost his temper with both of residents #62 and #5. The Regional Administrator confirmed R #23 exhibited abusive behaviors towards R #62 on 7/18/14 and again with R #5 on 1/22/15 when he slapped face R #5' on 1/22/15. 3. Interview with R #54 on 3/16/15 at 11:56 a.m. revealed that R #54 has heard another resident being abused. R #54 stated hearing R #15 being yelled at by a staff member in the adjoining bathroom. R #54 stated the Certified Nursing Assistant (CNA 4) yelled at R #15 repeatedly to hurry up and finish because CNA 4 had to go home. R #54 stated this was reported to the DON. A second interview was conducted with R #54 on 3/18/15 at 12:15 p.m. to verify the statement in regard to the report of abuse of R #15. R #54 repeated the statement An aide was yelling repeatedly at the resident next door when R #15 was in the bathroom to Hurry up and finish because she CNA 4 had to go home. R #54 stated, I reported this to the DON last week. A review of the annual MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was completed for R #54 scoring fifteen (15) out of 15 BIMS score, indicating no cognitive impairment. Observation on 3/18/15 at 12:20 p.m. of the bathroom shared by R #54 and R #15 revealed the doors provided visual privacy but did not provide privacy of conversation. This was verified by a second surveyor during the investigation. Interview on 3/18/15 at 5:45 p.m. with the DON verified an incident was reported to her last week (March 2015) which involved R #15 and R #54. Interview on 3/18/15 at 6:05 p.m. the DON and the owner of the facility revealed the DON felt the allegation did not meet the criteria of abuse. Interview on 3/17/15 at 9:34 a.m. with R #15 revealed most of the time staff did not treat her with respect and dignity, the resident refused to give names of staff. A review of the facility policy titled, Abuse Reporting and Investigation an undated document, revealed a definition of verbal abuse was defined as: . any use of oral, written, or gestured language that includes disparaging and derogatory terms to residents or their families or within hearing distance, to describe residents, regardless of their age, ability to comprehend or disability . The definition of mental abuse was defined, but not limited to, as humiliation, harassment, threats of punishment, or withholding of treatment or services. A review of the facility ' s policies and procedures revealed a second document titled, Abuse, Neglect and Exploitation Reporting Requirements & Guidance for Conducting Investigations dated 1/18/08 revealed the definition of Abuse to be the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain and /or mental anguish. Based on the interviews with R #54 related to the yelling by the CNA, R #54 considered the behavior as abusive. Based on the interview with R #15, who refused to give staff names and indication of a fear of retaliation, who stated that she felt disrespected and not treated with dignity, mental anguish and humiliation is present. These adjectives are in the facility's policy as abuse, however per interview with the DON, on 3/18/15 at 6:05 p.m., she felt this was not abuse. The facility presented an acceptable Credible Allegation of Jeopardy Removal (CAJR) on May 21, 2015. Based on this CAJR, it was determined that the immediate jeopardy had been removed on May 21, 2015, at which time the facility had implemented the following interventions: 1. On May 20, 2015, an inservice was conducted titled, Combative Behavior, Working with Nursing Home and Long-term Care Residents. 2. On May 20, 2015, R #23 care plan was updated to reflect history of aggressive behavior with a goal that resident will not harm themselves or others secondary to behaviors through next review and resident embellishes and manipulates situations. 3. On May 20, 2015, an inservice was conducted on the reporting requirements of Georgia Administrable Code Section 31-8-10 on what is abuse, neglect or exploitation and how to report, and DHR, Abuse Neglect and Exploitation Reporting Requirements and Guidance for conducting and investigation. 4. On May 20, 2015, inservice nursing staff on proper way to speak to residents and allowing residents to speak-up on any concerns they many have without the fear for retaliation or reprisal. 5. The DON and Administrator will monitor resident's behavior during the normal course of business. Care Plan will be updated as necessary to reflect resident's behaviors. DON and Administrator will review the 24-hour report to see if any behaviors occurred during off hours and address these with nursing staff and resident as appropriate. Other resident with combative history will have their Care plan updated to reflect same and will be adjusted, modified and/or deleted as appropriate. 