Every finding on record at Diversicare of Copper Basin

Based on facility document review and interview the facility failed to notify the Long-Term Care (LTC) Ombudsman of resident discharges from the facility timely for 62 residents of 62 residents discharged from 2/1/2026 through 7/29/2026.The findings include: Review of a facility document titled, Social Services Manual, dated 2024, revealed .the center must send a copy of the notice of transfer or discharge to the representative of the Office of the State Long Term Care (LTC) Ombudsman. The center must maintain evidence that the notice was sent to the Ombudsman . Review of a resident discharge report from 2/1/2026-7/29/2026 revealed 62 residents had been discharged from the facility. During an interview on 7/29/2026 at 3:45 PM, the Social Services Director/Admissions Coordinator (SSD/AC) stated she had not notified the ombudsman when a resident was discharged from the facility. The SSD/AC confirmed she had not notified the ombudsman of any discharges from the facility. During an interview on 7/29/2026 at 3:48 PM, the Administrator confirmed the ombudsman had not been notified of any discharges from the facility. During an interview on 7/29/2026 at 4:00 PM, the Travel Business Office Manager (TBOM) stated she was not aware the ombudsman had to be notified of facility discharges. The TBOM confirmed the ombudsman had not been notified of any discharges from the facility.

Based on facility policy review, medical record review, observation and interview, the facility failed to implement appropriate infection prevention and control practices related to hand hygiene during medication administration for 1 resident (Resident #20) of 1 of 2 medication administrations observed.The findings include: Review of the facility's policy titled, Medication Administration, dated 2026, revealed .Medications are administered by licensed nurses .as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .Wash hands prior to administering medication .Remove medication .taking care not to touch medication with bare hand . Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Major Depressive Disorder, and Benign Prostatic Hypertrophy (Enlarged Prostate). Review of the Physician's Orders for Resident #20 dated 7/12/2026, revealed .Tamsulosin [Flomax] .0.4 MG [milligram] .by mouth once daily for Benign Prostatic Hypertrophy .Tradjenta .5 MG .by mouth one time a day for Diabetes .Sertraline [Zoloft] .50 MG .one time a day for Depression .Metformin .500 MG .one time a day for Diabetes . During an observation of medication administration pass of Resident #20 on 7/28/2026 at 7:58 AM, Licensed Practical Nurse (LPN) H touched the Tamsulosin, the Tradjenta, the Sertraline, and the Metformin with her bare hands while she prepared the medications. Continued observation revealed LPN H administered the medication to Resident #20. During an interview on 7/28/2026 at 8:00 AM, LPN H confirmed she touched Resident #20's medications with her bare hands, placed them in a small plastic cup and administered the medications to the resident.

Based on facility policy review, medical record review, observation, and interview, the facility failed to secure medications for 3 residents (Resident #2, Resident #42, and Resident #49) of 37 residents reviewed for accident hazards. The Findings include: Review of the facility's undated policy titled, Resident Self-Administration of Medication revealed, .It is the policy of this facility .A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely .All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Diabetes, Presence of Cardiac Pacemaker, Depression, Hypertension, and Personal History of Malignant Neoplasm of Prostate. Review of a Clinical Health Status Evaluation dated 6/30/2026 revealed .Does the resident wish to self-administer medication .no . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. During an observation and interview in Resident #2's room on 7/28/2026 at 9:00 AM, revealed a bottle of antacid on the resident's over-bed table. Resident #2 stated .I Just take them [antacid] when I need to During an observation in Resident #2's room on 7/29/2026 at 8:24 AM, revealed a bottle of antacid on the resident's over-bed table. Review of the medical record revealed Resident #2 did not have a Physician's Order for the antacid. Further review revealed no documentation Resident #2 had been assessed to administer his own medications. During an observation and interview in Resident #2's room on 7/29/2026 at 2:30 PM, revealed a bottle of antacid on the resident's over-bed table. Registered Nurse (RN) A stated Resident #2 was not assessed to self-administer his medications. RN A confirmed the antacid should not be on the resident's over-bed table. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with diagnosis including Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side. Review of a Clinical Health Status Evaluation for Resident #42 dated 6/5/2026, revealed .Does the resident wish to self-administer medication .no . Review of a quarterly MDS assessment dated [DATE], revealed Resident #42 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. During an observation in Resident #42's room on 7/27/2026 at 12:01 PM, revealed an opened box of laxative tablets on the resident's bedside table. During an observation in Resident #42's room on 7/28/2026 at 9:07 AM, revealed an opened box of laxative tablets on the resident's bedside table. During an observation and interview in Resident #42's room on 7/29/2026 at 2:19 PM, with Licensed Practical Nurse (LPN) C and the Director of Nursing (DON) revealed an opened box of laxatives on the resident's bedside table. LPN C and the DON confirmed Resident #42 was not assessed to self administer medications and the laxatives should not be at bedside. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including Chronic Combined Systolic and Diastolic Congestive Heart Failure, Diabetes Mellitus, and Seasonal Allergic Rhinitis. Review of a Physician's Order for Resident #49 dated 7/21/2026, revealed an order for Fluticasone Propionate Suspension (a medication used to treat allergy symptoms) 50 micrograms (mcg) 1 spray in each nostril one time a day. Review of a Clinical Health Status Evaluation for Resident #49 dated 7/22/2026, revealed .Self-Administration medications .Does the resident wish to self-administer medication .No . Review of a 5-day MDS assessment dated [DATE], revealed Resident #49 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. During an observation and interview in Resident #49's room on 7/27/2026 at 2:24 PM, revealed a box containing Fluticasone Propionate 50 mcg Nasal Spray on Resident #49's overbed table. Resident #49 stated he did not know why the medication was left in his room. During an observation in Resident #49's room on 7/28/2026 at 1:48 PM, revealed a box containing Fluticasone Propionate 50 mcg nasal spray on Resident #49's overbed table and a box containing Fluticasone Propionate 50 mcg nasal spray on the table beside the bed. During an observation and interview in Resident #49's room on 7/29/2026 at 2:20 PM with LPN C, revealed one box containing Fluticasone Propionate 50 mcg nasal spray on the overbed table and one box containing Fluticasone Propionate 50 mcg nasal spray at the bedside. LPN C confirmed Resident #49 was not assessed to self-administer medications and the medication should not have been left in his room. During an interview on 7/29/2026 at 3:10 PM, the DON stated residents had to be assessed to keep medications at the bedside. The DON confirmed Residents #2, #42, and #49 had not been assessed to self-administer medications and the medications observed in the resident's room had not been stored appropriately.

Based on medical record review and interviews, the facility failed to maintain accurate medical records related to Physician's Order for Scope of Treatment (POST) forms and Physician's Orders for 2 residents (Resident #5 and Resident #38) of 17 residents reviewed for POST forms. The findings include: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including Vascular Dementia, Muscle Weakness, Chronic Obstructive Pulmonary Disease and Atrial Fibrillation. Review of a document titled, Tennessee Physician Orders for Scope of Treatment (POST), for Resident #5 dated [DATE], revealed .Resuscitate (CPR) . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 scored an 8 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Review of the Physician's Orders for Resident #5 dated [DATE], revealed .Do Not Resuscitate [the Physician's order noted Resident #5 as CPR] . Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Diabetes Mellitus, Hyperlipidemia, and Emphysema. Review of the electronic medical record for Resident #38 revealed a POST form dated [DATE] which indicated .Resuscitate (CPR) . Review of a 5-day MDS assessment dated [DATE], revealed Resident #38 scored a 3 on the BIMS assessment which indicated the resident had severe cognitive impairment. Review of the Physician's Orders for Resident #38 dated [DATE], revealed .Do Not Resuscitate [the POST form indicated CPR] XXX[DATE] [order date] . During an interview on [DATE] at 4:04 PM, Registered Nurse (RN) B stated she would check the physician's orders to confirm a resident's code status. During a telephone interview on [DATE] at 5:31 PM, Licensed Practical Nurse (LPN) C stated she would check the physician's order to confirm a resident's code status. During a telephone interview on [DATE] at 5:38 PM, RN G stated she would check the physician's order to confirm a resident's code status. During a medical record review and interview on [DATE] at 10:42 AM, RN B confirmed the POST form scanned into the electronic medical record for Resident #38 indicated CPR and the order indicated Do Not Resuscitate. During an interview on [DATE] at 7:16 PM, the Director of Nursing confirmed the Physician's Order for code status did not match the POST form for Resident #5's and Resident #38's medical record.

Based on facility policy review, medical record review, and interviews, the facility failed to protect 2 residents (Resident #3 and Resident #42) from physical abuse during resident-to-resident altercations of 3 residents reviewed for abuse. Review of the facility's policy Abuse, Neglect, Misappropriation, Exploitation, dated January 2019, revealed .Purpose: To prohibit and prevent abuse .Physical Abuse .hitting, slapping, punching . Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia with Psychotic Disturbance, Generalized Anxiety Disorder, and Restlessness/Agitation. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including Dementia and Generalized Muscle Weakness. Review of a quarterly MDS assessment dated [DATE], revealed Resident #14 scored a 1 on the BIMS assessment which indicated the resident had severe cognitive impairment. Review of the comprehensive care plan dated 5/11/2026, revealed Resident #14 .have behaviors which include: Verbally abusive, physically abusive, rejection of care .will calm down with staff intervention .behavior will stop with staff intervention .Let .physician know if .behaviors are interfering with .daily living . Review of a General Note dated 5/30/2026, revealed .Resident [#3] reported to staff that he was having words with his roommate [Resident #14] when the roommate grabbed his left wrist. He grabbed .my wrist. Residents were separated, skin assessment completed with no bruising, redness or deformity noted to left wrist., x-ray of left wrist ordered .Other resident [Resident #14] was moved . Review of a Radiology Report dated 6/1/2026, for Resident #3 revealed .wrist .left .results: no acute fracture or dislocation . Review of the Physician's Orders for Resident #14 dated 7/1/2026, revealed . Carbamazepine [medication to treat agitation] 100 mg [milligrams] one time a day .AM [morning] and 200 mg one time a day .HS [hour of sleep] .Lorazepam [medication to treat anxiety] 0.5 mg every 8 hours as needed . During an interview on 7/29/2026 at 3:23 PM, Resident #3 stated there had been no prior incidents with Resident #14 prior to 5/30/2026 and stated he did not want to discuss the incident and stated he Resident #14 did not hurt him. During an interview on 7/29/2026 at 4:48 PM, Certified Nursing Assistant (CNA) D stated he provided care for Residents #3 and #14 routinely, worked on 5/30/2026, and was assigned to care for Residents #3 and #14 (roommates). CNA D also stated he had not observed any agitation or behaviors from Resident #3 or #14 during the shift (7:00 AM- 7:00 PM). Licensed Practical Nurse (LPN) C informed CNA D an alleged altercation had taken place where Resident #14 grabbed Resident #3's wrist (unable to recall which wrist) and possibly twisted it. Certified Nursing Assistant (CNA) D was instructed to assess Resident #3's wrist and hand for any signs of injury such as swelling, bruising, or pain. Resident #3 did not complain of pain and did not have any signs of injury on 5/30/2026. CNA D stated he was assigned to Resident #3 on 5/31/2026 (day after the alleged incident), CNA D continued to assess the resident's wrist and hand for signs of injury, the resident did not complain of pain, and there were no signs of injury. Further interview revealed CNA D had not observed Resident #14 having any physical altercations with any other resident prior to 5/30/2026. During an interview on 7/29/2026 at 4:55 PM, LPN C stated she cared for Residents #3 and #14 routinely, worked on 5/30/2026 (7:00 AM-7:00 PM), and was assigned to care for Residents #3 and #14. LPN C also stated she did not observe an altercation between the residents during the shift (7:00 AM-7:00 PM). Further interview revealed LPN F had informed LPN C of an alleged altercation where Resident #14 grabbed Resident #3's left wrist and twisted it. Resident #14 was immediately placed on 1:1 observation and relocated to a private room. Resident #3's wrist, arm, and hand was assessed for injury and there was no injury. Resident #3 denied any pain and informed LPN C he was fine. Continued interview revealed LPN C worked on 5/31/2026 and continued to assess Resident #3's left wrist for signs of injury. Resident #3 did not complain of pain and there were no signs of injury. LPN C had not observed Resident #14 having any physical altercations with any other resident prior to 5/30/2026. During an interview on 7/29/2026 at 5:00 PM, CNA E stated she worked on 5/30/2026 (7:00 AM-7:00 PM), was assigned to work on the hallway where Resident #3 and #14 resided, was not assigned to care for the residents directly, but had assisted with Resident #14's care. CNA E stated she did not observe any agitation or behaviors from Resident #3 or #14 throughout the shift and did not witness Resident #14 grab Resident #3's arm. Further interview revealed CNA E overheard Resident #3 tell LPN C Resident #14 .pulled his hand . LPN C asked Resident #3 if he was hurt and the resident stated .no he [Resident #14] is just an [explicative] . CNA E was instructed to .keep an eye . on Resident #3's wrist (unable to recall which wrist) for signs of injury such as swelling, pain, or bruising, there were no signs of injury, and the resident did not complain of pain. CNA E stated she worked on 5/31/2026 and worked the same hallway as she did on 5/30/2026. CNA E continued to observe Resident #3 for signs of injury, there were none, and the resident did not complain of any pain. Further interview revealed CNA E had not observed Resident #14 having any physical altercations with any other resident prior to 5/30/2026. During an interview on 7/29/2026 at 5:00 PM, LPN F stated she worked on 5/30/2026 (7:00 AM-7:00 PM), was assigned to work on the hallway where Resident #3 and #14 resided but was not assigned to care for the residents directly. LPN F also stated Resident #3 exited the therapy gym after receiving therapy services and reported Resident #14 had twisted his left wrist (did not give an exact time). LPN F reported the allegation to Resident #3's nurse (LPN C), the resident was assessed for injury, there were no signs of injury, and the resident denied pain. Resident #14 was placed on 1:1 supervision, moved to a private room, and the Director of Nursing (DON) and Administrator were notified immediately of the allegation. Further interview revealed LPN F had not observed Resident #14 having any physical altercations with any other resident prior to 5/30/2026. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with diagnosis including Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side. Review of a quarterly MDS assessment dated [DATE], revealed Resident #42 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of a General Note dated 7/2/2026 .Resident [Resident #42] reported roommate [Resident #14] aggressive with him both verbally and physically. [Resident #42] reported and staff overheard that his roommate [Resident #14] came over to his side of curtain and told him he needed to get out of here. [Resident #42] told roommate [Resident #14] that he needed to get out of his part of the room and that's when his roommate [Resident #14] slapped me -on the arm and then across my face. He [Resident #42] indicated that it was to his right arm and right side of face. At the time of exam, no injuries noted. [Resident #42] was asked if he would like to go to the hospital for a full evaluation, and he declined stating he [Resident #14] didn't hit me that hard, I'm ok . During an interview on 7/29/2026 at 10:40 AM, CNA I stated she was picking up dinner trays and overheard Resident #14 and Resident #42 arguing in their room. Resident #42 stated to CNA I that Resident #14 had slapped him on the arm and face. CNA I removed Resident #14 from the room and reported the altercation to the charge nurse which was the DON that evening. During an interview on 7/29/2026 at 11:03 AM, the DON stated he did not witness the altercation between Residents #42 and #14 but was informed by CNA I what had occurred. The DON stated Resident #14 was removed immediately from the room. Resident #42 was assessed for injuries, and none were observed. Resident #14 was sent to the emergency room, returned within a few hours, and was placed in a private room. The DON also stated Resident #42 stated he was not hurt. During an interview on 7/29/2026 at 6:02 PM, the Social Service Director/Admissions Coordinator (SSD/AC) stated Resident #3 reported Resident #14 had grabbed or twisted his arm on 5/30/2026. Resident #14 was placed on 1:1 supervision, moved to a private room, and evaluated by psychiatric services for an increase in behaviors. Further interview revealed Resident #14 remained in the private room until his moods and behaviors stabilized. Resident #14's mood and behaviors were stabilized after medication changes and was moved in with Resident #42 (unsure of exact date) approximately 1 month after the 5/30/2026 allegation. Continued interview revealed on 7/2/2026 Resident #42 reported Resident #14 slapped him. Resident #14 was placed on 1:1 supervision, transported to the emergency room for evaluation, returned to the facility within a few hours, placed in a private room, and remained in a private room currently. The SSD/AC stated Resident #14 had not had any further incidents since the incident on 7/2/2026 with Resident #42. During an interview on 7/29/2026 at 7:22 PM, the DON stated LPN F reported an allegation of abuse on 5/30/2026. Resident #3 informed LPN F Resident #14 grabbed and twisted his left arm and the alleged altercation was not witnessed. Resident #14 was placed on 1:1 supervision, moved to a private room, and evaluated by psychiatric services for an increase in behaviors. The DON assessed Resident #3's left wrist, arm, hand, and fingers for injury and there were no visible injuries. Resident #3 was offered to be evaluated at the emergency room and refused. Further interview revealed Resident #14 remained in the private room until his moods and behaviors stabilized. Resident #14's mood and behaviors were stabilized after medication changes and the resident moved in with Resident #42 (unsure of exact date) approximately 1 month after the 5/30/2026 incident. There were no reported altercations which involved Resident #14 prior to the 5/30/2026 incident with Resident #3. Continued interview revealed on 7/2/2026, Resident #42 reported Resident #14 slapped him. Resident #14 was placed on 1:1 supervision, transported to the emergency room for evaluation, returned to the facility within a few hours, placed in a private room, and remained in a private room currently. The DON stated Resident #3 had not had any further incidents since the incident on 7/2/2026 with Resident #42. During a telephone interview on 7/29/2026 at 6:54 PM, the Behavioral Health Physician Assistant (BHPA) stated she was familiar with Resident #14 and aware of the altercation on 5/30/2026 which involved Resident #3. The BHPA assessed Resident #14 after the incident had occurred and ordered the resident a mood stabilizer and had increased the dose of medication until the resident's moods and behaviors stabilized. Further interview revealed Resident #14 was placed with another roommate (Resident #42) and Resident #14 slapped Resident #42. Resident #14 was placed in a private room and remains in a private room currently. Continued interview revealed there had been no further incidents involving Resident #14 and stated the facility could not have foreseen the 2nd incident due to the resident being stabilized and no further incidents of agitation or aggression.

Based on Centers for Medicare and (&) Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 review, medical record review, and interview, the facility failed to accurately code a Minimum Data Set (MDS) assessment for Hospice services for 1 resident (Resident #4) of 12 residents reviewed for MDS assessments. The findings include: Review of Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1, dated 10/2025, revealed .primary purpose as an assessment instrument is to identify resident care problems that are addressed in an individualized care plan .the assessment [MDS] accurately reflects the resident's status .registered nurse conducts or coordinates each assessment .Hospice Care .Code residents identified as being in a hospice program . Review of the medical record revealed, Resident #4 was admitted to the facility on [DATE] with diagnoses including Senile Degeneration of Brain, Anorexia, Anxiety, and Depression. Review of a Nursing progress note for Resident #4 dated 10/28/2025, revealed .Resident arrived at the [Long Term Care Facility] .admitted to [Hospice] on 10/27/2025 [prior to admission to the facility] . Review of a comprehensive care plan for Resident #4 dated 4/28/2026, revealed .The resident has a terminal prognosis and receives hospice services . [hospice] effective 10/27/2025 . Review of a quarterly MDS assessment for Resident #4 dated 4/28/2026, revealed Resident #4 scored a 4 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review of the MDS assessment revealed .the resident had not received hospice services. Review of a Physicians Order for Resident #4 dated 6/5/2026, revealed . [Hospice] effective 10/27/2025 . During an interview on 7/29/2026 at 4:17 PM, the Director of Nursing confirmed the MDS assessment for Resident #4 was coded inaccurately and the facility had failed to identify hospice services for Resident #4 on the MDS assessment.

Based on facility policy review, observations, and interviews, the facility failed to ensure the kitchen cooking equipment was maintained in a sanitary condition and failed to discard an expired cold food item in 1 of 1 walk-in refrigerator which had the potential to affect 29 of 29 residents. The findings include: Review of the facility's undated policy titled, Policy Statement, revealed .the food service area shall be maintained in a clean and sanitary manner .all equipment .shall be washed to remove or completely loosen soils by using manual .means necessary and sanitized . During an observation and interview of the cooking area on [DATE] at 12:15 PM, with the Dietary Manager (DM) revealed the griddle cook top had brownish-black food debris present with a grease-like residue impacted to the inner parameter of the griddle. Further observation revealed a grease-like residue with various brownish-black food particles present on the outer left panel of the griddle which extended down to the gas range. The DM stated the griddle cook top and the cooking surfaces were .wiped down . after each use and deep cleaned each night. During an observation and interview of the walk-in refrigerator area on [DATE] at 12:27 PM, with the DM, revealed one 32-ounce (oz) container of lime juice with an open date of ,d+[DATE] (year unknown) and no expiration date labeled on the product. The DM stated opened food items stored in the refrigerator should be discarded within 7 days of opening. The DM confirmed the expired lime juice was available for resident use and should be discarded. During an observation and interview of the cooking area on [DATE] at 9:55 AM, with the DM, revealed the griddle cook top had brownish-black food debris present with a grease-like residue impacted to the inner parameter of the griddle. Continued observation revealed a grease-like residue present with various brownish-black food particles to the outer left panel of the griddle which extended down to the gas range. The DM confirmed the griddle cook top and the left panel of the griddle was not maintained in a sanitary condition and needed to be cleaned.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure oxygen tubing and humidification bottles were dated for 1 resident (Resident #8) of 4 residents reviewed for oxygen. The findings include: Review of the facility's policy titled, Oxygen Safety, revised 3/1/2022, revealed .The purpose of this procedure are to provide general information concerning oxygen safety and to promote safety precautions during oxygen administration .Steps in the Procedure .The tubing connected to the oxygen cylinder must be checked to assure that it is free of kinks. Tubing should be changed per manufactures guidance. Document initals and date of the tubing change on the tubing .The humidifying bottle should be used with all delivery systems unless contraindicated .Water bottle should be changed every 7 days. Document initials and date of the change on the water bottle . Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Chronic Congestive Heart Failure, Chronic Respiratory Failure, Obstructive Sleep Apnea, and Hypertensive Heart and Chronic Kidney Disease. Review of a Physician's Order for Resident #8 dated 7/31/2024, revealed .Oxygen: Oxygen at 3 LPM [liters per minute] via NC [nasal cannula] .every shift . Review of the comprehensive care plan for Resident #8 dated 9/9/2024, revealed .resident has .Respiratory Failure .OXYGEN SETTINGS: O2 [oxygen] via nasal cannula as ordered . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 scored a 7 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was severely cognitively impaired. Further review revealed Resident #8 received oxygen therapy. During multiple observations on 3/24/2025 at 11:51 AM, 3/24/2025 at 12:31 PM, and 3/25/2025 at 8:46 AM, Resident #8 received humidified oxygen at 3 liters by nasal cannula. There was no date or staff initials on the oxygen tubing or humidification bottle. During an observation and interview in Resident #8's room on 3/25/2025 at 9:09 AM, with Licensed Practical Nurse (LPN) B, revealed the resident was on humidified oxygen at 3 liters by nasal cannula. LPN B confirmed the humidification bottle and oxygen tubing were not dated. LPN B stated the Central Supply Coordinator was responsible to change the tubing and humidification bottles and dates were to be on the bottle with the date they were changed. LPN B confirmed she was not aware how long the tubing or bottle had been in use because it was not dated. During an interview on 3/25/2025 at 3:25 PM, the Central Supply Coordinator stated she was responsible to change the oxygen tubing and humidification bottles for residents receiving oxygen weekly. The Central Supply Coordinator confirmed the tubing and humidification bottles were to be labeled with the date they were changed. The Central Supply Coordinator stated the date of the change was not documented anywhere except on the tubing and humidification bottle. During an interview on 3/25/2025 at 3:45 PM, the Registered Nurse (RN) MDS Coordinator confirmed oxygen tubing and humidification bottles were to be changed every 7 days and as needed. The RN MDS Coordinator stated the tubing and humidification bottles were to be dated when changed and the Central Supply Coordinator was responsible to change them. The RN MDS Coordinator stated he was unaware of anywhere the tubing and humidification bottle date would be documented other than on the tubing and bottles. The RN MDS Coordinator stated Resident #8 had no respiratory infections or respiratory problems recently.

