Every finding on record at Gallaway Health and Rehab

Based on personnel file review, facility document review and interview, Administration failed to ensure that nursing services were provided by qualified personnel when the facility hired an imposter nurse (Imposter Nurse A) to function as a Licensed Practical Nurse (LPN) using another LPN's (LPN C) Tennessee license. The findings include: Review of Imposter Nurse A's personnel file revealed a letter from a Tennessee Criminal History Record Request for Imposter Nurse A's first and last name revealed, .NO TENNESSEE CRIMINAL HISTORY RECORD HAS BEEN FOUND FOR THE PERSON LISTED BELOW. There was no national background check found in the personnel file. Review of the I-9 form (Employment Eligibility Verification) used to verify the identity and legal authorization of individuals hired for employment in the United States dated 04/11/2023, revealed Imposter Nurse A's legal first and last name, along with a birth certificate and a valid Driver's license from another state. The last name used on the I-9 form was the same as the Driver's license. Review of a license verification form revealed the nursing license was in the name of the LPN. LPN C had the same first name as Imposter Nurse A but a different last name. Review of two Tennessee Abuse Registry checks dated 04/05/2023 revealed one check was for LPN C's name and the second check was for Imposter Nurse A's name. Review of the Offer Letter to Imposter Nurse A dated and signed by the candidate on 04/11/2023 revealed, .We are pleased to offer you the Temporary/Contract LPN.Start Date: 4/11/23 - 6/6/23 . Review of the time sheet for Imposter Nurse A revealed she worked in the facility on 04/11/2023, 04/12/2023, 04/13/2023, 05/02/2023, 05/09/2023, 05/10/2023, 05/12/2023, 05/13/2023, and 05/14/2023. Review of two separation notices revealed the first notice dated 05/08/2023 with a last day worked date of 05/02/2023 showed Voluntary Separation without Notice.Resignation No Notice. The second separation notice dated 05/22/2023 with a last day worked date of 05/14/2023 showed Voluntary Separation without Notice.Resignation No Notice. No paperwork was provided related to the rehire of Imposter Nurse A after the first termination. During an interview on 10/1/2025 beginning at 9:15 AM, the Human Resource Director admitted there was no policy related to hiring. The Human Resource Director confirmed Imposter Nurse A did work onsite at the facility briefly and was terminated for failure to attend training. The Human Resource Director reiterated she was terminated again for failure to come in as needed. Imposter Nurse A was hired as a Licensed Practical Nurse to render nursing services, and she was only terminated for failure to complete her training. The facility employed an unqualified person. There was no information given to the surveyor as to any cross reference of inconsistencies with the different names listed on the employment application, I-9 form and the nursing license verification form submitted by the candidate.

Based on facility policy review, medical record review, email correspondence review, observation, and interview, the facility failed to protect the residents' right to be free from neglect for 3 of 14 (Resident #6, Resident #1, and Resident #12) sampled residents reviewed for abuse and neglect. Resident #6, a vulnerable, cognitively impaired, totally dependent resident who required enteral feeding (method of delivering nutrition directly into the gastrointestinal tract) for nutrition was reviewed for neglect. On 3/20/2025, the nurse documented Resident #6 had a tear on the side of the feeding port of the percutaneous endoscopic gastrostomy (PEG) tube which caused leakage of the feeding onto the bed. Resident #6 did not receive a new PEG tube until 4/7/2025, 19 days after the tear was found, which allowed for leakage of the enteral nutrition for 19 days. Resident #6's weight was 137 pounds (lbs.) on 3/14/2025 and decreased to 117 lbs. on 4/3/2025. Resident #6 sustained a severe weight loss of 14.59 percent (%) in 20 days which delayed healing on her current Stage 3 pressure ulcer/injury (a deep wound that involves full-thickness tissue loss) on the Left Ischial Tuberosity (the bony prominence on the posterior bottom left part of the pelvis). Resident #6 was noted to have a new in-house acquired blister on 4/8/2025, on her right lower back. On 4/16/2025 a new Stage 2 pressure ulcer/injury (partial thickness skin loss involving the epidermis and or dermis) to her coccyx was identified. On 4/30/2025, a new Deep Tissue Injury (DTI) (a pressure-related injury to the soft tissue under the skin) on her left heel was identified. The Registered Dietician confirmed the tear in the feeding tube contributed to Resident #6's severe weight loss Resident #1, a vulnerable, cognitively impaired resident who required 2-person, mechanical lift assistance for transfers sustained a left, distal femur fracture (a break in the lower part of the left thigh bone, just above the knee joint) when staff transferred her without the use of the mechanical lift on 7/4/2025. Resident #1 had a prior improper transfer without the use of the mechanical lift which resulted in a toe fracture (broken bone). The Certified Nursing Assistant (CNA) found Resident #1 sitting in her wheelchair screaming with excruciating pain on 7/4/2025 and attempted to stand Resident #1 up to transfer her to the bed without notifying the nurse for evaluation of Resident #1's pain, which resulted in increased pain. The CNA then picked Resident #1 up and placed her in bed, without the use of the 2-person mechanical lift. The nurse's assessment completed after Resident #1 was placed in the bed revealed bruising and swelling of her left knee. An X-Ray was obtained which revealed Resident #1 had a left distal femur fracture. The facility's failures resulted in Immediate jeopardy for Resident #1 and Resident #6. The facility also neglected to maintain and provide the ordered enteral feeding as scheduled for Resident #12's continuous enteral feed on 8/20/2025. 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) was identified related to the facility's failure to provide necessary goods and services to Resident #1 and Resident #6. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) of F-600 on 8/14/2025 at 10:53 AM. An amended template for F-600 was given to the Administrator and the DON on 8/20/2025 at 11:53 AM, in the Conference Room. The facility was cited at F-600 at a scope and severity of J, which constitutes Substandard Quality of Care. A partial extended survey was conducted from 8/20/2025 through 8/22/2025. An acceptable Removal Plan, which removes the immediacy of the Jeopardy for F-600 was received on 8/22/2025. The Removal Plan was validated onsite by the surveyor on 8/22/2025 through audit review, medical record review, observation, review of education records, and staff interviews. The IJ began on 3/20/2025 and was removed on 8/23/2025. The facility's noncompliance at F-600 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1.Review of the facility policy titled, Abuse Prevention Program F600, dated 8/2024 revealed, .Residents have the right to be free from abuse, neglect.resulting physical harm, pain.Abuse also includes the deprivation by an individual, including a caretaker, of goods and services that are necessary to attain or maintain, physical, mental or psychological well-being.Neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.The facility administration and employees are committed to protecting residents from abuse by anyone including, but not necessarily limited to.facility staff.Identification of occurrences and patterns of potential mistreatment/abuse.The reporting and filing of accurate documents relative to incidents of abuse.The implementation of changes to prevent future occurrences of abuse.The current .components of the CMS [Centers for Medicare and Medicaid Services] directed Abuse Condition of Participation .Reporting to the state is per state guidelines. Review of the undated policy titled, KARDEX, revealed .the KARDEX is a vital section that outlines each resident's individualized daily care plan. It provides detailed instructions on various aspects of care, including the resident's daily activities.includes information on the resident's mobility.specific safety needs.and transfer methods.It notes whether the resident can ambulate independently. Review of the facility policy titled, Assessing Falls and Their Causes Guidelines, dated 10/2024, revealed, .The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall.Residents must be assessed in a timely manner for potential causes of falls.Relevant environmental issues should be addressed promptly.If a resident has just fallen.nursing staff will record.and evaluate for possible injuries to the head, neck, spine, and extremities.nursing staff will provide appropriate first aid.Documentation will include any observed signs or symptoms of pain, swelling, bruising.An incident report must be completed for residents falls. The incident report form should be completed by the nursing supervisor on duty at the time.no later than 24 hours after the fall occurs. Review of the facility policy titled, .Abuse Prevention Program, Recognizing Signs and Symptoms of Abuse/Neglect (Identification), dated 10/2024, revealed .Neglect occurs when the facility is aware of, or should have been aware of goods and services that a resident (s) requires but the facility fails to provide them to the resident (s), resulting in, or may result in, physical harm, pain.Signs of / Actual Physical Neglect.unexplained weight loss.Possible signs/symptoms.Inconsistent injury explanation. Review of the facility policy titled, .Comprehensive Care Plans, dated 3/2025, revealed .An individualized comprehensive person centered care plan that includes measurable objectives and time frames to meet the resident's medical, nursing, mental cultural and psychological needs is developed for each resident.The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS and physicians [physician's] orders. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.Each resident's comprehensive care plan is designed to.Incorporate identified problem areas.The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of care plans.At least quarterly.The IDT [Interdisciplinary Team] will outline services in the comprehensive care plan that meet professional standards of quality or accepted standards of clinical practice. Review of the facility policy titled, Enteral Nutrition ., dated 5/2025, revealed .Adequate nutritional support through enteral feeding will be provided to residents as ordered.A dietitian will assess residents who are receiving enteral feedings, and will make appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings and to prevent complications associated with enteral feedings and to prevent complications associated with enteral feedings.Enteral feeding orders will be written to ensure consistent volume infusion. The following information will be included to ensure that the full volume will be infused, regardless of any interruption of feeding.Rate of infusion.Total calories per day.Total daily volume to be infused (number of ml (milliliter) per day).Central supply or Food Service Manager will be responsible for ordering all tube feeding supplies. Review of the facility policy titled, Wound Care Guidelines, dated 6/2025, revealed .The purpose of this procedure is to provide guidelines for the care of wounds and to promote healing. Review of the facility policy titled, Exercise of Rights/Resident Rights ., dated 11/2024, revealed .Our residents have the right to a dignified existence.access to persons and services inside and outside the facility.Our residents have equal access to quality care.Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.Staff shall treat cognitively impaired residents with dignity and sensitivity. Review of the facility policy titled, Change in a Resident's Condition or Status ., dated 10/2024, revealed .The facility staff shall promptly notify the resident, his or her Attending Physician, and resident representative of changes in the resident's medical.condition and/or status.The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician.A need to alter the resident's medical treatment significantly.A need to transfer the resident to a hospital/treatment center.There is change in the resident's level of care status. Review of the facility policy titled, Pressure Injury/Skin Breakdown-Clinical Guidelines, dated 6/2025, revealed .The nursing staff will complete an evaluation of the skin.Based upon need and the results of the evaluations the staff will implement interventions for the prevention and care of skin issues.Nutritional supplementation should be based on realistic appraisal of need and identification of medical conditions and factors that affect.weight.and overall nutritional balance. Review of the facility policy titled, Quality of Life-Activities of Daily Living ., dated 4/2025, revealed .The community environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being.Residents whom are unable to carry out activities of daily living receive the necessary care and services to maintain good nutrition.Residents are provided with appropriate care.Utilize ADL [activities of daily living] reports, paper or electronic to assess ADL decline.Update care plan appropriately and interventions as needed. Review of the facility policy titled, Accidents and Incidents - Investigating and Reporting ., dated 10/2024, revealed .All accidents or incidents involving residents, employees.The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.The following data, as applicable, shall be included.nature of the injury.circumstances surrounding the accident or incident.condition of the injured person.disposition of the injured.Any corrective action taken.The Director of Nursing.shall review and complete.The Administrator shall review. 2. Review of the medical record revealed Resident #6 was admitted on [DATE], with diagnoses which included Encephalopathy, Aphasia, Dysphagia, and Cognitive Communication Deficit. Review of the Medication Administration Record (MAR) dated 3/2025, revealed Resident #6 had scheduled continuous enteral feed for Jevity (calorically dense, fiber-fortified nutrition that provides balanced nutrition for long term tube feeding) 1.5 at 55 milliliter (ml)/Hour via (by way of) PEG tube. Resident #6's enteral feed order revealed to turn off the pump at 11:00 AM and turn the pump back on at 1:00 PM. Review of the Weights and Vitals Summary revealed Resident #6 weighed 137 lbs. on 3/14/2025. Review of the Progress Notes for Resident #6 dated 3/20/2025, revealed .Peg [PEG] tube.needs to be replaced due to tear on the side at the port. Tape use [used] to secure the spike [the end of the tubing connected to the residents PEG tube] into the port. Review of the Skin & (and) Wound Evaluation for Resident #6 dated 3/24/2025, revealed a Stage 2 pressure ulcer to the Resident's Left Ischial Tuberosity which measured 2.0 centimeter (cm) in Length (l) by 2.5 cm width (w) by 0 depth (d) which equaled a total area of 3.7 cm2 (centimeter squared a unit used in the measurement of area). Review of the Weights and Vitals Summary revealed Resident #6 weighed 117 lbs. on 4/3/2025. Review of the Progress Notes for Resident #6 dated 4/3/2025, revealed .NP [Nurse Practitioner] spoke with this residents' RP [Resident's Responsible Party] regarding weight loss and slow decline in status. Review of Hospital #3's After Visit Summary dated 4/7/2025 revealed Resident #3's Peg tube was replaced. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #6 had poor short term and long-term memory. Resident #6 was dependent on staff for all activities of daily living. Resident #6 had an unplanned weight loss during the assessment reference period. Resident #6 received all nutrition through her PEG tube. Resident #6's pressure ulcer declined from Stage 2 to a Stage 3. Review of the medical record revealed Resident #6 was diagnosed with Abnormal Weight loss and Protein-Calorie Malnutrition on 4/8/2025. Review of the MAR dated 4/2025, revealed Resident #6 had scheduled continuous enteral feed for Jevity 1.5 at 55 ml/hour via PEG tube from 4/1/2025 through 4/8/2025. Resident #6's enteral feed was changed on 4/8/2025 to Jevity 1.5 at 65 ml/hour via PEG tube. Resident #6's enteral feed order revealed to turn off pump at 11:00 AM and turn pump back on at 1:00 PM Review of the NP Progress Notes dated 4/8/2025, revealed .Follow up.Prior unintended weight loss of 20lbs [20 lbs] .Patient [Resident #6] was found to have a dysfunctional PEG tube and it has since been replaced. She has also been moved to a room closure [closer] to nursing station for closer monitoring.Abnormal weight loss: PEG tube replaced. Will continue to monitor intake and feeding schedule . Review of the Skin & Wound Evaluation for Resident #6 dated 4/8/2025, revealed a new in-house pressure ulcer on her right lower back measuring 1.0 cm (l) by 1.5 cm (w). Review of the Nutrition Note dated 4/8/2025, revealed .A nutritional assessment was completed on this date for [Named Resident #6]. Resident's current weight.117.2 - 4/4/2025.Resident has had a weight change over the last 30 days. weight down 20# [20 lbs.] in 30 days, 14.5 % loss significant. Resident's current diet order .NPO [nothing by mouth] .Resident has stage II [2] pressure injury [ulcer] .per most recent skin report.Resident has skin concern(s) per most recent skin report.Enteral regimen has been unchanged since January and weight had been stable with gradual gain noted. Prostate [liquid protein].was added in March. Multiple pressure wounds noted, new area noted today. Labs reviewed.Peg tube was replaced 4/7 [4/7/2025] d/t [due to] split in tube.Rec [recommendation] to increase enteral [feeding] to Jevity 1.5 @ [at] 65ml/hr [hour] x [times] 22 hours. Review of the Skin & Wound Evaluation for Resident #6 dated 4/9/2025, revealed the pressure ulcer to the Left Ischial Tuberosity had progressed to a Stage 3 area. The Stage 3 pressure area had increased in size to 2.9 cm (l) by 3.2 cm (w) by 1.3 cm (d) which equaled a total area of 7.1 cm2. Review of the Skin & Wound Evaluation for Resident #6 dated 4/16/2025, revealed a new in- house acquired Stage 2 pressure ulcer on the coccyx that measured 2.9 cm(l) by 6.3 cm (w) by 0.1 cm (d) which equaled a total area of 13.1 cm2. Review of the Order Summary Report for Resident #6 revealed, .May substitute feeding formula as needed. Jevity 1.2 for 1.5.active.4/26/2025. Review of the Skin & Wound Evaluation for Resident #6 dated 4/30/2025, revealed a new in-house acquired Deep Tissue Injury (intact skin that is purple or maroon in color, with a blood-filled blister or other evidence of damage) on the left heel that measured 3.8 cm (l) by 2.5 cm (w) by 0 cm (d) which equaled a total area of 7.1 cm2. Review of an email sent by the Director of Nursing to the Director of Food Hospitality and Nutrition dated 7/17/2025, revealed .I have had a third feeding pump to malfunction. I notified the manufacturer a few months ago. I sent two back. The issues I have found have been inaccurate history recordings and not infusing properly. A return email from [Named Supply Company Representative] dated 7/30/2025, revealed, .I'm doing a day trip.tomorrow. I can be at your facility between 10-10:30 to dive into the pump issue. During an interview on 8/15/2025 at 11:45 AM, CNA U stated, .[Named Resident #6 ] is total assist with everything.she doesn't eat by mouth she has a feeding tube.she has had weight loss.the tube would not stay connected and the feeding would be all over the bed.they [nursing staff] tried to say the resident was doing it but I don't think she is capable of doing that.the tube had a split in it so there was no suction to it.I had brought it to the nurses attention that it was going all over the bed.I know it went on for over a month. Call placed to Licensed Practical Nurse (LPN) V (nurse who noted the tear in the PEG on 3/20/2025) on 8/15/2025 at 11:54 AM, left message for a return call. LPN V did not return the call. During a telephone interview on 8/18/2025 at 12:09 PM, Wound Care Nurse #2 stated, .[Named Resident #6] had a stage one [pressure ulcer] on admission to her coccyx.she started losing weight because the feeding would not stay connected.feeding would be on the bed, I would have to find a CNA to help me clean her up when I went to do wound care.about a month before the facility sent her out to get the tube fixed.a PRN [as needed] nurse documented that the tube had a slit in it and the tube was being taped.the Unit Manager was made aware.losing weight developing more wounds.the family came up there [to the facility] often they were very unsatisfied with her care and talked to the DON. During a telephone interview on 8/18/2025 at 12:23 PM, the Registered Dietician (RD) stated, .she [Resident #6] had a significant weight loss on my 4/8/2025 [referring to her progress note] review.20 lbs. in 30 days.she had her PEG tube replaced.and her weight started going up.the PEG tube had a split in the tube.it is possible formula was leaking out.I seen the split noted in the nurse note for 3/20/2025, so the PEG tube needed replaced.PEG was replaced on 4/7/2025.I don't know why it took that long.since the tube was replaced, her weight has improved.I don't remember no [a] formal meeting about her weight loss .prior to the significant weight loss, her weight had been pretty stable without any significant loss.4/8 [4/8/2025] note I do note a pressure wound and on 3/14/2025, I added a protein supplement for her. During an interview on 8/18/2025 at 1:30 PM, LPN S stated, .[Named Resident #6] had a split in her peg tube .I don't recall why it wasn't changed sooner .I think once they found out they got it fixed . During a telephone interview on 8/18/2025 at 2:03 PM, CNA T stated, .she [Resident #6] had some weight loss, yes .we were out of Jevity 1.5 we were going all over the building trying to find some .they gave her Glucerna [nutritional supplement for diabetics] .the Unit Manager poured the Glucerna in the Jevity bottle .I don't know when her peg tube was taped up .her brother is the one that brought it to everyone's attention, he took pictures of it . During an interview on 8/18/2025 at 3:10 PM, the Unit Manager stated, .they [RD/NP] assumed the weight loss was from the feeding and they changed her [Resident #6] feeding .