6. On May 20, 2015, the Resident Council President at the facility request called a special meeting of the resident Council to clarify that residents have the right to voice concerns, file grievances or speak up without fear of reappraisal or retribution should they have such fear. 7. The DON and Administrator will report findings to the QAPI/RM Committee to address any concerns or to develop other interventions or approaches. During this extended survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the CAJR referenced above, with findings as follows: - On May 21, 2015, review of facility inservice sign-in sheets, dated May 20, 2015, (no times), titled, Combative Behavior, Working with Nursing Home and Long-term Care Residents revealed a total of forty-five (45) staff signatures. On May 21, 2015 at 10:45 a.m. the Regional Administrator confirmed the inservice was conducted, in accordance with Step #1 of the CAJR referenced above, after the January 22, 2015 incident in which R#4 was abused by R #23. -On May 21, 2015, review of R #23 care plan was review and confirmation completed to included the identified revisions as indicated in accordance with Step #2 reflecting a history of aggressive behavior. On May 21, 2015 at 10:45 a.m. the Regional Administrator confirmed the plan of care for R#23 was updated conducted, in accordance with Step #2 of the CAJR referenced above, after the January 22, 2015 incident in which R#4 was abused by R #27. -On May 21, 2015, review of the facility inservice sign-in sheets dated May 20, 2015 (no times), titled, Reporting requirements of Georgia Administrable Code Section 31-8-10 on what is abuse, neglect or exploitation and how to report, and DHR, Abuse Neglect and Exploitation Reporting Requirements and Guidance for conducting and investigation revealed a total of fifty-five (55) staff signatures. On May 21, 2015 at 10:45 a.m. the Regional Administrator confirmed the inservice was conducted, in accordance with Step #3 of the CAJR referenced above. -On May 21, 2015, review of the facility inservice sign-in sheets dated May 20, 2015, (no times), titled, Resident's Right: to voice concerns with fear of retaliation revealed a total of forty-three (43) staff signatures. On May 21, 2015 at 10:45 a.m. the Regional Administrator confirmed the inservice was conducted, in accordance with Step #4 of the CAJR referenced above. -On May 21, 2015, interview with the DON and Administrator revealed confirmation that the 24-hour report was reviewed and the revisions of the care plans has started, in accordance with Step #5 of the CAJR referenced above. -On May 21, 2015, interview with the Regional Administrator at 10:45 a.m. confirmed a Resident Counsel called meeting was conducted on Mary 20, 2015. Observation of the dining room doors on May 20, 2015 at 3:30 p.m. revealed a called Resident Counsel Meeting in accordance with Step #6 of the CAJR referenced above. -On May 21, 2015 at 10:45 a.m. the Regional Administrator confirmed the DON and Administrator would be reporting the findings to the QAPI/RM Committee, in accordance with Step #7 of the CAJR referenced above. Based on these corrective actions which had been developed and implement by the facility on May 20, 2015 as outlined in the CAJR referenced above, it was determined that the immediacy of the deficient practice was removed on may 21, 2015; however, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility implemented corrective actions including policy changes, monitoring of compliance through the 24 hours report, and revisions of care plans, as of May 21, 2015, the inservice training had been completed to 55 staff, however it did not include staff members who had been off-duty or on leave, there fore the facility's in-service training would need to be re-evaluated at a future date. Additionally, the on-going care plan revisions, the DON and Administrator review of the 24 hour report and the reporting to QAPI/RM committee could not be fully assessed. Therefore, the PI Committee's ongoing oversight of facility staff conformance could not be fully assessed at the time of survey, exit and will need further evaluation at a future date. Based on the above, due to the need for continued evaluation of the facility's corrective action plans to ensure ongoing effectiveness, application and completion , the noncompliance continues with the he scope and severity reduced to the E level.