Every finding on record at Four Oaks Health Care Center

Based on review of facility policy, review of medical records, review of facility investigation documentation, and interviews, the facility failed to protect the residents' right to be free from physical abuse by a staff member for 1 resident (Resident #21) of 15 residents reviewed for abuse. The facility was cited at Past Non-Compliance for F-600. Non-compliance began on 6/1/2025 and ended on 6/6/2025.The facility is not required to submit a Plan of Correction for F-600.The findings include:Review of the facility's undated policy titled, Abuse, Neglect, and Exploitation, revealed .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse .Abuse means the willful infliction of injury .or punishment with resulting physical harm, pain or mental anguish .it includes .physical abuse .includes but not limited to hitting, slapping .The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written .prohibiting and preventing all forms of abuse .Recognizing signs of abuse .Identifying, correcting and intervening in situations in which abuse .is more likely to occur .assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms . Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including Difficulty in Walking, Chronic Kidney Disease Stage 4, and Lack of Coordination. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #21 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident had severe cognitive impairment. The resident required partial/moderate assistance from staff with toileting hygiene, personal hygiene, and transfers. Review of a comprehensive care plan for Resident #21 revised 3/18/2025, revealed .requires assistance with ADLS [activities of daily living] .Transfer .Partial/Moderate assistance .exhibiting affectionate behaviors towards staff .Assist the resident to develop more appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately .If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident .has impaired cognitive function . Review of a witness statement dated 6/1/2025, revealed .I [Housekeeping Aide (HA) A] am reporting .incident on .around 9:00 am [AM] on May 31, 2025 [5/31/2025] [Resident #21] grabbed my bottom [buttocks], I was not thinking and my reaction caused me to open handed smack him, I left no marks .back of hand rt [right] side of face .He was in sitting position in bed . Review of a BIMS assessment for Resident #21 dated 6/1/2025, revealed a score of 3 which indicated the resident had severe cognitive impairment. Review of a facility reported incident dated 6/1/2025, revealed .on 6/1/25 [6/1/2025], [perpetrator, HA A] reported that on 5/31/25 [5/31/2025] at approx [approximately] 9am [9:00AM] .she was grabbed by [Resident #21] as she was cleaning his room and responded by turning and backhanding him across the face .Resident has Bims [BIMS] of 3 .When NHA [Nursing Home Administrator] interviewed on 6/1/25 [6/1/2025] he states he has no recollection of any thing [anything] happening yesterday .He denied that he grabbed her and he states no one has touched him .full body assessment and MD/PA [Medical Doctor/Physician Assistant] to assess .Will also be followed by Psych [Psychiatric Provider] and Social Services for Psychosocial Well being [wellbeing] .Interview of all residents with BIMS of 11 or greater to ensure no other incidents have occurred .Skin assessments completed for all resident [residents] with BIMS of less than 11 to ensure no injuries .are present .none found .Staff member was immediately suspended .until investigation has been completed .Door codes changed .All staff educated .preventing, reporting, and identifying abuse immediately or before next scheduled shift .MD, APS [Adult Protective Services], Ombudsman and conservator notified .Adhoc [an urgent meeting] QAPI [Quality Assurance Performance Improvement] to implement all interventions . Review of a facility 5 day follow up investigation dated 6/6/2025, revealed .Resident [Resident #21] (BIMS 3) denies .anything occurred .The conervator [Conservator] was notified .police dept. [department], APS, and the ombudsman were all notified of reported incident .No witnesses of alleged incident .On 6/1/25 [6/1/2025] an interview with [HA A] .reported she had a trauma response to inadvertently strike him [Resident #21] on the face with an open back of her hand .All other residents that had a BIMS of 11 or higher were interviewed .All staff were educated in identifying, preventing and reporting abuse and on the abuse policy of facility .Resident was assessed by Psych NP [Psychiatric Nurse Practitioner], Social worker and Facility Physician Assistant .All staff were educated and tested on recognizing, preventing, and reporting abuse . The staff member [HA A] .was terminated .Staff will continue to receive monthly abuse training for not less than 6 months .resident [Resident #21] was assessed for psychosocial concerns and signs/ symptoms of abuse for 3 days . During a telephone interview on 12/2/2025 at 1:40 PM, Registered Nurse (RN) Supervisor stated she was able to recall the allegation of physical abuse which involved HA A and Resident #21. The RN Supervisor stated several months ago (unable to recall exact date) HA A had reported to her while HA A was cleaning Resident #21's room, Resident #21 had grabbed HA A on the buttocks and out of reflex she smacked Resident #21. The RN Supervisor stated she immediately notified the Abuse Coordinator/ Administrator by telephone and made her aware of the situation. The RN Supervisor stated she supervised HA A at the nurses' station until the Administrator arrived at the facility. The RN Supervisor stated when the Administrator arrived at the facility HA A went with the Administrator to the Administrator's office. The RN Supervisor stated she interviewed and assessed Resident #21's skin. The RN supervisor stated Resident #21 did not report he had been smacked. The RN Supervisor stated Resident #21 did not have any redness or signs of injury. The RN Supervisor stated she did recall receiving education on Abuse by the facility that same day. The RN Supervisor stated she was familiar with HA A and worked with her several times (about every other weekend). The RN Supervisor stated she had never witnessed or received reports from staff or residents of HA A being abusive towards any of the residents. During an interview on 12/3/2025 at 8:35 AM, the Administrator stated she recalled the allegation of Physical Abuse which involved HA A smacking Resident #21. The Administrator stated on 6/1/2025 she had received a telephone call from the RN Supervisor who reported to her HA A had reported Resident #21 had grabbed HA A on the buttocks and HA A smacked Resident #21. The Administrator stated she immediately went to the facility and got a statement from HA A and then placed HA A on suspension pending results of an investigation. The Administrator confirmed HA A had stated to her while HA A was cleaning Resident #21's room he had grabbed her (HA A) on the buttocks, and as a response she (HA A) smacked him (Resident #21) across the face using the back of her hand. The Administrator stated during an interview with Resident #21 on 6/1/2025 Resident #21 did not report being smacked or grabbing HA A on the buttocks. The Administrator stated a skin assessment was completed on Resident #21 on 6/1/2025 which revealed no redness or signs of injury. The Administrator stated the local police department, Adult Protective Services, and the local State Ombudsman were notified of the alleged incident. The Administrator stated all residents in the facility with a BIMS of 11 or higher were interviewed and they reported no concerns of being abused. The Administrator stated skin assessments were conducted on all residents in the facility with a BIMS of less than 11 which revealed no concerns or signs of physical abuse. The Administrator stated 100% of all staff members in the facility were educated on preventing, recognizing, and reporting abuse. The Administrator further stated HA A employment was terminated as of 6/2/2025. The Administrator stated the alleged date of compliance was 6/3/2025. During a telephone interview on 12/3/2025 at 9:19 AM, HA A stated she recalled the alleged incident which involved herself and Resident #21. HA A stated several months ago (unable to recall the exact date) she was cleaning Resident #21's room and when she bent over Resident #21 grabbed her on her behind (buttocks). HA A stated out of response she smacked him [Resident #21] across the face using the back of her hand. HA A confirmed contact was made between the back of her hand and Resident #21's face. HA A further confirmed she meant to smack him. HA A stated .I didn't hit him hard enough to leave any marks just enough for him to know he should not grab people like that .no man should grab a woman like that .I don't even allow my husband to touch me like that . HA A further stated she reported the incident to a nurse at the facility (unable to recall the name of the nurse) and the Administrator. HA A continued to state she no longer worked for the facility. A plan of correction was developed from 6/1/2025- 6/3/2025 to address the deficient practice identified. The corrective actions were validated on-site by the surveyor on 12/1/2025-12/3/2025 through interviews and review of facility documents. Local police department, Adult Protective Services, and the Local state Ombudsman were notified of the alleged incident. The facility's Plan of Correction included the following:1). Resident #21 was evaluated by a Psychiatric Nurse Practitioner, the facility Social Worker, and the facility's Physician Assistant with no concerns of injury or psychosocial harm. 2). All residents in the facility with a BIMS of 11 or higher were interviewed with no concerns for abuse. 3). Skin assessments were conducted on all residents in the facility with a BIMS of less than 11. 4). 100% of active staff were educated regarding preventing, recognizing, and reporting abuse from 6/1/2025 through 6/3/2025. Surveyor verified on site the following:1). Reviewed and validated onsite: Education related to abuse and abuse reporting with sign in sheets by all staff. 2). Reviewed and validated onsite: Skin Assessments conducted on 6/1/2025 for Residents with a BIMS of less than 11 with no concerns.3). Reviewed and validated onsite: Interviews conducted on 6/1/2025 for Residents with BIMS of greater than 11 with no concerns.4). Reviewed and validated onsite: The alleged abuse was reviewed in a at risk Quality Assurance Performance Improvement (QAPI) meeting held on 6/1/2025. Multiple staff interviews in various departments during the survey 12/1/2025 through 12/3/2025, staff verified through interviews they had received education on preventing, recognizing, and reporting abuse and were knowledgeable about the policies.The deficient practice was cited as past noncompliance for F-600 and the facility is not required to submit a plan of correction.Non-Compliance began on 6/1/2025 and ended on 6/6/2025 after the 5 day follow up investigation had been completed.

Based on review of facility policy, review of medical records, and interview, the facility failed to resubmit a Pre-admission Screening and Resident Review (PASARR) timely after a new mental health diagnosis was added for 1 resident (Resident #9) of 5 residents reviewed for PASARR.The findings include: Review of the facility's undated policy titled, Coordination with PASARR Program, revealed .This facility coordinates assessments with the .[PASARR] program .to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services .appropriate to their needs .any level II resident who experiences a significant change in status will be referred promptly to the mental health or intellectual disability authority for additional resident review . Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnosis including Anxiety Disorder, Lack of Coordination and Muscle Weakness. Continued review revealed the resident received a new mental health diagnosis of Paranoid Schizophrenia on 4/21/2024. Review of an approved PASARR Level II screen for Resident #9 dated 5/16/2023, revealed .If you have .changes in your physical or mental health .The nursing home must submit a new .screening . Review of the Comprehensive Care Plan revision on 4/23/2024 revealed Resident #9 had a care plan for PASRR. Review of an annual Minimum Data Set (MDS) assessment for Resident #9 dated 1/3/2025, revealed Resident #9 had an active diagnosis which included Schizophrenia. Review of the medical record revealed a new PASARR for Resident #9 had not been submitted after a new mental health diagnosis was added of Paranoid Schizophrenia 4/21/2024. During a record review and interview on 12/3/2025 at 7:55 AM, the Administrator and Director of Nursing (DON) stated the facility had not identified the need to refer Resident #9 to the State Designated Agency for a new PASARRS after a new mental health diagnosis was added for Resident #9 until 12/3/2025. Continued interview confirmed the facility failed to follow the policy for referring to the state agency for PASARRS after the new mental health diagnosis was added for Resident #9.