Based on facility policy review, medical record review, and interviews the facility failed to provide advanced notice of care plan conference meetings for 3 residents (Resident #1, #8, and #18) of 12 residents reviewed. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, revealed .The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .The IDT includes .The Attending Physician .A registered nurse [RN] who has responsibility for the resident .A nurse aid who has responsibility for the resident .The resident and the resident's legal representative (to the extent practicable); and .Other appropriate staff or professionals as determined by the resident's needs or as requested by the resident .Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to .Participate in the planning process .Participate in establishing the expected goals and outcomes of care .Participate in determining the type, amount, frequency and duration of care .The resident will be informed of his or her right to participate in his or her treatment .The care planning process will .Facilitate resident and/or representative involvement . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Anorexia, Major Depression, Adjustment Disorder with Mixed Anxiety and Depressed Mood, and Hypertension. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident was cognitively intact. During an interview on 3/24/2025 at 11:15 AM, Resident #1 stated she had never been invited or participated in a care plan meeting. During an interview on 3/26/2025 at 9:10 AM, the RN MDS Coordinator stated the Social Services/Admissions Director was responsible for inviting residents and resident representatives to care plan meetings. During an interview on 3/26/2025 at 8:25 AM, the Social Services/Admissions Director stated she did not automatically notify or invite residents or resident representatives to quarterly care plan meetings. The Social Services/ Admissions Director stated .I understand I'm supposed to . and confirmed she had not invited Resident #1 nor the resident's representative to participate in quarterly care plan meetings. During an interview on 3/26/2025 at 8:51 AM, the Administrator confirmed his expectation was residents and resident representatives were to be invited to the quarterly care plan meetings. During a telephone interview on 3/26/2025 at 9:51 AM, the Director of Nursing (DON) stated the Social Services/ Admissions Director worked with the MDS Coordinator and scheduled the care plan conference meetings. During an interview on 3/26/2025 at 1:38 PM, the RN MDS Coordinator stated he was unaware when the last care plan meeting was held for Resident #1 and stated the last documentation of a care plan meeting for the resident was 12/4/2023 and the resident had attended. 41782 Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Chronic Congestive Heart Failure, Seizures, Chronic Pain, Delusional Disorders, Chronic Respiratory Failure, and Anxiety. Review of the quarterly MDS assessment dated [DATE], revealed Resident #8 scored a 7 on the BIMS assessment which indicated the resident was severely cognitively impaired. During a telephone interview on 3/24/2025 at 2:11 PM, Resident #8's responsible party reported she had never been invited to or participated in a care plan meeting. During an interview on 3/26/2025 at 8:57 AM, the Social Services/Admissions Director stated she was responsible to coordinate the 72-hour care plan meeting. Residents and family were invited to the care plan meeting in person or by phone. The previous receptionist was responsible to send out invites to family members and residents for quarterly care plan meetings. The Social Services/Admissions Director stated when the receptionist quit .about a year ago .I guess nobody was inviting residents and families to the meetings .I found that out today . The Social Services/Admissions Director stated she had not attended quarterly plan meetings and .I should be from what I understand this morning . It will be my job going forward to invite residents and families to the care plan meetings .I didn't know what I didn't know . The Social Services/Admissions Director stated she was made aware by the Administrator this morning that she would be responsible to start inviting residents and families to the quarterly care plan meetings. The Social Services/Admissions Director was unaware when the last care plan meeting was for Resident #8. During an interview on 3/26/2025 at 9:10 AM, the RN MDS Coordinator stated the Social Services/Admissions Director was responsible to invite residents and families to care plan meetings. The RN MDS Coordinator stated the facility had identified a concern .during the transition .within the last month . that residents and families were not being invited to the care plan meetings. Care plan meetings were attended by the RN MDS Coordinator, Social Services/Admissions Director, Dietary, Nursing representative, and therapy and activities representative if possible. The RN MDS Coordinator stated he was unaware where it was documented that residents or families were invited to attend the care plan meetings. During an interview on 3/26/2025 at 1:39 PM, the RN MDS Coordinator was unaware when the last care plan meeting was for Resident #8 and stated the last documentation of a care plan meeting for the resident was 12/4/2023 and Resident #8's responsible party attended. 49786 Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder, Other Specified Disorders of Teeth and Supporting Structure. Review of a significant change MDS assessment dated [DATE], revealed Resident #18 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of the medical record for Resident #18 revealed no documentation the resident or resident representative were provided advanced notice of care plan conference meetings or evidence care plan conferences were held. During an interview on 3/25/2025 at 11:30 AM, Resident #18 stated he had never been notified verbally or in writing of quarterly care plan conference meetings. During an interview on 3/26/25 at 9:20 AM, the facility Social Services/Admissions Director stated she did not notify or invite Resident #18 or resident representative to participate in quarterly care plan conference meetings. During an interview on 3/26/2025 at 2:00 PM, the RN MDS coordinator stated he was unable to locate documentation to indicate the facility provided advanced notice to Resident #18 or resident representative of quarterly care plan conference meetings.

Based on medical record review and interview the facility failed to ensure the medical record was complete and accurate related to Advance Directives for 1 resident (Resident #432) of 16 residents reviewed for Advance Directives. The findings include: Review of the medical record revealed Resident #432 was admitted to the facility on [DATE] with diagnoses including Multiple Sclerosis, History of Falling, and Need for Assistance with Personal Care. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #432 scored a 15 on the Brief Interview for Mental Status assessment which indicated the resident was cognitively intact. Review of the Baseline Care Plan for Resident #432 dated 3/7/2025 revealed .CODE STATUS .Do Not Resuscitate .Living will/advanced directive will be honored .Physician's order of code status .Honor resident wishes . Review of the ADMISSION AGREEMENT dated 3/7/2025, revealed .Attachment C - Advance Directive Acknowledgement I have executed an Advance Directive . Continued review revealed .Attachment D - Advance Directives . was a chart that was to be completed to show if the resident had .Living Will; Declaration or Directive to Physicians .Power of Attorney (Business and Financial Management) .Durable Power of Attorney for Healthcare .Guardian .Do Not Resuscitate .Other (specify) . and .Advance Directive(s) received and placed in Resident's medical record .Center representative told Advance Directive (s) exists, but resident has not produced copies . was blank and had not been completed. Continued review revealed there was no signature from facility staff or the resident/resident representative for the section that stated .The Resident acknowledges that it is the Resident's responsibility to provide the Center with copies of the Resident's advance directives for incorporation into the Resident's medical record . During an interview on 3/25/2025 at 2:19 PM, the Administrator stated there were no Advance Directives in Resident #432's medical record. During an interview on 3/25/2025 at 2:48 PM, Resident #432 stated she had a Durable Power of Attorney and Living Will. Resident #432 was unable to recall if the facility had requested a copy of her advance directives on admission. During an interview on 3/26/2025 at 8:37 AM, the Social Services/Admissions Director stated she was responsible to complete the Admission Agreement with the resident or resident representative on admission including the Advance Directive sections. Resident #432's daughter completed the Admission Agreement with the Social Services/Admissions Director on admission and reported she believed the resident had medical and financial Power of Attorney. The Social Services/Admissions Director asked Resident #432's daughter to bring in the form and take it to the Business Office to be placed in the medical record. The Social Services/Admissions Director stated she spoke with Resident #432 on admission but did not ask the resident specifics about her Advance Directives. The Social Services/Admissions Director was unaware if Resident #432's daughter provided a copy of the Advance Directive and stated she was unaware who was responsible to follow up on ensuring Advance Directives were brought in for the medical record. This surveyor reviewed the Admission Agreement sections related to Advance Directives with the Social Services/Admissions Director and the Social Services/Admissions Director confirmed the section to indicate what Advance Directives the resident had was blank and incomplete. During an interview on 3/26/2025 at 9:27 AM, the Administrator confirmed the Social Services/Admissions Director was responsible to complete the Admission Agreement including the Advance Directive sections. The Administrator confirmed it was his expectation the forms were filled out completely and Resident #432's Advance Directive section of the Admission Agreement was not complete.

Based on review of the Resident Assessment Instrument (RAI) Manual 3.0, medical record review, observation and interview the facility failed to accurately assess dentition for 1 resident (Residents #18) of 12 residents reviewed. The findings include: Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder, Other Specified Disorders of Teeth and Supporting Structure. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #18 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed Resident #18 had no tooth fragments and no broken natural teeth. Review of the RAI Manual dated 10/2024, revealed .The RAI process has multiple regulatory requirements .the assessment accurately reflects the resident's status .SECTION L: ORAL/DENTAL STATUS .intended to record any dental problems .No natural teeth or tooth fragment(s) .broken natural teeth . During an interview and observation on 3/25/2025 at 11:30 AM, Resident #18 stated he has had broken and missing teeth for years. Observation of Resident #18's oral cavity revealed multiple missing natural teeth, multiple broken natural teeth, and tooth fragments. Resident #18 stated he had no difficulty eating and no mouth pain. During an interview and observation in Resident #18's room, on 3/26/2025 at 2:52 PM, the MDS Coordinator stated he was responsible for the oral/dental assessment on the MDS assessment dated [DATE] for Resident #18. Observation revealed the resident had multiple missing and broken natural teeth as well as tooth fragments. The MDS Coordinator confirmed Resident #18's MDS assessment dated [DATE] was not accurate.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure resident health information remained private and confidential for 1 resident (Resident #28) of 4 residents observed during medication administration, which had the potential to allow unauthorized individuals access to the residents's private health information. The findings include: Review of the facility's undated policy titled, Protected Health Information (PHI), Management and Protection, revealed .It is the responsibility of all personnel who have access to resident and facility information to ensure that such information is managed and protected to prevent unauthorized release or disclosure . Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Diabetes, and Muscle Weakness. During an observation and interview on 3/25/2025 at 8:29 AM, on the B hall, revealed Licensed Practical Nurse (LPN) A walked away from the medication cart to enter Resident #28's room and left the computer screen unlocked which revealed Resident #28's private health information. Further observation revealed LPN A returned to the medication cart at 8:31 AM. LPN A stated she .forgot . to ensure the computer screen was locked and covered before leaving the medication cart. LPN A confirmed Resident #28's private health information was not protected and was available for the public to view. During an interview on 3/25/2025 at 2:11 PM, the Administrator stated when a staff member accessed the electronic medical record by computer, the staff member should ensure the computer screen was locked and covered to maintain the residents' privacy. The Administrator confirmed Resident #28's private health information was not protected on the B hall when LPN A failed to ensure the computer screen was locked and covered prior to leaving the medication cart.