[Named LPN V] never told anybody about the tear in the PEG tube .she forgot to say anything .[Family Member (FM) W] found the hole in her tube and the tape wrapped around it .he showed me .we got her sent out to get it [tube] replaced that same day .the order is on 4/7/2025 to send her out, I thought we sent her out before then .the DON reviews the nurses notes .[Named LPN V] taped it [slit in tube] up .it was never reported to me .[FM W] said it was leaking and it did have tape on it .it did have a hole in it .the slit was actually in the tube .from what I saw .[LPN V] was only one reported .I don't know how long it had been that way .the DON was told she [Resident #6] does have a slit in it [tube] and it had been leaking . During a telephone interview on 8/18/2025 at 3:50 PM, NP #1 stated, .the PEG tube, the fluid wasn't running through it .wasn't getting her [Resident #6] nutrition .I do recall that .she had a couple of issues with her tubing .I don't remember exactly .that was contributing to the weight loss .the machine [feeding pump] was beeping a lot .I don't know how long that went on .I don't recall the nurse that told me about it .there were a lot of wounds .the enteral feed was noted on the bed . During an interview on 8/18/2025 on 4:08 PM, FM W stated, .in October 2024 she [Resident #6] had one bed sore on her bottom, the wound nurse then healed it up .she kept getting bed sores .I walked in and found the tube leaking, feeding all over the bed .the cover was brown .I found it [slit in tube] in April it was taped up all around .they moved her closer to the desk .the [Named DON & Administrator] put her on 1 on 1 for a month .during that time she didn't have a bed sore or anything .they were switching her feedings around and I could tell because the feeding would be a different color when I came in .During the interview FM W showed this surveyor a picture dated 4/7/2025 at 10:32 AM of Resident #6's PEG tube which revealed a hole in the connection at the end of her tube. During an interview on 8/18/2025, at 5:15 PM, the MDS Coordinator was asked why Resident #6 had a significant change assessment completed on 4/8/2025. The MDS Coordinator stated, .due to weight loss .the reason was unknown until they [facility] done [did] an investigation .monitored the [Named feeding pump] pumps and ordered new ones .we had faulty pumps .labs [laboratory values checked] were done to look for an underlying cause .sent her out to get a new [feeding] tube it was leaking .I am not sure when the leaking started .they were unsure about the weight loss but thought that may have had something to do with it .she had a stage 2 pressure ulcer that declined to a stage 3 pressure ulcer . During an interview on 8/18/2025, at 5:24 PM, the DON was asked if the damaged feeding tube contributed to Resident #6's weight loss. The DON stated, .4/3 [2025] the Restorative CNA weighed her and it [Resident #6's weight] was 117 lbs .she did look thinner, we reweighed her again the weight was the same .I had been auditing the pumps .Friday we have PAR [Patient at Risk] days .I would audit the pump .the first time I saw the split was on 4/3/2025 .the nurses never notified me the PEG was leaking .she is a nurse why didn't she notify the physician, no need to call me .new PEG tube on 4/7 [2025] . The DON was asked if she observed the split on 4/3/2025, why did it take until 4/7/2025 for Resident #6 to get a new PEG tube. The DON stated, .we got her out as soon as we could . The DON was asked if a resident's PEG tube should have a hole/tear in it. The DON stated, .Absolutely not, it was so minute .one CNA had said it was leaking .where you connect the tubing .nothing about it not flushing that I recall .I missed it in the notes .4/3 [2025] was when I first knew .I did not think it contributed to her weight loss .it could leak some of her nutrition out but it was so minute . The DON was asked if a different enteral formula was ever used for Resident #6. The DON stated, .the Unit Manager was on the floor late one afternoon and she poured Jevity 1.2 in it .I got on to her about it .I think we got a doctor order to substitute with the other Jevity .I done [did] an investigation about this .because it was a large weight loss .the nurse put in the notes about the slit in the tubing 3/20/2025 . The DON was asked if the family had ever called her about the feeding color looking different. The DON stated, .he called me at midnight .the feeding came in late that night .4/25 [2025] we replaced the pumps, 4 times I had voiced a complaint to the company about them .[Named LPN V] did not report it [slit in the tube] to the oncoming nurse [on 3/20/2025] .4/3/2025 is when we knew .I will have to look at that on why she didn't go out right then .we got right on it . Observation in Resident #6's room on 8/19/2025 at 8:20 AM, revealed the Resident's enteral feed bottle of Jevity 1.5 was completely empty and the enteral tubing line was clear without any feeding in the line. During an interview on 8/19/2025 at 8:30 AM, RN F stated, .I normally catch it [referring to the enteral feed for Resident #6] in time . During an interview on 8/21/2025 at 10:30 AM, CNA U stated, .her wounds were smaller, but they became larger when she was losing weight . During an interview on 8/21/2025 at 4:50 PM, Regional Director of Clinical Services #1 was asked if the facility had an Intake and Output (I & O) for Resident #6. She stated, I will look. Regional Director of Clinical Services #1 came back to the surveyor and stated, .We didn't have an I & O for [Named Resident #6] . During an interview on 8/27/2025 at 11:12 AM, the Unit Manager reviewed the picture FM W had provided. The Unit Manager stated, .that is not the area where I seen [saw] the tape .I seen the tape around the tubing, around another hole in the tubing below that area . During a telephone interview on 8/27/2025 at 2:22 PM, the Medical Director (MD) was asked what a nurse should do if a resident has a tear in their feeding tube. The MD stated, .report it to us, send [the resident] to the ER [Emergency Room] . The MD was asked if Resident #6's weight loss was discussed in the Quality Assurance Performance Improvement (QAPI) meeting. The MD stated, .Yes, yes, right and we changed the tube to solve the problem . 3. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnosis which included Major Depressive Disorder, Hypertension, Dysphagia, Abnormalities of gait and mobility, Psychosis, and other lack of coordination. Review of the Physical Therapy evaluation and Plan of Treatment for Resident #1 dated 5/1/2025 revealed impaired physical mobility and total dependence with transfers. Review of the Annual MDS dated [DATE], revealed Resident #1 had a BIMS score of 6, which indicated severe cognitive impairment. Resident #1 was dependent on staff for toileting, bathing, lower body dressing, sit to stand, chair/bed-to chair transfer, and walking 10 feet was not attempted. Resident #1's MDS did not reflect the use of a mechanical lift. Resident #1 had impairment to one side of her lower extremity. Resident #1 had no falls since the prior assessment. Review of the care plan revealed, .Focus.[Named Resident #1] has an ADL Self Care Performance Deficit r/t [related to] Stroke and Hemiplegia.Revision on: 05/05/2025.Interventions.TRANSFER: [Named Resident #1] requires times 2-person total Mechanical.lift with medium sling for transfers. Date Initiated: 05/08/2014 Revision on: 05/13/2025. Review of the Incident Description for Resident #1 dated 7/4/2025, revealed .10:00 [AM].Nursing Description.bruise noted on l [left] knee, pt [patient] reported pain when positioned to perform peri [perineal] care.Injury Type.Abrasion.Injury Location.Left Knee (front). Review of the facility investigation revealed a written statement completed by RN F dated 7/4/2025, which stated, .CNAs asked me to look at patient [Named Resident #1]. I walked to her room and she was yelling Ow it hurts. Swelling of left knee, light bruise noted on assessment. Pt repositioned w/[with] pillows under knee. Call [Named on call company].Hospice, DON, Manager. Review of the Radiology Results Report for Resident #1 dated7/5/2025, revealed .KNEE 1 OR 2 VIEWS.Reason for Study.PAIN IN LEFT KNEE.FINDINGS: There is a moderately displaced fracture of the distal femoral metaphysis [portion of the thigh bone located just below the knee joint] with adjacent soft tissue swelling.There are moderate degenerative changes. Bones are osteopenic. CONCLUSION: Fracture of the distal femur. Review of the MAR for Resident #1 dated 7/2025, revealed Morphine Sulfate Oral Solution 10 milligram (mg)/ 5 ml (milliliter) with a start date of 7/5/2025. The nurse noted a pain level of 10 on 7/5/2025 (pain scale 1-10 with 10 being the highest level of pain). Review of the care plan revealed, .Focus.Potential for pain R/T fx [fracture] left femur.Place overbed table away from resident's leg. Put water on bed side table with in reach.Date Initiated: 07/05/2025. Review of the facility investigation completed by the Administrator dated 7/5/2025, revealed, .DESCRIPTION OF INCIDENT.[Named Resident #1] responds to name. Disoriented to time, place, and situation. Long and short term memory are impaired. Communicates with simple words.Does not speak much. Requires assistance of one person to shower, dress, and have personal hygiene needs met.Requires assistance of two people to transfer by mechanical lift now. She did transfer with one person assist as she was able to stand and pivot.12 falls since her admission in 2014.On 7/4/25 [2025] at 10:01 AM, resident c/o [complained of pain] when staff was changing brief. [Named RN F] was summoned to the room to assess resident.observed edema to left knee.called the NP to report findings. New orders given for ice and pain medication.notified [Hospice #1].Hospice nurse enroute to the facility to assess resident at 10:20 [AM] on 7/5/24 [2024]. The x-ray results were received and it indicated a fracture of the left distal femur.She has had several fractures in the past. Left femur fracture with repair, exact date unknown.Upon observation of [Resident #1] in the bed as she was positioned the day the pain began, I, [Named DON], observed the over bed table next to her bed. The left knee was on the side of the bed next to the over bed table. The corner of the table lined up with the bruise and abrasion on her left knee. If a staff member pushed the table over her unaware that they hit her knee, it would hit her knee and possible [possibly] cause a fracture of the left femu