Based on facility policy review, medical record review, facility investigation documentation review, and interview, the facility failed to protect the residents' right to be free from accidents related to an elopement for 1 resident (Resident #6) of 6 residents reviewed for accidents. F689 was cited as past noncompliance and the facility is not required to submit a Plan of Correction. The findings include: Review of facility's undated policy titled, Elopement Risk, revealed .This facility ensures that residents who exhibit unsafe wandering behavior and/or at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to unsafe wandering or elopement risk .Elopement occurs when a resident leaves the premises or a safe area without authorization .and/or any necessary supervision to do so Safe premises refers to the facility and premises or grounds of the property . Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including Traumatic Hemorrhage of Cerebrum, Fracture of Base of Skull, and Depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 required set up assistance with activities of daily living (ADL's). Resident #6 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment which indicated moderate cognitive impairment Review of the care plan for Resident #6 dated 8/16/2024 and revised on 10/6/2024 revealed .Resident is at risk for elopement [related to] cognitive impairment, exhibits unsafe wandering behaviors, has expressed desire to leave .Resident prepared letter of plan of living arrangements, including monetary means .Resident will be safe in facility and will not exit facility unsupervised .Distract resident from wandering by offering pleasant diversions, structured activities, food . Review of the facility investigation documentation revealed on 10/6/2025 at 12:30 AM, staff became aware Resident #6 was not in the facility. Resident #6 had broken the lock on his bedroom window and exited the building through the window. The resident left a note stating he did not want to stay at the facility any longer. Review of a Social Services note dated 10/6/2025 revealed .On October 2nd, 3rd and 4th I [Social Services Director] had conversations with [Resident #6] regarding discharge. He expressed that he wanted to leave the facility .He mentioned that he had secured a place in Kingsport and was going to social security [office] on Monday to get back his check .I advised that if he could wait until Monday, we would try to do the discharge safely. On October 6th, I was notified that [Resident #6] was not in building. Upon arrival and calling police a note was found that stated he had decided to leave .His letter is consistent with the plans he shared with me when discussing possible discharge . During an interview on 2/25/2025 at 12:50 PM, The Administrator stated .[Resident #6] left me a note saying he wasn't going to stay any longer .we called the police and reported he had left, and we showed them the note .he broke the lock on the window with a butterknife and went out the window . During a telephone interview on 2/26/2025 at 8:15 AM, Local Police Sergeant stated .I got the call that somebody had gone missing .[facility staff] gave me some information on [Resident #6] .what we determined is he had escaped through the window . During a telephone interview on 2/26/2025 at 8:45 AM, Resident #6's sister stated .[Resident #6] eloped out of a window, he had a traumatic brain injury in July of last year he couldn't care for himself so we put him in [the facility] .he would call me .I told the police he went to Kingsport because I knew he had so called friends there .I got a call from [physician's office] that said [Resident #6] came by yesterday [2/25/2025] to reschedule an appointment that he had missed I have no idea where he is at now .he doesn't want help .he has made that clear . The facility was cited F-689 as past non-compliance. The facility's corrective actions were validated onsite by the surveyor on 3/5/2025. The corrective action plan included a Root Cause Analysis (RCA) Review of the corrective action plan revealed the following: 1. Corrective action (s) accomplished for those residents found to have been affected by the deficient practice: a. On 10/6/2024, Resident #6 was not present in room. elopement procedures were put into place per policy including searching for the resident, securing exits, performing head count, and notifying local police. Interview with the Administrator, the Director of Nursing (DON), and Maintenance Director on 3/5/2025 confirmed elopement procedure was put into place. b. The resident did not return to the facility. Review of Resident #6's medical record, current facility census, and interview with the Administrator and DON on 3/5/2025 confirmed the resident did not return to the facility. c. On 10/6/2024, the residents' elopement risk assessment and care plan were reviewed by Administrator and information given to police. Review of Resident #6's risk assessment and care plan revealed the resident was at risk for elopement interview with a local police Sergeant on 2/26/2025 and the Administrator on 3/5/2025 confirmed the information was given to the local police department. d. On 10/6/2024 all windows and doors throughout facility were checked to ensure proper locking mechanisms were in place by the Maintenance Director and the lock on the resident's room was replaced. Observation of the bedroom window Residents #6 eloped through with the Maintenance Director, review of window lock audit dated 10/6/2024, and interview with the Maintenance Director on 3/5/2025 confirmed windows and doors throughout the facility were checked and Resident #6's window lock was replaced. e. On 10/6/2024, all center door codes were changed by facility Maintenance Director. Doors were set to alarm when opened greater than15 seconds. Doors were set to auto lock upon closure. Observation of 9 of 9 doors and interview on 3/5/2025 with the Maintenance Director confirmed all doors were in working order, codes were changed and not visible to the public or residents, and alarms were set and in working condition. 2. Other residents having the potential to be affected by the same practice and corrective actions taken: a. On 10/6/2024 a 100% review of all resident's elopement assessments was completed to ensure resident assessments were up to date and accurate with changes made as needed. All residents care plans were reviewed to ensure the current assessment was reflected appropriately on the care plan. Review was completed by the DON, Assistant Director of Nursing ( ADON) and Wound Care Nurse (WCN). Review of facility resident elopement system audit form, care plans, midnight census report dated 10/5/2024 and interview with the DON, and ADON, on 3/5/2025 confirmed the review was completed. 3. What measures will be put into place or what systemic changes were made to ensure that the practice does not recur: a. Facility Administration including Administrator, and Staff Development Coordinator (SDC) began educating all staff on 10/6/2024 and continued educating all staff prior to beginning work their next scheduled shift. Education included elopement prevention, importance of privacy with door code including new system related to only staff having code, and new signage to be placed on front door. Additionally, the Elopement Risk Policy and the Abuse, Neglect, and Exploitation Policy were also presented. To ensure retention, all staff completed a post test that required 100% compliance. If a staff member did not meet 100% compliance, reeducation was completed until threshold was achieved. Any staff member that was assigned as needed (PRN), on Paid Time Off (PTO), or on Family Medical Leave (FMLA) will require education and the post test before their next scheduled shift. Observation of two signs at the front entrance to remind people to make sure door lock has engaged and instructions to use the doorbell for staff to open the door, review of facility list of employees, education sign in sheets, and post tests confirmed education was completed on 10/7/2024 interview with multiple staff including Dietary Aide, Social Services, Business Office Manager, Occupational Therapist, Environmental Services Director, Multiple Licensed Practical Nurses (LPNs), Certified Nurse Assistants (CNAs) and 2 night shift CNAs, 1 night shift LPN, and 1 night shift Registered Nurse (RN) confirmed education was completed and the staff were knowledgeable. b. Beginning 10/6/2024 elopement drills were completed on each shift by Maintenance Director and will continue to be completed monthly or as needed. Review of facility elopement drills and interview with the Maintenance Director on 3/5/2025 confirmed elopement drills were completed in 10/2025, 11/2024, and 2/2025. Interview with the Administrator revealed elopement drills were continued quarterly after 11/2024 and were ongoing. c. On 10/6/2024, all outside doors alarms were verified to alarm when open greater than 15 seconds by Maintenance Director. Observation on 3/5/2025 with the Maintenance Director confirmed all outside doors were checked and working properly. d. Window audits will be increased to weekly x4 weeks, then biweekly for 4 weeks until 100% compliance is achieved by Maintenance Director. Audits will then revert to monthly audits. Review of weekly and monthly window lock audit checklist and interview with the Maintenance Director on 3/5/2025 confirmed audits were conducted. 4. Corrective action(s) monitored to ensure the practice will not recur: a. Beginning 10/6/2024, the Maintenance Director will perform manual checks on all windows to ensure latches were secured and doors of the facility had proper function of locks and alarms. These audits will be conducted weekly for 4 weeks, then biweekly for 4 weeks, then monthly as previously required. Any concerns identified will be immediately reported and corrected to the Administrator by the Maintenance Director. Audits will be reviewed in monthly Quality Assurance Performance Improvement (QAPI). Review of QAPI sign in sheets dated 10/6/2024 , 10/28/2024, 12/9/2024, 1/13/2025, and 2/24/2025, Window Lock Audits, Exit Door Locks audits, and interview with the Maintenance Director on 3/5/2025 confirmed the Audits were completed, reviewed monthly in QAPI, and were ongoing. b. Any issues with non-compliance will be presented to the Quality Assessment and Assurance (QAA) Committee (Administrator, Director of Nursing, Medical Director, Assistant Director of Nursing, MDS Coordinator, Social Services Director, Admissions Director, Maintenance Director, Dietary Supervisor, and Environmental Supervisor) for review and resolution. If non-compliance is identified, audits will start back at the beginning occurring weekly for 4 weeks, then biweekly for 4 weeks, then monthly as regularly scheduled. Review of QAA sign in sheets dated 10/6/2024, 10/28/2024, 12/9/2024, 1/13/2025, and 2/24/2025, interview with the Administrator and Maintenance Director on 3/5/2025 confirmed meeting was held with the required member and no new noncompliance was identified.

Based on facility policy review, medical record review, facility documentation, and interview the facility failed to promptly notify family of a room change and of the resident's transportation to a cancelled appointment for 1 Resident (Resident #2) of 5 residents reviewed for resident rights. The findings include: Review of the facility's Policy titled, Notification of Changes undated showed .The purpose of this policy is to ensure the facility promptly informs the resident .resident's representative when there is a change requiring notification .Circumstances requiring notification include .A transfer .from the facility .A change of room .assignment .Additional considerations .Competent individuals .the facility must still .notify resident's representative, if known . Review of the medical record showed Resident #2 was admitted to the facility on [DATE] with diagnoses including Anxiety Disorder, Dementia, and Depression, the resident discharged to a funeral home on 6/17/2023. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #2's Brief Interview of Mental Status (BIMS) score was 10 indicating the resident had moderate cognitive impairment. The resident required assistance of one or more persons with activities of daily living (ADL's). Review of facility's grievance log showed DATE OF GREIVANCE .5/25/2023 .[Resident #2] went to cancelled appointment .DATE COMPLAINANT NOTIFIED .5/25 [5/25/2023] . During an interview on 9/6/2023 at 11:00 AM, the Social Services Director stated .I own that one I messed up there I just forgot to notify them [Resident #2's family] when she [Resident #2] moved rooms I didn't notify the family .she [Resident #2] had 2 different appointment dates for the same doctor she went to the earlier one and the other one got cancelled and I forgot to cancel transportation for the later one but they did get there and realized she didn't have a appointment and they brought her back .I normally call the families and have them meet them there but on that one being cancelled I didn't . During an interview on 9/8/2023 at 10:40 AM, the Administrator stated .she [Social Services Director] did not call her [Resident #2's daughter] right away of the room change .the appointment had been cancelled but the social services director had failed to communicate that with staff and staff did not cancel transportation so staff did get the resident [Resident #2] ready for the appointment transportation did pick her up arrived at the office to find there was not an appointment and brought her back .family would normally be at the appointment but they were not notified .