Based on review of facility policy, medical record review, facility documentation review, review of police reports, review of personnel files, interviews, and observations, the facility failed to prevent sexual abuse for 2 residents (#13 and #11) of 28 residents reviewed for abuse. The facility's failure to prevent abuse resulted in Resident #13 and #11 sustaining sexual abuse and psychosocial harm. The facility's failure placed Resident #13 and #11 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Executive Director (ED) was notified of the Immediate Jeopardy on 3/3/2022 at 4:47 PM. The facility was cited at F-600 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was removed onsite and was effective 2/17/2022 - 3/3/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 3/4/2022 at 2:07 PM and the corrective actions were validated onsite by the surveyors on 3/4/2022. The findings include: Review of the facility policy titled, Protection of Residents: Reducing the Threat of Abuse & Neglect, revised 8/10/2021, revealed .Sexual Abuse-Non-consensual sexual contact of any type with a resident. Includes .sexual harassment .sexual coercion, or sexual assault .Each resident has the right to be free from abuse .Residents must not be subjected to abuse by anyone. This includes .staff .The facility is required to protect a resident from non-consensual sexual relations . Medical record review showed Resident #13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #13's Comprehensive Care Plan initiated 12/31/2019 (current active care plan), revealed .Resident has limited physical mobility r/t [related to] Stroke .At risk for change in mood or behavior .uses antidepressant medication r/t Depression .has [CONDITION(S)]/[CONDITION(S)] r/t stroke . Record review of Resident #13's quarterly Minimum Data Set Assessment (MDS) dated [DATE], revealed the resident scored a 10 on the Brief Interview for Mental Status (BIMS), indicating the resident had moderate cognitive impairment. Further review revealed the resident required extensive assistance of 2 staff members for bed mobility, limited assistance of 1 staff member for transfers, and assistance of 2 staff members for toileting. Review of facility documentation dated 2/17/2022, showed .Two CNAs [Certified Nursing Assistants] and nurse came to the DON [Director of Nursing] to report CNA observed male staff member in resident's room kneeling beside resident .One CNA observed staff members hand underneath resident's covers. The other CNA observed .[Maintenance Assistant's name] getting up from kneeling position and noticed his hands at his crotch area on the outside of his pants adjusting something .The male staff member was observed walking out of the resident's room as they started to enter it .Resident stated that male staff member had touched her and .when the CNAs uncovered resident to do care .resident's left breast was exposed .asked resident if she had uncovered it [left breast] and resident stated .'No, he [Maintenance Assistant] did' . Review of local Sheriff's Office documentation dated 2/17/2022 at 3:03 PM, showed .Offense Description .Rape .received a call from the [facility] .about a sexual assault that occurred at their facility . [DON] .stated that one of the residents had been sexually assaulted .[Resident #13] stated that a man [Maintenance Assistant] that was working on the cabinet in her room pulled up her shirt and touched her breast .the man also exposed his genitals to her while he was touching her breast .the touching was underneath her clothes directly on her breast .[Resident #13] .physically helpless against the sexual assault . Review of the Maintenance Assistant's (MA's) Personnel File revealed the MA was employed at the facility beginning 11/23/2020 and was placed on suspension pending investigation on 2/17/2022. The MA's last day working at the facility was 2/17/2022. A background check and references had been completed prior to employment with no issues identified. Record review of Resident #13's Psychiatric Evaluation dated 2/18/2022, showed .seen for assessment after alleged incident involving resident .patient .alert and oriented to name, place, and year .She says that she has been anxious and a little depressed .She appears dysphoric [uneasy/dissatisfied] and .anxious .Will increase [MEDICATION(S)] [used to treat depression and sleep disturbance] . Record review of Resident #13's Physician's Order dated 2/18/2022, showed [MEDICATION(S)] had been increased from 25 milligrams (mg) to 50 mg every night. During an interview on 2/28/2022 at 3:02 PM, CNA #1 stated on 2/17/2022 she and CNA #2 observed the MA squatted at the side of Resident #13's bed, between the bed and the wall. CNA #1 and CNA #2 observed the MA's hand moving under Resident #13's blanket. The CNA's entered Resident #13's room as the MA exited Resident #13's room. During an interview on 3/1/2022 at 8:23 AM, CNA #2 stated on 2/17/2022 she and CNA #1 had observed the MA in Resident #13's room. The CNA stated she observed the MA leaned down at the bedside toward the resident, with his hand moving under the resident's cover. He stood up and adjusted his crotch area as if he was aroused. The CNA stated Resident #13 was observed lying in bed with her shirt pulled up and her left breast was exposed. CNA #2 stated Resident #13 was asked if she pulled her shirt up and the resident stated he [Maintenance Assistant] pulled it up because he wanted to see. The charge nurse, Licensed Practical Nurse (LPN) #1 was notified of the incident on 2/17/2022. During a telephone interview on 3/1/2022 at 2:55 PM, the Police Captain stated he investigated an allegation of sexual abuse on 2/17/2022 for Resident #13. When interviewed by the Police Captain, Resident #13 confirmed the MA had touched her inappropriately. During a telephone interview on 3/1/2022 at 3:10 PM, the Psychiatric Nurse Practitioner (NP) stated she had assessed Resident #13 on 2/18/2022. The NP confirmed she did not ask Resident #13 about the incident that occurred on 2/17/2022. The NP stated .the resident seemed more anxious than normal .I kind of feel like she was anxious about what happened, but I didn't go into any detail . Continued interview revealed the NP increased Resident #13's depression medication after the incident on 2/17/2022. During an interview on 3/1/2022 at 3:44 PM, the Assistant Director of Nursing (ADON) stated she was working on 2/17/2022. The DON and ADON had accompanied the detective to Resident #13's room. The resident informed the detective a male staff member (MA) had entered her room, exposed himself, exposed her breast, and twisted her nipple to make it hard. During an interview with Resident #13 on 3/2/2022 at 1:24 PM, the resident stated the MA had .touched my .[looked at her left breast] .and showed me his equipment [genitals] . During a telephone interview on 3/2/2022 at 1:50 PM, the DON stated CNA #1, CNA #2, and LPN #1 reported an allegation of sexual abuse on 2/17/2022 and the facility began an investigation. The DON stated she interviewed Resident #13 and the resident stated the MA had touched her breast and showed his privates (genitals). Continued interview revealed Resident #13 indicated to the DON the MA wanted the resident to touch his privates. During a telephone interview on 3/2/2022 at 3:21 PM, the Medical Director stated Resident #13 was having more anxiety and trouble sleeping since the alleged incident of abuse on 2/17/2022. The Medical Director stated if someone was .attacked, molested, or assaulted .they would be upset but it's .like winning the lottery, it'll wear off . Medical record review showed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #11's Comprehensive Care Plan initiated 12/17/2020 (current active care plan), showed .Resident has limited physical mobility r/t [related to] Neurological deficits .ADL [Activities of Daily Living] self-care performance deficit r/t contractures, rom [Range of Motion] limitations .behavior problems of depression . Record review of Resident #11's Activity Progress Note dated 11/3/2021, showed .Res. [Resident] said that she would like to come 2 to 3 x's [times] a week to activities . Record review of Resident #11's quarterly MDS assessment dated [DATE], showed Resident #11 had clear speech, was usually understood, was usually able to understand others, and was totally dependent for all ADLs. Staff interviews for cognitive patterns showed the resident's short- and long-term memory was intact. The resident was able to recall the current season, the location of her room, and staff members' names and faces. Continued review showed the resident was aware she was in a nursing facility. Record review of Resident #11's Activity Progress Notes dated 1/7/2022-1/26/2022, showed the resident had refused to attend activities on 1/7/2022, 1/10/2022, 1/13/2022, 1/18/2022, and 1/26/2022. Further review of the 1/26/2022 Activity Progress Note showed the resident had been encouraged to start coming to more group activities. Record review of Resident #11's Psychotherapy Progress Note dated 1/13/2022, showed .Patient is seen today for current significant symptoms of depression and anxiety .encouraged .to get out of bed/out of room and engage in physical activities and positive interactions with social support systems . Record Review of Resident #11's Staff Assessment for Mental Status dated 2/17/2022, showed a BIMS score of 14, which indicated the resident was cognitively intact. Review of local Sheriff's Office documentation, dated 2/17/2022 at 7:46 PM, showed .Offense Description .Rape .received a second call from the [facility] .reporting another sexual assault .spoke with [Resident #11] .stated that [Maintenance Assistant's name] had touched her breast and vagina underneath her clothes .he [penetrated vagina with his fingers] .incident took place .2/17/2022 .but had happened twice .[Resident #11] did indicate that [Maintenance Assistant's name] penetrated her vagina with his finger .[Resident #11] .physically helpless against the sexual assaults . Record review of Resident #11's Trauma assessment dated [DATE], showed .Physical assault .Happened to me [Resident #11] .Sexual assault .Happened to me [Resident #11] .unwanted or uncomfortable sexual experience .Happened to me [Resident #11] .Severe human suffering .Happened to me [Resident #11] .Repeated, disturbing, and unwanted memories of the stressful experience .Moderately .Avoiding memories, thoughts, or feelings related to the stressful experience .Moderately .Trouble falling or staying asleep .Extremely . Record review of a Psychiatric Evaluation dated 2/18/2022, showed .she [Resident #11] becomes tearful .Patient says she has not been sleeping well .Patient again becomes tearful .She appears .anxious .Will increase [MEDICATION(S)] [medication used for depression] and [MEDICATION(S)] [medication used for sleep] . Record review of Resident #11's Physician's Order dated 2/18/2022, showed [MEDICATION(S)] had been increased from 20 mg to 30 mg daily and [MEDICATION(S)] had been increased from 6 mg to 10 mg every night. Record review of Resident #11's Physician's Order dated 2/24/2022, showed [MEDICATION(S)] had been discontinued and a new order for [MEDICATION(S)] 25 mg every night for [CONDITION(S)] (difficulty sleeping). During an observation and interview on 2/28/2022 at 11:51 AM, Resident #11 was sitting up in bed in her room. Resident #11 revealed she had been abused at the facility. The resident stated (MA's name) touched her breast and vagina. Continued interview confirmed the abuse had occurred more than once. The resident was unable to recall the exact date of the previous abuse incident which involved the MA in the facility. During an interview on 2/28/2022 at 3:18 PM, CNA #3 stated approximately a month ago Resident #11's television was not working. The CNA stated she asked the resident if she wanted the MA to come fix the television and Resident #11 yelled out No. CNA #3 reported the incident to LPN #2 and the LPN instructed the CNA to report the concern to the Social Worker (SW). During an interview on 3/1/2022 at 8:23 AM, CNA #2 stated she had witnessed the MA exiting Resident #11's room the morning of 2/17/2022, on two separate occasions. CNA #1 informed CNA #2 the MA made Resident #11 feel uncomfortable and should not have been in the resident's room on 2/17/2022. CNA #2 was unaware prior to the incident on 2/17/2022 that Resident #11 had requested the MA not enter her room. During an observation and interview on 3/1/2022 at 9:18 AM, Resident #11 was sitting up in bed in her room. Resident #11 stated she did not tell anyone of the prior abuse because she feared the MA. During a telephone interview on 3/1/2022 at 2:55 PM, the Police Captain stated he investigated an allegation of sexual abuse on 2/17/2022 for Resident #13. Later in the day on 2/17/2022, the department was notified of a second sexual abuse allegation involving Resident #11. Resident #11 confirmed she had been sexually assaulted by the MA. During a telephone interview on 3/1/2022 at 3:07 PM, the MA stated .I have retained a lawyer and he has told me not to talk to anyone without him . During a telephone interview on 3/1/2022 at 3:10 PM, the Psychiatric NP stated she had assessed Resident #11 on 2/18/2022. The NP stated the resident was anxious and tearful, but Resident #11 did not tell the NP what happened. The NP stated she had been assessing Resident #11 every other week and the last few times she noticed the resident had not been getting up for activities in the last month like she had always done previously. The NP increased the resident's antidepressant and sleep medication on 2/18/2022 after the incident on 2/17/2022. The following week (2/24/2022) Resident #11 informed the NP that she was still not sleeping, and the NP discontinued [MEDICATION(S)] and ordered [MEDICATION(S)]. During an interview on 3/1/2022 at 3:30 PM, the SW stated CNA #3 had reported approximately December 2021 - January 2022, Resident #11's television had not been working and the resident did not want the MA in her room to fix her television. The SW informed the ADON and DON immediately of Resident #11's request to not have the MA in her room. During an interview on 3/1/2022 at 3:44 PM, the ADON stated she was working on 2/17/2022, and during the facility's abuse investigation for Resident #13, Resident #11 was interviewed and asked if she felt safe at the facility. Resident #11 responded no in a forceful tone. During further interview by the facility, Resident #11 reported the MA had touched her breast and vagina on more than one occasion. The ADON stated Resident #11 had been having trouble sleeping and felt more anxious since the incident on 2/17/2022. Continued interview revealed Resident #11 informed the detective the MA had touched her breast on 2/17/2022 and on another occasion (the resident was unable to recall the specific date of the previous abuse incident). The resident stated MA had penetrated her vagina with his fingers prior to 2/17/2022. Further interview with the ADON showed Resident #11 .was almost relieved that someone had asked her the right questions . During an interview on 3/2/2022 at 10:07 AM, LPN #2 stated CNA #3 had reported to her approximately a month and a half ago Resident #11 did not want the MA to come in her room to fix her television. LPN #2 instructed CNA #3 to report the concern to the SW because she (LPN #2) was busy. Continued interview revealed LPN #2 denied she was aware Resident #11 felt uncomfortable with the MA being in her room. During an interview on 3/2/2022 at 11:20 AM, the Activities Director stated Resident #11 had decreased participation in activities over the past month or so and would not allow her window blinds to be open in her room. During a telephone interview on 3/2/2022 at 1:50 PM, the DON stated CNA #1, CNA #2, and LPN #1 reported an allegation of sexual abuse on 2/17/2022 and the facility began an investigation. The DON stated during the facility abuse investigation, Resident #11 reported she was afraid of the MA and stated he touched her breast, vagina, and he penetrated her vagina with his fingers prior to the incident on 2/17/2022. The DON stated Resident #11 had been more tearful, withdrawn, and had trouble sleeping. The DON stated .I guess you could say her behaviors were signs of abuse . The DON revealed staff had not informed her Resident #11 was uncomfortable with the MA being in her room prior to 2/17/2022. During a telephone interview on 3/2/2022 at 2:20 PM, the Psychotherapist stated she was aware of the abuse allegations for Resident #11 on 2/17/2022. The Psychotherapist stated Resident #11 acknowledged she had been abused on 2/17/2022 to the Psychotherapist. The Psychotherapist asked Resident #11 if someone hurt her, and she replied yes. The Psychotherapist confirmed Resident #11 had been harmed by the MA and did not feel the resident had verbalized the extent of the trauma she had suffered from the sexual abuse. During a telephone interview on 3/2/2022 at 3:33 PM, the Psychiatric NP confirmed Resident #11 was more tearful and withdrawn since the 2/17/2022 incident. Further interview confirmed the incident had caused Resident #11 psychological harm. During a telephone interview on 3/3/2022 at 8:16 AM, the DON stated she would expect a resident to be scared, cry, and more withdrawn if abuse had occurred. During a telephone interview on 3/3/2022 at 8:25 AM, the Psychiatric NP stated she would expect a resident who had been abused to be depressed, anxious, tearful, and have [CONDITION(S)] (trouble sleeping). During an interview on 3/3/2022 at 3:14 PM, the ED stated he was the Abuse Coordinator and was not made aware of concerns or the abnormal behaviors of Resident #11. Continued interview revealed if staff had reported Resident #11 had been more anxious, tearful, had decreased activities, and mood changes to him, he would have further investigated Resident #11's behaviors. Continued interview with the ED confirmed if those concerns and behaviors had been investigated, the sexual abuse that occurred to Resident #11 and Resident #13 on 2/17/2022 may not have taken place. The ED confirmed Resident #11 had suffered trauma and grief from the abuse incidents. During a telephone interview on 3/4/2022 at 10:45 AM, Resident #11's family member stated she had noticed the resident was more withdrawn and had communicated less since Christmas. The Facility corrective actions include: 1. Associate (Maintenance Assistant) was suspended pending investigation on 2/17/2022. 2. Associate's keys were taken by associate's supervisor, Maintenance Director on 2/17/2022. 3. All facility doors with code accessibility were changed by the Maintenance Director on 2/17/2022. 4. Residents #11 and #13 had an Incident Report completed and were assessed for injuries, and had skin, pain, and psychosocial assessments completed by a licensed nurse on 2/17/2022. 5. Residents #11 and #13's family and Physicians were notified of the incident by the DON and the ED on 2/17/2022. 6. Residents #11 and #13 were evaluated by Psychiatric Services on 2/18/2022. 7. Resident's #11 and #13 had behavior management care plans reviewed and updated, behavior management flowsheets reviewed and updated, and resident profile care plan reviewed and updated by a licensed nurse on 2/18/2022 and 3/4/2022. 8. Notifications were made to the following local and state agencies, the Medical Director was notified by the ED and the DON on 2/17/2022, the local Ombudsman and Adult Protective Services were notified by the ED on 2/18/2022, local police department was notified by the DON on 2/17/2022, and the State Agency was notified by the ED on 2/17/2022. 9. All residents with a BIMS of 9 or higher will be interviewed for any allegations of abuse/neglect/misappropriation by the Social Worker on 2/17/2022. All residents with a BIMS of 8 or less will have a skin assessment completed to identify any potential unreported abuse by a licensed nurse by 2/17/2022. 10. All current residents will be assessed for behavioral signs and symptoms of potential abuse, which include, [CONDITION(S)], withdrawal, decreased activity, increased anxiety, decreased social interaction and depressive behaviors by a licensed nurse and/or social service director by 3/4/2022. 11. All current residents identified with psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 12. All resident comment concern cards and resident council minutes for the past 180 days will be reviewed for any allegations of abuse/neglect/misappropriation by the ED on 3/4/2022. 13. All associates working on 3/4/2022 will be interviewed for any allegations of abuse/neglect/misappropriation including any behavioral signs and symptoms of potential abuse to include [CONDITION(S)], withdrawal, decreased activity, and increased anxiety by the Regional Vice President (RVP) and the Regional Director of Clinical Services. Any associate that has not been interviewed will not be allowed to work until the interview is complete. All interviews will be completed by 3/7/2022. 14. During the monthly Quality Assurance Performance Improvement Program (QAPI) committee meetings, the ED will be responsible for reviewing the abuse reporting log, and compliance rounds and comment/concern cards for any trends and patterns. 15. The Director of Social Services will be responsible for reviewing the behavior management flowsheets for trends and patterns (including behavioral signs and symptoms of potential abuse). 16. The DON will be responsible for reviewing the Event Management System for trends and patterns (including potential physical/sexual abuse). 17. The Staff Development Director will be responsible for reviewing education for trends and patterns (including protection of residents, reducing the threat of abuse/neglect, and behavior management education). 18. On 3/4/2022, the RVP provided education to the ED and DON to ensure the abuse policies are implemented to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in bodily injury, or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the ED of the facility and to other officials (including to the State Agency and Adult Protective Services) and to ensure all allegations of abuse and neglect are promptly and thoroughly investigated. Education included: Protection of Residents-Reducing the threat of abuse and neglect (including identify signs and symptoms of abuse) Resident Rights Behavior Health Management Event Management System 19. The ED, DON, ADON, Staff Development Coordinator (SDC) and/or licensed nurse will provide education to all facility staff to 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, to the ED of the facility and to other officials (including to the State Survey Agency and Adult Protective Services) and to ensure all allegations of abuse and neglect are promptly and thoroughly investigated. Education included: Protection of Residents: Reducing the threat of abuse and neglect (including identify signs and symptoms of abuse). 20. The DON, ADON, SDC, and/or licensed nurse will provide education to all licensed nurses and certified nursing assistants on the following: Event Management System Resident Rights Behavior Health Management Any associate who has not completed training by 3/7/2022 will not be allowed to work until training is completed. The ED, DON, SDC, and/or licensed nurse will provide education to all new associates upon hire during orientation. 21. Assigned Interdisciplinary Team (IDT) Members provided abuse reporting education to the resident council and all residents with a BIMS score of 9 or above by 2/18/2022. 22. All resident comment and concern cards will be reviewed for allegation of abuse during daily stand-up meeting. The ED will be responsible for ensuring appropriate reporting and investigation. 23. Assigned department heads will perform daily compliance rounds that include monitoring of reporting allegations of abuse and types of abuse through interviews with 5 residents and 5 staff members and resident observations. 24. All resident skin assessments will be conducted weekly and reviewed during daily grand rounds for potential abuse. The DON and/or ADON will be responsible for notifying the ED and initiating the investigation. 25. Signage will be posted by the time clock on 2/18/2022 identifying all allegations are to be reported to the ED immediately with their contact number. It will also include a second person, the DON, and their contact number to be notified when the ED cannot be reached. 26. The ED will be responsible for ensuring timely reporting to state agencies through investigations and maintaining an abuse reporting log. 27. Prior to submitting final investigation to required agencies a member of the regional team will review the investigations to ensure a thorough investigation was completed. 28. The RVP will review the abuse reporting log and investigations during facility visits. 29. QAPI meeting held 3/4/2022 regarding the plan of removal. 30. The ED, DON, and IDT completed a Root Cause Analysis on 3/4/2022. On 3/4/2022, the surveyors validated the Maintenance Assistant was suspended on 2/17/2022 confirmed by review of a suspension form dated 2/17/2022 and interviews with the Maintenance Director and ED. On 3/4/2022, the surveyors validated associate's (MA) keys were taken and facility door codes were changed by the Maintenance Director on 2/17/2022. Confirmed by review of an Intrafacility Request For Repairs or Alterations form dated 2/17/2022 and interview with the Maintenance Director. On 3/4/2022, surveyors validated Residents #11 and #13 had an Incident Report completed, were assessed for injuries, had skin, pain, and psychosocial assessment completed, and family and Physicians were notified of the incident on 2/17/2022. Residents #11 and #13 were evaluated by Psychiatric Services on 2/18/2022, had behavior management care plans reviewed and updated, behavior management flowsheets reviewed and updated, and resident profile care plan reviewed and updated on 2/18/2022 and 3/4/2022. On 3/4/2022, surveyors validated notifications were reported timely to the ED, DON, Medical Director, local Ombudsman, Adult Protective Services, local police department and the State Agency. On 3/4/2022, surveyors validated all residents with a BIMS of 9 or higher were interviewed for any allegations of abuse, neglect, and misappropriation on 2/17/2022. All residents with a BIMS of 8 or less had skin assessments completed to identify any potential unreported abuse on 2/17/2022. On 3/4/2022, surveyors validated all current residents were assessed for behavioral signs and symptoms of potential abuse, which included, [CONDITION(S)], withdrawal, decreased activity, increased anxiety, decreased social interaction and depressive behaviors. The facility-initiated identification of residents with psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/4/2022, surveyors validated the facility reviewed all resident comment concern cards and resident council minutes for the past 180 days for allegations of abuse, neglect, and misappropriation. Interview with the ED confirmed he had reviewed all comment concern cards and resident council minutes for the past 180 days and there were no concerns of abuse allegations. On 3/4/2022, surveyors interviewed all associates working on 3/4/2022 to ensure understanding of allegations of abuse/neglect/misappropriation, including any behavioral signs and symptoms of potential abuse to include, [CONDITION(S)], withdrawal, decreased activity and increased anxiety. On 3/4/2022, surveyors validated through interview the ED is responsible for reviewing the abuse reporting log, and compliance rounds and comment/concern cards for any trends and patterns. Interview with the Director of Social Services showed she is responsible for reviewing the behavior management flowsheets for trends and patterns (including behavioral signs and symptoms of potential abuse). Interview with the DON showed she is responsible for reviewing the Event Management System for trends and patterns (including potential physical/sexual abuse). Interview with the Staff Development Director revealed she is responsible for reviewing education for trends and patterns, including protection of residents, reducing the threat of abuse/neglect, and behavior management education. Information will be discussed in the monthly Quality Assurance Performance Improvement Program (QAPI) committee meetings. On 3/4/2022 the surveyors validated the ED and DON were in serviced on the facility abuse policy to ensure implementation of all alleged abuse, and to ensure all allegations of abuse and neglect are promptly and thoroughly investigated. Interviews with the ED, DON, ADON, Staff Development Coordinator (SDC) showed education was provided to all facility staff working on 3/4/2022 on the facility's abuse policy and behavior health management to recognize behavioral changes as a sign of abuse. Any associate who had not completed training will not be allowed to work until training is completed. The ED, DON, SDC, and/or licensed nurse will provide education to all new associates upon hire during orientation. On 3/4/2022, surveyors validated education was provided during the resident council meeting to all residents with a BIMS score of 9 or above by 2/18/2022. On 3/4/2022, surveyors validated the ED reviewed concern and comment cards for allegations of abuse during daily stand-up meetings. The ED is responsible for ensuring appropriate reporting and investigation. On 3/4/2022, surveyors validated department heads had performed daily compliance rounds that included monitoring reports of abuse, types of abuse through interviews with 5 residents and 5 staff members, and resident observations. On 3/4/2022, surveyors validated all resident skin assessments were conducted weekly and reviewed during daily grand rounds for potential abuse. The DON and/or ADON are responsible for notifying the ED and initiating the investigation. On 3/4/2022, surveyors validated sign [TRUNCATED]