Based on facility policy review, medical record review, and interview, the facility failed to develop and implement a person-centered care plan for 1 of 3 (Resident #3) sampled residents reviewed. The findings include: 1.Review of the undated facility policy titled, KARDEX revealed, .the KARDEX is a vital section that outlines each resident's individualized daily care plan. It provides detailed instructions on various aspects of care, including the resident's daily activities.includes information on the resident's mobility.specific safety needs.and transfer methods.It notes whether the resident can ambulate independently. Review of the facility policy titled, F 656, F 657, F 658 Comprehensive Care Plans, with an effective date of 3/2025 revealed, .An individualized comprehensive person centered care plan that includes measurable objectives and time frames to meet the resident's medical, nursing, mental cultural and psychological needs is developed for each resident. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.Each resident's comprehensive care plan is designed to.Incorporate identified problem areas.The IDT [Interdisciplinary Team] will outline services in the comprehensive care plan that meet professional standards of quality or accepted standards of clinical practice. Review of the facility policy titled, Safe Lifting and Movement of Residents, with an effective date of 10/2024 revealed, .to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents.Manual lifting of residents shall be eliminated when feasible.Staff will document resident transferring and lifting needs in the care plan.assessment shall include.Resident's mobility.Weight-bearing ability.Cognitive status. 2.Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD- group of lung diseases that make it difficult to breathe), Dementia, History of falling, Drug Induced Subacute Dyskinesia (disorder that causes involuntary movements), and Anxiety. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated severe cognitive impairment. Resident #3 was coded 1 dependent for all Functional Abilities which included eating, bathing, dressing, hygiene, and toileting. Resident #3 was dependent for all bed mobility and transfers. Review of the comprehensive care plan for Resident #3 dated 4/27/2025 revealed, .risk for falls r/t [related/to] confusion.Interventions.Anticipate and meet [Named Resident #3]'s needs.requires activities that minimize the potential for falls while providing diversion and distraction.Due to increased alertness staff to check resident at end of shift.Move all furniture out of room. Leave bed and mattress only.[Named Resident #3] has potential for respiratory complications r/t Emphysema [lung disease that damages the lungs and makes it difficult to breathe]/ COPD.Interventions.Head of bed to be elevated.or out of bed upright in a chair during episodes of difficulty breathing.Monitor/document for anxiety [worry, nervousness, restlessness, sleep disturbances].[Named Resident #3] has potential.impairment to skin integrity r/t fragile skin, constant movement while awake.Interventions.Use caution during transfers and bed mobility.[Named Resident #3] has potential for acute/chronic pain r/t impaired physical status.Interventions.Monitor for and report to charge nurse s/s of pain-facial grimacing, moaning, groaning, resistive to movement. Review of the Skin and Wound Evaluation for Resident #3 dated 5/5/2025 revealed, .Skin Condition.Redness.Sacrum blanchable redness sacral area.no other new skin issues noted. Review of the Incident Report for Resident #3 dated 5/6/2025 at 8:50 AM revealed, .Bruise.CNA [Certified Nursing Assistant-] entered the room to provide care.observed bruises on the resident.front left lateral [outside] medial [inside] leg.inner [inside] left lateral [outside] knee.front left lateral leg.front of left lateral knee.front of the left lower leg.front of the right knee.right shin.right outer elbow.right shoulder.right cheek.left chin.left side of neck.left shoulder.left upper arm.left inner elbow.resident sent to ED [Emergency Department] for evaluation.police presence.Predisposing Physiological [related to the mind] Factors.Impaired Memory.Incontinent.Agitated/Anxious.Confused.Decreased safety awareness.Delusions.Hallucinations.Impulsive.Involuntary Movements.Receives Antipsychotics [Seroquel-rare, very low probability meaning most people will not experience the side effect of increased bruising].Predisposing Situation Factors.A cna [CNA BB] new to [Named Facility] assigned to resident last night [5/5/2025 to 5/6/2025]. Review of a Progress Note for Resident #3 dated 5/6/2025 at 9:58 AM revealed, .Resident [Resident #3] noted to have discoloration to right side of her face.Nodule noted right side forehead with discoloration.Under left chin dark blackish looking discoloration quarter size.both shoulders notes to have purplish [purple] discoloration, both arms.several new areas of discoloration.both tops of hands with new areas of discoloration.legs with new areas of discoloration. Behind right ear small new area of discoloration.order to send resident to ER [Emergency Room]. Review of the Incident Report for Resident #3 dated 5/6/2025 at 12:00 PM revealed, .Fall: Known Cause.Incident Description. [CNA BB] assigned to resident last night 7pm 7am [5/5/2025 to 5/6/2025] reported.resident was on her floor mattress multiple times last night.resident was on the floor multiple times last night up against the night stand, with her legs under the bed, lying on her side with face on floor.Resident with multiple bruising to body.[CNA BB] said she placed resident on the mat and in the bed multiple times last night. Review of CNA BB‘s handwritten signed statement dated 5/6/2025 revealed, .The going [CNA] gave me a walk through.on who does what, Incontinent or not.showed me when [where] the linen and garbage was.I checked on her [Resident #3].changed her.left the room. Later I heard her Really loud so I went Back in the Room she was hanging on the side of the Bed So I sled [slid] her down on the mat BC [because] I couldn't continue to put her Back in the Bed.I know I went In there at least 7-8 time [times] due to her loudness I went I [in] there one time she was on her side by the dressers I place her Back on the mat.me lifting on her trying to get her Back on the mat all night long.All night she was hollering .constantly moving all over the room off the mat.she have a bruise by her foot Is due to her Being on the mat. During an interview on 8/25/2025 at 4:24 PM the Director of Nursing (DON) stated .[Named CNA] said she picked up [Named Resident #3] 6 or 7 times during the night [5/5/2025-5/6/2025].[CNA] said she picked [Resident #3] up by putting her arms under [Resident #3's] arms and put her back on the bed or mattress on the floor beside the bed.that is how she got the bruises to her shoulders. The rest of the bruising came from falling off the low bed and bumping into things in the room while crawling around. The DON was asked if there was furniture in Resident #3's room. The DON responded, Yes, a bed, a bedside table and an over the bed table. The DON was asked if Resident #3 required a two person assist with mechanical lift for transfers. The DON responded, Yes. The DON reviewed Resident #3's comprehensive care plan and confirmed Resident #3 was care planned for falls with interventions which included move all furniture out of room, leave mattress and bed only. The DON also confirmed Resident #3 should have been care planned for two-person with mechanical lift transfer assistance and was not. During a telephone interview on 8/27/2025 at 9:35 AM, CNA BB stated 5/5/2025 was her first shift on the Memory Care Unit and she had no orientation other than paperwork/computer lessons on the job since being hired. CNA BB stated she did not get report on the residents at shift change and she did not know how to access the resident's care plan on the computer. CNA BB stated Resident #3 had fallen off the bed on to a cushioned mat several times during the night and also crawled around in the floor. CNA BB was asked if Resident #3 required a two-person assisted mechanical lift for transfers. CNA BB replied, .I really don't know what she required, I was told it was normal to leave her on the mat all night. CNA BB confirmed she pulled Resident #3 up and put her back on the bed multiple times without assistance and without using a mechanical lift. CNA BB was asked if she had reported Resident #3's falls to Licensed Practical Nurse (LPN) Y. She replied, .No, I figured she knew because she was sitting in the hall outside of her [Resident #3's] room all night.I figured it was something she [Resident #3] do [does] all the time, since the nurse didn't say anything. During an interview on 8/27/2025 at 6:16 PM the MDS Coordinator stated per facility policy residents who cannot bear weight require a two person assist with a mechanical lift. The MDS Coordinator reviewed Resident #3's comprehensive care plan and confirmed a care plan was not developed and implemented for transfer assistance. The MDS Coordinator stated Resident #3 was unable to bear weight and should have had a care plan for transfers using 2 person assist with the use of a mechanical lift.

Based on policy review, job description review, facility investigation review, medical record review, observation, and interview, the facility failed to ensure a resident's right to be free from abuse and neglect for 6 of 15 sampled residents (Resident #1, #2, #3, #4, #5, and #14) reviewed for abuse. The facility's failure to ensure a resident's right to be free from abuse and neglect resulted in Immediate Jeopardy when the facility failed to assess and provide timely treatment for an injury of unknown origin that resulted in a fracture for Resident #5; and a fall that resulted in a fracture for #14; and failed to prevent, identify, and monitor Resident #1 resulting in multiple resident-to-resident altercations with Resident #2 and #3. The facility's failure to provide supervision and ensure a safe environment resulted in Immediate Jeopardy for Resident #1, #2, #3, #4, #5, and #14. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Interim Administrator and Interim Director of Nursing (IDON) were notified of the Immediate Jeopardy (IJ) for F-600 on 11/21/2022 at 5:43 PM, in the Conference Room. The Interim Administrator and Regional Vice-President were notified of the second Immediate Jeopardy (IJ) for F-600 on 12/7/2022 at 5:31 PM. The facility was cited Immediate Jeopardy at F-600. The facility was cited F-600 at a scope and a severity of J, which is Substandard Quality of Care. A partial extended survey was conducted from 12/12/2022 through 12/13/2022. The Immediate Jeopardy existed from 8/19/2022 through 12/13/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 12/13/2021 at 8:42 AM, and was validated onsite by the surveyors on 12/14/2022 through review of root cause analysis, in-services, audits, and staff interviews conducted. The findings include: 1. Review of the facility's policy titled, .Abuse Investigations ., revealed .Reports of resident abuse, neglect, and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Should an incident or suspected incident of resident abuse .neglect or injury of unknown source be reported, the Administrator, or his/her designee will appoint a member of management to investigate the alleged incident .The individual conducting the investigation will, at a minimum .Review the completed documentation forms .Interview the person(s) reporting incident; Interview any witnesses to the incident; Interview the resident (as medically appropriate) .Interview the resident's roommate .Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .the QA [Quality Assurance] team should evaluate the following .a. Changes that may need to be made to prevent further occurrences; b. Defining how care will be changed or improved to protect residents; c. Immediate and ongoing training needs and staff competency as needed; d. Identification of staff member(s) whom will carry out a-c; e. Identification of QAPI [Quality Assurance and Performance Improvement] team member whom will monitor the above . Review of the facility's Charge Nurse JOB DESCRIPTION, dated 6/2021, revealed .Perform administrative duties such as the documenting of: nurses' notes, doctors' orders .reports, evaluations .charts, resident assessments and care plans .Report accidents and incidents when they occur, including all complaints and grievances made by residents and/or their families . Review of the facility's policy titled, .Abuse Prevention Program, Screening of Employees, dated 8/2022, revealed .The facility administration and employees are committed to protecting residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers .family members .friends, visitors, or any other individual . Review of the facility's policy titled, .Abuse Program: Training, Reporting and Response, Covered Individual Responsibilities, dated 10/2022, revealed .The facility, through the Administrator or their designee, will report alleged violations related to .neglect, or abuse, including injuries of unknown source .the results of all investigations to the proper authorities within prescribed time frames . Review of the facility's electronic health record (EHR) neurochecks protocol revealed neurochecks were to be completed every 15 minutes times (x) 4, every 30 minutes x 4, every 1 hour x 2, then every shift x 72 hours. 2. Review of the medical record, revealed Resident #5 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease, Dementia, Diabetes, Osteoarthritis, Psychosis, Scoliosis, and Anxiety. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment, and required extensive assistance for activities of daily living (ADLs). Review of the Nurse Practitioner Progress Note dated 8/20/2022 at 8:05 AM, revealed .notified by nurse .resident complains of pain in L [left] shoulder .Will get STAT [urgent] xray of L shoulder. If abnormal pt [patient] will need FTF [Face to face] . Review of the Nursing Note dated 8/20/2022 at 8:21 AM, revealed .This nurse [Licensed Practical Nurse (LPN) #2] was called to resident's room by CNA [Certified Nursing Assistant #1] asking me to assess resident arm d/t [due to] complaints of pain. Upon entering room, this nurse observed resident lying in bed with L arm cradled to side of body. Resident [Resident #5] stated her arm was 'hurting real [really] bad' when asked where she was hurting resident stated her shoulder while guarding her L arm. Limited ROM [Range of motion] noted. When this nurse asked resident what happened she stated there was 'a girl that worked with them (referring to the CNA at bedside) that was real rough.' This nurse notified unit manager on duty, DON [Director of Nursing] and telehealth contacted at this time. Orders given to STAT x-ray L shoulder and notify telehealth with results. Review of the Nursing Note dated 8/20/2022 at 2:45 PM, [Named mobile X-ray company] in facility to complete ordered x-rays . Review of the Nursing Note dated 8/20/2022 at 9:12 PM, revealed .X ray result indicates left shoulder humeral fracture .Resident was transferred to [named hospital] at 9:20pm [9:20 PM] . Review of the Nursing Note dated 8/21/2022 at 4:45 AM, revealed .Return with injury to L humeral, swollen, warm to touch, sling placed. Follow up appointment with [named Orthopedic Clinic] .within a week . Observations in the resident's room on 11/17/2022 at 10:05 AM, 2:53 PM, and 11/21/2022 at 5:21 PM, revealed Resident #5 was lying in bed, her bed was against the wall on the right side, the call light was in reach, no side rails were present, no odors were noted, and the resident appeared thin and frail. Observation on 11/29/2022 at 9:17 AM, revealed Resident #5 was in bed, the head of her bed was raised, she was awake and alert, her call light was in reach. During an interview conducted on 12/5/2022 at 4:15 PM, CNA #1 was asked about Resident #5's incident. CNA #1 stated, I went in to dry [named Resident #5] she didn't say nothing when I flipped her toward the wall then I turned her back toward me she said 'oh' I asked her what's wrong. [Named Resident #5] said 'I'm hurting, my arm.' I asked her what happened to you she said 'that girl beat the [expletive] out of me' I ran out of the room for the nurse. I got [named LPN #1] and told him [named Resident #5] said her arm hurt that a girl beat the [expletive] out of her. So, we went into her room. He asked her and she told him the same thing. I said what you going to do before I leave. He said I'm going to order an x-ray. He said for me to go on home he would handle it. The next morning [8/20/2022] when I came in .I had the same section. I went in and asked [named Resident #5] how you doing today. She said her arm still hurt. I ran got the other nurse, [named LPN #2]. Told her to check on [name Resident #5] her arm still hurts. Told her [named LPN #1] was supposed to got an x-ray last night [8/19/2022]. [Named LPN #2] pulled the cover back, and she said, 'I think her arm is broke'. I told her about telling [named LPN #1] the night before [8/19/2022], and evidently didn't order the x-ray he said he was going to order. The left arm was purple in color at the upper arm. [Named LPN #2] went got 2 other nurses, and they came in the room. They said to get x-ray ordered. [Named Resident #5] stated the white girl beat her. She is sometimes oriented. She recognizes me and I talk with her regularly. This is the first time I ever heard her say something like this had happened. During an interview conducted on 12/6/2022 at 10:15 AM, LPN #2 was asked about the incident with Resident #5. LPN #2 stated, .I came in to work on 8/20/2022 at about 7:30. [Named CNA #1] came to me and stated she had reported to [named LPN #1] the night before [8/19/2022] that [named Resident #5] had been complaining of arm pain. The resident was still complaining the next morning of arm pain and [named CNA #1] came to get me. I assessed the resident's arm. I got [named LPN #6] to come assess resident's arm. Her arm had bruising at the bicep area of her arm, and the shoulder area didn't look right. We contacted telehealth and got an order for x-ray and notified the DON and Administrator. It was a STAT order for x-ray. They came and done the x-ray. We got a phone call and fax alert with the result of x-ray. I relayed the results to telehealth doctor, and they gave orders to send her [Resident #5] to the ER [emergency room ]. I believe it was on my shift I sent her out to ER. She was complaining of pain . LPN #2 was asked if Resident #5 told her what happened to her arm. LPN #2 stated, [Named Resident #5] told me the 'big white, fat, bi*** shook' her. I wasn't here the day before [8/19/2022] .[Named CNA #4] does fit that description . During an interview conducted on 12/6/2022 at 10:49 AM, LPN #6 was asked about the incident with Resident #5. LPN #6 stated, [Named LPN #2] came got me and wanted me to look at her [Resident #5's] arm. Her left arm was bruised and didn't look right. I instructed to call [named former DON] and tell her it's an injury of unknown origin. [Named Resident #5] said 'that girl hurt my arm, she was [NAME] as a bull, and she hurt my arm.' I told [named LPN #2] to call telehealth, family, and doctor, and let them know. They came and did X-ray .I know she did go to the hospital . During a telephone interview conducted on 12/8/2022 at 9:35 AM, CNA #4 was asked about the incident with Resident #5. CNA #4 confirmed the former DON called her about the bruising found on Resident #5. CNA #4 confirmed she was 1 of the 2 white CNAs and stated, .possibility I worked, I don't remember working with her that day . During a telephone interview conducted on 12/8/2022 at 12:40 PM, the former Administrator was asked about the incident with Resident #5. The former Administrator stated, I do remember that. An abuse incident should have been done. [Named Resident #5] described [Named CNA #4], but she didn't work with her in that time frame. The doctor had seen her on Wednesday, and she told us on Friday .I spoke with MD [Medical Doctor] and FNP [Family Nurse Practitioner] .and she didn't have any problem of pain. The person she described didn't work in that time frame. We looked at the schedule to see what staff worked .had diagnoses of fractures in past. We did see that she had comorbidities and we noted she had a turtleneck on. She could have been injured putting on that tight turtleneck. We concluded unsubstantiated abuse, but she had a fracture from manipulating her arm, instead of intentionally hurting her . During a telephone interview conducted on 12/14/2022 at 8:44 AM, LPN #1 was asked about the incident with Resident #5's injured arm. LPN #1 confirmed his statement dated 9/8/2022 was true, and that Resident #5 did not have any falls on his shift. LPN #1 stated, I was told by the nurse when I came on, that she [Resident #5] had a fracture per x-ray . Resident #5 first said she was in pain and alleged abuse by a staff member on 8/19/2022 at about 7:00 PM, to CNA #1. CNA #1 alleged she reported the allegation to LPN #1 that night. LPN #1 did not document an assessment of Resident #5, did not do an incident report, and did not report the allegation of abuse. CNA #1 reported the same to LPN #2 on 8/20/2022, about 12 hours later. Resident was given Tylenol for the pain on 8/20/2022 at 8:00 AM, an X-ray was obtained at 2:45 PM on 8/20/2022, and results showed left humerus fracture. Tylenol was given again at 8:39 PM on 8/20/2022, when Resident #5 was transferred out to a hospital for the fracture. Therefore, Resident #5 suffered with the fracture for over 24 hours with only two doses of Tylenol for pain before being sent out to the hospital. This resulted in an Immediate Jeopardy for neglect of Resident #5. 3. Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE], with diagnoses of Schizophrenia, Dementia with Behavioral Disturbance, Chronic Kidney Disease, Seizures, Malnutrition, and Chronic Hepatitis C. Review of the quarterly MDS dated [DATE], revealed Resident #1 had severely impaired cognition, physical behaviors directed towards others on 4-6 of 7 days, and verbal behaviors directed towards others on 1-3 of 7 days. Review of the Care Plan revised 9/9/2022, revealed .History of Exhibits violent angry outburst and behavior problems towards staff and other residents .Violent outburst on 2 other residents .Sent to [named hospital] and returned .Placed on One-on-one supervision/care . Review of the Nurses Note dated 9/20/2022 at 5:17 AM, revealed, .Res [Resident] did get up and wonder [wander] periodically and push on exit door handles. No one on one personnel avail [available] for res [resident] and staff safety. DON [Director of Nursing] notified . Review of the Nurses Note dated 9/21/2022 at 12:20 AM, revealed .No one on one personnel avail for res and staff safety .DON notified . Review of daily assignment sheets for 9/8/2022-12/2/2022 revealed the following: a. One (1) CNA [Certified Nursing Assistant] was assigned to the Gardens [secure locked unit] from 7:00 PM-7:00 AM, and no one was assigned to provide one on one supervision for Resident #1 on 9/8/2022, 9/10/2022, 9/15/2022, 9/22/2022, 9/24/2022, and 9/27/2022. b. Two (2) CNAs were assigned to the Gardens from 7:00 PM to 7:00 AM and no one was assigned to provide one on one supervision for Resident #1 on 9/9/2022, 9/11/2022, 9/14/2022, 9/16/2022, 9/19/2022, 9/23/2022, 9/25/2022, 9/26/2022, 10/2/2022, 10/14/2022, 10/23/2022, 10/24/2022, 11/11/2022, 11/12/2022, 11/15/2022, and 11/30/2022. c. No one was assigned to provide one on one supervision for Resident #1 from 3:00 PM-7:00 PM on 10/31/2022. d. No one was assigned to provide one on one supervision for Resident #1 from 7:00 AM-7:00 PM on 12/2/2022. Review of the Incident Report dated 11/10/2022 at 2:15 PM, revealed Resident #1 was observed lying on his back on the hallway floor and Resident #2 was on top of him. Resident #2 had his hands around Resident #1's throat. 4. Review of the medical record, revealed Resident #3 was admitted to the facility on [DATE], with diagnoses of Alzheimer's, Hypertension, Depression, and Dementia. Review of the quarterly MDS assessment dated [DATE], revealed Resident #3 had a BIMS of 3, which indicated severe cognitive impairment, and no behaviors were coded. Review of a witness statement signed by CNA #5 and dated 9/7/2022, revealed CNA #5 was giving shift report to CNA #6 on 9/7/2022 at approximately 6:55 PM. Resident #3 walked toward Resident #1 who was sitting in a chair in the Day Room, Resident #1 reached up and struck Resident #3 with his closed fist on her left jaw. CNA #6 stepped in between the residents and CNA #5 took Resident #3 to a safe area. The CNAs reported the incident to LPN #3. Observation in the Day Room on 11/17/2022 at 10:21 AM, revealed Resident #3 was fully clothed, sat in a wheelchair, and watched television. Observation in the Resident's Room on 11/28/22 at 10:27 AM, revealed Resident #3 was in bed, her eyes were closed, and she appeared to be asleep. Observation in the Resident's Room on 12/6/22 at 2:56 PM, revealed Resident #3 was in bed, her head was covered with a wrap, and she was turned toward the wall. 6. Review of the medical record, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Dementia, Hypertension, and Malnutrition. Review of the quarterly MDS assessment dated [DATE], revealed Resident #4 had severe cognitive impairment. Review of an Incident Audit Report dated 9/7/2022, revealed .Incident Description .9/07/2022 [9/7/2022] .20:45 [8:45 PM] .Writer [LPN #3] standing at med [medication] cart passing medication when writer observed res [Resident #1] walking up behind res [Resident #4] .Res [Resident #1] struck res .[Resident #4] .in the rear right side of his neck with a closed fist. Writer immediately jumped in between the residents and redirected res .Resident #1] .away from res [Resident #4] .Writer walked down to his room and put cna [CNA] as one on one with res. [Resident #1]. Writer went back and assessed resident [Resident #4], Res [Resident #4] had no obvious signs of injury and made no faces of pain or any complaints . Observation in the Day Room on 11/17/22 at 10:23 AM, revealed Resident #4 was fully clothed, sat in a chair, and played with the drawstring of his pants. Observation on the Secure Unit hall on 11/29/22 at 9:14 AM, revealed Resident #4 was fully clothed, sat in a chair, his eyes were closed, and he appeared to be asleep. Observation in the Activity Room on 12/2/22 at 10:45 AM, revealed Resident #4 interacted with other residents. During an interview conducted on 11/17/2022 at 9:15 AM, the Interim Administrator confirmed staff was not providing one on one care for Resident #1 at the time of the incident on 11/10/2022. During an interview conducted on 11/17/2022 at 1:47 PM, CNA #2 confirmed she was scheduled to sit one on one with Resident #1 on 11/10/2022 from 7:00 AM-7:00 PM. CNA #2 was asked what time she arrived. CNA #2 stated, About 2 [2:00 PM] .I clocked in, put my belongings up in the breakroom in the Gardens, then used the restroom in the breakroom, and, literally, we heard the commotion . CNA #2 was asked if she saw anyone sitting outside Resident#1's room when she arrived. CNA #2 stated, No, there was no one out there . CNA #2 was asked if there were there any papers on the table. CNA #2 stated, No, it wasn't there. I had to ask for it [1:1 Monitoring Sheet] . CNA #2 was asked who was supposed to be sitting with him before she arrived. CNA #2 stated, That I'm not for sure .they knew I was running late and expected somebody to be there when I arrived .they always said that somebody needs to be with him .so I thought by me running late, they would have somebody there. CNA #2 was asked what she saw when she heard the commotion and came out of the break room. CNA #2 stated, [Named Resident #2] was on top of [named Resident #1] saying 'he hit me .he hit me in the back of my head' . CNA #2 was asked if she had ever seen Resident #1 be aggressive toward anyone. CNA #2 stated, Yes .He will get angry toward me to the point where I'm literally scared, and I have seen him get mean and holler at other residents or staff, and I did see him hit one of our other staff members before .it can be like a light switch. He will be sweet one second and then just flip. You never know when he will get in that mood . During an interview on 11/17/2022 at 2:20 PM, LPN #6 was asked who was sitting with Resident #1 when CNA #2 arrived on 11/10/2022. LPN #6 stated, No one, [named the Scheduler] said [named CNA #2] was going to be late .we had to just watch out for him .do the best we could. LPN #6 was asked if anyone was with him when the incident happened. LPN #6 stated, No . LPN #6 was asked if she asked the Scheduler when she realized CNA #2 was going to be late. LPN #6 stated, I did, I was like who is coming in .She said she was going to talk to .the Restorative Aide to come sit with him until CNA #2 came in. LPN #6 was asked if the Restorative Aide came to sit with him. LPN #6 stated, No. LPN #6 was asked if he was ever alone. LPN #6 stated, Yes ma'am. We would just check .he was sleeping, which made it easy for us to watch . LPN #6 was asked if she saw the altercation between Resident #1 and Resident #2. LPN #6 stated, No. During an interview on 11/17/2022 at 2:37 PM, the Nurse Practitioner (NP) was asked if Resident #1 was supposed to have someone with him at all times. The NP stated, Yes, he's on 1 on 1 supervision .it was my understanding that no one was actually assigned to him that day. They were having to more or less take turns watching him. I wasn't aware at the time .but there was no one assigned to him that day . During an interview conducted on 11/21/2022 at 2:43 PM, LPN #3 confirmed Resident #1 was placed on 1:1 monitoring on 9/8/2022 after 2 altercations with other residents. LPN #3 stated, .I said look this guy just can't keep walking around here hitting people . LPN #3 was asked if staff was provided to sit 1 on 1 with Resident #1 on 9/20/2022. LPN #3 confirmed no one was available to sit with Resident #1. LPN #3 stated, .That was like my last resort of asking them over and over again, and nobody was doing nothing . LPN #3 was asked what the DON said when she was notified. LPN #3 stated, She told me that she would get somebody, or she would call the staffing person .but nothing ever happened .I had one CNA I had to take off the floor. I had 2, I had 1 do the 1 on 1. One CNA would get a section and 1 on 1 [assigned to take care of the men and provide one on one care for Resident #1] and the other CNA had the women. LPN #3 was asked what if the CNA that was assigned to take care of the men and sit one on one with resident #1 had to take care of someone else. LPN #3 stated, The rationale was he was asleep through the night . LPN #3 was asked if there were other times when Resident #1 was left alone. LPN #3 stated, Oh yeah absolutely, when she was making rounds .I knew that still wasn't adequate, so that's why I started documenting . LPN #3 was asked if the same issue was present with no staff scheduled for 1 on 1 supervision for Resident #1 on 9/21/2022. LPN #3 stated, Yes ma'am, the same issue. Then what they started doing was, once they realized that I was documenting, they started scheduling 1 on 1 for my shift only .they brought somebody in. They did it right once I started documenting, so when I wasn't working or on the weekends .the only reason I know is because I picked up [weekend shifts] .you've got 2 CNAs on the hall .it's impossible, because that means she [the CNA providing 1 on one supervision for Resident #1] wouldn't have cared for anybody else. LPN #3 was asked if the facility provided any special education for providing 1 on 1 supervision for Resident #1. LPN #3 stated, No, it was just like they didn't want to do 1 on 1, but if they had to it was just like grab somebody and sit with him .with [Resident #1] you need somebody who understands his disability, his dementia, and triggers, and be proactive in stopping triggers .to keep him from becoming violent, if they had taken the time to do it right .they could've . LPN #3 was asked if it was safe for the other residents for Resident #1 to be left unsupervised. LPN #3 stated, Oh, absolutely not. During an interview conducted on 11/21/2022 at 3:54 PM, the Interim Administrator confirmed the 1:1 Monitoring sheets were incomplete. The Interim Administrator stated, .Originally, we thought she was sitting with him when technically, when she came to work, she put her stuff down and went to the bathroom, she had not technically gone to sit with him yet .basically what we failed to do was follow the resident's plan of care .we determined that the resident's POC [Plan of Care] was not followed per doctor's orders .resulted in physical altercation [with Resident #2] . During an interview conducted on 12/1/2022 at 12:00 PM, the Medical Director confirmed he was not aware there were days the facility did not have staff to provide 1 on 1 monitoring for Resident #1, and that Resident #1 always needed staff supervision. During a telephone interview on 12/1/2022 at 3:13 PM, the Regional Nurse Consultant (RNC) confirmed she was not part of the determination to place Resident #1 in 1 on 1 monitoring indefinitely. The RNC stated, .Have a task in POC [Point of Care CNA documentation system] which, to my understanding, they did not utilize .they were using paper .the 1 on 1 documentation .should have been in POC .I wasn't aware until sometime in October that he had been on 1 on 1 for this extended period of time . The RNC confirmed that she was not aware there were days the facility did not provide staff for 1 on 1 monitoring until 11/10/2022, when she saw the resident-to-resident incident submitted. The RNC stated, .that's not a resident-to-resident, that's a report under neglect, because he was care-planned for 1 on 1 .if there was a staffing issue .supposed to notify [named interim Administrator] and then [named IDON] to obtain a replacement . 