Based on facility policy review, medical record review, facility investigation, and interview the facility failed to prevent abuse for 1 Resident (Resident #3) of 5 residents reviewed for abuse. The findings include: Review of facility abuse policy titled Abuse, Neglect, and Exploitation undated showed .It is the policy of this facility to provide protections .that prohibit and prevent abuse .Abuse means the willful infliction of injury .Willful' means the individual must have acted deliberately, not that the individual must have intended to inflict injury . Review of the medical record showed Resident #3 was admitted to the facility on [DATE] with diagnoses including Schizophrenia, Anxiety Disorder, and Depressive Episodes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #3's Brief Interview of Mental Status (BIMS) score was 13 indicating the resident was cognitively intact. The resident required assistance of one or more persons with activities of daily living (ADL's). Review of the medical record showed Resident #4 was admitted to the facility on [DATE] with diagnoses including Dementia, Depressive Episodes, and Anxiety. Review of the quarterly MDS assessment dated [DATE] showed Resident #4's BIMS score was 10 indicating the resident had moderate cognitive impairment. The resident required assistance of one person with ADL's. Review of facility investigation showed on 5/31/2023 at 8:08 PM, License Practical Nurse (LPN) #1 heard yelling at the nurses station she immediately went to the nurses station and saw Resident #4 yelling at Resident #3 in front of the nurses station Resident #3 reported Resident #4 kicked her in the knee Resident #3 had a small scratch/scrape on her left leg it was verified a verbal incident occurred that led to physical contact between the two residents Resident #3 did have a minor abrasion as a result. During a telephone interview on 9/7/2023 at 12:35 PM, LPN #1 stated .I was giving meds and heard a altercation near the desk [nurses station] .[Resident #3] said [Resident #4] kicked her in the leg and we lifted the pants leg and seen a little bit of blood and we got them separated . During an interview on 9/8/2023 at 10:40 AM, The Administrator stated .I was notified that evening that [Resident #3] and [Resident #4] had had an incident and [Resident #3] said [Resident #4] had kicked her .we did conclude that [Resident #4] pushed [Resident #3's] leg and by doing so caused the abrasion .

Based on facility policy review, medical record review, observation, and interview the facility failed to maintain infection control for 2 residents (Resident #33 and Resident #41) in contact isolation, failed to maintain infection control for 1 resident (Resident #96) with a foley catheter, and failed to maintain infection control during the medication administration for 1 resident (Resident #28) of 16 residents reviewed. The findings include: Review of the facility policy Isolation Precautions not dated revealed, .Contact precautions are measures that are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the resident or the resident's environment . Resident #33 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Hypertension, Anxiety Disorder, and Insomnia. Observation on 2/22/2023 at 8:44 AM, outside Resident #33's room, revealed a sign posted .Stop Contact Precautions .put on gloves before room entry .put on gown before room entry . Continued observation revealed Housekeeper #1 and Housekeeper #2 entered the room and failed to put on gloves or a gown prior to entering the room to obtain dirty linen. Interview with Housekeeper #1 and Housekeeper #2 on 2/22/2023 at 8:45 AM, outside Resident #33's room, confirmed the housekeepers failed to put on gloves or gown prior to entering the contact precaution isolation room. Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 2/23/2023 at 1:06 PM, in the conference room, confirmed I would expect them (staff) to follow the policy (isolation precautions policy). Resident #41 was admitted to the facility on [DATE], with diagnoses including Heart Disease, Chronic Kidney Disease, Heart Failure, and Cirrhosis of the Liver. Observation outside Resident #41's room on 2/21/2023 at 12:21 PM, revealed a sign posted .Stop Contact Precautions .put on gloves before room entry .put on gown before room entry . Continued observation revealed Certified Nursing Assistant (CNA) #1 delivered a meal tray and failed to don gloves prior to entering and setting up the meal tray. During an interview with CNA #1 on 2/21/2023 at 12:22 PM, outside Resident #41's room, confirmed the CNA failed to don gloves as required. The CNA stated .It's something I would normally do . During an interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 2/23/2023 at 1:06 PM, in the conference room, confirmed I would expect them (staff) to follow the policy (isolation precautions policy). Resident #96 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Bipolar Disorder, Anxiety Disorder, Inflammation of Vagina, and Post Operative Incision and Drainage procedure. Observation of Resident #96 on 2/21/2023 at 11:19 AM, in the resident room, revealed Resident #96 resting in the bed with a urinary catheter visible and on the floor beside the bed. Interview and observation with Registered Nurse (RN) #1 on 2/22/2023 at 8:55 AM, revealed Resident #96 resting in the bed with a urinary catheter visible and on the floor beside the bed. Continued interview with RN #1 confirmed she was aware the resident's catheter was on the floor She [Resident #96] doesn't like us to attach it (urinary catheter) to the bed. During an interview with the DON and ADON on 2/23/2023 at 1:06 PM, in the conference room, revealed the DON was aware of the resident not wanting the urinary catheter attached to the bed. Continued interview confirmed the DON was aware catheters were to be kept off the floor to maintain infection control practices. 46931 Resident #28 was admitted to the facility on [DATE], with diagnoses including Unspecified Dementia, Unspecified Intellectual Disabilities, Xerosis Cutis (dry skin), Cognitive Communication Deficit, and Adult Failure to Thrive. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 2, indicating the resident had severe cognitive impairment. Review of a physician's order dated 8/2/2022, showed Resident #28 had an order for .hydrOXYzine HCl [medication used for itching] 25 MG [milligrams] .Give 25 mg by mouth two times a day for itching . During an observation and interview on 2/22/2023 at 8:16 AM, showed Registered Nurse (RN) #1 was preparing medications for administration to Resident #28. RN #1 dropped a Hydroxyzine HCl tablet onto the computer laptop and then picked it up and placed it into Resident #28's medication cup for administration. RN #1 then administered the medications to Resident #28. Following administration of the medications, RN #1 confirmed she dropped the Hydroxyzine HCl tablet onto the computer laptop and she should have discarded the tablet. During an interview with the Director of Nursing (DON) on 2/23/2023 at 1:01 PM, the DON confirmed that her expectation was that if a medication was dropped onto a computer the medication should have been discarded as per standard practice.

Based on facility policy review, medical record review, and interview, the facility failed to determine on admission if the resident had formulated an advance directive or to determine whether the resident wished to formulate an advance directive for 2 residents (Resident #13 and Resident #30) of 16 residents reviewed for advanced directives. The findings include: Review of the facility policy titled, Residents' Rights Regarding treatment and Advanced Directives, undated, stated .On admission, the facility will determine if the resident has executed an advanced directive, and if not, determine whether the resident would like to formulate an advanced directive . Resident #13 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Dysphagia, Heart Failure, Anxiety, and Gastrostomy Status. Review of the admission Minimum Data Set (MDS) dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident had severe cognitive impairment. Review of Resident #13's Admission Agreement dated 1/6/2023, showed it had not been determined if the resident had an advanced directive or if she wanted to formulate an advanced directive. During an interview on 2/22/2023 at 1:37 PM, the Admissions and Marketing Director stated it was her responsibility to assist residents or their family to complete the admission agreement paperwork with the resident. The Admissions and Marketing Director confirmed Resident #13's admission agreement was incomplete, and the facility had not determined upon her admission if she had formulated an advanced directive or if she desired to formulate an advanced directive. During an interview on 2/23/2023 at 1:09 PM, the Director of Nursing (DON) confirmed it was the policy of the facility to determine upon admission to the facility if a resident had formulated an advanced directive or if the resident desired to formulate an advanced directive. The DON confirmed Resident #13 had not been assessed upon admission to determine if she had formulated or wished to formulate an advanced directive. 45837 Resident #30 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Unspecified Dementia, Generalized Anxiety Disorder, and Cognitive Communication Deficit. Review of an admission document dated 8/27/2021, showed consent for admission and treatment, a consent for assignment of pharmacy benefits and a consent for mental health treatment. No documentation showed if the resident had an advance directive or if she wanted to formulate an advance directive. Review of a Physician Orders for Scope of Treatment (POST) form dated 2/1/2023, showed Resident #30 was a Do Not Resuscitate (DNR) with limited additional interventions. Review of a quarterly MDS assessment dated [DATE] showed Resident #30 had severe cognitive impairment. The resident required limited assistance of 1 staff with bed mobility and toilet use, extensive assistance of 1 staff with transfers and supervision with walking and personal hygiene. During an interview on 2/23/2023 at 10:07 AM, the Administrator stated it was the policy of the facility that the staff explained advance directives, and they periodically check to see if a resident or their representative needed to change the status of an advance directive or add a new one. The Administrator confirmed she had no documentation whether the resident had executed an advance directive or not, and she did not have documentation that the facility had given advance directive information to the resident's representative.

Based on medical record review and interview, the facility failed to develop a baseline care plan to address the care and treatment of an indwelling catheter for one resident (Resident #96) of 16 residents reviewed for baseline care plans. The findings include: Resident #96 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Bipolar Disorder, Anxiety Disorder, Inflammation of the Vagina, and post operative Incision and Drainage procedure. Review of a Physician order dated 2/17/2023 revealed, .catheter .every shift for monitoring . Review of Resident #96's current baseline care plan revealed no use of a indwelling catheter, or care and treatment of the residents indwelling urinary catheter. Interview and medical record review with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 2/23/2023 at 1:08 PM, in the conference room, confirmed the baseline care plan failed to address the use, treatment and care of the indwelling urinary catheter for Resident #96.

Based on medical record review and interview the facility failed to revise a care plan to include changes in the plan of care for two residents (Resident #33 and Resident #41) for contact precautions of 16 residents reviewed for transmission precautions. The finding include: Resident #33 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Hypertension, Anxiety disorder, and Insomnia. Review of a Physician order dated 2/20/2023 revealed, .contact isolation r/t (related to) Gastroenteritis: private room, private toileting, all services provided in room . Continued review showed Resident #33's current Plan of Care revealed no documentation of the contact isolation. Resident #41 was admitted to the facility on [DATE] with diagnoses including Heart Disease, Chronic Kidney Disease, Heart Failure, and Cirrhosis of Liver. Review of a Physician order dated 2/20/2023 revealed, .contact isolation r/t (related to) Gastroenteritis: private room, private toileting, all services provided in room . Continued review showed Resident $41's current Plan of Care revealed no documentation of the contact isolation. Interview and review of the Plan of Care with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 2/23/2023 at 1:06 PM, in the conference room, confirmed the Plan of Care was not revised to reflect the Contact Isolation for Resident #33 and Resident #41. 40639

Based on facility policy review, medical record review, observation, and interview, the facility failed to implement a fall intervention to prevent a fall for 1 resident (Resident #3) of 3 residents reviewed for accidents. The findings include: Review of the facility's undated policy titled, Fall Prevention Program, showed .Each resident will .receive care and services .to minimize the likelihood of falls .Implement person centered interventions . Review of the facility's undated policy titled, Fall Risk Assessment, showed .It is the policy of this facility to ensure the facility provides an environment that is free from accident hazards .An 'At Risk for Fall' care plan will be completed .will include interventions .to reduce the risk of an accident . Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Unspecified Dementia, History of Falling, Muscle Weakness and Difficulty Walking. Review of the Care Plan dated 11/24/2020, showed Resident #3 was at risk for falls related to her diagnosis of Dementia with interventions including, .Dycem [a sticky fabric applied to a surface to prevent sliding] to (L) [left] side of bed . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #3 was cognitively intact and required limited assistance of 1 staff for bed mobility, transfer, dressing and toileting. The resident had no falls since prior assessment. Review of a fall investigation dated 1/7/2023, showed an unwitnessed fall happened when Resident #3 stated she was reaching for something and fell to the floor. No injury was observed, and there was no transfer to the hospital. An observation on 2/22/2023 at 8:45 AM, in Resident #3's room, showed the resident lying in bed without Dycem on the bed. During an interview and observation on 2/23/2023 at 10:16 AM, in Resident #3's room, the Director of Nursing (DON) stated when a resident had a fall, new interventions were added to the care plan by the MDS coordinator after an Interdisciplinary team meeting. The DON stated interventions were dated and put on the care profile so that all staff could see the interventions. The DON stated that it was her expectation that staff implemented the interventions. Continued interview at Resident #3's bedside showed no Dycem was on the bed. Resident #3 stated that she wanted the Dycem back on the bed because it kept her from slipping off her bed. The DON confirmed that the intervention of Dycem to the bed had not been implemented to prevent an accident.