Based on review of facility policy, medical record review, facility investigation review, review of police reports, observation, and interviews, the facility failed to identify and investigate signs and symptoms of abuse for 2 residents (#11 and #13) and failed to investigate an allegation of abuse timely for 1 resident (#5) of 28 residents reviewed for abuse. The facility's failure to identify and investigate signs and symptoms of abuse resulted in Residents #11 and #13 sustaining sexual abuse and psychosocial harm. The sexual abuse placed Residents #11 and #13 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) The Executive Director (ED) was notified of the Immediate Jeopardy on 3/3/2022 at 4:47 PM. The facility was cited at F-610 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was removed onsite and was effective 2/17/2022 - 3/3/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 3/4/2022 at 2:07 PM and the corrective actions were validated onsite by the surveyors on 3/4/2022. The findings include: Review of the facility's policy titled, Protection of Residents: Reducing the Threat of Abuse & Neglect revised 8/10/2021, revealed, .Each resident has the right to be free from abuse .Residents must not be subjected to abuse by anyone. This includes .staff .The facility is required to protect a resident from non-consensual sexual relations .Examples of injuries that could indicate abuse include .Sudden changes in behavior .including signs of fear .withdrawing from activities previously enjoyed, or becoming uncommunicative .Increased agitation around certain nursing home staff .Sudden or unexplained changes in behaviors and/or activities such as fear of a person .reports of abuse are promptly and thoroughly investigated .administrator/designee will investigate .All associates are mandated to immediately report suspected resident abuse .to their immediate supervisor .All alleged or suspected violations involving mistreatment, abuse .will be immediately reported to the administrator and/or director of nursing . Medical record review showed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #11's Comprehensive Care Plan dated 12/17/2020, showed .Resident has limited physical mobility r/t [related to] Neurological deficits .Activities of Daily Living (ADL) self-care performance deficit r/t contractures, rom [Range of Motion] limitations .behavior problems of depression . Record review of Resident #11's Activity Progress Note dated 11/3/2021, showed .Res. [Resident] said that she would like to come 2 to 3 x's [times] a week to activities . Record review of Resident #11's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #11 had clear speech, was usually understood, was usually able to understand others, and was totally dependent for all ADLs. Staff interviews for cognitive patterns showed the resident's short- and long-term memory was intact. The resident was able to recall the current season, location of her room, staff names and faces, and that she was in a nursing facility. Record review of Resident #11's Activity Progress Notes dated 1/7/2022 - 1/26/2022, showed the resident had refused to attend activities on 1/7/2022, 1/10/2022, 1/13/2022, 1/18/2022, and 1/26/2022. The 1/26/2022 Activity Progress Note revealed the facility had identified the resident's change of behavior with attending activities and Resident #11 was encouraged to start coming to more group activities by the facility. Record review of Resident #11's Psychotherapy Progress Note dated 1/13/2022 showed .Patient is seen today for current significant symptoms of depression .anxiety .encouraged .to get out of bed/out of room .engage in physical activities .positive interactions with social support systems . Record review of Resident #11's Staff Assessment for Mental Status dated 2/17/2022 showed a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. Record review of a facility abuse investigation dated 2/17/2022, showed Resident #11 had been asked if she felt comfortable with staff members and the resident stated .'No' .She said [Maintenance Assistant (MA)] .was staff member who made her uncomfortable .he had touched her breast and inside her vagina . Further review showed the facility did not ask Resident #11 if there had been any prior incidents of abuse. Review of local Sheriff's Office documentation dated 2/17/2022 at 7:46 PM, showed .Offense Description .Rape .spoke with [Resident #11] .stated that [MA's name] had touched her breast and vagina underneath her clothes .he [penetrated her vagina with his fingers] .incident took place .2/17/2022 .but had happened twice .[Resident #11] did indicate that [MA] penetrated her vagina with his finger .[Resident #11] .physically helpless against the sexual assaults . During an observation and interview on 2/28/2022 at 11:51 AM, Resident #11 was sitting up in bed in her room. Resident #11 revealed she had been abused at the facility. The resident stated the MA touched her breast and vagina. Continued interview confirmed the abuse had occurred more than once. The resident was unable to recall the exact date of the previous abuse incident which involved the MA in the facility. During an interview on 2/28/2022 at 3:02 PM, Certified Nursing Assistant (CNA) #1 stated approximately a month ago, CNA #1 assisted Resident #11 with her meal, in the resident's room. The CNA stated during the meal the MA entered Resident #11's room, stood at the foot of the bed, and stared at Resident #11 without speaking. CNA #1 stated .did not think anything of it [incident of MA in resident's room during meal] .thought it was strange . CNA #1 stated approximately a week later, the MA entered the room a second time, stood at the foot of the bed, and stared at the resident without speaking. The CNA stated Resident #11 stiffened her entire body and pushed back in the bed. CNA #1 asked the resident if the MA made her feel uncomfortable and the resident stated yes. CNA #1 stated she informed the MA that Resident #11 did not want him in her room. CNA #1 reported the incident to Licensed Practical Nurse (LPN) #2, that Resident #11 did not want him (MA) in her room, and he made her (Resident #11) uncomfortable. CNA #1 stated CNA #3 had informed her of a prior incident where the resident had requested the MA not to enter her room (CNA #1 was unable to recall the exact date of the prior incident). During an interview on 2/28/2022 at 3:18 PM, CNA #3 stated approximately a month ago Resident #11's television was not working. The CNA stated she asked the resident if she wanted the MA to fix the television and Resident #11 yelled out No. The CNA reported the incident to LPN #2 and the LPN instructed CNA #3 to report the incident to the Social Worker (SW) because she (LPN #2) was busy. During an observation and interview on 3/1/2022 at 9:18 AM, Resident #11 was sitting up in bed in her room. Resident #11 revealed she did not tell anyone of the prior abuse because she feared the MA. During a telephone interview on 3/1/2022 at 3:10 PM, the Psychiatric Nurse Practitioner (NP) stated she assessed Resident #11 every other week and the last few times she had noticed the resident had not been getting up for activities and had noticed a change of behaviors in the last month. During an interview on 3/1/2022 at 3:30 PM, the SW stated CNA #3 had reported approximately December 2021 - January 2022, Resident #11 did not want the MA in her room. The SW informed the Assistant Director of Nursing (ADON) and Director of Nursing (DON). During an interview on 3/1/2022 at 3:44 PM, the ADON stated the facility did not interview Resident #11 prior to 2/17/2022 regarding Resident #11's concerns with the MA. During an interview on 3/2/2022 at 10:07 AM, LPN #2 stated CNA #3 had reported to her approximately a month and a half ago Resident #11 did not want the MA to come in her room to fix her television. LPN #2 instructed CNA #3 to report the concern to the SW because she (LPN #2) was busy. LPN #2 denied she was aware Resident #11 felt uncomfortable with the MA being in her room. During an interview on 3/2/2022 at 11:20 AM, the Activities Director revealed Resident #11 had previously enjoyed activities such as exercise, bingo, and sitting outside. Further interview confirmed the Activities Director did not identify Resident #11's behaviors and reduced participation in activities as signs or symptoms of abuse. During an interview on 3/2/2022 at 3:47 PM, the SW stated she had informed the ADON and the DON (specific date unknown) Resident #11 did not want the MA in her room to fix her television. The ADON and DON told the SW .it's probably because [Resident #11] doesn't like loud people so that's probably what it was . During a telephone interview on 3/2/2022 at 8:43 PM, CNA #6 (night shift CNA) stated she noticed Resident #11 had used her call bell more frequently over the past couple of months when the MA entered the facility between 4:30 - 5:00 AM. CNA #6 stated when the call light was answered, Resident #11 denied needing assistance. After the alleged perpetrator (MA) was escorted from the facility on 2/17/2022, Resident #11 used her call light less frequently to request assistance. During a telephone interview on 3/2/2022 at 8:55 PM, CNA #7 (night shift CNA) stated Resident #11 had odd behaviors for the past couple of months. Continued interview revealed the resident had refused baths and had used her call bell more frequently. CNA #7 revealed she responded to Resident #11's call light and asked the resident what the resident needed, and Resident #11 would state she did not need assistance. CNA #7 stated .in hindsight, I think the call bell pushing was because of [MA] .I did tell the nurse when [Resident #11] was refusing baths .looking back the resident's behaviors were signs of abuse . During an interview on 3/3/2022 at 3:14 PM, the ED stated he was the Abuse Coordinator and was not made aware of concerns or the abnormal behaviors of Resident #11. He stated if staff had reported Resident #11 had been more anxious, tearful, had decreased activities, and mood changes to him, he would have further investigated Resident #11's behaviors. The ED confirmed Resident #11 had suffered trauma and grief from the abuse incidents. Medical record review showed Resident #13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #13's Comprehensive Care Plan dated 12/31/2019, revealed .Resident has limited physical mobility r/t Stroke .At risk for change in mood or behavior .uses antidepressant medication r/t Depression .has [CONDITION(S)]/[CONDITION(S)] r/t stroke . Record review of Resident #13's quarterly MDS assessment dated [DATE], revealed the resident scored a 10 on the BIMS, indicating she had moderate cognitive impairment. Further review revealed the resident required extensive assistance of 2 staff members for bed mobility, limited assistance of 1 staff member for transfers, and assistance of 2 staff members for toileting. Record review of a facility Incident Report dated 2/17/2022, showed .Two CNAs and nurse came to the DON to report CNA observed male staff member in resident's room [Resident #13] kneeling beside resident .One CNA observed staff members hand underneath resident's [Resident #13] covers. The other CNA observed .[MA] getting up from kneeling position and noticed his hands at his crotch area on the outside of his pants adjusting something .The male staff member was observed walking out of the resident's room as they started to enter it .Resident [#13] stated that male staff member had touched her and .when the CNAs uncovered resident to do care .resident's left breast was exposed .asked resident if she had uncovered it [left breast] and resident stated .'No, he [MA] did' . Review of local Sheriff's Office documentation dated 2/17/2022 at 3:03 PM, showed .Offense Description .Rape .received a call from the [facility] .about a sexual assault that occurred at their facility .[DON] .stated that one of the residents had been sexually assaulted .[Resident #13] stated that a man that was working on the cabinet in her room pulled up her shirt and touched her breast .the man also exposed his genitals to her while he was touching her breast .the touching was underneath her clothes directly on her breast .[Resident #13] .physically helpless against the sexual assault . During an interview on 2/28/2022 at 3:02 PM, CNA #1 stated on 2/17/2022 she and CNA #2 observed the MA squatted at the side of Resident #13's bed, between the bed and the wall. CNA #1 and CNA #2 observed the MA's hand moving under Resident #13's blanket. The CNA's entered Resident #13's room as the MA exited Resident #13's room. During a telephone interview on 3/2/2022 at 1:50 PM, the DON confirmed allegations of abuse were to be reported to the DON, Social Worker, or the ED (Abuse Coordinator). During an interview on 3/3/2022 at 3:14 PM, the ED stated he was the Abuse Coordinator and was not made aware of concerns or the abnormal behaviors of Resident #11. Interview revealed if staff had reported Resident #11 had been more anxious, tearful, had decreased activities, and mood changes to him, he would have further investigated Resident #11's behaviors. The ED confirmed if those concerns and behaviors had been investigated, the sexual abuse that occurred to Resident #11 and Resident #13 on 2/17/2022 may not have taken place. Medical record review showed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's quarterly MDS assessment dated [DATE], showed the resident had a BIMS score of 3, indicating she had severe cognitive impairment. Medical record review showed Resident #15 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #15's 5-day MDS assessment dated [DATE], showed the resident had a BIMS score of 15, indicating she was cognitively intact. Review of Resident #5's Fax Order Request/Notification Form dated 3/2/2022, showed .Nurse reported [2/28/2022] that [Resident #15] told her that two CNA's [CNA #5 and #6] talked 'rough' to [Resident #5] and told her to 'shut up' . Continued review revealed an investigation was not initiated on 2/28/2022 for the allegation of abuse. During a telephone interview on 3/1/2022 at 9:45 PM, RN #1 stated Resident #15 had reported an allegation of abuse to her and LPN #3 .last night [2/28/2022] . Registered Nurse (RN) #1 stated she and LPN #3 had spoken to Resident #15 together when Resident #15 had reported that 2 CNA's (CNA #5 and #6) had yelled at her roommate (Resident #5) and squeezed her roommate's arm. RN #1 stated the ADON had been notified and stated she [ADON] would call the DON and .get back to her [RN #1] . RN #1 stated the ADON had not given her further instructions. During a telephone interview on 3/1/2022 at 10:12 PM, LPN #3 stated .I was in the room of a resident [Resident #15] last night [2/28/2022] and .she [Resident #15] felt like some [CNA's] get a little rough with her roommate [Resident #5] . LPN #3 stated Resident #15 said she worried that they (CNAs #5 and #6) were .grabbing [Resident #5] too hard and she [Resident #15] could hear them tell [Resident #5] to shut up. LPN #3 stated she and RN #1 went to the room to speak to Resident #15. LPN #3 stated Resident #5 could not answer questions and could not be interviewed about the allegation. LPN #3 stated she called the ADON and reported the allegation and was told the ADON would talk to the DON. LPN #3 stated the ADON did not call her back that night 2/28/2022. Continued interview revealed LPN #3 had not started an investigation for the allegation of abuse. During an interview on 3/2/2022 at 8:40 AM, the ADON confirmed LPN #3 had notified her about the allegation of abuse on 2/28/2022 at 9:31 PM when Resident #15 had stated CNAs #5 and #6 were rough with Resident #5. The ADON stated she had notified the DON. The DON .did not tell me [ADON] to start an investigation but told me that the nurses would be educated on night shift when she [DON] returned [from vacation] . The ADON confirmed .we should have investigated it [Resident #5's allegation of abuse on 2/28/2022] . During a telephone interview on 3/2/2022 at 8:36 PM, CNA #5 stated she did not tell Resident #5 to shut up. She denied ever being rough or abusive to residents in the facility. During a telephone interview on 3/2/2022 at 8:43 PM, CNA #6 denied being abusive or rough with Resident #5. During an interview on 3/3/2022 at 9:19 AM, Resident #15 stated the 2 CNAs (CNA #5 and #6) had been talking loudly on the night of 2/28/2022 and were .fussing among themselves . The Facility corrective actions include: 1. Associate (Maintenance Assistant) was suspended pending investigation on 2/17/2022. 2. Associate's keys were taken by associate's supervisor, Maintenance Director on 2/17/2022. 3. All facility doors with code accessibility were changed by the Maintenance Director on 2/17/2022. 4. Residents #11 and #13 had an Incident Report completed and were assessed for injuries, and had skin, pain, and psychosocial assessments completed by a licensed nurse on 2/17/2022. 5. Residents #11 and #13's family and Physicians were notified of the incident by the DON and the ED on 2/17/2022. 6. Residents #11 and #13 were evaluated by Psychiatric Services on 2/18/2022. 7. Resident's #11 and #13 had behavior management care plans reviewed and updated, behavior management flowsheets reviewed and updated, and resident profile care plan reviewed and updated by a licensed nurse on 2/18/2022 and 3/4/2022. 8. Notifications were made to the following local and state agencies, the Medical Director was notified by the ED and the DON on 2/17/2022, the local Ombudsman and Adult Protective Services were notified by the ED on 2/18/2022, local police department was notified by the DON on 2/17/2022, and the State Agency was notified by the ED on 2/17/2022. 9. All residents with a BIMS of 9 or higher will be interviewed for any allegations of abuse/neglect/misappropriation by the Social Worker on 2/17/2022. All residents with a BIMS of 8 or less will have a skin assessment completed to identify any potential unreported abuse by a licensed nurse by 2/17/2022. 10. All current residents will be assessed for behavioral signs and symptoms of potential abuse, which include, [CONDITION(S)], withdrawal, decreased activity, increased anxiety, decreased social interaction and depressive behaviors by a licensed nurse and/or social service director by 3/4/2022. 11. All current residents identified with psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 12. All resident comment concern cards and resident council minutes for the past 180 days will be reviewed for any allegations of abuse/neglect/misappropriation by the ED on 3/4/2022. 13. All associates working on 3/4/2022 will be interviewed for any allegations of abuse/neglect/misappropriation including any behavioral signs and symptoms of potential abuse to include [CONDITION(S)], withdrawal, decreased activity, and increased anxiety by the Regional Vice President (RVP) and the Regional Director of Clinical Services. Any associate that has not been interviewed will not be allowed to work until the interview is complete. All interviews will be completed by 3/7/2022. 14. During the monthly Quality Assurance Performance Improvement Program (QAPI) committee meetings, the ED will be responsible for reviewing the abuse reporting log, and compliance rounds and comment/concern cards for any trends and patterns. 15. The Director of Social Services will be responsible for reviewing the behavior management flowsheets for trends and patterns (including behavioral signs and symptoms of potential abuse). 16. The DON will be responsible for reviewing the Event Management System for trends and patterns (including potential physical/sexual abuse). 17. The Staff Development Director will be responsible for reviewing education for trends and patterns (including protection of residents, reducing the threat of abuse/neglect, and behavior management education). 18. On 3/4/2022, the RVP provided education to the ED and DON to ensure the abuse policies are implemented to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in bodily injury, or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the ED of the facility and to other officials (including to the State Agency and Adult Protective Services) and to ensure all allegations of abuse and neglect are promptly and thoroughly investigated. Education included: Protection of Residents-Reducing the threat of abuse and neglect (including identify signs and symptoms of abuse) Resident Rights Behavior Health Management Event Management System 19. The ED, DON, ADON, Staff Development Coordinator (SDC) and/or licensed nurse will provide education to all facility staff to 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, to the ED of the facility and to other officials (including to the State Survey Agency and Adult Protective Services) and to ensure all allegations of abuse and neglect are promptly and thoroughly investigated. Education included: Protection of Residents: Reducing the threat of abuse and neglect (including identify signs and symptoms of abuse). 20. The DON, ADON, SDC, and/or licensed nurse will provide education to all licensed nurses and certified nursing assistants on the following: Event Management System Resident Rights Behavior Health Management Any associate who has not completed training by 3/7/2022 will not be allowed to work until training is completed. The ED, DON, SDC, and/or licensed nurse will provide education to all new associates upon hire during orientation. 21. Assigned Interdisciplinary Team (IDT) Members provided abuse reporting education to the resident council and all residents with a BIMS score of 9 or above by 2/18/2022. 22. All resident comment and concern cards will be reviewed for allegation of abuse during daily stand-up meeting. The ED will be responsible for ensuring appropriate reporting and investigation. 23. Assigned department heads will perform daily compliance rounds that include monitoring of reporting allegations of abuse and types of abuse through interviews with 5 residents and 5 staff members and resident observations. 24. All resident skin assessments will be conducted weekly and reviewed during daily grand rounds for potential abuse. The DON and/or ADON will be responsible for notifying the ED and initiating the investigation. 25. Signage will be posted by the time clock on 2/18/2022 identifying all allegations are to be reported to the ED immediately with their contact number. It will also include a second person, the DON, and their contact number to be notified when the ED cannot be reached. 26. The ED will be responsible for ensuring timely reporting to state agencies through investigations and maintaining an abuse reporting log. 27. Prior to submitting final investigation to required agencies a member of the regional team will review the investigations to ensure a thorough investigation was completed. 28. The RVP will review the abuse reporting log and investigations during facility visits. 29. QAPI meeting held 3/4/2022 regarding the plan of removal. 30. The ED, DON, and IDT completed a Root Cause Analysis on 3/4/2022. On 3/4/2022, the surveyors validated the Maintenance Assistant was suspended on 2/17/2022 confirmed by review of a suspension form dated 2/17/2022 and interviews with the Maintenance Director and ED. On 3/4/2022, the surveyors validated associate's (MA) keys were taken and facility door codes were changed by the Maintenance Director on 2/17/2022. Confirmed by review of an Intrafacility Request For Repairs or Alterations form dated 2/17/2022 and interview with the Maintenance Director. On 3/4/2022, surveyors validated Residents #11 and #13 had an Incident Report completed, were assessed for injuries, had skin, pain, and psychosocial assessment completed, and family and Physicians were notified of the incident on 2/17/2022. Residents #11 and #13 were evaluated by Psychiatric Services on 2/18/2022, had behavior management care plans reviewed and updated, behavior management flowsheets reviewed and updated, and resident profile care plan reviewed and updated on 2/18/2022 and 3/4/2022. On 3/4/2022, surveyors validated notifications were reported timely to the ED, DON, Medical Director, local Ombudsman, Adult Protective Services, local police department and the State Agency. On 3/4/2022, surveyors validated all residents with a BIMS of 9 or higher were interviewed for any allegations of abuse, neglect, and misappropriation on 2/17/2022. All residents with a BIMS of 8 or less had skin assessments completed to identify any potential unreported abuse on 2/17/2022. On 3/4/2022, surveyors validated all current residents were assessed for behavioral signs and symptoms of potential abuse, which included, [CONDITION(S)], withdrawal, decreased activity, increased anxiety, decreased social interaction and depressive behaviors. The facility-initiated identification of residents with psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/4/2022, surveyors validated the facility reviewed all resident comment concern cards and resident council minutes for the past 180 days for allegations of abuse, neglect, and misappropriation. Interview with the ED confirmed he had reviewed all comment concern cards and resident council minutes for the past 180 days and there were no concerns of abuse allegations. On 3/4/2022, surveyors interviewed all associates working on 3/4/2022 to ensure understanding of allegations of abuse/neglect/misappropriation, including any behavioral signs and symptoms of potential abuse to include, [CONDITION(S)], withdrawal, decreased activity and increased anxiety. On 3/4/2022, surveyors validated through interview the ED is responsible for reviewing the abuse reporting log, and compliance rounds and comment/concern cards for any trends and patterns. Interview with the Director of Social Services showed she is responsible for reviewing the behavior management flowsheets for trends and patterns (including behavioral signs and symptoms of potential abuse). Interview with the DON showed she is responsible for reviewing the Event Management System for trends and patterns (including potential physical/sexual abuse). Interview with the Staff Development Director revealed she is responsible for reviewing education for trends and patterns, including protection of residents, reducing the threat of abuse/neglect, and behavior management education. Information will be discussed in the monthly Quality Assurance Performance Improvement Program (QAPI) committee meetings. On 3/4/2022 the surveyors validated the ED and DON were in serviced on the facility abuse policy to ensure implementation of all alleged abuse, and to ensure all allegations of abuse and neglect are promptly and thoroughly investigated. Interviews with the ED, DON, ADON, Staff Development Coordinator (SDC) showed education was provided to all facility staff working on 3/4/2022 on the facility's abuse policy and behavior health management to recognize behavioral changes as a sign of abuse. Any associate who had not completed training will not be allowed to work until training is completed. The ED, DON, SDC, and/or licensed nurse will provide education to all new associates upon hire during orientation. On 3/4/2022, surveyors validated education was provided during the resident council meeting to all residents with a BIMS score of 9 or above by 2/18/2022. On 3/4/2022, surveyors validated the ED reviewed concern and comment cards for allegations of abuse during daily stand-up meetings. The ED is responsible for ensuring appropriate reporting and investigation. On 3/4/2022, surveyors validated department heads had performed daily compliance rounds that included monitoring reports of abuse, types of abuse through interviews with 5 residents and 5 staff members, and resident observations. On 3/4/2022, surveyors validated all resident skin assessments were conducted weekly and reviewed during daily grand rounds for potential abuse. The DON and/or ADON are responsible for notifying the ED and initiating the investigation. On 3/4/2022, surveyors validated signage had been posted by the time clock with the ED and DON's contact information for reporting abuse allegations immediately. Interview with the ED confirmed he is responsible for ensuring timely reporting to state agencies through investigations and maintaining an abuse reporting log. The facility's noncompliance at F-610 continues at a scope and severity D for monitoring of the effectiveness of corrective actions to ensure sustained compliance. The facility is required to submit a Plan of Correction.