5. Review of the closed medical record, revealed Resident #2 was admitted to the facility on [DATE], with diagnoses of Dementia with Psychotic Disturbance, Diabetes, Epilepsy, Schizoaffective Disorder, and Speech Disorder. Review of the annual MDS assessment dated [DATE], revealed Resident #2 had a BIMS of 11, which indicated moderate cognitive impairment. Review of the Incident Report dated 8/21/2022, revealed Resident #2, who had highly impaired vision, ran over Resident #1's foot accidentally. Resident #1 hit [Resident #2] on the back of the head with his open hand. Review of the Incident Report dated 8/28/2022 at 6:56 PM, revealed Resident #1 was observed lying on the Day Room floor in a sleeping position with a scratch on the left side of his face. There was blood on the floor. Resident #2 was in his wheelchair, his lip was bloody, and he was holding onto Resident #1's arm, holding him on the floor. The altercation was unwitnessed and neither resident was able to tell staff what happened. Review of the Nursing Noted dated 11/10/2022 at 3;09 PM, revealed Resident #1 was observed lying on the floor, Resident #2 was on top of Resident #1 and had his hands around Resident #1's throat. Resident #2 was yelling He hit me in my head. During an interview conducted on 12/7/2022 at 9:03 AM, the MDS Coordinator was asked about the incident between Resident #1 and Resident #2. The MDS Coordinator confirmed the Care Plan for Resident #1 was not being followed for 1 on 1 monitoring, which resulted in an altercation between Resident #1 and Resident #2 on 11/10/2022. The facility failed to follow the Care Plan to monitor Resident #1 after the incident with Residents #3 and #4, and he later assaulted Resident #2. 6. Review of the closed medical record, revealed Resident #14 was admitted to the facility on [DATE], with diagnoses of COVID-19, Cerebral Infarction, Dementia, Alzheimer's Disease, Osteoporosis, Anxiety, and Vitamin D Deficiency. Review of the quarterly MDS assessment dated [DATE], revealed Resident #14 had a BIMS of 4, which indicated severe cognitive impairment. Review of the Nursing Note dated 10/27/2022 at 6:15 AM, revealed .[Named Resident #14] observed sitting on floor by his wheelchair .stated he was attempting to walk .Staff reeducated resident about att [attempting] to ambulate without asst [assistance] .DON [Director of Nursing] notified . Review of the fall Incident Report dated 10/27/2022, revealed Resident #14 sustained an unwitnessed fall with no injuries. Review of the fall investigation dated 10/27/2022, revealed the only neurochecks were completed on 10/27/2022 at 7:32 AM, 7:47 AM, and 8:02 AM. Neurocheck assessments were not completed for 72 hours per the facility's protocol for unwitnessed falls. Review of the Nursing Note dated 10/28/2022 at 7:07 AM, revealed .Therapy .went in res [resident's] rm [room] to perform exercise .Res complained of pain when therapy att [attempted] to get him up .advised oncoming nurse .MD [medical doctor] notified .bilat [bilateral] x-ray . Review of the telehealth Progress Notes dated 10/28/2022 at 1:48 PM, revealed .resident c/o [complained of] L hip pain .had a fall on 10/27/2022 at 0630 [6:30 AM] .Patient highly confused. Nurse states patient normally gets up to eat and do activities but refusing to get out of bed .decreased ROM to L hip .ASSESSMENT/DIAGNOSIS PLAN NOTES .Pain in left hip .STAT xray left hip 2 views . Review of the Physician's Order dated 10/29/2022, revealed a bilateral hip x-ray was ordered. The order was not entered into the electronic health record (EHR) as STAT and was not entered on the day the order was given [10/28/2022]. Review of the Nursing Note dated 10/29/2022 at 3:09 PM, revealed .[named mobile radiology company] completed hip xray. awaiting results at this time. Review of the Nursing Noted dated 10/31/2022 at 9:30 AM, showed the x-ray results revealed Resident #14 had a left hip fracture with moderate displacement. Facility notified the provider who gave an order to send the resident to the emergency room . Review of the Nursing Note dated 10/31/2022 at 10:25 AM, revealed Resident #14 was transferred to the emergency room for treatment of his left hip fracture [4 days after the fall]. During an interview conducted on 11/22/2022 at 12:16 PM, LPN #2 confirmed she worked 10/28/2022, the day following Resident #14's fall. LPN #2 stated, .Friday [10/28/2022] morning I come [came] back in to work and was told .he was complaining of pain and refusing to get up .[named LPN #3] said he had called telehealth .was just needing help getting the x-ray ordered through the mobile x-ray company .he said he needed help calling and we don't call, we do it all online .the password wasn't valid, and I couldn't log on to [named the mobile x-ray site] .when [named LPN #6] come [came] in, I asked her for the password, so we could get it ordered .[named LPN #6] took over the whole situation . During an interview conducted on 11/23/2022 at 9:39 AM, the Physical Therapist stated, .went in to do his [Resident #14] treatment, he had been able to sit, stand and transfer .he couldn't stand .because of pain .went and found [named LPN #3] .walked down with me and did assess him .[Resident #14] moaned and verbally complained about his left hip which was uncharacteristic of him .he would move his right side and say see no pain here, it's [pain] just right here .indicated his left upper leg . During an interview conducted on 12/1/2022 at 12:00 PM, the Medical Director confirmed that facility staff should fully follow physician's orders and should have followed up on Resident 14's STAT x-ray immediately, not waiting days later. During an interview conducted on 12/2/2022 at 1:28 PM, LPN #2 confirmed that she contacted telehealth through a facetime visit and obtained an order for a bilateral hip x-ray. LPN #2 stated, .I let [named LPN #6] know .she facilitated that and ordered it through [named mobile x-ray company]. LPN #2 confirmed she was not sure if she told LPN #6 the bilateral hip x-ray order was supposed to be entered STAT. LPN #2 was asked if she received report that the x-rays had not [NAME][TRUNCATED]

Based on policy review, medical record review, review of daily assignment sheets, time detail reports, Safety Check Log (1:1 Monitoring logs), and interview, the facility failed to implement care plan interventions for 1:1 monitoring for 1 of 18 (Resident #1) sampled residents which resulted in an Immediate Jeopardy when Resident #1, a severely cognitively impaired resident with a history of aggression and physical altercations, was left unattended by staff on 11/10/2022 and struck another resident (Resident #2) in the head, initiating an altercation. Immediate Jeopardy (IJ) is a situation in which a provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, severe injury, harm, impairment, or death to a resident. The Administrator was notified of the Immediate Jeopardy on 12/8/2022 at 10:07 AM, in the Conference Room. The facility was cited Immediate Jeopardy at F-656. The facility was cited at F-656 at a scope and severity of J. A partial extended survey was conducted from 12/12/2022 through 12/13/2022. The IJ was effective 8/19/2022 through 12/13/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 12/13/2021 at 8:42 AM, and was validated onsite by the surveyors on 12/14/2022 through review of root cause analysis, in-services, audits, and staff interviews conducted. The findings include: 1. Review of the facility's policy titled, Using the Care Plan, dated 5/2022 revealed, .The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident . 2. Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Schizophrenia, Dementia with Mood Disturbance/Behavioral Disturbance/Psychotic Disturbance, Seizures, Hypertension, and Chronic Hepatitis C. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had severely impaired cognition, physical behaviors directed towards others on 4-6 of 7 days and verbal behaviors directed towards others on 1-3 of 7 days. Review of the Care Plan dated 4/8/2022 revealed, .History of Exhibits violent angry outburst and behavior problems towards staff and other residents .9/8/22 Violent outburst on 2 other residents .Sent to [named hospital] and returned .Placed on One-on-one supervision/care .revised 9/9/2022 . Review of the telehealth Physician's Progress Note dated 9/7/2022 at 9:28 PM, revealed, .pt [patient - Resident #1] having severe psychosis. assaulted 2 other residents. agree w/ [with] RN [Registered Nurse] that patient should go under 48 hours psych [psychiatric] watch . Review of the Nurses Note dated 9/9/2022 at 2:03 AM revealed, Resident is on one on one [supervision] at this time. Review of the Nurses Note dated 9/20/2022 at 5:17 AM revealed, Res [Resident #1] sleep most of shift, no behaviors noted. Res did get up and wonder [wander] periodically and push on exit door handles. No one on one personnel avail [available] for res [resident] and staff safety. DON [Director of Nursing] notified . Review of the Nurses Note dated 9/21/2022 at 12:20 AM revealed, Res sleep most of shift, no behaviors noted. No one on one personnel avail for res and staff safety DON notified . Review of the daily assignment sheet dated 11/10/2022 revealed Certified Nursing Assistant (CNA) #2 was assigned to work on the Garden's Hall (secure unit), where Resident #1 resided, from 7:00 AM -7:00 PM with 2 other CNAs. Review of time detail report dated 11/10/2022 revealed CNA #2 clocked in at 1:52 PM. Review of the Nurses Note dated 11/10/2022 at 2:49 PM revealed, .Resident observed laying in hallway floor on back with resident .[Resident #2] laying on top of him .while on floor resident .[Resident #2] was observed with hands around [named Resident #1] neck . There was no documentation Resident #1 was on 1:1 staff observations during this time. Review of the medical record revealed Resident #1 was transferred to the emergency room (ER) evaluation on 11/11/2022 and readmitted to the facility on [DATE]. Review of the Physician's Progress Note dated 11/15/2022 at 7:18 PM revealed, .readmitted after an altercation with another resident on last week. Resident was being attacked by another resident [Resident #2] after the other resident stated [named Resident#1] hit him on his head .He is being supervised by staff, as he has been on 1:1 supervision for some time due to his attacks towards other residents in the past . 