Based on facility policy review, facility documentation review, medical record review, observation, and interview, the facility failed to prevent verbal abuse by a staff member to 1 resident (Resident #2) of 8 residents reviewed for abuse. The facility was cited as past noncompliance and the facility is not required to submit a Plan of Correction for F-600. The findings include: Review of the facility policy titled, Resident Right undated, showed .Purpose To establish guidelines for the recognition and respect of resident's rights .General Guidelines .It is our belief that .a resident have the right to expect certain standards of care and considerations while at our facility. You have the right to .Considerate and respectful care, including consideration of psychosocial, spiritual, cultural, and safety needs . Review of the facility policy titled, Abuse, Neglect, and Exploitation undated, showed .Verbal Abuse means the use of oral .communication or sounds that willfully includes disparaging and derogatory terms to residents .or within their hearing distance regardless of their age, ability to comprehend, or disability .New employees will be educated on abuse .Existing staff will receive annual education through planned in-services and as needed .Training topics will include .Prohibiting and preventing all forms of abuse .Identifying what constitutes abuse .Recognizing signs of abuse .Reporting process for abuse .Understanding behavioral symptoms of residents that may increase the risk of abuse .Aggressive and/or catastrophic reactions of resident .Possible indicator of abuse include .Verbal abuse of a resident overheard . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive Care Plan dated 1/26/2022 showed Resident #2 required assistance with Activities of Daily Living (ADLs). The care plan showed the resident had behavioral problems related to .pinches and grabs at staff at times . with interventions including .Explain all procedures to the resident before starting and allow the resident to adjust to changes .Assist the resident to develop more appropriate methods of coping and interacting . Review of the admission Minimum Data Set (MDS) assessment dated [DATE] showed Resident #2 had severe cognitive impairment, had trouble concentrating, and did not exhibit any behaviors during the look back period. The MDS showed Resident #2 required extensive assistance of 2 staff for bed mobility, transfers, dressing, toileting, and hygiene. Resident #2 required extensive assistance of 1 staff for eating and locomotion and received antipsychotic medications. Review of a Reportable Event Form with a Date of Occurrence alleged on 2/22/2022 showed .As [Resident #2] was being moved to another room, and during bed to chair transfer by [CNA #4] .housekeepers observed [Resident #2] reach out towards [CNA #4] .the housekeepers heard [CNA #4] [say] .I told you not to [expletive] pinch or hit me again .the housekeepers reported the words heard to their supervisor and to two other staff [the 2 other staff were unknown] .At an unknown later time .other .staff .reported .this [to the Administrator] .began an investigation Review of the facility memo dated 2/28/2022 and 3/1/2022 (documented on same page) authored by the Regional Director of Operations, showed on 2/28/2022 .Met with .[Administrator] today is his last day as Administrator and was following up on a Verbal Abuse allegation .[Administrator] indicated 'I met with the Resident and her husband .for all purposes she was fine and in her usual state of mind .it was unusual for [CNA #4] to respond that way and felt it was an unintentional response/reaction and that she was very emotionally lately due to being pregnant .[CNA #4] had not been back to work since the incident . Continued review showed CNA #4 resigned from the facility. During an interview on 3/16/2022 at 10:50 AM, Resident #2's spouse stated the Administrator had told him of a CNA who had used some harsh words with Resident #2. Resident #2's spouse stated .She [Resident #2] will hiss and spit at you like a cat . Resident #2's spouse stated the verbal abuse used by CNA #4 towards Resident #2 .was not really abusive in my opinion, because she gets like that with me and I feel like cussing myself .I don't feel like my wife was abused at all .A CNA saying a bad word or using harsh language under the circumstances is not abuse . Resident #2's spouse stated he had wished the incident had not happened but did understand how the incident could have occurred. During an observation on 3/15/2022 at 11:00 AM, showed Resident #2 in her room, the resident did not exhibit any behaviors. During an interview on 3/16/2022 at 9:56 AM, CNA #1 stated he had cared for Resident #2 and at times Resident #2 attempted to scratch, pinch, or hit during resident care due to her cognitive impairment. CNA #1 stated Resident #2 had no change in her demeanor and did not exhibit any behaviors after the allegation of verbal abuse on 2/22/2022. During an interview on 3/16/2022 at 11:25 AM, Licensed Practical Nurse (LPN) #1 stated she worked on 2/22/2022 and observed CNA #4 being loud but did not witness any foul language. During an interview on 3/16/2022 at 11:36 AM, the Housekeeping Director stated on 2/22/2022, the day of the incident, she overheard CNA #4 say to Resident #2 in a high pitched voice .I don't want you scratching me like you did when I got you up .I am pregnant and that hurt me . The Housekeeper Director stated 2 housekeepers (Housekeeper #1, and #2) who were in the doorway of Resident #2's room earlier that day, reported to her they overheard CNA #4 say to the resident .don't [expletive] scratch me . The Housekeeping Director stated CNA #4 talked with a high pitch voice, was loud .time but that is just how she is . The Housekeeping Director stated after Housekeeper #2 reported to her what she had overheard CNA #4 say to Resident #2, she instructed the housekeeper to report the incident to the Administrator. The Housekeeping Director stated, Housekeeper #1 told her CNA #4 came back later and apologized for her language.I don't think the girl [CNA #4] meant any harm just for some reason she slipped that day . The Housekeeping Director stated Resident #2 was not upset, was not tearful, or anxious when she was with CNA #4 on that day. During an interview on 3/16/2022 at 12:54 PM, Housekeeper #1 stated CNA #4 was assisting to transfer Resident #2 and Resident #2 started grabbing at CNA #4 and CNA #4 said .don't (expletive) scratch me or hit me . Resident #2 did not exhibit aggression and she did not feel the resident had any intentions of hurting CNA #4. Housekeeper #1 stated that same afternoon she reported the verbal abuse to the Housekeeping Director and stated .I left it there .I didn't speak more of it after that . Housekeeper #1 stated CNA #4 approached her later that day and apologized for the language she used during the care of Resident #2. Housekeeper #1 further stated Resident #2 did not appear to be in any distress after the incident. During an interview on 3/16/2022 at 1:33 PM, CNA #3 stated CNA #4 had asked for her help to change Resident #2 on the 2nd dry round on the day of the incident because CNA #4 had told her Resident #2 had been grabbing and hitting her that day when she was providing care to the resident. CNA #3 stated while she was assisting CNA #4 to provide care to Resident #2, the resident was grabbing and pinching CNA #4 and CNA #4 asked Resident #2 to please stop. CNA #3 stated CNA #4 did not use any curse words and was not abusive at all to the resident. CNA #4 stated she did not witness CNA #4 being verbally abusive to Resident #2. During an interview on 3/16/2022 at 1:51 PM, the Administrator (former DON) stated she first learned about the allegation of verbal abuse on Thursday night after being notified by the corporate office, 2 days after the incident and stated the staff had not reported the incident to her. The DON stated when she was notified of the allegation, she reached out to the Admissions Director and was told the Administrator knew the situation and details of what was going on. The DON confirmed the language used by CNA #4 to Resident #2 was inappropriate. The facility immediately implemented corrective actions. The facility's corrective actions were validated onsite by the surveyor on 3/16/2022. The corrective action plan included the following: On 3/16/2022, the surveyor verified by 8 random resident interviews, interviews of 3 LPN's, 3 CNA's, 2 housekeepers, and 1 Housekeeping Director, the facility had interviewed and inquired about abuse by any staff including by CNA #4 and no other allegations were noted. The surveyor verified by 8 random resident interviews, the facility staff had discussed abuse and abuse reporting with them and the 8 residents did not have any concerns of abuse. On 3/16/2022, the surveyor verified the Administrator had been terminated by interview with the Director of Operations, due to the Administrator's failure to immediately investigate and report an allegation of abuse which occurred on 2/22/2022. On 3/16/2022, the surveyor verified by interview with the Administrator, Admissions Director, Business Office Manager, and the Housekeeping Director they had been educated on the types of abuse, how to recognize abuse, how to respond to allegations of abuse, and reporting of abuse. On 3/16/2022, the surveyor verified by interviews with the Administrator, Admissions Director, Business Office Manager, the Housekeeping Director, 3 LPN's, 3 CNA's, and 2 housekeepers they had been educated on a communication format Whatsapp group chat for an immediate need or response from the administration in the event of abuse. All interviewed staff stated they had been educated by the Regional Director of Operations and the Administration on abuse and abuse reporting and were able to verbalize understanding of action steps to take in the event of abuse. On 3/16/2022, the surveyor verified by review of Inservice Training Sign In Sheets, review of the facility's abuse policy, and interviews with staff, the staff were educated on abuse, abuse reporting, and the facility's abuse policy on 3/1/2022 and 3/9/2022. On 3/16/2022, the surveyor verified by review of the Ad Hoc Quality Assurance Performance Improvement (QAPI) documentation and sign in sheet, the QAPI committee which included the Medical Director initiated a Performance Improvement Plan (PIP) related to the timeliness of investigating and reporting allegations of abuse. All staff were to be re-educated by 3/9/2022. Interviews with staff and review of in-service sign in sheets showed all staff were re-educated on abuse, abuse reporting, communication of abuse to appropriate leadership/administration, and reporting to the state agency and appropriate authorities. On 3/16/2022, the surveyor verified QAPI Performance Improvement Plan (PIP) was initiated on 2/28/2022. Review showed the QAPI committee will conduct monthly audits for 3 months beginning 3/2022-5/2022 to evaluate the effectiveness of the action plans to timely investigate and report allegations of abuse and follow the facility's policy related to abuse. The Facility alleges compliance on 3/9/2022.