Based on review of facility policies, medical record review, facility documentation review, interviews, and observation, the facility failed to identify and address a pattern of behavioral changes for Resident #11. Resident #11 sustained sexual abuse on more than one occasion which resulted in psychological and psychosocial harm. The facility's failure to identify and address behavior changes placed Resident #11 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Executive Director (ED) was notified of the Immediate Jeopardy on 3/3/2022 at 4:47 PM. The facility was cited at F-743 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was removed onsite and was effective 2/17/2022 - 3/3/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 3/4/2022 at 2:07 PM and the corrective actions were validated onsite by the surveyors on 3/4/2022. The findings include: Review of the facility's policy titled, Behavioral Health Management with an effective date of 5/6/2019, revealed, .Facility staff must .Monitor .resident closely for expressions or indications of distress .Share concerns with the interdisciplinary team (IDT) to determine underlying causes .Ensure appropriate follow-up . Review of the facility's policy titled, Protection of Residents: Reducing the Threat of Abuse & Neglect revised 8/10/2021, revealed, .Examples of injuries that could indicate abuse include .Sudden changes in behavior .including signs of fear .withdrawing from activities previously enjoyed, or becoming uncommunicative .Increased agitation around certain nursing home staff .Sudden or unexplained changes in behaviors and/or activities such as fear of a person .reports of abuse are promptly and thoroughly investigated .administrator/designee will investigate . Medical record review showed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #11's Comprehensive Care Plan dated 7/17/2019, showed .Resident will participate in activities of choice 2 to 3 times per week .behavior problems of depression . Record review of Resident #11's Activity Progress Note dated 11/3/2021, showed .Res. [Resident] said that she would like to come 2 to 3 x's [times] a week to activities . Record review of Resident #11's Psychotherapy Progress Note dated 11/11/2021, showed .Patient is seen today for current significant symptoms of depression and anxiety .Cognitive-behavioral therapy-used to reframe negative anxious/depressed thoughts . Record review of Resident #11's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #11 had clear speech, was usually understood, was usually able to understand others, and was totally dependent for all Activities of Daily Living (ADLs). Staff interviews for cognitive patterns showed short- and long-term memory were intact. The resident was able to recall the current season, location of her room, and staff names and faces. The resident was able to recall she was in a nursing facility. The resident did not exhibit behaviors during the 7-day look back period. Record review of Resident #11's Activity Progress Notes dated 1/7/2022 - 1/26/2022, showed the resident had refused to attend activities on 1/7/2022, 1/10/2022, 1/13/2022, 1/18/2022, and 1/26/2022. The 1/26/2022 Activity Progress Note revealed the facility had identified the resident's change of behavior to attend activities and Resident #11 was encouraged to start coming to more group activities by the facility. Record review of Resident #11's Psychotherapy Progress Note dated 1/13/2022 showed .Patient is seen today for current significant symptoms of depression .anxiety .encouraged .to get out of bed/out of room .engage in physical activities .positive interactions with social support systems . Record review of Resident #11's Staff Assessment for Mental Status dated 2/17/2022 showed a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. Record review of a facility abuse investigation dated 2/17/2022, showed Resident #11 had been asked if she felt comfortable with staff members. The resident stated .'No' .She said [Maintenance Assistant (MA) name] .was staff member who made her uncomfortable .he had touched her breast and inside her vagina . Record review of Resident #11's Psychiatric Evaluation dated 2/18/2022, showed .[Resident #11] is seen for reassessment of mood and sleep after allegations were made involving resident .she becomes tearful .says she has not been sleeping well .again becomes tearful .she appears anxious and does not expand on conversation . During an interview on 2/28/2022 at 11:51 AM, Resident #11 stated she had been abused by the MA. Further interview revealed the MA .touched my breast and vagina .happened more than once . During an interview on 2/28/2022 at 3:02 PM, Certified Nursing Assistant (CNA) #1 stated approximately a month ago, CNA #1 assisted Resident #11 with her meal, in the resident's room. The CNA stated during the meal the MA entered Resident #11's room, stood at the foot of the bed, and stared at Resident #11 without speaking. CNA #1 stated approximately a week later the MA entered the room a second time, stood at the foot of the bed, and stared at the resident without speaking. The CNA stated Resident #11 stiffened her entire body and pushed back in the bed. CNA #1 asked the resident if the MA made her feel uncomfortable and the resident stated yes. CNA #1 informed the MA that Resident #11 did not want him in her room. CNA #1 reported the incident to Licensed Practical Nurse (LPN) #2. During an interview on 2/28/2022 at 3:18 PM, CNA #3 stated approximately a month ago Resident #11's television was not working. The CNA stated she asked the resident if she wanted the MA to fix the television and Resident #11 yelled out No. The CNA reported the incident to LPN #2 and the LPN instructed CNA #3 to report the concern to the Social Worker (SW). During an observation and interview on 3/1/2022 at 9:18 AM, Resident #11 was sitting up in bed in her room. Resident #11 revealed she did not tell anyone of the prior abuse because she feared the MA. During a telephone interview on 3/1/2022 at 3:10 PM, the Psychiatric Nurse Practitioner (NP) stated she had been assessing Resident #11 every other week and the last few times she had noticed the resident had not been getting up for activities and had noticed a change of behaviors in the past month. During an interview on 3/1/2022 at 3:30 PM, the SW stated CNA #3 had reported approximately December 2021 - January 2022, Resident #11 did not want the MA in her room. The SW informed the Assistant Director of Nursing (ADON) and Director of Nursing (DON). During an interview on 3/1/2022 at 3:44 PM, the ADON stated the facility did not interview Resident #11 prior to 2/17/2022 regarding Resident #11's concerns with the MA. During an interview on 3/2/2022 at 10:07 AM, LPN #2 stated CNA #3 had reported approximately a month and a half ago Resident #11 did not want the MA to come in her room. LPN #2 instructed CNA #3 to report to the SW because she (LPN#2) was busy. During an interview on 3/2/2022 at 11:20 AM, the Activities Director stated Resident #11 had decreased participation in activities over the last month or so and had stopped allowing her blinds to be opened in her room. The resident had previously enjoyed activities such as exercise, bingo, and sitting outside. The Activities Director confirmed Resident 11 had decreased participation in activities. During a telephone interview on 3/2/2022 at 1:50 PM, the DON stated staff had not informed her of Resident #11 being uncomfortable with the MA being in her room. (The SW reported to the DON and ADON Resident #11 did not want the MA in her room). Continued interview revealed the facility failed to identify a pattern of behavior changes for Resident #11. During a telephone interview on 3/2/2022 at 2:20 PM, the Psychotherapist stated recently Resident #11 would not attend activities and stated .she was feeling down . The Psychotherapist confirmed Resident #11 had been psychologically harmed by the sexual abuse she experienced at the facility. During a telephone interview on 3/2/2022 at 3:21 PM, the Medical Director stated .I don't remember . if Resident #11 was more withdrawn and not attending activities. The Medical Director stated Resident #11 had informed him that she was .sad . had increased anxiety, and trouble sleeping. Further interview showed .anybody would have psychological harm .scared .withdrawn . (after sexual abuse). He also stated if someone was attacked, molested, or assaulted by a person they would be upset .but it's like winning the lottery, it'll wear off . During a telephone interview on 3/2/2022 at 3:33 PM, the Psychiatric NP confirmed Resident #11 was tearful, withdrawn, and anxious and had suffered psychological harm. During a telephone interview on 3/2/2022 at 8:43 PM, CNA #6 (night shift CNA) stated she noticed Resident #11 had used her call bell more frequently over the past couple of months when the MA entered the facility between 4:30 - 5:00 AM. CNA #6 stated when the call light was answered Resident #11 denied needing assistance. After the alleged perpetrator (MA) was escorted from the facility on 2/17/2022, Resident #11 used her call light less frequently to request assistance. During a telephone interview on 3/2/2022 at 8:55 PM, CNA #7 (night shift CNA) stated Resident #11 had odd behaviors for the past couple of months. The resident had refused baths and had used her call bell more frequently. CNA #7 stated she responded to Resident #11's call light and asked what the resident needed, and the resident would state she did not need assistance. CNA #7 stated .in hindsight, I think the call bell pushing was because of [Maintenance Assistant's name] .I did tell the nurse when [Resident #11] was refusing baths . During a telephone interview on 3/3/2022 at 8:16 AM, the DON confirmed if an individual had been abused, she would expect them to be scared, tearful, and withdrawn. During a telephone interview on 3/3/2022 at 8:25 AM, the Psychiatric NP stated she would expect a person who had been abused to exhibit signs of depression, anxiety, tearful, and trouble sleeping. During an interview on 3/3/2022 at 3:14 PM, the ED if staff had reported Resident #11 had been more anxious, tearful, had decreased activities, and mood changes to him, he would have further investigated. The ED confirmed Resident #11 had suffered trauma and grief from the abuse incidents she experienced at the facility. Continued interview revealed the residents' behaviors were not shared with the Interdisciplinary Team. The Facility corrective actions include: 1. Associate (Maintenance Assistant) was suspended pending investigation on 2/17/2022. 2. Associate's keys were taken by associate's supervisor, Maintenance Director on 2/17/2022. 3. All facility doors with code accessibility were changed by the Maintenance Director on 2/17/2022. 4. Residents #11 and #13 had an Incident Report completed and were assessed for injuries, and had skin, pain, and psychosocial assessments completed by a licensed nurse on 2/17/2022. 5. Residents #11 and #13's family and Physicians were notified of the incident by the DON and the ED on 2/17/2022. 6. Residents #11 and #13 were evaluated by Psychiatric Services on 2/18/2022. 7. Resident's #11 and #13 had behavior management care plans reviewed and updated, behavior management flowsheets reviewed and updated, and resident profile care plan reviewed and updated by a licensed nurse on 2/18/2022 and 3/4/2022. 8. Notifications were made to the following local and state agencies, the Medical Director was notified by the ED and the DON on 2/17/2022, the local Ombudsman and Adult Protective Services were notified by the ED on 2/18/2022, local police department was notified by the DON on 2/17/2022, and the State Agency was notified by the ED on 2/17/2022. 9. All residents with a BIMS of 9 or higher will be interviewed for any allegations of abuse/neglect/misappropriation by the Social Worker on 2/17/2022. All residents with a BIMS of 8 or less will have a skin assessment completed to identify any potential unreported abuse by a licensed nurse by 2/17/2022. 10. All current residents will be assessed for behavioral signs and symptoms of potential abuse, which include, [CONDITION(S)], withdrawal, decreased activity, increased anxiety, decreased social interaction and depressive behaviors by a licensed nurse and/or social service director by 3/4/2022. 11. All current residents identified with psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 12. All resident comment concern cards and resident council minutes for the past 180 days will be reviewed for any allegations of abuse/neglect/misappropriation by the ED on 3/4/2022. 13. All associates working on 3/4/2022 will be interviewed for any allegations of abuse/neglect/misappropriation including any behavioral signs and symptoms of potential abuse to include [CONDITION(S)], withdrawal, decreased activity, and increased anxiety by the Regional Vice President (RVP) and the Regional Director of Clinical Services. Any associate that has not been interviewed will not be allowed to work until the interview is complete. All interviews will be completed by 3/7/2022. 14. During the monthly Quality Assurance Performance Improvement Program (QAPI) committee meetings, the ED will be responsible for reviewing the abuse reporting log, and compliance rounds and comment/concern cards for any trends and patterns. 15. The Director of Social Services will be responsible for reviewing the behavior management flowsheets for trends and patterns (including behavioral signs and symptoms of potential abuse). 16. The DON will be responsible for reviewing the Event Management System for trends and patterns (including potential physical/sexual abuse). 17. The Staff Development Director will be responsible for reviewing education for trends and patterns (including protection of residents, reducing the threat of abuse/neglect, and behavior management education). 18. On 3/4/2022, the RVP provided education to the ED and DON to ensure the abuse policies are implemented to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in bodily injury, or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the ED of the facility and to other officials (including to the State Agency and Adult Protective Services) and to ensure all allegations of abuse and neglect are promptly and thoroughly investigated. Education included: Protection of Residents-Reducing the threat of abuse and neglect (including identify signs and symptoms of abuse) Resident Rights Behavior Health Management Event Management System 19. The ED, DON, ADON, Staff Development Coordinator (SDC) and/or licensed nurse will provide education to all facility staff to 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, to the ED of the facility and to other officials (including to the State Survey Agency and Adult Protective Services) and to ensure all allegations of abuse and neglect are promptly and thoroughly investigated. Education included: Protection of Residents: Reducing the threat of abuse and neglect (including identify signs and symptoms of abuse). 20. The DON, ADON, SDC, and/or licensed nurse will provide education to all licensed nurses and certified nursing assistants on the following: Event Management System Resident Rights Behavior Health Management Any associate who has not completed training by 3/7/2022 will not be allowed to work until training is completed. The ED, DON, SDC, and/or licensed nurse will provide education to all new associates upon hire during orientation. 21. Assigned Interdisciplinary Team (IDT) Members provided abuse reporting education to the resident council and all residents with a BIMS score of 9 or above by 2/18/2022. 22. All resident comment and concern cards will be reviewed for allegation of abuse during daily stand-up meeting. The ED will be responsible for ensuring appropriate reporting and investigation. 23. Assigned department heads will perform daily compliance rounds that include monitoring of reporting allegations of abuse and types of abuse through interviews with 5 residents and 5 staff members and resident observations. 24. All resident skin assessments will be conducted weekly and reviewed during daily grand rounds for potential abuse. The DON and/or ADON will be responsible for notifying the ED and initiating the investigation. 25. Signage will be posted by the time clock on 2/18/2022 identifying all allegations are to be reported to the ED immediately with their contact number. It will also include a second person, the DON, and their contact number to be notified when the ED cannot be reached. 26. The ED will be responsible for ensuring timely reporting to state agencies through investigations and maintaining an abuse reporting log. 27. Prior to submitting final investigation to required agencies a member of the regional team will review the investigations to ensure a thorough investigation was completed. 28. The RVP will review the abuse reporting log and investigations during facility visits. 29. QAPI meeting held 3/4/2022 regarding the plan of removal. 30. The ED, DON, and IDT completed a Root Cause Analysis on 3/4/2022. On 3/4/2022, the surveyors validated the Maintenance Assistant was suspended on 2/17/2022 confirmed by review of a suspension form dated 2/17/2022 and interviews with the Maintenance Director and ED. On 3/4/2022, the surveyors validated associate's (MA) keys were taken and facility door codes were changed by the Maintenance Director on 2/17/2022. Confirmed by review of an Intrafacility Request For Repairs or Alterations form dated 2/17/2022 and interview with the Maintenance Director. On 3/4/2022, surveyors validated Residents #11 and #13 had an Incident Report completed, were assessed for injuries, had skin, pain, and psychosocial assessment completed, and family and Physicians were notified of the incident on 2/17/2022. Residents #11 and #13 were evaluated by Psychiatric Services on 2/18/2022, had behavior management care plans reviewed and updated, behavior management flowsheets reviewed and updated, and resident profile care plan reviewed and updated on 2/18/2022 and 3/4/2022. On 3/4/2022, surveyors validated notifications were reported timely to the ED, DON, Medical Director, local Ombudsman, Adult Protective Services, local police department and the State Agency. On 3/4/2022, surveyors validated all residents with a BIMS of 9 or higher were interviewed for any allegations of abuse, neglect, and misappropriation on 2/17/2022. All residents with a BIMS of 8 or less had skin assessments completed to identify any potential unreported abuse on 2/17/2022. On 3/4/2022, surveyors validated all current residents were assessed for behavioral signs and symptoms of potential abuse, which included, [CONDITION(S)], withdrawal, decreased activity, increased anxiety, decreased social interaction and depressive behaviors. The facility-initiated identification of residents with psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/4/2022, surveyors validated the facility reviewed all resident comment concern cards and resident council minutes for the past 180 days for allegations of abuse, neglect, and misappropriation. Interview with the ED confirmed he had reviewed all comment concern cards and resident council minutes for the past 180 days and there were no concerns of abuse allegations. On 3/4/2022, surveyors interviewed all associates working on 3/4/2022 to ensure understanding of allegations of abuse/neglect/misappropriation, including any behavioral signs and symptoms of potential abuse to include, [CONDITION(S)], withdrawal, decreased activity and increased anxiety. On 3/4/2022, surveyors validated through interview the ED is responsible for reviewing the abuse reporting log, and compliance rounds and comment/concern cards for any trends and patterns. Interview with the Director of Social Services showed she is responsible for reviewing the behavior management flowsheets for trends and patterns (including behavioral signs and symptoms of potential abuse). Interview with the DON showed she is responsible for reviewing the Event Management System for trends and patterns (including potential physical/sexual abuse). Interview with the Staff Development Director revealed she is responsible for reviewing education for trends and patterns, including protection of residents, reducing the threat of abuse/neglect, and behavior management education. Information will be discussed in the monthly Quality Assurance Performance Improvement Program (QAPI) committee meetings. On 3/4/2022 the surveyors validated the ED and DON were in serviced on the facility abuse policy to ensure implementation of all alleged abuse, and to ensure all allegations of abuse and neglect are promptly and thoroughly investigated. Interviews with the ED, DON, ADON, Staff Development Coordinator (SDC) showed education was provided to all facility staff working on 3/4/2022 on the facility's abuse policy and behavior health management to recognize behavioral changes as a sign of abuse. Any associate who had not completed training will not be allowed to work until training is completed. The ED, DON, SDC, and/or licensed nurse will provide education to all new associates upon hire during orientation. On 3/4/2022, surveyors validated education was provided during the resident council meeting to all residents with a BIMS score of 9 or above by 2/18/2022. On 3/4/2022, surveyors validated the ED reviewed concern and comment cards for allegations of abuse during daily stand-up meetings. The ED is responsible for ensuring appropriate reporting and investigation. On 3/4/2022, surveyors validated department heads had performed daily compliance rounds that included monitoring reports of abuse, types of abuse through interviews with 5 residents and 5 staff members, and resident observations. On 3/4/2022, surveyors validated all resident skin assessments were conducted weekly and reviewed during daily grand rounds for potential abuse. The DON and/or ADON are responsible for notifying the ED and initiating the investigation. On 3/4/2022, surveyors validated signage had been posted by the time clock with the ED and DON's contact information for reporting abuse allegations immediately. Interview with the ED confirmed he is responsible for ensuring timely reporting to state agencies through investigations and maintaining an abuse reporting log. The facility's noncompliance at F-743 continues at a scope and severity D for monitoring of the effectiveness of corrective actions to ensure sustained compliance. The facility is required to submit a Plan of Correction. Refer to F-600

Based on review of the facility policies, review of facility investigations, review of police reports, record reviews, interviews, and observations, the facility's Quality Assurance Performance Improvement (QAPI) program failed to identify a quality deficiency and implement interventions to address the root cause of behaviors when Resident #11 displayed signs and symptoms of abuse which resulted in 2 residents (#11 and #13) sustaining sexual abuse on 2/17/2022 and led to psychosocial harm for Residents #11 and #13. The facility's failure to identify and investigate signs and symptoms of abuse resulted in Resident #11 and Resident #13 sustaining sexual abuse on 2/17/2022, Resident #11 sustained sexual abuse prior to the incident on 2/17/2022 and placed both residents in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements for participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Executive Director (ED) was notified of the Immediate Jeopardy at F-600, F-610, and F-743 on 3/3/2022 at 4:47 PM. The Regional Director of Clinical Services and Divisional and Regional Vice Presidents were notified of the Immediate Jeopardy at F-865 on 3/4/2022 at 11:15 AM. The Immediate Jeopardy was removed onsite and was effective 2/17/2022-3/3/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 3/4/2022 at 2:07 PM and the corrective actions were validated onsite by the surveyors on 3/4/2022. The findings include: Review of facility policy titled, Quality Assurance and Performance Improvement, dated 3/13/2020 showed .The focus of the QAPI program is to promote .quality of care .QAPI program is the way to promote continuous improvement of the facility .When negative trends are identified .root cause analysis and evidence-based strategies, such as Plan-Do-Study-Act. Performance improvement projects will be utilized .The facility will gather and analyze data .determine if gaps in process or patterns are identified .that may impact quality of care or quality of life .When in depth analysis is required, identification of the underlying root cause and contributing factors may be performed by using such as the Five Why's, flowcharting, Failure Mode and Effects Analysis (FMEA), and Fishbone Diagrams . Review of the facility policy titled, Protection of Residents: Reducing the Threat of Abuse & Neglect, revised 8/10/2021 showed .All personnel will promptly report any incident or suspected incident of resident abuse .to their immediate supervisor .facility representative .director of nursing .executive director .abuse will be reviewed by the QAPI committee . Review of a QAA Committee document undated, revealed the QAPI Committee Members included Medical Director, ED, Director of Nursing (DON), Assistant Director of Nursing (ADON), Infection Prevention Nurse, Social Services, Medical Records, Minimum Data Set (MDS) Coordinator, Director of Rehab, Office Manager, Environment Services Manager, Activities Director, and the Consultant Pharmacist. Record review showed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #11's Activity Progress Notes dated 1/7/2022 - 1/26/2022, showed the resident had refused to attend activities on 1/7/2022, 1/10/2022, 1/13/2022, 1/18/2022, and 1/26/2022. Review of the 1/26/2022 Activity Progress Note revealed the facility had identified the resident's change of behavior to attend activities and Resident #11 was encouraged to start coming to more group activities by the facility. Record review showed Resident #13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility investigations and police reports revealed on 2/17/2021, the police received 2 separate reports of sexual abuse perpetrated on Residents #11 and #13 by the Maintenance Assistant (MA). During an interview on 2/28/2022 at 3:02 PM, Certified Nursing Assistant (CNA) #1 stated on 2/17/2022 she and CNA #2 observed the MA squatted at the side of Resident #13's bed, between the bed and the wall. CNA #1 and CNA #2 observed the MA's hand moving under Resident #13's blanket. The CNA's entered Resident #13's room as the MA exited Resident #13's room. Further interview revealed approximately a month ago, CNA #1 assisted Resident #11 with her meal, in the resident's room. The CNA stated during the meal the MA entered Resident #11's room, stood at the foot of the bed, and stared at Resident #11 without speaking. CNA #1 stated .did not think anything of it [incident of MA in resident's room during meal] .thought it was strange . CNA #1 stated approximately a week later the MA entered the room a second time, stood at the foot of the bed, and stared at the resident without speaking. The CNA stated Resident #11 stiffened her entire body and pushed back in the bed. CNA #1 asked the resident if the MA made her feel uncomfortable and the resident stated yes. CNA #1 informed the MA that Resident #11 did not want him in her room. CNA #1 reported the incident to Licensed Practical Nurse (LPN) #2 and that Resident #11 did not want him (MA) in her room, and he made her (Resident #11) uncomfortable. CNA #1 stated CNA #3 had informed her of a prior incident where the resident had requested the MA not to enter her room (CNA #1 was unable to recall the exact date of the prior incident). During an interview on 2/28/2022 at 3:18 PM, CNA #3 stated about a month ago Resident #11's television messed up and she (CNA) asked her (Resident #11) if she needed to get the MA to fix the television and Resident #11 said, No in a loud voice. CNA #3 stated she did not ask Resident #11 why she did not want the MA to look at her television. CNA #3 stated she informed LPN #2 and LPN #2 requested CNA #3 to inform the Social Worker (SW). CNA #3 stated she informed the SW immediately. During an interview on 3/1/2022 at 10:11 AM, the Regional Vice President (RVP) stated on 2/17/2022 he received a call from the Executive Director (ED) of the facility that Resident #13 had been sexually abused by the MA. While interviewing other residents about abuse on 2/17/2022, Resident #11 signaled for the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) to come into her room. Resident #11 informed the ADON the MA had touched her and put his fingers inside of her on 2 separate occasions. During an interview on 3/1/2022 at 3:30 PM, the SW stated CNA #3 had reported approximately December 2021 - January 2022, Resident #11 did not want the MA in her room. The SW informed the DON. During an interview on 3/1/2022 at 3:44 PM, the ADON stated the facility did not interview Resident #11 prior to 2/17/2022 regarding Resident #11's concerns with the MA. During an interview on 3/1/2022 at 3:44 PM, the ADON stated she was working on 2/17/2022 when Resident #11 reported the MA had touched her breast and vagina on more than one occasion. The resident stated it had also occurred prior to 2/17/2022. The ADON stated Resident #11 had been having trouble sleeping and felt more anxious since the incident. Resident #11 .was almost relieved that someone had asked her the right questions . The ADON stated staff never thought to ask her if someone had touched her inappropriately (prior to the 2/17/2022 incident). During an interview on 3/2/2022 at 10:07 AM, LPN #2 stated CNA #3 had reported to her approximately a month and a half ago Resident #11 did not want the MA to come in her room to fix her television. LPN #2 instructed CNA #3 to report the concern to the SW. During an interview on 3/2/2022 at 11:20 AM, the Activities Director stated Resident #11 had decreased participation in activities over the last month or so and had stopped allowing her blinds to be opened in her room. The Activities Director confirmed she had not identified Resident #11's behaviors as a sign or symptom of abuse. The Activities Director and the Activities Assistant had discussed Resident #11's decreased participation in activities, but she was unsure if they had reported the behavior to the nursing staff. When the Activities Director asked if Resident #11 was feeling okay, she would say no, but the Activities Director did not further investigate the resident's decreased participation of activities. During a telephone interview on 3/2/2022 at 1:50 PM, the DON stated when Resident #11 was interviewed and asked on 2/17/2022 if she was afraid of anyone, she stated yes and named the MA by his first name. Resident #11 told the DON the MA had touched her breast on 2/17/2022 and touched her breast and vagina one other time prior to 2/17/2022, but she was unable to recall the date. The DON stated the anxious behaviors Resident #11 was having prior to 2/17/2022 could have been signs of abuse, but the DON stated she was unaware the MA made Resident #11 feel uncomfortable or the resident had not been attending activities as usual. The DON stated Resident #11 had been more tearful and had trouble sleeping prior to 2/17/2022. After the abuse surfaced (on 2/17/2022) and Resident #11 got it off her chest she became less withdrawn. The DON stated she was unaware that Resident #11 did not want the MA in her room. During a telephone interview on 3/2/2022 at 3:21 PM, the Medical Director stated Resident #13 was having more anxiety and trouble sleeping. The Medical Director stated if a reasonable person was .attacked, molested, or assaulted .they would be upset but it's .like winning the lottery, it'll wear off . During a telephone interview on 3/2/2022 at 3:33 PM, the Psychiatric Nurse Practitioner (NP) stated the sexual abuse incidents had affected Resident #11, and she had .become more tearful and more withdrawn and that was not her . The sexual abuse incidents had caused Resident #11 psychological harm. During a telephone interview on 3/3/2022 at 8:16 AM, the DON stated she would expect a resident to be scared, cry, and withdrawn more if abuse had occurred. Review of the facility stand up meeting minutes from December 2021 - February 2022 revealed Resident #11's decrease in activities and change in behaviors were not discussed. Continued review revealed abuse concerns were not identified. During an interview on 3/3/2022 at 3:14 PM, the ED stated he was the Abuse Coordinator. The ED stated the facility conducts daily stand-up meetings Monday-Friday to discuss resident/staff concerns. The ED was not made aware of concerns or abnormal behaviors prior to 2/17/2022 for Resident #11. If staff had reported that Resident #11 had been more anxious, tearful, had decreased activities, and behavior changes to him, he would have further investigated. The ED confirmed if those behaviors had been identified and investigated, the sexual abuse that occurred on 2/17/2022 to Residents #11 and #13 may not have taken place. The ED confirmed Resident #11 had suffered trauma and grief from the abuse incidents. Continued interview revealed the residents' behaviors were not shared with the Interdisciplinary Team. The Facility corrective actions include: 1. Associate (Maintenance Assistant) was suspended pending investigation on 2/17/2022. 2. Associate's keys were taken by associate's supervisor, Maintenance Director on 2/17/2022. 3. All facility doors with code accessibility were changed by the Maintenance Director on 2/17/2022. 4. Residents #11 and #13 had an Incident Report completed and were assessed for injuries, and had skin, pain, and psychosocial assessments completed by a licensed nurse on 2/17/2022. 5. Residents #11 and #13's family and Physicians were notified of the incident by the DON and the ED on 2/17/2022. 6. Residents #11 and #13 were evaluated by Psychiatric Services on 2/18/2022. 7. Resident's #11 and #13 had behavior management care plans reviewed and updated, behavior management flowsheets reviewed and updated, and resident profile care plan reviewed and updated by a licensed nurse on 2/18/2022 and 3/4/2022. 8. Notifications were made to the following local and state agencies, the Medical Director was notified by the ED and the DON on 2/17/2022, the local Ombudsman and Adult Protective Services were notified by the ED on 2/18/2022, local police department was notified by the DON on 2/17/2022, and the State Agency was notified by the ED on 2/17/2022. 9. All residents with a BIMS of 9 or higher will be interviewed for any allegations of abuse/neglect/misappropriation by the Social Worker on 2/17/2022. All residents with a BIMS of 8 or less will have a skin assessment completed to identify any potential unreported abuse by a licensed nurse by 2/17/2022. 10. All current residents will be assessed for behavioral signs and symptoms of potential abuse, which include, [CONDITION(S)], withdrawal, decreased activity, increased anxiety, decreased social interaction and depressive behaviors by a licensed nurse and/or social service director by 3/4/2022. 11. All current residents identified with psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 12. All resident comment concern cards and resident council minutes for the past 180 days will be reviewed for any allegations of abuse/neglect/misappropriation by the ED on 3/4/2022. 13. All associates working on 3/4/2022 will be interviewed for any allegations of abuse/neglect/misappropriation including any behavioral signs and symptoms of potential abuse to include [CONDITION(S)], withdrawal, decreased activity, and increased anxiety by the Regional Vice President (RVP) and the Regional Director of Clinical Services. Any associate that has not been interviewed will not be allowed to work until the interview is complete. All interviews will be completed by 3/7/2022. 14. During the monthly Quality Assurance Performance Improvement Program (QAPI) committee meetings, the ED will be responsible for reviewing the abuse reporting log, and compliance rounds and comment/concern cards for any trends and patterns. 15. The Director of Social Services will be responsible for reviewing the behavior management flowsheets for trends and patterns (including behavioral signs and symptoms of potential abuse). 16. The DON will be responsible for reviewing the Event Management System for trends and patterns (including potential physical/sexual abuse). 17. The Staff Development Director will be responsible for reviewing education for trends and patterns (including protection of residents, reducing the threat of abuse/neglect, and behavior management education). 18. On 3/4/2022, the RVP provided education to the ED and DON to ensure the abuse policies are implemented to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in bodily injury, or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the ED of the facility and to other officials (including to the State Agency and Adult Protective Services) and to ensure all allegations of abuse and neglect are promptly and thoroughly investigated. Education included: Protection of Residents-Reducing the threat of abuse and neglect (including identify signs and symptoms of abuse) Resident Rights Behavior Health Management Event Management System 19. The ED, DON, ADON, Staff Development Coordinator (SDC) and/or licensed nurse will provide education to all facility staff to 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, to the ED of the facility and to other officials (including to the State Survey Agency and Adult Protective Services) and to ensure all allegations of abuse and neglect are promptly and thoroughly investigated. Education included: Protection of Residents: Reducing the threat of abuse and neglect (including identify signs and symptoms of abuse). 20. The DON, ADON, SDC, and/or licensed nurse will provide education to all licensed nurses and certified nursing assistants on the following: Event Management System Resident Rights Behavior Health Management Any associate who has not completed training by 3/7/2022 will not be allowed to work until training is completed. The ED, DON, SDC, and/or licensed nurse will provide education to all new associates upon hire during orientation. 21. Assigned Interdisciplinary Team (IDT) Members provided abuse reporting education to the resident council and all residents with a BIMS score of 9 or above by 2/18/2022. 22. All resident comment and concern cards will be reviewed for allegation of abuse during daily stand-up meeting. The ED will be responsible for ensuring appropriate reporting and investigation. 23. Assigned department heads will perform daily compliance rounds that include monitoring of reporting allegations of abuse and types of abuse through interviews with 5 residents and 5 staff members and resident observations. 24. All resident skin assessments will be conducted weekly and reviewed during daily grand rounds for potential abuse. The DON and/or ADON will be responsible for notifying the ED and initiating the investigation. 25. Signage will be posted by the time clock on 2/18/2022 identifying all allegations are to be reported to the ED immediately with their contact number. It will also include a second person, the DON, and their contact number to be notified when the ED cannot be reached. 26. The ED will be responsible for ensuring timely reporting to state agencies through investigations and maintaining an abuse reporting log. 27. Prior to submitting final investigation to required agencies a member of the regional team will review the investigations to ensure a thorough investigation was completed. 28. The RVP will review the abuse reporting log and investigations during facility visits. 29. QAPI meeting held 3/4/2022 regarding the plan of removal. 30. The ED, DON, and IDT completed a Root Cause Analysis on 3/4/2022. On 3/4/2022, the surveyors validated the Maintenance Assistant was suspended on 2/17/2022 confirmed by review of a suspension form dated 2/17/2022 and interviews with the Maintenance Director and ED. On 3/4/2022, the surveyors validated associate's (MA) keys were taken and facility door codes were changed by the Maintenance Director on 2/17/2022. Confirmed by review of an Intrafacility Request For Repairs or Alterations form dated 2/17/2022 and interview with the Maintenance Director. On 3/4/2022, surveyors validated Residents #11 and #13 had an Incident Report completed, were assessed for injuries, had skin, pain, and psychosocial assessment completed, and family and Physicians were notified of the incident on 2/17/2022. Residents #11 and #13 were evaluated by Psychiatric Services on 2/18/2022, had behavior management care plans reviewed and updated, behavior management flowsheets reviewed and updated, and resident profile care plan reviewed and updated on 2/18/2022 and 3/4/2022. On 3/4/2022, surveyors validated notifications were reported timely to the ED, DON, Medical Director, local Ombudsman, Adult Protective Services, local police department and the State Agency. On 3/4/2022, surveyors validated all residents with a BIMS of 9 or higher were interviewed for any allegations of abuse, neglect, and misappropriation on 2/17/2022. All residents with a BIMS of 8 or less had skin assessments completed to identify any potential unreported abuse on 2/17/2022. On 3/4/2022, surveyors validated all current residents were assessed for behavioral signs and symptoms of potential abuse, which included, [CONDITION(S)], withdrawal, decreased activity, increased anxiety, decreased social interaction and depressive behaviors. The facility-initiated identification of residents with psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/4/2022, surveyors validated the facility reviewed all resident comment concern cards and resident council minutes for the past 180 days for allegations of abuse, neglect, and misappropriation. Interview with the ED confirmed he had reviewed all comment concern cards and resident council minutes for the past 180 days and there were no concerns of abuse allegations. On 3/4/2022, surveyors interviewed all associates working on 3/4/2022 to ensure understanding of allegations of abuse/neglect/misappropriation, including any behavioral signs and symptoms of potential abuse to include, [CONDITION(S)], withdrawal, decreased activity and increased anxiety. On 3/4/2022, surveyors validated through interview the ED is responsible for reviewing the abuse reporting log, and compliance rounds and comment/concern cards for any trends and patterns. Interview with the Director of Social Services showed she is responsible for reviewing the behavior management flowsheets for trends and patterns (including behavioral signs and symptoms of potential abuse). Interview with the DON showed she is responsible for reviewing the Event Management System for trends and patterns (including potential physical/sexual abuse). Interview with the Staff Development Director revealed she is responsible for reviewing education for trends and patterns, including protection of residents, reducing the threat of abuse/neglect, and behavior management education. Information will be discussed in the monthly Quality Assurance Performance Improvement Program (QAPI) committee meetings. On 3/4/2022 the surveyors validated the ED and DON were in serviced on the facility abuse policy to ensure implementation of all alleged abuse, and to ensure all allegations of abuse and neglect are promptly and thoroughly investigated. Interviews with the ED, DON, ADON, Staff Development Coordinator (SDC) showed education was provided to all facility staff working on 3/4/2022 on the facility's abuse policy and behavior health management to recognize behavioral changes as a sign of abuse. Any associate who had not completed training will not be allowed to work until training is completed. The ED, DON, SDC, and/or licensed nurse will provide education to all new associates upon hire during orientation. On 3/4/2022, surveyors validated education was provided during the resident council meeting to all residents with a BIMS score of 9 or above by 2/18/2022. On 3/4/2022, surveyors validated the ED reviewed concern and comment cards for allegations of abuse during daily stand-up meetings. The ED is responsible for ensuring appropriate reporting and investigation. On 3/4/2022, surveyors validated department heads had performed daily compliance rounds that included monitoring reports of abuse, types of abuse through interviews with 5 residents and 5 staff members, and resident observations. On 3/4/2022, surveyors validated all resident skin assessments were conducted weekly and reviewed during daily grand rounds for potential abuse. The DON and/or ADON are responsible for notifying the ED and initiating the investigation. On 3/4/2022, surveyors validated signage had been posted by the time clock with the ED and DON's contact information for reporting abuse allegations immediately. Interview with the ED confirmed he is responsible for ensuring timely reporting to state agencies through investigations and maintaining an abuse reporting log. The facility's noncompliance at F-865 continues at a scope and severity D for monitoring of the effectiveness of corrective actions to ensure sustained compliance. The facility is required to submit a Plan of Correction. Refer to F-600, F-610, and F-743