Based on review of facility policy, facility documentation review, review of facility investigation, and interview, the facility failed to report an allegation of abuse to the State Agency (SA) within two hours, in accordance with Federal Law, for 1 resident (Resident #2) of 8 residents reviewed for abuse. The facility was cited as past noncompliance and the facility is not required to submit a Plan of Correction for F-609. The findings include: Review of the facility policy titled, Abuse, Neglect, and Exploitation undated, showed .Verbal Abuse means the use of oral .communication or sounds that willfully includes disparaging and derogatory terms to residents .or within their hearing distance regardless of their age, ability to comprehend, or disability .New employees will be educated on abuse .Existing staff will receive annual education through planned in-services and as needed .Training topics will include .Identifying what constitutes abuse .Reporting process for abuse .Possible indicator of abuse include .Verbal abuse of a resident overheard .Investigation of Alleged Abuse .An immediate investigation is warranted when suspicion of abuse .or reports of abuse .occur .Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies as is required .within specified timeframes .Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse .or Not later than 24 hours if the event that cause the allegation do not involve abuse and do not result in serious bodily injury . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive Care Plan dated 1/26/2022 showed Resident #2 required assistance with Activities of Daily Living (ADLs). The care plan showed the resident had behavioral problems related to .pinches and grabs at staff at times . with interventions including .Explain all procedures to the resident before starting and allow the resident to adjust to changes .Assist the resident to develop more appropriate methods of coping and interacting . Review of the admission Minimum Data Set (MDS) assessment dated [DATE] showed Resident #2 had severe cognitive impairment and required extensive assistance of 2 staff for bed mobility, transfers, dressing, toileting, and hygiene. Review of a Reportable Event Form with a Date of Occurrence of 2/22/2022 at 10:00-11:30 AM and a reported date of 2/24/2022 at 7:15 AM, showed .As [Resident #2] was being moved to another room, and during bed to chair transfer by [CNA #4] .housekeepers [Housekeeper #1 and #2] observed [Resident #2] reach out towards [CNA #4] .the housekeepers heard [CNA #4] [say] .I told you not to [expletive] pinch or hit me again .the housekeepers reported the words heard to their supervisor and to two other staff [2 other staff unknown]. At an unknown later time .staff .reported back .[to the Administrator] .began an investigation immediately [2 days after the allegation of verbal abuse] . During an interview on 3/16/2022 at 11:36 AM, the Housekeeping Director stated on 2/22/2022, the 2 housekeepers (Housekeepers #1 and #2) who were in the Resident #2's room reported when Resident #2 was being transferred by the CNA #4, the housekeepers overheard CNA #4 say .don't [expletive] scratch me . The Housekeeping Director stated after Housekeeper #2 reported to her what she overheard CNA #4 say to Resident #2, she instructed Housekeeper #2 to report it to the Administrator. The Housekeeping Director stated 2 days after the incident on 2/24/2022 went to Housekeeper #2 and asked her if she had reported the incident to the Administrator. The Housekeeping Director stated Housekeeper #2 told her she was unable to find the Administrator that day and did report it to him or the DON. The Housekeeping Director stated she asked Housekeeper #2 why she had not gone to find the Administrator to report it, and the housekeeper stated .by that time it was time to go home . The Housekeeping Director confirmed she did not report the allegations of verbal abuse to the Administrator after it was reported to her by the housekeeping staff on 2/22/2022. During an interview on 3/16/2022 at 12:54 PM, Housekeeper #1 stated on 2/22/2022, the day of the incident, Resident #2 was being moved from one room, off isolation, to another room. CNA #4 was assisting Resident #2 with a transfer and observed Resident #2 grabbing at CNA #4. CNA #4, said to Resident #2 .don't (expletive) scratch me or hit me . Housekeeper #1 stated on the afternoon of 2/22/2022, she reported the incident to the Housekeeping Director and .I left it there .I didn't speak more of it after that . Housekeeper #1 stated she received a call from the Administrator 1 to 2 days later and was asked what happened. The day after the call from the Administrator, Housekeeper #1 stated she wrote a statement and gave to the Administrator (3 days after the incident). Housekeeper #1 stated she and Housekeeper #2 had reported the verbal abuse to their supervisor, the Housekeeping Director and did not report the verbal abuse to the Administrator or to the DON. During an interview on 3/16/2022 at 1:16 PM, the Business Office Manager (BOM) stated Housekeeper #2 came to her and had asked who she should report an incident of a CNA being mean to a resident. The BOM stated she instructed Housekeeper #2 she should report to the DON, but since the Administrator was in the building and he was the abuse coordinator, she needed to tell him first. The BOM stated, the Administrator inquired about the abuse allegation 2 days later. During an interview on 3/16/2022 at 1:51 PM, the Administrator (former DON) stated she first learned about the allegation of verbal abuse on Thursday night (2/24/2022) after being notified by the corporate office, 2 days after the incident. The DON stated she spoke to the Administrator (no longer employed at the facility) and he stated he had tried to start the initial report to the state agency and could not get into the state system to report and had faxed the report. The current Administrator confirmed the former Administrator did not investigate or report the allegations of verbal abuse to the state agency until 2 days after the incident occurred. During an interview on 3/16/2022 at 2:00 PM, the Regional Director of Operations stated she was notified on Friday (2/25/2022) after the verbal abuse allegation on 2/22/2022 by the Chief Operating Officer. The Director of Operations stated she spoke with the Administrator the following Monday and he had stated he had conducted the investigation and stated as far as he could remember he was told on Thursday and started the investigation at that time. The Director of Operations stated the Administrator had advised her he was notified of the allegation of verbal abuse, which occurred on 2/22/2022, 2 days after the incident on 2/24/2022 and immediately began the investigation. The facility immediately implemented corrective actions. The facility's corrective actions were validated onsite by the surveyor on 3/16/2022. The corrective action plan included the following: On 3/16/2022, the surveyor verified by 8 random resident interviews, interviews of 3 LPN's, 3 CNA's, 2 housekeepers, and 1 Housekeeping Director, the facility had interviewed and inquired about abuse by any staff including by CNA #4 and no other allegations were noted. The surveyor verified by 8 random resident interviews, the facility staff had discussed abuse and abuse reporting with them and the 8 residents did not have any concerns of abuse. On 3/16/2022, the surveyor verified the Administrator had been terminated by interview with the Director of Operations, due to the Administrator's failure to immediately investigate and report an allegation of abuse which occurred on 2/22/2022. On 3/16/2022, the surveyor verified by interview with the Administrator, Admissions Director, Business Office Manager, and the Housekeeping Director they had been educated on how to respond to allegations of abuse and reporting of abuse. On 3/16/2022, the surveyor verified by interviews with the Administrator, Admissions Director, and the Business Office Manager had been educated on a communication format Whatsapp group chat for an immediate need or response from the administration in the event of abuse. All interviewed staff stated they had been educated by the Regional Director of Operations and the Administration on abuse reporting and were able to verbalize understanding of action steps to take in the event of abuse. On 3/16/2022, the surveyor verified by review of Inservice Training Sign In Sheets, review of the facility's abuse policy, and interviews with staff, the staff were educated timely abuse reporting and the facility's abuse policy on 3/1/2022 and 3/9/2022. On 3/16/2022, the surveyor verified by review of the Ad Hoc Quality Assurance Performance Improvement (QAPI) documentation and sign in sheet, the QAPI committee which included the Medical Director initiated a Performance Improvement Plan (PIP) related to the timeliness of investigating and reporting allegations of abuse. All staff were to be re-educated by 3/9/2022. Interviews with staff and review of in-service sign in sheets showed all staff were re-educated on abuse, abuse reporting, communication of abuse to appropriate leadership/administration, and reporting to the state agency and appropriate authorities. On 3/16/2022, the surveyor verified QAPI Performance Improvement Plan (PIP) was initiated on 2/28/2022. Review showed the QAPI committee will conduct monthly audits for 3 months beginning 3/2022-5/2022 to evaluate the effectiveness of the action plans to timely investigate and report allegations of abuse and follow the facility's policy related to abuse. The facility alleges compliance on 3/9/2022.

Based on review of facility policy, medical record review, and interview, the facility failed to report an injury of unknown origin to the state survey agency within 2 hours for 1 resident (#3) of 5 residents reviewed for accidents. The findings included: Review of the facility policy titled Abuse Prevention Policy & Procedure, revised date 8/2017, revealed .An injury should be classified as an 'injury of unknown source' following conditions when both met: 1. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and 2. The injury is suspicious because the extent of the injury or the location of the injury .Investigation - Additionally, the facility will thoroughly investigate all injuries of unknown origin to determine if abuse or neglect was involved .Policy Statement: Any allegation of abuse is reported immediately to the state agency .as required by state and federal guidelines within 2 hours if serious harm or allegations are a result of abuse . Medical record review showed Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident scored a 3, indicating severe cognitive impairment, on the Brief Interview for Mental Status (BIMS). Continued review showed the resident required extensive assistance for bed mobility, transfers, and activities of daily living with 2-person assist. Medical record review of a Nurse Practitioner's (NP) progress note dated 9/7/2021 showed .Patient [Resident #3] seen today due to staff report of increased left hip pain .No falls reported by nursing however, it is very possible patient fell and got herself back up and did not report it . Medical record review of a Nurse's Note dated 9/7/2021 at 1:01 PM showed the resident was seen by the NP for complaints of left hip pain and the NP ordered a x-ray of the resident's left hip. Medical record review of a Mobile Images Patient Report for Resident #3 dated 9/7/2021 showed .Findings: There is a superior dislocation [out of alignment] of the left hip arthroplasty [previous surgical repair of the hip] . Medical record review of a Nurse's note dated 9/7/2021 at 10:20 PM showed Resident #3 was sent to the emergency department (ED) where the dislocation was successfully repositioned and the resident returned to the facility. The family, the Director of Nursing (DON), and the Assistant DON were notified. Medical record review of a Physician's History and Physical dated 9/8/2021 showed Resident #3 underwent a closed reduction of the left hip in the ED on 9/7/2021. During an interview on 12/21/2021 at 2:00 PM, Licensed Practical Nurse (LPN) #1 stated the resident was alert but confused and could be noncompliant with care at times. Further interview revealed the staff was unaware of how Resident #3 injured her hip. During an interview on 12/21/2021 at 2:45 PM, the DON confirmed the facility failed to report an injury of unknown origin to the state survey agency for Resident #3.