Based on facility policy review, medical record review, and interview, the facility failed to report an allegation of abuse timely to the State Survey Agency for 1 resident (Resident #5) of 28 residents reviewed for abuse. The findings include: Review of the facility policy titled, Protection of Residents: Reducing the Threat of Abuse & Neglect, revised 8/10/2021, showed .Reporting Allegations .In response to allegations of abuse .mistreatment, the facility must .Ensure that all alleged violations involving abuse .mistreatment .are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse .to the administrator of the facility and to other officials ( .including to the State Survey Agency .) All associates are mandated to immediately report suspected resident abuse .to their immediate supervisor .All alleged or suspected violations involving mistreatment, abuse .will be immediately reported to the administrator and/or director of nursing . Medical record review showed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Medical record review showed Resident #15 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #15's 5-day MDS assessment dated [DATE], showed the resident had a BIMS score of 15, indicating she was cognitively intact. Review of Resident #5's Fax Order Request/Notification Form dated 3/2/2022, showed .Nurse reported [2/28/2022] that [Resident #15] told her that two CNA's [Certified Nursing Assistants, CNA #5 and #6] talked 'rough' to [Resident #5] and told her to 'shut up' . During a telephone interview on 3/1/2022 at 9:45 PM, Registered Nurse (RN) #1 stated Resident #15 had reported an allegation of abuse to her and Licensed Practical Nurse (LPN) #3 .last night [2/28/2022] . RN #1 stated she and LPN #3 spoke with Resident #15 on 2/28/2022. Resident #15 reported 2 CNA's (CNA #5 & #6) yelled at her roommate (Resident #5) and squeezed her roommate's arm. RN #1 stated the Assistant Director of Nursing (ADON) had been notified on 2/28/2022 and stated she (ADON) would call the Director of Nursing (DON). During a telephone interview on 3/1/2022 at 10:12 PM, LPN #3 stated .I was in the room of resident [Resident #15] last night [2/28/2022] and .she [Resident #15] felt like some [CNA's] get a little rough with her roommate [Resident #5] . LPN #3 further stated Resident #15 was worried that they (CNAs #5 & #6) were .grabbing [Resident #5] too hard and she [Resident #15] could hear them tell [Resident #5] to shut up. LPN #3 stated she called the ADON and reported the allegation and was told the ADON would talk to the DON. During an interview on 3/2/2022 at 8:30 AM, the Executive Director (ED) confirmed the allegation of abuse was reported to the ADON on 2/28/2022. The ED stated .the nurse did the right thing and reported immediately to the ADON, but the ADON did not report to me. She said she called the DON .the DON is on vacation . The ED confirmed the allegation of abuse had not been reported to the State Survey Agency timely. During an interview on 3/2/2022 at 8:40 AM, the ADON confirmed LPN #3 had notified her about the allegation of abuse on 2/28/2022 at 9:31 PM. The ADON stated she had notified the DON on 2/28/2022 and the DON stated she would .handle it when she got back [the DON was to return on 3/7/2022] . During an interview on 3/3/2022 at 9:19 AM, Resident #15 stated the 2 CNAs (CNA #5 and #6) had been talking loudly on the night of 2/28/2022 and were .fussing among themselves . During a telephone interview on 3/2/2022 at 1:50 PM, the DON confirmed she had been made aware of the abuse allegation by Resident #15 on .Monday night (2/28/2022) . The DON stated the ADON thought the CNAs were .being loud and arguing with each other . The DON confirmed allegations of abuse were to be reported to the DON, Social Worker, or the ED (Abuse Coordinator). During an interview on 3/4/2022 at 8:20 AM, the ED confirmed the DON was expected to return from vacation on 3/7/2022 (7 days after the alleged incident occurred).

Based on review of facility policy, review of facility documentation, medical record review and interview, the facility's Administrator failed to ensure the facility addressed staff noncompliance with Personal Protective Equipment (PPE) usage, and failed to ensure COVID-19 recommendations and guidance for the control of COVID-19 in the facility was communicated to key clinical staff, which resulted in the spread of COVID-19 to 44 of 49 residents (#26, #28, #22, #23, #27, #25, #24, #29, #14, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #15, #16, #17, #18, #19, #20, #21, #2, #38, #42, #1, #3, #31, #32, #33, #34, #35, #37, #39, #40, #41, #43, #44, #30, and #36) in the facility and contributed to the death of 8 of 44 residents (#26, #28, #22, #23, #27, #25, #24, and #29) who tested positive for COVID-19, placing the residents in Immediate Jeopardy. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Executive Director (ED)/Administrator and the Director of Nursing (DON) were informed of the IJ on [DATE] at 3:14 PM via teleconference. The facility was cited Immediate Jeopardy at F-835(L), F-865(L), and F-880(L) The Immediate Jeopardy was removed onsite and was effective [DATE] - [DATE]. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on [DATE]. The corrective actions were verified onsite on [DATE]. The findings include: Review of the facility's policy titled, Division of Responsibilities for Infection Prevention and Control Activities dated [DATE], showed .The Executive Director (the Administrator of the facility) is ultimately responsible for the Infection Prevention and Control Program . Review of the Executive Director Job Description, revised [DATE], showed .The Executive Director provides leadership and direction for overall facility operations to provide quality patient care in accordance with all .regulations .Provides oversight of key areas including .clinical operations . Review of the facility's undated policy titled, Grievance Procedure stated .It is essential that problems be dealt with quickly and effectively .Prompt .handling of associates' concerns .is necessary .the associate .may discuss the issue with the Executive Director. All matters related to the problem will be re-examined and evaluated . Review of guidance from the Tennessee Department of Health, Communicable and Environmental Dieseases and Emergency Prepardness Division (CEDEP), Healthcare Associated Infections (HAI) team, dated [DATE], showed .Assess any staff who were in contact with the 6 positive employees to determine potential exposures. I (the HAI Preventionist) have listed the chart to follow for determining any exposures, the risks, and the actions that need to be taken .Ensure you (the facility) are continuing to assess all s/s (signs and symptoms) of COVID-19 3 times a day .Increase your auditing of Infection Control activities such as .PPE (person protective equipment) .monitoring staff compliance . CNA #1 last worked on [DATE] prior to having received a positive COVID-19 test result on [DATE]. CNA #4 last worked on [DATE] prior to having received a positive COVID-19 test result on [DATE]. CNA #2 last worked on [DATE] prior to having received a positive COVID-19 test result on [DATE]. LPN #6 last worked on [DATE] from 6:36 PM until 9:00 PM, prior to having received a positive COVID-19 test result on [DATE]. CNA #8 last worked on [DATE] prior to having received a positive COVID-19 test result on [DATE]. CNA #9 last worked on [DATE] prior to having received a positive COVID-19 test result on [DATE]. Review of the facility's policy titled, Coronavirus (COVID 19) ([DIAGNOSES REDACTED]-CoV-2), revised [DATE] and [DATE], stated, .Respirators with exhalation valves are not recommended for source control as they allow for unfiltered exhaled air and should not be used . Review of the medical record for all residents in the facility showed respiratory and symptom assessments were conducted twice per day and not 3 times per day as recommended by the HAI Preventionist. During interviews on [DATE] at 4:41 PM and on [DATE] at 10:01 AM, the Director of Maintenance and Environmental Services stated the facility held daily morning meetings with all Department Heads (Administrator, Director of Nursing, Director of Rehabilitation, Dietary representative, Director of Social Services, Director of Maintenance and Environmental Services) of the facility Monday through Friday. The Maintenance Director stated he attended the daily meetings and revealed he had informed the Administrator and other department heads his concern with staff not wearing PPE or wearing PPE incorrectly. The Director of Maintenance and Environmental Services stated the department heads were advised by the Administrator to address observations of staff not wearing PPE or not wearing PPE correctly immediately with the staff member. In addition the staff were advised to provide reminders to each other as well. Further interview confirmed the Director of Maintenance and Environmental Services was advised by the Administrator he would .look into it (staff noncompliance with PPE) . but noncompliance with staff not wearing their PPE had .gotten to the point where you are feeling like you're beating your head against the wall . During a telephone interview on [DATE] at 11:53 AM, CNA #3 stated .they have discussed it with us. If we see someone not wearing their PPE properly we need to gently remind them to put it on correctly . CNA #3 confirmed she had observed CNA #1 and CNA #4 not wearing their mask, including the night of [DATE] when she was working a shift with CNA #1 who had complained of feeling ill. During an interview on [DATE] at 12:36 PM and [DATE] at 3:14 PM, the Director of Nursing (DON) stated they had daily stand-up meetings, but she had not been able to attend all of the meetings. Ongoing interview confirmed she had not been made aware of the HAI recommendation made to the ED/Administrator on [DATE] to complete respiratory assessments on residents 3 times daily during the morning meetings. Further interview confirmed she had not been informed by the Administrator that the use of N95 respirators with exhalation valves were not recommended by the Centers for Disease Control (CDC) and per facility policy dated [DATE], and confirmed the masks had been available for staff use until [DATE]. Further interview confirmed she had seen and reprimanded CNA #1 on [DATE] for not wearing her face mask properly. During a telephone interview on [DATE] at 7:16 PM, the Medical Director stated the facility had good policies and protocols to prevent the spread and transmission of COVID-19. The Medical Director confirmed COVID-19 .is coming from somewhere . The Medical Director confirmed .Middle of July no cases, something happened a breach or something that made this happen (the spread of COVID-19 throughout the facility) . During a telephone interview with the HAI Preventionist assigned to work with the facility by the Regional Health Department after the COVID-19 outbreak in the facility on [DATE] at 12:30 PM, revealed she participated in a call on [DATE] with the ED/Administrator and the Infection Preventionist of the facility and had discussed the outbreak in the facility. The HAI Preventionist stated she discussed how to contact trace the positive cases, ensure respiratory assessments were completed 3 tiems daily on residents, ensure staff were wearing face masks properly and following social distancing, audit staff usage of proper PPE usage, and measures to mitigate the spread of COVID-19 in the facility. During a telephone interview on [DATE] at 5:00 PM, the ED/Administrator confirmed the facility failed to follow the HAI guidance received [DATE] regarding the contact tracing of any staff who were in contact with the 6 positive employees to determine potential exposures. During a telephone interview on [DATE] at 11:00 AM, CNA #5 stated she had to provide ongoing verbal reminders to multiple night shift nurses and CNA's to wear their PPE. Continued interview revealed on one occasion a CNA refused to don the required face shields stating .it doesn't say on the picture you have to (pointing to a PPE flyer which did not include the use of face shields on it) and they continued to go on in (into the facility) .at that time we were required to wear a face shield at all times. CNA #5 confirmed she did not report to the Administrator each time she saw nurses or CNA's not wearing the required PPE or wearing it incorrectly but did provide reminders to the staff member as instructed previously by administration. CNA #5 stated .we knew it was going to happen (COVID-19 outbreak in the facility) .it was a matter of time, that's why the Maintenance Director (Director of Maintenance and Environmental Services) kept reporting it (non-compliance with PPE) .he saw night shift (staff) not wearing their mask like they were supposed to .we all did .how many times should you have to remind them . During a telephone interview on [DATE] at 12:06 PM, Dietary Aide #1 stated .No, you do not have to wear a mask in the kitchen .some of the (kitchen) staff wear the mask, some don't .I make pudding, set up the trays .I usually set the fork, dessert, tea (on the meal tray) and push on to the cook I don't wear it (the mask) when I come in and set up the dessert .I don't wear it a lot of the time when I'm a checker (dietary role involving the process of verifying the meal served on the tray matches the order on the meal card) .it's too hot to use it (the face mask and face shield) . Dietary Aide #1 stated .(ED/Administrator) hasn't fussed at me about not wearing my mask . During a telephone interview on [DATE] at 2:58 PM, the Infection Preventionist (IP) stated the ED/Administrator was the point person who received the updated COVID-19 guidance and recommendations from the corporate office, and was responsible for disseminating the information to the Infection Preventionist and other key clinical staff .(The ED/Administrator) is responsible for contacting the HAI team and the health department and (he then) gives out the information . Ongoing interview confirmed the Infection Preventionist was aware PPE compliance was an identified ongoing problem .We were telling all our staff members and our team leaders to remind staff (about the proper use of PPE); it was a constant team effort .Reminders were a constant work in progress . The Infection Preventionist stated the ED/Administrator received calls from the corporate office on Tuesdays and Thursdays. The IP stated she had not received information directly from the Administrator but would typically receive the infomation at a later time from the DON. During a telephone interview on [DATE] at 4:20 PM, the ED/Administrator and Regional Director of Clinical Services confirmed the corporate office gave the updated information to the ED/Administrator of the facility daily and the ED/Administrator was responsible for distributing the information verbally or via email to the Infection Preventionist. Continued interview revealed the ED/Administrator denied knowledge that staff were noncompliant with PPE usage. Resident #26 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#26 was sent to the emergency room (ER). Review of the Hospitalist Admission Note dated [DATE] for Resident #26 showed lab .Result [DIAGNOSES REDACTED]-CoV-2 .Detected . Review of the Critical Care Medicine Death Summary dated [DATE], showed Resident #26 was admitted to the hospital on [DATE] and the resident expired on [DATE] due to .Acute hypoxemic [MEDICAL CONDITION] due to COVID-19 pneumonia with multisystem organ failure . Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #28 received a positive test result on [DATE]. Review of the Progress Note [DATE] at 2:00 AM showed Resident #28 was sent to the ER due to .c/o (complaints of) feeling bad . Review of the Emergency Department Nurse Documentation dated [DATE], showed Resident #28 .Presenting .Shortness of breath .covid positive .has bilateral pneumonia . Review of the Progress Note dated [DATE], showed Resident #28 expired on [DATE]. Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #22 had a positive result for COVID-19. Review of the physician's orders [REDACTED].Transfer/Discharge resident (Resident #22) to ER . due to decreased oxygen saturation, elevated temperature, decreased level of consciousness, and abnormal lung sounds. Review of the Progress Note dated [DATE] at 11:20 PM, showed Resident #22 was transferred to the ER. The laboratory called the facility to advise Resident #22's [DIAGNOSES REDACTED] CoV-2 test was positive. The facility notified the hospital of the positive result. Review of a hospital Discharge Summary showed Resident #22 expired on [DATE] due to the [DIAGNOSES REDACTED]. Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV2 test dated [DATE], showed Resident #23 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed .resident (Resident #23) observed without pulse or resps. (respirations) .Funeral home notified . Resident #27 was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Resident #27's [DIAGNOSES REDACTED] CoV-2 test dated [DATE] and reported on [DATE], showed a positive result. Review of the Progress Notes dated [DATE] at 9:20 AM showed Resident #27 was found unresponsive to verbal stimuli and .with further assessment nurse noted that resident was not breathing and she was unable to find a pulse .CPR (cardiopulmonary resuscitation) was initiated .Emergency Medical Services (EMS) arrived at 9:40 AM .contacted (ER Physician) who stopped code and pronounced (death) at 9:44 AM . Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #25 received a positive test result on [DATE]. Review of the physician's orders [REDACTED].#25 showed send the resident to the ER to evaluate and treat. Continued review showed no signs or symptoms were documented. Review of the hospital History and Physical dated [DATE], showed Resident #25's chief complaint .(hospice) .Impression COVID-19, [MEDICAL CONDITION] .Failure to thrive . Review of a hospital Discharge Summary dated [DATE], showed Resident #25 was admitted to the hospital on [DATE] with the chief complaint of COVID-19, Acute on [MEDICAL CONDITION], and [MEDICAL CONDITION]. Resident #25 was admitted to inpatient hospice for [MEDICAL CONDITION] due to COVID-19. The Discharge Summary showed Resident #25 expired on [DATE]. Resident #24 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #24 received a positive result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #24 was found to have no pulse or respirations at 6:00 AM and was pronounced deceased . Resident #29 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #29 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #29 was pronounced deceased 1:20 AM by the RN on duty. Resident # 14 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #14 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #14 had recovered from COVID-19 and was transferred out of the isolation unit. Review of facility documentation dated [DATE], showed the 1st round of COVID-19 testing was conducted on [DATE], after the facility discovered that Certified Nursing Assistant (CNA) #1 worked on [DATE], with signs and symptoms of COVID-19, and was not sent home. Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test date [DATE], showed Resident #4 and received a positive test result on [DATE]. Review of the physician's orders [REDACTED].#4 had an order to discontinue contact and droplet precautions. Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #5 received a positive test result on [DATE]. Review of the physician's orders [REDACTED].#5 had an order to discontinue the contact and droplet precautions. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #6 received a positive test result on [DATE]. Review of the physician's orders [REDACTED].#6 had an order to discontinue isolation precautions. Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #7 received a positive test result on [DATE]. A Room Change Notification dated [DATE], showed Resident #7 was transferred out of an isolation room. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test date [DATE], showed Resident #8 received a positive test result on [DATE]. Review of a Room Change Notification dated [DATE], showed Resident #8 was transferred out of an isolation room. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #9 received a positive test result on [DATE]. Review of a Room Change Notification dated [DATE], showed Resident #9 was transferred out of an isolation room. Review of the facility documentation dated [DATE], showed a 2nd round of facility wide resident testing was conducted on [DATE], after the facility discovered that CNA #1 worked on [DATE] with signs and symptoms of COVID-19, and was not sent home. Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #10 received a positive test result on [DATE]. During interview on [DATE], the Regional Director of Clinical Services stated Resident #10 had been recovered from COVID-19 and was transferred out of the isolation unit. Resident # 11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV2 test dated [DATE], showed Resident #11 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #11had recovered from COVID-19 and isolation precautions were discontinued. Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test date [DATE], showed Resident #12 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #12 had recovered from COVID-19 and isolation precautions were discontinued. Resident # 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #13 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #13 had recovered from COVID-19 and isolation precautions were discontinued. Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #15 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #15 had recovered from COVID-19 and isolation precautions were discontinued. Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test date [DATE], showed Resident #16 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #16 had recovered from COVID-19 and isolation precautions were discontinued. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #17 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #17 had recovered from COVID-19 and isolation precautions were discontinued. Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #18 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #18 had recovered from COVID-19 and isolation precautions were discontinued. Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 dated [DATE], showed Resident #19 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #19 had recovered from COVID-19 and transferred out of the isolation unit. Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #20 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #20 had recovered from COVID-19 and transferred out of the isolation unit. Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #21 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #21 had recovered from COVID-19 and transferred out of the isolation unit. Review of facility documentation dated [DATE], showed a 3rd round of facility wide resident testing was conducted. Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #2 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #2 had recovered from COVID-19 and isolation precautions were discontinued. Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #38 received a positive test result on [DATE], showed a positive result. Review of the Progress Note dated [DATE], showed Resident #38had recovered from COVID-19 and isolation precautions were discontinued. Resident #42 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #42 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #42 had recovered from COVID-19 and isolation precautions were discontinued. Review of facility documentation dated [DATE], showed a 4th round of facility wide resident testing was conducted. Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #1 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #1 had recovered from COVID-19 and isolation precautions were discontinued. Resident #3 was admitted to the facility [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #3 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #3 had recovered from COVID-19 and isolation precautions were discontinued. Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #31 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #31 had recovered from COVID-19 and isolation precautions were discontinued. Resident #32 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #32 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #32 had recovered from COVID-19 and isolation precautions were discontinued. Resident #33 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #33 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #33 had recovered from COVID-19 and isolation precautions were discontinued. Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #34 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #34 had recovered from COVID-19 and isolation precautions were discontinued. Resident #35 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #35 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #35 had recovered from COVID-19 and isolation precautions were discontinued. Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review