Based on review of facility policy, medical record review, and interview, the facility failed to investigate an injury of unknown origin for 1 resident (#3) of 5 residents reviewed for accidents. The findings included: Review of the facility policy titled Abuse Prevention Policy & Procedure, revised date 8/2017, revealed .An injury should be classified as an 'injury of unknown source' following conditions when both met: 1. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and 2. The injury is suspicious because the extent of the injury or the location of the injury .Investigation - Additionally, the facility will thoroughly investigate all injuries of unknown origin to determine if abuse or neglect was involved . Medical record review showed Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident scored a 3, indicating severe cognitive impairment, on the Brief Interview for Mental Status (BIMS). Continued review showed the resident required extensive assistance for bed mobility, transfers, and activities of daily living with 2-person assist. Medical record review of a Nurse Practitioner's (NP) progress note dated 9/7/2021 showed .Patient [Resident #3] seen today due to staff report of increased left hip pain .No falls reported by nursing however, it is very possible patient fell and got herself back up and did not report it . Medical record review of a Nurse's Note dated 9/7/2021 at 1:01 PM showed the resident was seen by the NP for complaints of left hip pain and the NP ordered a x-ray of the resident's left hip. Medical record review of a Mobile Images Patient Report for Resident #3 dated 9/7/2021 showed .Findings: There is a superior dislocation [out of alignment] of the left hip arthroplasty [previous surgical repair of the hip] . Medical record review of a Nurse's note dated 9/7/2021 at 10:20 PM showed Resident #3 was sent to the emergency department (ED) where the dislocation was successfully repositioned and the resident returned to the facility. The Director of Nursing (DON) and the Assistant DON were notified. During an interview on 12/21/2021 at 2:45 PM, the DON confirmed the facility failed to investigate an injury of unknown origin for Resident #3 and failed to follow facility policy.

Based on review of facility policy, medical record review, review of Emergency Medical Services (EMS) documentation, and interview, the facility failed to ensure a completed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's failure to ensure a completed POST form was in the medical record and available to staff placed Resident #1 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) when Resident #1 was found unresponsive and facility staff initiated Cardiopulmonary Resuscitation (CPR) and lifesaving interventions against the resident's and the resident's representative's wishes. The Administrator and the Director of Nursing (DON) were notified of the IJ on [DATE] at 4:30 PM, in the conference room. The facility was cited Immediate Jeopardy (IJ) for F-678 at a scope and severity of J which constitutes Substandard Quality of Care. The IJ was effective on [DATE] and was removed on [DATE] when the facility implemented a corrective action plan. Corrective actions were validated onsite by the surveyor on [DATE]. The IJ was cited as past noncompliance and the facility is not required to submit a Plan of Correction. The findings include: Review of the facility's policy titled Cardiopulmonary Resuscitation (CPR), undated, showed .If a resident experiences a [CONDITION(S)], facility staff will provide basic life support .In accordance with the resident's advance directives . Review of the facility's policy titled Do Not Resuscitate Order [DNR] dated [DATE] showed .To ensure that the resident's wishes are honored with regard to extraordinary measures used to prolong life .Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect .Do Not Resuscitate orders must be .maintained in the residents medical record and on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident expired on [DATE] in the facility. Medical record review of a POST form for Resident #1 dated [DATE] (Resident #1 was scheduled to be admitted to the facility on [DATE], but her admission was delayed until [DATE]) showed .Do Not Attempt Resuscitation .Comfort Measures . The POST form was completed and signed by Nurse Practitioner (NP) #1 on [DATE]. Medical record review of a current care plan for Resident #1 dated [DATE] showed .CODE STATUS: DNR .advance directives will be implemented per resident's choice . Review of EMS records dated [DATE] at 8:00 AM for Resident #1 showed .[facility] staff called .they initiated CPR .staff stated they brought in breakfast and found her [Resident #1] unresponsive .staff stated patient [Resident #1] had a DNR but they could not find it .CPR and ventilation were continued per protocols .After > [greater than] 20 minutes of CPR all EMS providers concluded to terminate all efforts to revive patient . Medical record review of a Nurse's Progress Note dated [DATE] at 9:24 AM showed .[Certified Nursing Assistant (CNA) #2] entered resident [Resident #1's] room at approximately 7:45am, resident unresponsive at that time. [CNA #2] called [Licensed Practical Nurse (LPN) #1] to room. EMS [emergency medical services] then notified and code [CPR] initiated. Family notified. Family expressed to [LPN #1] they would like to withdraw care and cease life saving measures. EMS exited facility .FNP [Family Nurse Practitioner] notified .Resident pronounced [death pronounced] at 9:03am by [Registered Nurse (RN) #1] . During an interview on [DATE] at 12:15 PM, the Director of Nursing (DON) stated .I got the call [on [DATE]] from the nurse [LPN #1] .she said that she went into the [Resident #1's] room after they had taken her breakfast and she didn't have a pulse and wasn't breathing, and she [LPN #1] went to check her code status and they couldn't find the POST form; so they initiated CPR . During an interview on [DATE] at 12:45 PM, LPN #1 stated .that morning [[DATE]] my CNAs took her [Resident #1's] breakfast tray in and when they went to pick up the tray, she was not responsive. I went and checked on her. She was nonresponsive .She had no pulse and she wasn't breathing .I went to find her POST form code status and it was not on file .I looked on the computer and there was no POST form scanned in .Then I went to the folder behind the nurses station and she [Resident #1] had a face sheet, but no POST form was on file .I called EMS and started CPR .It was me and my CNA [CNA #1] who did CPR .[CNA #2] was the one who found her .I did CPR until EMS got there .EMS took over the code .I don't know how long I performed CPR .They [EMS] asked for the POST form and I told them that we did not have one on file and they said they had to perform the code since we didn't have one on file .They couldn't revive her and they pronounced her here at the facility .We looked on the hospital discharge records from before she came here and she was a DNR on those records, but EMS wouldn't take it because it wasn't a signed form. It was just a note in the hospital records; not an order or a POST form . During a telephone interview on [DATE] at 10:00 AM, CNA #1 stated .I was passing trays .I was coming out of a room and I saw her [LPN #1] running into her [Resident #1's] room and when I got in there [LPN #1] had started doing compressions [chest compressions] .I ran and got the mouth piece and started doing the airway .I cleared her throat .and I put the mouth piece that goes over their mouth and I pumped the bag [Ambu bag, device used to provide ventilation] while [LPN #1] did the compressions .I did it [provided ventilation] until EMS told me to quit doing it .one of the EMS took over and then I stopped .I went back to the nurses station .[RN #1] was coming in to pronounce [Resident #1 deceased ] .I didn't know where the DNR [POST form] was . During an interview on [DATE] at 11:30 AM, the Admissions Director/Coordinator stated .I got the family [Resident #1's family] to fill it [POST form] out to me verbally and I took it to the doctor's box to be signed [on [DATE]] .I did not tell the nurses. I just put it in the box .I didn't tell anyone . During a phone interview on [DATE] at 11:55 AM, LPN #2 stated .when they [staff] said that they were coding [performing CPR on Resident #1], I searched the computer and I didn't find anything .I found no POST form at all .It is usually scanned in [the Electronic Medical Record (EMR)] .After EMS was gone I started reading back through the hospital notes trying to find out what her [Resident #1's] code status was .I never found a completed POST form for her . During a telephone interview on [DATE] at 1:30 PM, CNA #2 stated .I found the resident [Resident #1] nonresponsive in her room .20 minutes earlier I had just talked to her, and she was fine .I ran to get the crash cart [cart containing equipment and medications used in an emergency] and the nurse was trying to find the DNR [post form] .[LPN #1] started CPR . During an interview on [DATE] at 2:45 PM, NP #1 stated .whatever day I get it [POST form] in my box is what day I sign it .I signed it [Resident #1's POST form] on ,d+[DATE] [[DATE]] so that is when I received it .I have a box at the nurses station and they [staff] put the POST forms in there .[Admissions Director/Coordinator] gets them [resident/resident's representative] to fill it out and it [POST form] gets put in my box for me to sign .if I am here, they [staff] bring it to me. But if I'm not here, it gets put in my box and I check it first thing when I get here .after I sign .I put it in the medical records box at the nurses station so it can be scanned into the chart and copied and put into the binder [code book] .I am here every day Monday through Friday .I do not think she [Resident #1] should have had CPR performed .I would have expected them [staff] to call the family and keep her comfortable .not do CPR .she should not have had CPR performed . During an interview on [DATE] at 3:00 PM, RN #1 stated .I received a call and they [staff] said they needed me to come down and pronounce [declare time of death] .I went down and pronounced her [Resident #1] .I did not see any POST form for her . During a telephone interview on [DATE] at 3:15 PM, Resident #1's sister stated .they [facility staff] called me and said that [Resident #1] had passed away .she was not supposed to receive CPR .she didn't want CPR. She didn't want that . During an interview on [DATE] at 10:35 AM, the Minimum Data Set (MDS) Coordinator stated .I filled out her [Resident #1's] care plan .I got the information from her hospital discharge records .that's where I saw that she was a DNR . During an interview on [DATE] at 12:40 PM, the Medical Director stated .she [Resident #1] should not have had CPR performed. It's not what the patient wanted .the problem was it [POST form] wasn't available when it should have been . During an interview on [DATE] at 1:00 PM, the Admissions Director/Coordinator stated .I picked the signed copy [signed POST form] up from the medical records box at the nurse's station and the signed copy got left with the admission paperwork in my office .I didn't scan it into the medical record .I found it with the admissions paperwork the next day after the incident . The facility's corrective actions were validated onsite by the surveyor on [DATE]. The corrective action plan included the following: On [DATE], the facility initiated a Root Cause Analysis Summary. Review of the Root Cause Analysis Summary and interview on [DATE] at 1:30 PM, with the DON, confirmed the root cause analysis was initiated on [DATE]. On [DATE], the DON reviewed all in house resident's medical records to ensure a POST form and DNR orders were in the EMR and code book (resident code status book). Review of the code book, review of the facility's midnight census report dated [DATE], and interview on [DATE] at 12:15 PM, with the DON, confirmed the audit was completed on [DATE] with no errors identified. On [DATE] - [DATE], the DON or her designee provided education to licensed staff regarding CPR, the DNR policy, and the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Education was provided to the Admissions Director/Coordinator regarding the process for POST forms: POST forms should be completed and signed during pre-admission process, or on admission, by the resident or the resident's representative and the MD/NP, and then scanned into the medical record. If the MD/NP was not available to sign at that time, the information should be communicated to nursing staff and the POST form should be hand delivered to nursing so the MD/NP can be contacted, and signatures obtained. Review of staff in-service sign in sheets, facility employee list, and interview on [DATE] at 1:30 PM, with the DON, confirmed education was provided to the Admissions Director/Coordinator and all facility licensed staff. Staff interviews conducted on [DATE] - [DATE] with 3 CNA's working day shift (6 AM - 6 PM), 3 CNA's working night shift (6 PM - 6 AM), 3 LPN's working day shift (6 AM - 6 PM), 3 LPN's working night shift (6 PM - 6 AM), 3 RN's working day shift (6 AM - 6 PM), 2 RN's working night shift (6 PM - 6 AM), and the Admissions Director/Coordinator confirmed they had received the education and were aware of the facility's CPR and DNR policies and procedures for POST forms. On [DATE], a Quality Assurance Process Improvement (QAPI) meeting was held, and the following recommendation were made: All new admissions will be reviewed for a completed POST form and a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Any corrections needed will be addressed immediately by the DON or designee. The reviews will be ongoing with no stop date. Review of a QAPI sign in sheet dated [DATE] and interview on [DATE] at 12:15 PM, with the DON, confirmed the QAPI meeting was held, reviews had been completed with no issues identified, and were ongoing with no stop date. On [DATE], the DON or her designee initiated a weekly audit of new resident admissions and randomly selected in house residents to confirm a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Any discrepancies or issues identified will be addressed immediately by DON or designee. The weekly audits will be ongoing with no stop date. Results of audits will be presented to the QAPI Committee during monthly meetings for further recommendations for 3 months or until compliance is attained. Review of the facility's Code Status System Audit forms dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], the QAPI sign in sheet dated [DATE], and interview on [DATE] at 12:15 PM with the DON, confirmed the audits were completed with no issues identified, were ongoing with no stop date, and had been presented to the QAPI Committee.