Based on review of facility policy, review of facility documentation, medical record review, and interview, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify breaches in infection control practices in the facility and failed to monitor infection control practices which contributed to the transmission of COVID-19 within the facility. This failure resulted in the spread of COVID-19 to 44 of 49 residents (#26, #28, #22, #23, #27, #25, #24, #29, #14, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #15, #16, #17, #18, #19, #20, #21, #2, #38, #42, #1, #3, #31, #32, #33, #34, #35, #37, #39, #40, #41, #43, #44, #30, and #36) in the facility and contributed to the death of 8 of 44 residents (#26, #28, #22, #23, #27, #25, #24, and #29) who tested positive for COVID-19, placing the residents in Immediate Jeopardy (IJ), a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident. The ED/Administrator and the Director of Nursing (DON) were informed of the IJ on [DATE] at 3:14 PM via teleconference. The facility was cited an Immediate Jeopardy at F-835(L), F-865(L), and F-880(L). The Immediate Jeopardy was removed onsite and was effective [DATE] - [DATE]. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on [DATE]. The findings include: Review of the facility policy, Quality Assessment and Assurance Committee Roles and Responsibilities dated [DATE], stated, .The QAA (Quality Assessment and Assurance) committee must .Meet .as needed to .evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary Develop and implement appropriate plans of action to correct identified quality deficiencies . Review of guidance from the Tennessee Department of Health, Communicable and Environmental Diseases and Emergency Preparedness Division (CEDEP), Healthcare Associated Infections (HAI) team, dated [DATE] (8 days after the facility received the first positive COVID-19 test), showed .Assess any staff who were in contact with the 6 positive employees to determine potential exposures. I (the HAI Preventionist) have listed the chart to follow for determining any exposures, the risks, and the actions that need to be taken .Ensure you (the facility) are continuing to assess all s/s (signs and symptoms) of COVID-19 3 times a day .Increase your auditing of Infection Control activities such as .PPE (person protective equipment) .monitoring staff compliance . Review of facility documentation for the initial 6 COVID-19 positive employees showed the following: CNA #1 last worked on [DATE] prior to having received a positive COVID-19 test result on [DATE]. CNA #4 last worked on [DATE] prior to having received a positive COVID-19 test result on [DATE]. CNA #2 last worked on [DATE] prior to having received a positive COVID-19 test result on [DATE]. LPN #6 last worked on [DATE] from 6:36 PM until 9:00 PM, prior to having received a positive COVID-19 test result on [DATE]. CNA #8 last worked on [DATE] prior to having received a positive COVID-19 test result on [DATE]. CNA #9 last worked on [DATE] prior to having received a positive COVID-19 test result on [DATE]. Resident #26 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the Physician's Order Listing Report dated [DATE], showed Resident #26 was sent to the emergency room (ER). Review of the Hospitalist Admission Note dated [DATE] for Resident #26 showed lab .Result [DIAGNOSES REDACTED]-CoV-2 .Detected . Review of the Critical Care Medicine Death Summary dated [DATE], showed Resident #26 was admitted to the hospital on [DATE] and the resident expired on [DATE] due to .Acute hypoxemic [MEDICAL CONDITION] due to COVID-19 pneumonia with multisystem organ failure . Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #28 received a positive test result on [DATE]. Review of the Progress Note [DATE] at 2:00 AM showed Resident #28 was sent to the ER due to .c/o (complaints of) feeling bad . Review of the Emergency Department Nurse Documentation dated [DATE], showed Resident #28 .Presenting .Shortness of breath .covid positive .has bilateral pneumonia . Review of the Progress Note dated [DATE], showed the facility learned .through .Obituary . that Resident #28 expired on [DATE]. Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #22 had a positive result for COVID-19. Review of the Physician's Order Listing Report dated [DATE], showed .Transfer/Discharge resident (Resident #22) to ER . due to decreased oxygen saturation, elevated temperature, decreased level of consciousness, and abnormal lung sounds. Review of the Progress Note dated [DATE] at 11:20 PM, showed Resident #22 was transferred to the ER. The laboratory called the facility to advise Resident #22's [DIAGNOSES REDACTED] CoV-2 test was positive. The facility notified the hospital of the positive result. Review of a Hospital Discharge Summary dated [DATE], showed Resident #22 was admitted to the hospital with [REDACTED]. Continued review showed Resident #22 expired on [DATE] due to the [DIAGNOSES REDACTED]. Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV2 test dated [DATE], showed Resident #23 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #23 was observed without a pulse or .Funeral home notified . Resident #27 was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Resident #27's [DIAGNOSES REDACTED] CoV-2 test dated [DATE] and reported on [DATE], showed a positive result. Review of the Progress Notes dated [DATE] at 9:20 AM showed Resident #27 was found unresponsive to verbal stimuli and .with further assessment nurse noted that resident was not breathing and she was unable to find a pulse .CPR (cardiopulmonary resuscitation) was initiated .Emergency Medical Services (EMS) arrived at 9:40 AM .contacted (ER Physician) who stopped code and pronounced (death) at 9:44 AM . Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #25 received a positive test result on [DATE]. Review of the Physician's Order Listing Report dated [DATE] for Resident #25 showed send the resident to the ER to evaluate and treat. Continued review showed no signs or symptoms were documented. Review of the hospital History and Physical dated [DATE], showed Resident #25's chief complaint .(hospice) .Impression COVID-19, [MEDICAL CONDITION] .Failure to thrive . Review of a hospital Discharge Summary dated [DATE], showed Resident #25 was admitted to the hospital on [DATE] with the chief complaint of COVID-19, Acute on [MEDICAL CONDITION], and [MEDICAL CONDITION]. Resident #25 was admitted to inpatient hospice for [MEDICAL CONDITION] due to COVID-19. The Discharge Summary showed Resident #25 expired on [DATE]. Resident #24 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #24 received a positive result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #24 was found to have no pulse or respirations at 6:00 AM and was pronounced deceased . Resident #29 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #29 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #29 was pronounced deceased 1:20 AM by the RN on duty. Resident # 14 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #14 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #14 had recovered from COVID-19 and was transferred out of the isolation unit. Review of facility documentation dated [DATE], showed the 1st round of COVID-19 testing was conducted on [DATE], after the facility discovered that Certified Nursing Assistant (CNA) #1 worked on [DATE], with signs and symptoms of COVID-19, and was not sent home. Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test date [DATE], showed Resident #4 and received a positive test result on [DATE]. Review of the Physician's Order dated [DATE], showed Resident #4 had an order to discontinue contact and droplet precautions. Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #5 received a positive test result on [DATE]. Review of the Physician's Order dated [DATE], showed Resident #5 had an order to discontinue the contact and droplet precautions. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #6 received a positive test result on [DATE]. Review of the Physician's Orders dated [DATE], showed Resident #6 had an order to discontinue isolation precautions. Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #7 received a positive test result on [DATE]. A Room Change Notification dated [DATE], showed Resident #7 was transferred out of an isolation room. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test date [DATE], showed Resident #8 received a positive test result on [DATE]. Review of a Room Change Notification dated [DATE], showed Resident #8 was transferred out of an isolation room. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #9 received a positive test result on [DATE]. Review of a Room Change Notification dated [DATE], showed Resident #9 was transferred out of an isolation room. Review of the facility documentation dated [DATE], showed a 2nd round of facility wide resident testing was conducted on [DATE], after the facility discovered that CNA #1 worked on [DATE] with signs and symptoms of COVID-19, and was not sent home. Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #10 received a positive test result on [DATE]. During interview on [DATE], the Regional Director of Clinical Services stated Resident #10 had been recovered from COVID-19 and was transferred out of the isolation unit. Resident # 11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV2 test dated [DATE], showed Resident #11 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #11had recovered from COVID-19 and isolation precautions were discontinued. Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test date [DATE], showed Resident #12 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #12 had recovered from COVID-19 and isolation precautions were discontinued. Resident # 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #13 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #13 had recovered from COVID-19 and isolation precautions were discontinued. Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #15 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #15 had recovered from COVID-19 and isolation precautions were discontinued. Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test date [DATE], showed Resident #16 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #16 had recovered from COVID-19 and isolation precautions were discontinued. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #17 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #17 had recovered from COVID-19 and isolation precautions were discontinued. Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #18 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #18 had recovered from COVID-19 and isolation precautions were discontinued. Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 dated [DATE], showed Resident #19 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #19 had recovered from COVID-19 and transferred out of the isolation unit. Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #20 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #20 had recovered from COVID-19 and transferred out of the isolation unit. Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #21 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #21 had recovered from COVID-19 and transferred out of the isolation unit. Review of facility documentation dated [DATE], showed a 3rd round of facility wide resident testing was conducted. Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #2 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #2 had recovered from COVID-19 and isolation precautions were discontinued. Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #38 received a positive test result on [DATE], showed a positive result. Review of the Progress Note dated [DATE], showed Resident #38had recovered from COVID-19 and isolation precautions were discontinued. Resident #42 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #42 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #42 had recovered from COVID-19 and isolation precautions were discontinued. Review of facility documentation dated [DATE], showed a 4th round of facility wide resident testing was conducted. Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #1 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #1 had recovered from COVID-19 and isolation precautions were discontinued. Resident #3 was admitted to the facility [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #3 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #3 had recovered from COVID-19 and isolation precautions were discontinued. Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #31 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #31 had recovered from COVID-19 and isolation precautions were discontinued. Resident #32 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #32 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #32 had recovered from COVID-19 and isolation precautions were discontinued. Resident #33 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #33 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #33 had recovered from COVID-19 and isolation precautions were discontinued. Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #34 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #34 had recovered from COVID-19 and isolation precautions were discontinued. Resident #35 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #35 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #35 had recovered from COVID-19 and isolation precautions were discontinued. Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #37 received a positive test result on [DATE]. During an interview on [DATE] at 1:20 PM, the of Clinical Services stated Resident #37 had recovered from COVID-19 and isolation precautions were discontinued. Resident #39 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #39 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #39 had recovered from COVID-19 and isolation precautions were discontinued. Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #40 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #40 had recovered from COVID-19 and isolation precautions were discontinued. Resident #41 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #41 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #41 had recovered from COVID-19 and isolation precautions were discontinued. Resident #43 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #43 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #43 had recovered from COVID-19 and isolation precautions were discontinued. Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #44 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #44 had recovered from COVID-19 and isolation precautions were discontinued. Review of facility documentation dated [DATE], showed a 5th round of facility wide resident testing was conducted. on [DATE]. Resident #30 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #30 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #30 had recovered from COVID-19 and isolation precautions were discontinued. Resident #36 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #36 received a positive test result on [DATE]. Review of the Progress Note dated [DATE], showed Resident #36 had recovered from COVID-19 and isolation precautions were discontinued. Review of facility documentation dated [DATE] - [DATE], showed respiratory and symptom assessments were only conducted 2 timers per day on all residents in the facility, not 3 times per day, as recommended by the HAI Preventionist. Review of the QAPI meeting sign-in sheets from [DATE] through [DATE], and the Infection Control COVID-19 QAPI plan, initiated [DATE], showed the ED/Administrator, the Medical Director, and the DON were members of the committee and present at each of the meetings. Further review revealed the format of the sign-in sheet listed the job titles on the left side of the paper, next to a blank for the corresponding associate to sign on the right side of the paper. Ongoing review showed the job title Infection Preventionist was not listed. Continued review revealed the line indicating a signature for the .Staff Development Coordinator . was signed by the Licensed Practical Nurse (LPN) trainer/Infection Preventionist. Continued review of the QAPI plan showed the facility held Ad Hoc QAPI meetings with the ED/Administrator, the Medical Director, and the DON on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] which discussed the increasing number of positive COVID-19 residents and staff and the Infection Preventionist was not in attendance to those meetings. Ongoing review showed the facility was tracking the increasing number of positive COVID-19 cases as the facility received them however was not completing and documenting audits of proper PPE usage of employees of the facility as recommended by the HAI Preventionist. During an interview on [DATE] at 4:41 PM and on [DATE] at 10:01 AM, the Director of Maintenance and Environmental Services confirmed he had seen staff not wearing the required PPE, had observed staff wearing their PPE incorrectly, and had noticed staff wearing face masks with exhalation valves as recently as [DATE]. Ongoing interview revealed facility staff including Certified Nursing Assistants and nurses ongoing noncompliance with PPE had .gotten to the point where you're feeling like you're beating youre head against the wall . Ongoing interview confirmed the department heads had discussed the non-compliance in morning meetings. He stated he had voiced his concerns about staff not complying with the PPE requirements to administration on several occasions and was told the ED/Administrator would .look into it .but nothing ever changed . Further interview confirmed he continued to provide reminders to staff to wear their PPE correctly, but felt like his .hands were tied . During a telephone interview on [DATE] at 11:53 AM, CNA #3 stated .they have discussed it with us. If we see someone not wearing their PPE properly we need to gently remind them to put it on correctly . Further interview confirmed CNA #3 had observed staff, including CNA #1 and CNA #4, not wearing their masks, including the night of [DATE] when she worked a shift with CNA #1 who was knowingly sick. Further interview confirmed management had not questioned her about the night of [DATE]. During a telephone interview on [DATE] at 7:16 PM, the Medical Director stated the facility had good policies and protocols to prevent the spread and transmission of COVID-19. The Medical Director confirmed COVID-19 was coming into the facility .from somewhere . The Medical Director stated .Middle of July no cases, something happened a breach or something that made this happen (the spread of COVID-19 throughout the facility) . The Medical Director stated if the facility staff followed all the requirements (Infection Control and CDC guidance) .this wouldn't have happened .this is why prevention is number 1 . During a telephone interview with the HAI Preventionist on [DATE] at 12:30 PM, revealed she had been on a call on ,[DATE]