Based on review of facility policy, review of medical records, review of Emergency Medical Services (EMS) documentation, and interview, the facility failed to ensure a medical record was complete and accurate for 1 resident (Resident #1) of 6 residents reviewed for advance directive status. Resident #1's medical record did not include a completed Physicians Order for Scope of Treatment (POST) form indicating the resident's end of life wishes, resulting in facility staff initiating Cardiopulmonary Resuscitation (CPR) and lifesaving interventions against the resident's and the resident's representative's wishes, and placing Resident #1 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator and the Director of Nursing (DON) were notified of the IJ on [DATE] at 4:30 PM, in the conference room. The facility was cited Immediate Jeopardy (IJ) for F-842 at a scope and severity of J. The IJ was effective on [DATE] and was removed on [DATE] when the facility implemented a corrective action plan. Corrective actions were validated onsite by the surveyor on [DATE]. The IJ was cited as past noncompliance and the facility is not required to submit a Plan of Correction. The findings include: Review of the facility's policy titled Do Not Resuscitate Order dated [DATE] showed .To ensure that the resident's wishes are honored with regard to extraordinary measures used to prolong life .Do Not Resuscitate orders must be .maintained in the residents medical record and on the Physicians Orders for Scope of Treatment (POST) form . Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident expired on [DATE] in the facility. Medical record review of a POST form for Resident #1 dated [DATE] (Resident #1 was scheduled to be admitted to the facility on [DATE], but her admission was delayed until [DATE]) showed .Do Not Attempt Resuscitation .Comfort Measures . The POST form was completed and signed by Nurse Practitioner (NP) #1 on [DATE]. Review of EMS records dated [DATE] at 8:00 AM for Resident #1 showed .[facility] staff called .they initiated CPR .staff stated patient [Resident #1] had a DNR but they could not find it .After > [greater than] 20 minutes of CPR all EMS providers concluded to terminate all efforts to revive patient . Medical record review of a Nurse's Progress Note dated [DATE] at 9:24 AM showed .[Certified Nursing Assistant (CNA) #2] entered resident [Resident #1's] room at approximately 7:45am, resident unresponsive at that time .EMS then notified and code [CPR] initiated. Family notified. Family expressed to [Licensed Practical Nurse (LPN) #1] they would like to withdraw care and cease life saving measures .Resident pronounced [death pronounced] at 9:03am by [Registered Nurse (RN) #1] . During an interview on [DATE] at 12:15 PM, the Director of Nursing (DON) stated .I got the call [on [DATE]] from the nurse [LPN #1] .she [LPN #1] went to check her code status and they couldn't find the POST form, so they initiated CPR . During an interview on [DATE] at 12:45 PM, LPN #1 stated .I went to find her POST form code status and it was not on file .I looked on the computer and there was no POST form scanned in .then I went to the folder behind the nurses station and she [Resident #1] had a face sheet, but no POST form was on file .I called EMS and started CPR .I did CPR until EMS got there .EMS took over the code .they [EMS] asked for the POST form and I told them that we did not have one on file and they said they had to perform the code since we didn't have one on file .they couldn't revive her and they pronounced her here at the facility .we looked on the hospital discharge records from before she came here and she was a DNR on those records, but EMS wouldn't take it because it wasn't a signed form. It was just a note in the hospital records, not an order or a POST form . During an interview on [DATE] at 11:30 AM, the Admissions Director/Coordinator stated .I got the family [Resident #1's family] to fill it [POST form] out to me verbally and I took it to the doctor's box to be signed [on [DATE]] .I did not tell the nurses. I just put it in the box .I didn't tell anyone . During a phone interview on [DATE] at 11:55 AM, LPN #2 stated .when they [staff] said that they were coding [performing CPR on Resident #1], I searched the computer, and I didn't find anything .I found no POST form at all .it is usually scanned in [the Electronic Medical Record (EMR)] .I never found a completed POST form for her . During an interview on [DATE] at 2:45 PM, NP #1 stated .whatever day I get it [POST form] in my box is what day I sign it .I signed it [Resident #1's POST form] on ,d+[DATE] [[DATE]], so that is when I received it .I have a box at the nurses station and they [staff] put the POST forms in there .[Admissions Director/Coordinator] gets them [resident/resident's representative] to fill it out and it [POST form] gets put in my box for me to sign .if I am here they [staff] bring it to me. But if I'm not here, it gets put in my box and I check it first thing when I get here .after I sign .I put it in the medical records box at the nurse's station so it can be scanned into the chart and copied and put into the binder [code book] .I am here every day, Monday through Friday . During an interview on [DATE] at 12:40 PM, the Medical Director stated .the problem was it [POST form] wasn't available when it should have been . During an interview on [DATE] at 1:00 PM, the Admissions Director/Coordinator stated .I picked the signed copy [signed POST form] up from the medical records box at the nurse's station and the signed copy got left with the admission paperwork in my office .I didn't scan it into the medical record .I found it with the admissions paperwork the next day after the incident . The facility's corrective actions were validated onsite by the surveyor on [DATE]. The corrective action plan included the following: On [DATE], the facility initiated a Root Cause Analysis Summary. Review of the Root Cause Analysis Summary and interview on [DATE] at 1:30 PM, with the DON, confirmed the root cause analysis was initiated on [DATE]. On [DATE], the DON reviewed all in house resident's medical records to ensure a POST form and DNR orders were in the EMR and code book (resident code status book). Review of the code book, review of the facility's midnight census report dated [DATE], and interview on [DATE] at 12:15 PM, with the DON, confirmed the audit was completed on [DATE] with no errors identified. On [DATE] - [DATE], the DON or her designee provided education to licensed staff regarding CPR, the DNR policy, and the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Education was provided to the Admissions Director/Coordinator regarding the process for POST forms: POST forms should be completed and signed during pre-admission process, or on admission, by the resident or the resident's representative and the MD/NP, and then scanned into the medical record. If the MD/NP was not available to sign at that time, the information should be communicated to nursing staff and the POST form should be hand delivered to nursing so the MD/NP can be contacted, and signatures obtained. Review of staff in-service sign in sheets, facility employee list, and interview on [DATE] at 1:30 PM, with the DON, confirmed education was provided to the Admissions Director/Coordinator and all facility licensed staff. Staff interviews conducted on [DATE] - [DATE] with 3 CNA's working day shift (6 AM - 6 PM), 3 CNA's working night shift (6 PM - 6 AM), 3 LPN's working day shift (6 AM - 6 PM), 3 LPN's working night shift (6 PM - 6 AM), 3 RN's working day shift (6 AM - 6 PM), 2 RN's working night shift (6 PM - 6 AM), and the Admissions Director/Coordinator confirmed they had received the education and were aware of the facility's CPR and DNR policies and procedures for POST forms. On [DATE], a Quality Assurance Process Improvement (QAPI) meeting was held, and the following recommendation were made: All new admissions will be reviewed for a completed POST form and a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Any corrections needed will be addressed immediately by the DON or designee. The reviews will be ongoing with no stop date. Review of a QAPI sign in sheet dated [DATE] and interview on [DATE] at 12:15 PM, with the DON, confirmed the QAPI meeting was held, reviews had been completed with no issues identified, and were ongoing with no stop date. On [DATE], the DON or her designee initiated a weekly audit of new resident admissions and randomly selected in house residents to confirm a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Any discrepancies or issues identified will be addressed immediately by DON or designee. The weekly audits will be ongoing with no stop date. Results of audits will be presented to the QAPI Committee during monthly meetings for further recommendations for 3 months or until compliance is attained. Review of the facility's Code Status System Audit forms dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], the QAPI sign in sheet dated [DATE], and interview on [DATE] at 12:15 PM with the DON, confirmed the audits were completed with no issues identified, were ongoing with no stop date, and had been presented to the QAPI Committee. Refer to F-678.

Based on medical record review and interview the facility failed to maintain the hospice care plan on the medical record for 1 resident (#6) of 32 residents sampled. The findings include: Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident received hospice care. Medical record review of the Order Summary Report dated 9/25/18 revealed .Hospice care as ordered . Medical record review of the medical record revealed no documentation of a hospice care plan or visit notes. Interview with the Director of Nursing (DON) on 10/16/18 at 3:20 PM, in the DON's office, confirmed the resident had been receiving hospice services. Further interview confirmed the hospice care plan and visit notes are to be kept on the resident's medical record. Continued interview revealed no hospice care plan on the current medical record for Resident #6. Interview with the DON on 10/17/18 at 8:09 AM, in the DON's office, confirmed the facility failed to maintain the hospice information including the hospice care plan on the medical record for Resident #6.

Based on medical record review and interview, the facility failed to develop an individualized plan of care to identify required assistance for the transfer needs of 1 resident (#62) of 3 residents reviewed for accidents. The findings included: Medical record review revealed Resident #62 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 a Brief Interview of Mental Status (BIMS) of 3 (indicating severe cognitive impairment). Continued review revealed Resident #62 had been assessed for functional status with transfers (how the resident moves between surfaces including to or from bed/chair, wheelchair, or standing position) at a 4 indicating total dependence and required 2 plus persons for physical assistance. Review of the Care Plan dated 9/22/16 with a goal date of September 2017, revealed, .Problem/Need .ADL (Activities of Daily Living) - Resident requires assistance with and/or provision for ADL's - Dx (diagnosis) of Dementia, generalized weakness, decreased mobility. Continued review of the Care Plan Approaches (interventions) revealed, .assist with ADL's as needed. Continued review of the Care Plan for Falls revealed, .Risk for falls due to hx (history) of falls, generalized weakness, non-ambulatory, decreased mobility, decreased safety awareness, Dx dementia. Review of the Approaches (to prevent falls) revealed, .Assist with ADL/transfers as needed . Continued review of the Care Plan revealed no resident-specific guidance for transfer assistance for Resident #62. Review of the Certified Nurse Aide (CNA) Completed Care Task documentation dated 7/28/17 and 7/29/17 revealed Resident #62 had been transferred on these dates with the assistance of two persons and the assistance of one person. Medical record review of nurse's entry dated 7/29/17 at 12:03 PM, revealed Resident #62 .noted to have swelling, bruising, and warmth to left lower leg mid-calf, noted tightness of muscle with palpation .new order .ultrasound of LLE (left lower extremity) . Further review revealed Resident #62 was transferred to the hospital per family request at 1:34 PM. Medical record review of the emergency department history and physical dated 7/29/17 revealed .X-ray of left lower extremity shows comminuted [MEDICAL CONDITION] tibia .severe knee [MEDICAL CONDITION] .no surgical interventions planned . Interview with the MDS Coordinator #1 on 10/3/17 at 3:40 PM, in the MDS office confirmed the MDS assessment dated [DATE] was coded correctly for transfer needs requiring total dependence and 2 plus persons for physical assistance. Further interview with the MDS Coordinator #1 confirmed she was responsible for the development of the Care Plans and failed to develop individualized interventions for Resident #62 to address her total dependence on 2 person assistance for transfer needs. Interview with the Director of Nursing on 10/3/17 at 5:50 PM, in the Conference Room, confirmed the facility failed to individualize the care plan to meet the specific needs for transfer assistance for Resident #62.

Based on medical record review, review of facility investigation, and interview the facility failed to provide adequate supervision and assistance for 1 resident (#62) of 3 residents reviewed for accidents. The findings included: Medical record review revealed Resident #62 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) of 3 (indicating severe cognitive impairment), and functional status for transfer (how the resident moves between surfaces including to or from bed/chair, wheelchair, standing position) as a 4 indicating total dependence and requiring 2 plus persons physical assistance. Review of the Certified Nurse Aide (CNA) Completed Care Task documentation dated 7/28/17 and 7/29/17 revealed Resident #62 had been transferred on these dates with the assistance of two persons and the assistance of one person. Medical record review of the facility investigation dated 7/29/17 revealed Resident #62 sustained a left tibia/fibula fracture .incident was noted to be of unknown origin . Continued review revealed recommendations/corrective actions included 2 assist c (with) all transfers / mechanical lift c transfers. Medical record review dated 7/29/17 at 12:03 PM, revealed Resident #62 .noted to have swelling, bruising, and warmth to left lower leg mid-calf, noted tightness of muscle with palpation .new order .ultrasound of LLE (left lower extremity) . Further review revealed Resident #62 was transferred to the hospital per family request at 1:34 PM. Medical record review of the emergency department history and physical dated 7/29/17 revealed .X-ray of left lower extremity shows comminuted fracture of the proximal tibia .severe knee osteoarthritis .no surgical interventions planned .no clear cause of the fracture . Interview with Licensed Practical Nurse #1 on 10/3/17 at 10:36 AM, in the Conference Room, confirmed CNA #1 asked her before lunch on 7/29/17 to look at Resident #62's left leg. Further interview confirmed the left leg was swollen and bruised below the knee. Interview with CNA #1 on 10/3/17 at 11:10 AM, in the Conference Room, revealed along with CNA #2, at approximately 10:30 AM on 7/29/17, transferred Resident #62 from the chair to the bed and did not notice any abnormalities of the left leg or any signs or symptoms of pain. Further interview revealed at 11:30 AM, CNA #1 checked the resident for incontinence and noticed a bruise on her left shin. Telephone interview with CNA #2 on 10/3/17 at 11:25 AM, confirmed she transferred Resident #62 on 7/29/17 before breakfast from the bed to the chair without assistance. Continued interview with CNA #2 revealed .I know how to do it . Further interview confirmed prior to transferring her before lunch on 7/29/17 along with CNA #1 she noticed a bruise around the calf area of the left leg. Interview with the Medical Director on 10/3/17 at 5:30 PM, in the Conference Room revealed the leg is not healing because of her comorbidities .dementia .she has weak bones .transfer could have been a factor . Interview with the Director of Nurses on 10/3/17 at 5:50 PM, confirmed Resident #62 was totally dependent with 2 persons plus assist necessary for transfer at the time of the injury. Further interview confirmed Resident #62 was transferred from the bed to the chair with 1 staff member. Continued interview confirmed the facility had failed to ensure adequate supervision and assistance in transferring Resident #62.

Based on medical record review and interview, the facility failed to provide adequate nutritional interventions to aid in wound healing for 1 resident (#17) of 3 residents reviewed for pressure ulcers of 21 residents sampled. The findings included: Medical record review revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Nutritional Risk Review and Assessment form dated 5/8/17 revealed, .Nutritional Risk Score .12 .10 or more = (equals) High Risk .Pressure Ulcer Risk .3 .3 or more = High Risk . Medical record review of Departmental Notes dated 8/5/17 revealed, .dietary will observe for nutritional needs . Medical record review of Resident #17's Care Plan updated 8/10/17 revealed, .Resident is at risk for poor intake . Medical record review of lab results obtained from the hospital dated 8/14/17 revealed, .Total Protein (lab to measure protein in blood) .5.5 .L (low) .[MEDICATION NAME] (lab to measure [MEDICATION NAME] in blood) .2.2 L (low) . Medical record review of the Wound Assessment form dated 8/15/17 revealed .pressure ulcer .right heel .new wound .unstageable .pressure ulcer .left bottom of heel .new wound .unstageable . Medical record review of the Pressure Ulcer Prevention Checklist dated 8/25/17 revealed, .nutritional assessment: Dietary Consultation . Review of Resident #17's medical record revealed no dietary consultation after 8/5/17. Interview with the Dietary Manager on 10/04/17 at 10:47 AM, in the Dietary office, confirmed, .no dietary interventions had been initiated to aid in the healing of Resident #17's newly identified pressure ulcers . Interview with the Director of Nursing on 10/04/17 at 11:16 AM, confirmed the facility failed to provide the necessary dietary interventions to aid in Resident #17's pressure ulcer wound healing.

Based on medical record review and interview, the facility failed to ensure a safety device was in use and functioning for one resident (#15) resulting in a complex laceration (harm), and failed to ensure a restraint was applied correctly for one resident (#5) of twenty residents reviewed. The findings included: Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a facility investigation dated September 13, 2009, revealed "...CNA (certified nursing assistant) reported to this nurse that res. (resident) was on floor in room...staff to ensure bed is in lowest position when bed is occupied...will place alarming bed pad in resident's bed when arrives..." Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had long and short term memory problems, moderately impaired daily decision making skills for daily living, required limited assistance with bed mobility, and had falls in the past 31-180 days. Medical record review of the fall risk assessments dated January 9, 2010, and April 8, 2010, revealed the resident was at high risk for falls. Medical record review of the care plan updated April 8, 2010, revealed "...low bed in place...alarm bed pad in bed..." Medical record review of a nurse's note dated May 10, 2010, revealed "Upon entering resident's room, this writer found resident in the floor beside...bed. Resident's back was against...nightstand and...legs were under...bed. Staff raised the resident's bed. Large amount of blood was noted. There was a large deep tissue wound to left lower extremity ...EMS called ...." Review of a facility investigation dated May 10, 2010 revealed "...resident rolled out of bed...in floor beside bed...back against bedside table, both legs under bed...staff raised bed to get res. (resident's) legs from under bed...deep tissue wound noted to inner left lower extremity...large amount of bleeding noted...pressure applied..wound not measured...skin tear to left elbow..." Continued review of the facility investigation revealed "...upon investigation of residents bed and body position of resident...small amount of blood found on bed frame that indicates bed was about 6 inches off ground..." Review of the facility investigation revealed the presence of the bed pad alarm was not addressed. Review of an investigation interview form dated May 10, 2010, written by CNA #1 revealed "...I changed resident and lowered...bed to the floor...resident was pulling over to the right side holding on to the small rail on the bed...I told resident not to being (be) pulling over because...might fall...I went out of room to get more pads and I came back and resident...was in between (resident's) bed and bed side table...I raised bed a little and saw blood..." Review of an addendum to the hand written statement by CNA #1 dated May 13, 2010, revealed "...I went to clean linen room and got some pads...when I came back resident was in between(resident's) bed and the night stand on (resident's) right side...foot was under bed..I raised bed a little to see if I could see anything wrong...I noticed blood on...night gown..." Medical record review of the emergency room note dated May 5, 2010 revealed "...lac (laceration) 12 cm deep...Diagnoses...2 complex laceration LLE (left lower Extremity)..." Medical record review of a hospital history and physical dated May 10, 2010, revealed "...had a big laceration on the left lower leg on the middle of the thigh...also one laceration...left elbow and one on...forehead...will admit..." Medical record review of a hospital discharge summary dated May 13, 2010, revealed "...came to hospital with a huge left leg laceration...surgery was consulted and the wound was reapproximated, but the wound was extremely large and the anterior part of the wound could not be reapproximated again...on May 12, 2010, the patient is taken to OR (operating room) and wound was debrided and wound vac was placed...plan to change Vac every Monday, Wednesday, and Friday...was felt stable to (discharge) with IV antibiotics and...needs follow up with surgery in 2-3 weeks..." Telephone interview on August 31, 2010 at 1:15 p.m., with CNA #1 (on duty at the time of the fall) confirmed, on May 10, 2010, after performing incontinence care for the resident, CNA #1 left the room to obtain additional linens, the resident was in the bed with the bed in the lowest position. Upon returning to the resident's room approximately two minutes later the resident was on the floor on right side of the bed with legs under the bed and back against dresser, and the Nurse was summoned to the room. Continued interview confirmed the bed was raised and laceration was noted and the resident was sent to the hospital. Continued interview confirmed no alarm sounded at the time of the fall. Telephone interview with Registered Nurse #1 (on duty at the time of the fall on May 10, 2010) on August 31, 2010 at 1:45 p.m., confirmed on May 10, 2010 was called to the room and found the resident in the floor with legs under the bed. Continued interview confirmed the bed was raised and a large wound to the leg was noted, pressure was applied and the resident was transferred to the emergency room for treatment. Interview with the Administrator, Director of Nursing, Assistant Director of Nursing, and the Minimum Data Set Coordinator, on September 1, 2010 at 9:20 a.m., in the conference room confirmed, the resident was at high risk for falls and was to have a bed pad alarm in the bed with the bed in lowest position at the time of the fall on May 10, 2010. Further interview confirmed the presence of the bed pad alarm was not addressed in the facility investigation dated May 10, 2010. Continued interview confirmed on May 10, 2010, the resident sustained [REDACTED]. Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on August 30, 2010, at 10:00 a.m., revealed the resident seated in a wheelchair with a vest restraint in place. Continued observation revealed the vest was placed mid sternal on the chest with the upper straps over the shoulder area and criss crossing behind the neck. Observation and interview with the Assistant Director of Nursing on August 30, 2010, at 10:03 a.m., confirmed the upper straps were not to be criss crossed and the vest was not applied correctly. Review of the manufacturer's recommendation revealed "...must be used in conjunction with a metal seat belt..." Observation and interview on August 30, 2010 at 11:15 a.m., with the Assistant Director of Nursing revealed the resident seated in the wheelchair with vest restraint in place with no seat belt. Interview with the Assistant Director of Nursing confirmed no seat belt was in use as per the manufacturer's recommendations. C/O #