Based on review of facility policy, review of facility documentation, review of Healthcare Associated Infection (HAI) recommendations and guidance, medical record review, observation, and interview, the facility failed to send home a COVID-19 symptomatic staff, and failed to ensure staff followed Personal Protective Equipment (PPE) requirements for the mitigation and control of COVID-19 in the facility. The facility's failure resulted in the spread of COVID-19 to 44 of 49 residents (#26, #28, #22, #23, #27, #25, #24, #29, #14, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #15, #16, #17, #18, #19, #20, #21, #2, #38, #42, #1, #3, #31, #32, #33, #34, #35, #37, #39, #40, #41, #43, #44, #30, and #36) in the facility and contributed to the death of 8 of 44 residents (#26, #28, #22, #23, #27, #25, #24, and #29) who tested positive for COVID-19, placing the residents in Immediate Jeopardy. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Executive Director (ED)/Administrator and the Director of Nursing (DON) were informed of the IJ on [DATE] at 3:14 PM via teleconference. The Immediate Jeopardy was removed onsite and was effective [DATE] - [DATE]. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on [DATE]. The corrective actions were verified onsite by a surveyor on [DATE]. The findings include: Review of the facility's policy titled, COVID-19 Long Term Care Facility Guidance dated [DATE], stated, .CMS (Center for Medicare and Medicaid Services) and CDC (Centers for Disease Control) are now recommending the following immediate actions to keep .residents safe .Nursing homes should immediately ensure they are complying with all CMS and CDC guidance related to infection control .CMS has recently issued extensive infection control guidance .Long term care facilities should ensure all staff are using appropriate PPE (personal protective equipment) when they are interacting with residents .Full PPE (includes: National Institute for Occupational Safety and Health (NIOSH) approved N95 Respirator Mask, Surgical Mask, Face Shield or Goggles, Gown, Gloves. N95 respirator mask with exhalation valves are not recommended) should be worn per CDC guidelines for the care of any resident with known or suspected COVID-19 . Review of the facility's policy titled, Outbreak and/or Pandemic Control and Management revised [DATE] stated .Outbreak surveillance and controls should be considered a high priority of Infection Prevention and Control .the approach of investigating an outbreak includes, but is not limited to: determining if an outbreak has occurred, developing a case definition, case finding, analyzing the outbreak, formulating a hypothesis regarding the mechanism of transmission, designating control measures, evaluating control measures . Review of the facility Coronavirus Screening tool for Associates, revised [DATE], revealed .If an associate becomes sick while at work, the associate should self-isolate, keep on a facemask, report illness to a direct supervisor, and go home. The facility should, inform the facility infection preventionist . Review of emailed facility documentation sent from the facility's corporate division Vice President dated [DATE] at 5:12 PM showed .CDC just changed the definition of Health Care Personnel. It now includes ALL departments in our facilities .ALL associates will be required to wear a face shield while at the facility . Review of the facility's policy titled, Transmission-based Precautions and Isolation Procedures reviewed [DATE], stated .Don appropriate PPE upon entry into the environment (e.g. room .) of resident on transmission-based precautions . Review of the facility's policy titled, Coronavirus (COVID 19) ([DIAGNOSES REDACTED]-CoV-2), revised [DATE], stated, .Respirators with exhalation valves are not recommended for source control as they allow for unfiltered exhaled air and should not be used . Review of guidance from the Tennessee Department of Health, Communicable and Environmental Diseases and Emergency Preparedness Division (CEDEP), Healthcare Associated Infections (HAI) team, dated [DATE] at 5:50 PM (8 days after the facility received the first positive COVID-19 test), showed .Implement universal precautions for the entire facility .the use of face mask and eye protection continuously while at the facility for all employees while at the facility .Ensure you are continuing to assess all s/s (signs and symptoms) of COVID-19 3 times a day .Increase your auditing of Infection Control activities such as .social distancing .PPE .monitoring staff compliance . Review of the HAI recommendations and guidelines, dated [DATE], showed .Assess any staff who were in contact with the 6 positive employees to determine potential exposures. I have listed the chart to follow for determining any exposures, the risks, and the actions that need to be taken .Ensure you are continuing to assess all s/s (signs and symptoms) of COVID-19 3 times a day .Increase your auditing of Infection Control activities such as .PPE .monitoring staff compliance . Review of the facility documentation showed the potential exposures of COVID-19 positive employees was not completed. Review of facility documentation related to the initial 6 employees who tested positive for COVID-19 showed the following: CNA #1 last worked on [DATE] prior to having received a positive COVID-19 test result on [DATE]. CNA #4 last worked on [DATE] prior to having received a positive COVID-19 test result on [DATE]. CNA #2 last worked on [DATE] prior to having received a positive COVID-19 test result on [DATE]. LPN #6 last worked on [DATE] prior to having received a positive COVID-19 test result on [DATE]. CNA #8 last worked on [DATE] prior to having received a positive COVID-19 test result on [DATE]. CNA #9 last worked on [DATE] prior to having received a positive COVID-19 test result on [DATE]. Facility documentation review and medical record reviews dated [DATE] - [DATE], showed respiratory and symptoms assessments were only conducted 2 times per day on all residents in the facility, not 3 times per day, as recommended by the HAI Preventionist. Review of facility audit documentation revealed PPE compliance audits, and social distancing audits had not been completed prior to the start of the survey on [DATE]. During an interview on [DATE] at 6:50 PM, Certified Nursing Assistant (CNA) #1 stated during the course of her 12 hour shift (from 7:00 PM to 7:00 AM) the night of Saturday, [DATE], she became aware she was physically sick. When she initially came into work, she thought she was just hot from being outside and did not report any signs or symptoms on the entrance screening form but did report a temperature of 99.5 degrees. Over the course of her shift, prior to 1:30 AM, she became aware she was sick from the symptoms of .chilling .cold .felt tired .headache .wanted to sit down .bones aching . and indicated she knew she had a fever because she was .freezing . CNA #1 reported her symptoms to CNA #3 and directly to her charge nurse, Licensed Practical Nurse (LPN) #1. CNA #1 stated she was not told to go home, and she and CNA #4 continued working providing direct care to COVID-19 negative residents on the North Hall of the facility. Ongoing interview confirmed she and CNA #4 worked that night without wearing the required face shield, as recommended by the HAI Preventionist on [DATE] and as advised by the Regional Vice President email dated [DATE] and did not notify another nurse nor management of her symptoms. CNA #1 stated she had received ongoing education and in-services since ,[DATE] related to COVID-19 and .if I felt sick then tell the nurse and the nurse (LPN #1) was supposed to screen me but she didn't do that and I asked her to tell (RN Supervisor) but she didn't do that .so I kept working . CNA #1 stated she carpooled with CNA #4 to work and CNA #4 did not wear a mask during their commute. CNA #1 stated she became upset after learning CNA #4 was sent home due to being exposed to COVID-19 in the community and she was asymptomatic while she had to remain at work and was sick. Review of CNA #1's Education Acknowledgement Form dated [DATE] and signed by CNA #1 and the DON on [DATE], showed .This form is used to provide a record of incidental training that occurs within the course of employment .THIS DOCUMENT IN ITS ENTIRETY WILL BE PLACED IN YOUR PERSONNEL FILE .Training topic .Proper use of Face mask while in the facility .Associate was not wearing face covering appropriately when entering the facility, when walking in hallways of the facility and other area of the building . During a telephone interview on [DATE] at 11:21 AM, LPN #1 stated she worked night shift (7 PM to 7 AM) on Saturday [DATE]. She worked with CNA #1 and CNA #3 on the North Hall and .we didn't have any cases (of COVID-19) . prior to [DATE]. LPN #1 confirmed she was aware CNA #1 was sick, stating .All night they kept saying (CNA #1) was sick and I said OK . LPN #1 stated she overheard CNA #1 state .I don't know why (CNA #4) gets to go home when I'm the one who's been feeling bad all night . LPN #1 confirmed she did not send home CNA #1 .I don't go telling them (CNA's) what to do . LPN #1 confirmed she did not notify the House Supervisor, the Infection Preventionist, nor administration of CNA #1 not feeling well/being sick while on duty. Continued interview revealed CNA #4 was sent home by the RN House Supervisor on [DATE] after learning she had gone to a church revival and was exposed to COVID-19 persons in the community. Review of the Facility Schedule and assignment list dated [DATE] showed CNA #1 and CNA #4 provided care to the following 8 residents: Resident #26 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #26 scored a 7 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Resident #26 required extensive 2 staff assistance for bed mobility, extensive 1 staff assistance for dressing, and personal hygiene, was total dependent of 1 staff for toileting, and required supervision set up for eating. Review of the care plan revised [DATE], showed Resident #26 was at risk for respiratory infection related to COVID-19 with interventions including emphasize good hand washing techniques to all direct care staff. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #26 test result showed [MEDICAL CONDITION] was not detected on [DATE]. Review of the Respiratory Symptoms Screening Tool dated [DATE], showed Resident #26 had chills and a temperature of 100.0 degrees Fahrenheit (F) or greater in the last 24 hours. On [DATE] Resident #26 had a new onset of Malaise. On [DATE], Resident #26 had a temperature of 100.5 degrees, and a new onset of Shortness of Breath (SOB) and chills. Review of the physician's orders [REDACTED].#26 was sent to the emergency room . Review of the Progress Note dated [DATE], showed Resident #26 was transferred to the emergency room (ER) by Emergency Medical Services (EMS). Review of the Hospitalist Admission Note dated [DATE] for Resident #26 showed .Labs: Result [DIAGNOSES REDACTED]-CoV-2 .Detected . Review of the Critical Care Medicine Death Summary dated [DATE] showed Resident #26 was admitted to the hospital on [DATE] and the date of death was [DATE] due to .Acute hypoxemic [MEDICAL CONDITION] due to COVID-19 pneumonia with multisystem organ failure . Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the comprehensive MDS assessment dated [DATE], showed Resident #28 scored a 5 on the BIMS assessment which indicated severe cognitive impairment. The MDS assessment showed Resident #28 required limited 1 staff assistance for bed mobility, transfers, and walking in room, and required extensive 1 staff assistance with dressing, toileting, and hygiene. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #28 received a positive test result on [DATE]. Review of the Respiratory Symptoms Screening Tool dated [DATE]-[DATE] showed Resident #28 was afebrile and asymptomatic. On [DATE] at 5:38 PM and [DATE] at 3:28 AM, Resident #28 had a new onset of body aches and chills. The Respiratory Symptoms Screening Tool for Resident #28 dated [DATE] - [DATE] showed the assessments were only completed 2 times a day and not the 3 times a day as recommended by the HAI Preventionist on [DATE]. Review of the Progress Note dated [DATE] at 2:00 AM, showed Resident #28 was transferred to the ER. Review of the emergency room Nurse Documentation dated [DATE], showed Resident #28 was .COVID positive, had a chest x-ray today and has bilateral pneumonia . Review of the Progress Note dated [DATE], showed Resident #28 expired on [DATE]. Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] showed Resident #22 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. The MDS assessment showed Resident #22 required extensive assistance of 2 staff for dressing, toileting, and hygiene, was total dependent on 2 staff for bed mobility, and required extensive assistance of 1 staff for eating. Review of the Respiratory Symptoms Screening Tool dated [DATE] - [DATE], showed Resident #22 was asymptomatic and afebrile until [DATE] when Resident #22 was reported as having an occasional non-productive cough and was afebrile. On [DATE] Resident #22 was reported as having a temperature of 99.1 degrees F, cough, and chills. Review of the [DIAGNOSES REDACTED] CoV-2 test reported date [DATE] showed Resident #22 had a positive result for COVID-19. Review of Resident #22's Physician order [REDACTED]. Review of the Hospital Discharge Summary dated [DATE], showed Resident #22 was admitted to the hospital on [DATE] with the chief complaint of SOB. The Discharge Summary showed .Patient (Resident #22) with history of renal transplant, end-stage dementia who presented for SOB after being found positive for COVID-19. Patient required ICU level care as oxygenation worsened .transitioned to [MEDICAL CONDITION] (bilevel positive airway pressure) but unfortunately his respiratory status continued to decline on maximum settings .the patient did not want intubation .(Resident #22's family member) decided to make patient hospice and he was admitted for inpatient hospice care. Today ([DATE]) his respiratory rate slowed. Hospice came and pronounced the patient .Expired . Resident #27 was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the care plan initiated [DATE] and revised on [DATE] showed, Resident #27 was at risk for respiratory infection related to COVID-19 with interventions including emphasize good hand washing techniques to all direct care staff. Review of the 5 Day MDS assessment dated [DATE] showed Resident #27 scored a 3 on the BIMS assessment which indicated severe cognitive impairment. The MDS assessment showed Resident #27 required extensive 2 staff assistance for bed mobility, transfers, dressing, toileting, and hygiene. Review of the Respiratory Assessment Screening tool for Resident #27 dated [DATE] - [DATE] showed the assessments were only completed 2 times a day and not the 3 times daily as recommended by the HAI Preventionist on [DATE]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #27 received a positive test result on [DATE]. Resident #27's Progress Note dated [DATE] at 9:20 AM showed .staff entered room to find resident unresponsive to verbal stimuli, with further assessment nurse noted that resident was not breathing and she was unable to find a pulse .pronounced at 9:44 AM . Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the annual MDS assessment dated [DATE] revealed Resident #23 scored a 2 on the BIMS assessment which indicated severe cognitive impairment. The MDS assessment showed Resident #23 required extensive 2 staff assistance for bed mobility, toileting, and hygiene, and required extensive 1 staff assistance for eating. Review of the [DIAGNOSES REDACTED] CoV2 test dated [DATE], showed Resident #23 received a positive test result on [DATE]. Review of the Respiratory Assessment Screening Tool dated [DATE] - [DATE] showed the assessments were completed 2 times a day and not the 3 times a day as recommended by the HAI Preventionist on [DATE]. Review of the Progress Note dated [DATE] showed Resident #23 had a decline, poor appetite, cough and congestion. Review of the Progress Note dated [DATE] showed Resident #23 was found without a pulse or respirations .Funeral home notified . Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the annual MDS assessment dated [DATE], showed Resident #25 scored a 7 on the BIMS assessment which indicated severe cognitive impairment. The MDS assessment showed Resident #25 required extensive 2 staff assistance for bed mobility, transfers, and toileting, and was total dependent on 2 staff for hygiene. Review of the Respiratory Screening Assessment Tool dated [DATE] - [DATE] for Resident #25 showed the assessments were only completed 2 times a day and not the 3 times a day as recommended by the HAI Preventionist on [DATE]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #25 received a positive test result on [DATE]. Resident #25's physician's orders [REDACTED].Send resident to .ER . Review of a hospital Discharge Summary dated [DATE] showed Resident #25 was admitted to the hospital with [REDACTED]. Resident #25 was admitted to inpatient hospice for [MEDICAL CONDITION] due to COVID-19. The Discharge Summary showed Resident #25 expired on [DATE]. Resident #24 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the 5 Day MDS assessment dated [DATE] showed Resident #24 scored a 4 on the BIMS assessment which indicated severe cognitive impairment. Resident #24 required extensive 2 staff assistance with bed mobility, and toileting, and required extensive 1 staff assistance with dressing, eating, and hygiene. Review of the care plan revised [DATE], showed Resident #24 was at risk for respiratory infection related to COVID-19 with interventions including emphasize good hand washing techniques to all direct care staff. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #24 received a positive test result on [DATE]. Review of the Respiratory Symptoms Assessment Tool dated [DATE] - [DATE] for Resident #24, showed the assessment were only completed 2 times a day and not the 3 times daily as recommended by the HAI Preventionist on [DATE]. Review of the Progress Note dated [DATE] at 6:30 PM, showed Resident #24 was in bed with respirations uneven and labored, was not eating and had declined. Review of the Progress Note dated [DATE] showed, Resident #24 was found to have no pulse or respirations and was pronounced deceased . Resident #29 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the Respiratory Symptoms Screening Tool dated [DATE] - [DATE] for Resident #29, showed the assessments had only been completed 2 times a day and not the 3 times daily as recommended by the HAI Preventionist on [DATE]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #29 received a positive test result on [DATE]. Review of the Respiratory Symptoms Screening Tool dated [DATE] showed, Resident #29 had a temperature of 99.3 degrees. Review of the 5 day MDS assessment dated [DATE] showed Resident #29 scored a 00 on the BIMS assessment which indicated severe cognitive impairment. Resident #29 required extensive 2 staff assistance with bed mobility, and toileting, required extensive 1 staff assistance with dressing, eating, and personal hygiene. Resident #29's Progress Note dated [DATE] at 11:45 AM showed .In to check this resident at this time .laying in bed with eyes open do look fixed .feet have begun to mottle (irregular coloring of the skin due to decreased blood flow) .did notify DON of .decline . Review of the Progress Note dated [DATE] showed, Resident #29 was pronounced deceased at 1:20 AM by the Registered Nurse (RN) on duty. Resident # 14 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of a care plan initiated on [DATE] and revised on [DATE], showed Resident #14 had an actual infection related to COVID-19 with interventions including emphasize good hand washing techniques to all direct care staff. Review of a 5 day MDS assessment dated [DATE] revealed Resident #14 scored a 3 on the BIMS assessment which indicated severe cognitive impairment. Resident #14 required extensive 2 staff assistance with bed mobility, was total dependent on 1 staff for dressing, eating, and hygiene. Review of the Respiratory Symptoms Screening Tool for Resident #14 revealed assessments were only completed 2 times a day from [DATE] - [DATE] and [DATE] - [DATE] and not the 3 times a day as recommended by the HAI Preventionist on [DATE]. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #14 received a positive test result on [DATE]. Review of the Respiratory Symptom Assessment Tool dated [DATE], [DATE], and [DATE], showed Resident #14 exhibited a cough. On [DATE], Resident #14 had new onset of a sore throat and body aches. Review of the Progress Note dated [DATE], showed Resident #14 had a decline, poor appetite, cough, and congestion. Review of the Progress Note dated [DATE], showed Resident #14 had and active COVID-19 infection and family had requested Resident #14 be transferred to the ER. Resident #14's Hospital Admission History and Physical dated [DATE] showed .Chief Complaint .(Resident #14) tested COVID + (positive) .1 week ago, having increased weakness/AMS (Altered Mental Status) since. has been wearing 4L NC (oxygen 4 liters per minute by nasal cannula) for several days . Review of the Hospital Discharge Summary dated [DATE] showed Resident #14 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED].[MEDICAL CONDITION] due to COVID-19 infection .Acute metabolic [MEDICAL CONDITION] (An alteration of brain function or consciousness due to failure of other internal organs) due to infection and [MEDICAL CONDITION] .COVID 19 pneumonia . Review of the Progress Note dated [DATE], showed Resident #14 was transferred back to the facility and placed back in isolation precautions. Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of a care plan dated [DATE], showed Resident #4 .has actual infection related to COVID-19 . with interventions including encourage resident to wash their hands frequently. Review of the 5 Day MDS assessment dated [DATE] showed Resident #4 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. The MDS assessment showed Resident #4 required extensive assistance of 2 staff for bed mobility, dressing, personal hygiene, and toileting, and was total dependent of 2 staff for transfers. Review of the [DIAGNOSES REDACTED] CoV-2 test date [DATE], showed Resident #4 received a positive test result on [DATE]. The Respiratory Symptom Assessment Tool for Resident #4 dated [DATE] - [DATE] was only completed 2 times a day and not 3 times daily as recommended by the HAI Preventionist on [DATE]. Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. The care plan dated [DATE] showed Resident #5 had [MEDICAL CONDITION] with the interventions of .Check breath sounds and observe for labored breathing . The care plan revised on [DATE] showed Resident #5 had an actual infection related to COVID-19 with interventions including emphasize good hand washing techniques to all direct care staff. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #5 received a positive test result on [DATE]. The 5 Day MDS assessment dated [DATE] showed Resident #5 scored a 5 on the BIMS assessment which indicated severe cognitive impairment. The MDS assessment showed Resident #5 required extensive assistance of 2 staff for bed mobility, and toileting and was total dependent of 2 staff for dressing, and hygiene. Review of the Respiratory Symptoms Assessment tool showed Resident #5 complained of a sore throat on [DATE]; complained of body aches on [DATE] and [DATE]; had a temperature of 99.1; a sore throat, body aches, and chills on [DATE]; and body aches and chills on [DATE]. The Respiratory Symptoms Assessment Tool for Resident #5 dated [DATE] - [DATE] showed the assessments were only completed 2 times a day and not the 3 times daily as recommended by the HAI Preventionist on [DATE]. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of the care plan dated [DATE], showed Resident #6 had an actual infection related to COVID-19 with interventions including emphasize good hand washing techniques to all direct care staff. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #6 received a positive test result on [DATE]. Resident #6's 5 Day MDS assessment dated [DATE] showed Resident #6 scored a 1 on the BIMS assessment which indicated severe cognitive impairment. Resident #6 required extensive 2 staff assistance for bed mobility, extensive 1 staff assistance for dressing, hygiene, and toileting, and set up supervision for eating. Review of the Respiratory Systems Screening Tool for Resident #6 dated [DATE] - [DATE] showed the assessment screenings were only completed 2 times a day and not the 3 times daily as recommended by the HAI Preventionist on [DATE]. Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. The annual MDS assessment dated [DATE] showed Resident #7 scored a 3 on the BIMS assessment which indicated severe cognitive impairment. Resident #7 required extensive 2 staff assistance with bed mobility, transfers, toileting, and required extensive 1 staff assistance with dressing, and personal hygiene. Review of a care plan revised on [DATE] showed on [DATE] Resident #7 was at risk for Respiratory infection related to COVID-19 with interventions including emphasize good hand washing techniques to all direct care staff. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #7 received a positive test result on [DATE]. The Respiratory Symptoms Screening Tool dated [DATE]-[DATE] for Resident #7 was reviewed. On [DATE] Resident #7 had symptoms of loss of taste and smell; on [DATE] Resident #7 had a new onset of cough; On [DATE] and [DATE] Resident #7 complained of a new onset of body aches. The respiratory Symptoms Screening Tool dated [DATE]-[DATE] showed Resident #7 the assessments were only completed 2 times a day and not the 3 times daily recommended by the HAI Preventionist on [DATE]. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. The 5 Day MDS assessment dated [DATE] showed Resident #8 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Resident #8 required extensive assistance of 2 staff for bed mobility, extensive assistance of 1 staff for eating, and toileting, and was totally dependent on 1 staff for personal hygiene, and dressing. Review of a care plan revised [DATE], showed Resident #8 had an Activities of Daily Living (ADL) self-care deficit related to [MEDICAL CONDITION]. The care plan revised on [DATE] showed Resident #8 had an actual infection related to COVID-19 with interventions including emphasize good hand washing techniques to all direct care staff. Review of the [DIAGNOSES REDACTED] CoV-2 test date [DATE], showed Resident #8 received a positive test result on [DATE]. Review of the Respiratory Symptom assessment dated [DATE]-[DATE] showed Resident #8 was assessed twice daily and remained afebrile and asymptomatic of COVID-19. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #8 received a positive test result on [DATE]. The Respiratory Symptom Assessment Tool dated [DATE]-[DATE] for Resident #8, showed the assessments were only completed 2 times a day and not the 3 times daily as recommended by the HAI Preventionist on [DATE]. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Review of a care plan dated [DATE] and revised [DATE] showed Resident #9 had an ADL self-care performance deficit related to the [DIAGNOSES REDACTED].#9 had an actual infection related to COVID-19 with interventions including emphasize good hand washing techniques to all direct care staff. Review of the [DIAGNOSES REDACTED] CoV-2 test dated [DATE], showed Resident #9 received a positive test result on [DATE]. < (TRUNCATED)

Based on review of facility policy, medical record review, observation, and interview, the facility failed to maintain dignity while providing care for 1 resident (#38) and failed to maintain dignity by gaining permission prior to entering the resident's rooms for 4 residents (#88, #11, #59, #42, #9) of 29 residents reviewed. The facility's failure resulted in actual harm for resident #38. The findings included: Review of facility policy, Dignity, revised 6/17/08 revealed, .All residents are treated in a manner and in an environment that maintains and enhances each resident's dignity and respect in full recognition of his or her individuality .Respecting residents' private space .Assisting residents' in daily care in a dignified manner . Medical record review revealed Resident #38 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored a 10 on the Brief Interview for Mental Status (BIMS), indicating the resident had moderately impaired cognitive skills, required extensive assistance of 2 persons for bed mobility, and was totally dependent for toilet use. Observation and interview with Resident #38 on 4/6/16 at 10:25 AM revealed the resident lying on the bed in the resident's room. Continued interview with the resident revealed it often took 1 hour for the call light to be answered on the night shift. Continued interview revealed 2 Certified Nursing Assistants (CNAs) usually worked together on the night shift. Further interview revealed the resident needed to use the bedpan or go to the bathroom when the call light was pressed. Continued interview revealed the resident stated the staff would not give her a bedpan or take her to the bathroom because it took 2 assistants to assist with the bedpan or going to the bathroom. Further interview revealed the resident was aware of the need to urinate, however staff members had told her to go in her diaper. When asked how it made her feel to not be taken to the bathroom and be incontinent in her diaper/incontinence brief the resident stated it didn't make her feel good and she felt humiliated. Interview with Licensed Practical Nurse (LPN) #2 (has worked at the facility for approximately [AGE] years, was familiar with Resident #38 and was responsible for the resident's care on 4/6/16) on 4/6/16 at 11:55 AM, in the hallway revealed the resident always knew her family members, was having a good day today was alert and had called the nurse by name. Continued interview revealed the resident had always told her the truth. Interview with Registered Nurse (RN) #1 on 4/6/16 at 12:10 PM, in the hallway revealed she could not recall any instance in which Resident #38 had told her anything not true about another resident or staff member. Interview with Licensed Practical Nurse (LPN) #6 (has worked at the facility approximately [AGE] years and familiar with Resident #38) on 4/6/16 at 12:00 PM, in the MDS office revealed Resident #38 had never stated anything untrue about any staff member or other resident. Interview with the Director of Nursing (DON) on 4/6/16 at 4:42 PM, in the DON's office revealed Resident #38 was very interviewable and it was not acceptable for a resident to be told to use their diaper/incontinent brief. Continued interview with the DON confirmed Resident #38's dignity was not maintained. Observation on 4/6/16 at 11:57 AM, in the North 20 hall revealed CNA #3 failed to knock before entering Resident #88 and #11's room. Interview with CNA #3 at 11:58 AM, outside of the resident's room confirmed the CNA failed to knock before entering the resident's room. Interview with the DON on 4/7/16 at 1:15 PM, in the DON's office confirmed the facility failed to maintain dignity for Resident #88 and #11 per facility policy. Observation on 4/6/16 at 11:54 AM, in the North 20 hall revealed CNA #1 knocked on the door but failed to wait for permission to enter Resident #42 and #59's room. Interview with CNA #1 at 11:55 AM, outside of the resident's room confirmed the CNA failed to wait for permission to enter the resident's room. Interview with the DON on 4/7/16 at 1:15 PM, in the DON's office confirmed the facility failed to maintain dignity for Resident #42 and #59 per facility policy. Observation on 4/6/16 at 9:12 AM, on the 10 hallway revealed LPN #1 knocked on Resident #9's door and entered the room with medication in a cup without requesting permission to enter the resident's room. Further observation revealed Resident #9's privacy curtain was pulled covering the resident's private space near the door. Continued observation revealed CNA #2 and CNA #3 walked out of the room with LPN #1. Interview with CNA #3 on 4/6/16 at 9:16 AM, in the 10 hallway confirmed she and CNA #2 were providing resident care. Interview with LPN #1 on 4/6/16 at 9:21 AM, at the north hallway confirmed I just knocked and walked in (resident's room). LPN #1 confirmed she did not request permission or wait for permission to enter the resident's room after knocking on the door of Resident #9's room.