3. Review of daily assignment sheets from 9/8/2022-12/2/2022 revealed the following: On 9/8/2022, 9/10/2022, 9/15/2022, 9/22/2022, 9/24/2022, and 9/27/2022 there was one (1) CNA assigned to the Gardens Hall (Secure Unit) from 7:00 PM-7:00 AM, and there was no staff assigned to be on 1:1 with Resident #1. On 9/9/2022, 9/11/2022, 9/14/2022, 9/16/2022, 9/19/2022, 9/23/2022, 9/25/2022, 9/26/2022, 10/2/2022, 10/14/2022, 10/23/2022, 10/24/2022, 11/11/2022, 11/12/2022, 11/15/2022, and 11/30/2022 there were 2 CNAs assigned to the Gardens Hall from 7:00 PM to 7:00 AM, and no staff was assigned to be on 1:1 with Resident #1. No staff was assigned to be on 1:1 with Resident #1 from 3:00 PM-7:00 PM on 10/31/2022. No staff was assigned to be on 1:1 with Resident #1 from 7:00 AM-7:00 PM on 12/2/2022. 4. Review of the 1:1 Monitoring Sheets dated 9/8/2022-11/21/2022, revealed there was no documentation Resident #1 was being observed 1:1 on the following dates: (a) On 9/17/2022, 9/21/2022, 9/23/2022, 9/24/2022, 9/25/2022, 9/26/2022, 11/6/2022, and 11/10/2022. (b) On 10/22/2022 and 10/24/2022 from 7:00 AM to 7:00 PM. (c) On 11/1/2022 from 3:00 AM through 7:00 AM. (d) On 11/5/2022 from 7:00 AM through 11:59 PM. 5. During an interview conducted on 11/17/2022 at 9:15 AM, the Interim Administrator confirmed staff were not providing 1:1 care to Resident #1 at the time of the incident on 11/10/2022. During an interview conducted on 11/17/2022 at 1:47 PM, CNA #2 confirmed she was scheduled to observe 1:1 with Resident #1 on 11/10/2022 from 7:00 AM-7:00 PM. CNA #2 was asked what time she arrived. CNA #2 stated, About 2 [2:00 PM] .I clocked in, put my belongings up in the break room in the Gardens [Secure Unit], then used the restroom in the break room and literally we heard the commotion . CNA #2 was asked did you see anyone sitting outside Resident #1's room when you arrived. CNA #2 stated, No there was no one out there .a chair and an overbed table. CNA #2 was asked were there any papers on the table. CNA #2 stated, No it wasn't there I had to ask for it [1:1 Monitoring Sheet] . CNA #2 was asked who was supposed to be sitting with him before you arrived. CNA #2 stated, That I'm not for sure .they knew I was running late and expected somebody to be there when I arrived .they always said that somebody needs to be with him .so I thought by me running late they would have somebody there. CNA #2 was asked when you heard the commotion and came out of the break room, what did you see. CNA #2 stated, [Resident #2] was on top of [Resident #1] saying he hit me, he hit in the back of my head . CNA #2 was asked if she ever saw Resident #1 be aggressive toward anyone. CNA #2 stated, Yes .He will get angry toward me to the point where I'm literally scared, and I have seen him get mean and holler at other residents or staff; and I did see him hit one of our other staff members before .it can be like a light switch. He will be sweet one second and then just flip. You never know when he will get in that mood . During an interview conducted on 11/17/2022 at 2:20 PM, Licensed Practical Nurse (LPN) #6 was asked who was sitting with Resident #1 when CNA #2 arrived on 11/10/2022. LPN #6 stated, No one, [named the Scheduler] said [CNA #2] was going to be late .we had to just watch out for him to do the best we could. LPN #6 was asked if anyone was with him when this incident happened. LPN #6 stated, No . LPN #6 was asked when she realized CNA #2 was going to be late, if she informed the Scheduler. LPN #6 stated, I did, I was like who is coming in .She said she was going to talk to .the Restorative Aide to come sit with him until CNA #2 came in. LPN #6 was asked if the Restorative Aide came. LPN #6 stated, No. LPN #6 was asked if Resident #1 was alone at times. LPN #6 stated, Yes ma'am, we would just check .he was sleeping which made it easy for us to watch . LPN #6 was asked if anyone saw the altercation between Resident #1 and Resident #2. LPN #6 stated, No. During an interview conducted on 11/17/2022 at 2:37 PM, the Nurse Practitioner (NP) was asked if Resident #1 was supposed to have someone with him at all times. The NP stated, Yes, he's on one to one supervision .it was my understanding that no one was actually assigned to him that day, they were having to more or less take turns watching him. I wasn't aware at the time, but when I came to break up the altercation, the older CNA said something about maybe we were changing shifts .when the on-coming is coming on, the one leaving shouldn't leave his side, and I educated them about that .but there was no one assigned to him that day . During an interview on 11/21/2022 at 9:44 AM, the Interim Director of Nursing (IDON) confirmed the 1:1 Monitoring sheet documentation was incomplete. The IDON stated, .They are very random, they are not complete .I just collected what we had .I put them in order .obviously I saw that was not being done correctly . During an interview on 11/21/2022 at 10:10 AM, the Scheduler was asked if CNA #2 called and told her she was going to be late on 11/10/2022. The Scheduler stated, She texted my phone and told me she would be late, something about court. I told the nurse .she's going to be late .I was on a cart working . The Scheduler was asked if she knew what time CNA #2 arrived. The Scheduler stated, No, ma'am, I don't have access .that day [named CNA #2] was one on one . The Scheduler was asked who was one on one with Resident #1 until CNA #2 arrived. The Scheduler stated, I can't answer that, because I was on a cart on this side. The Scheduler was asked if she told anyone that she would send the Restorative Aide around to sit one on one with Resident #1. The Scheduler stated, No, I did not .if I'm on a cart, I don't do anything dealing with the staffing part, the staffing is already done .I just know I told the nurse that morning she was going to be late. The Scheduler was asked what her plan was for one on one with Resident #1. The Scheduler stated, I always tell the nurse, there's a unit manager back there, and there's a nurse and we can all help out .that's the way it's supposed to be . The Scheduler was asked if she knew what time she was told that CNA #2 had not made it to work yet. The Scheduler stated, .I was thinking it was around 11, I was in the Dining Room . The Scheduler was asked if she notified anyone that nobody was 1:1 with Resident #1 at that point. The Scheduler stated, No ma'am. During an interview conducted on 11/21/2022 at 2:43 PM, LPN #3 confirmed Resident #1 was placed on 1:1 monitoring on 9/8/2022 after 2 altercations with other residents. LPN #3 stated, .I said look this guy just can't keep walking around here hitting people . LPN #3 was asked they did not provide you staff to sit 1:1 on 9/20/2022. LPN #3 stated, That's correct .that was like my last resort of asking them over and over again and nobody was doing nothing . LPN #3 was asked when you notified the DON, what did she tell you. LPN #3 stated, She told me that she would get somebody or she would call the staffing person .but nothing ever happened .I had one CNA, I had to take 1 off the floor. I had 2, I had one do the 1 on 1. One CNA would get a section and 1 on 1 [assigned to take care of the men and provide 1:1 supervision for Resident #1] and the other CNA had the women. LPN #3 was asked what if the CNA assigned to men and 1:1 for Resident #1 had to take care of somebody else. LPN #3 stated, The rationale was he was asleep through the night, but I was trying to tell them [didn't have 1:1 staff]. LPN #3 was asked were there times when Resident #1 was left alone. LPN #3 stated, Oh yeah absolutely, when she was making rounds .I knew that still wasn't adequate, so that's why I started documenting . LPN #3 was asked if on 9/21/2022 there was the same issue with no staff scheduled for 1 on 1. LPN #3 stated, Yes ma'am, the same issue. Then what they started doing was once they realized that I was documenting, they started scheduling 1 on 1 for my shift only .they brought somebody in. They did it right once I started documenting, so when I wasn't working or on the weekends .the only reason I know is because I picked up [weekend shifts] .you've got 2 CNAs on the hall .it's impossible because that means she wouldn't have cared for anybody else. LPN #3 was asked did the facility provide any special education for 1 on 1. LPN #3 stated, No, it was just like they didn't want to do 1 on 1 but if they had to it was just like grab somebody and sit with him .with [Resident #1] you need somebody who understands his disability, his dementia, and triggers, and be proactive in stopping triggers .to keep him from becoming violent, if they had taken the time to do it right .they could've . LPN #3 was asked was it safe for the other residents for Resident #1 to be left unsupervised. LPN #3 stated, Oh, absolutely not. During an interview conducted on 11/21/2022 at 3:54 PM, the Interim Administrator confirmed the 1:1 Monitoring sheets were incomplete. The Interim Administrator stated, .Originally, we thought she was sitting with him when technically when she came to work, she put her stuff down and went to the bathroom, she had not technically gone to sit with him yet .basically what we failed to do was follow the resident's plan of care .we determined that the resident's POC [Plan of Care] was not followed per doctor's orders .resulted in physical altercation [with Resident #2] . During an interview conducted on 11/22/2022 at 11:15 AM, LPN #4 confirmed she was working on 11/10/2022. LPN #4 was asked when she was made aware that there was not a staff member for 1:1 for Resident #1. LPN #4 stated, .I was in meetings, so I think it was at the care plan meeting I was made aware the aide hadn't made it in yet and the [Scheduler] was made aware, also the DON .it was told that they were going to get someone to cover the 1 on 1 .the nurse on the unit told me the [Scheduler] was going to send someone down to take care of the 1 on 1 .I had to take care of PAR [the Patients at Risk meeting]. LPN #4 was asked what time the care plan meeting started. LPN #4 stated, Right after morning meeting, don't know if we were done early or late .It [the altercation] happened during PAR and the nurse called me down there and told me what had took place, I left PAR . LPN #4 was asked if PAR took place right after the care plan meeting. LPN #4 stated, PAR happens at 1:30 [PM]. Care Plan depends on how many residents there are on care plan . LPN #4 was asked what she did when she arrived on the hall. LPN #4 stated, Trying to figure out why it occurred, and the aide that was supposed to be in 1 on 1 wasn't down there when it happened .They had me down there thinking she was sitting with him .I wasn't aware of that part .I was thinking she was down there sitting with him and had to get up and go to the restroom .I wasn't aware that she had just come in and put her stuff down . LPN #4 was asked as the Unit Manager should she have been aware no one was sitting 1:1. LPN #4 stated, Yes ma'am. LPN #4 was asked if Resident #1 should be left alone at any time. LPN #4 stated, No ma'am. During an interview conducted on 11/29/2022 at 1:38 PM, the former DON denied having been notified of not having staff to provide 1:1 monitoring for Resident #1 on 9/20/2022 and 9/21/2022. The former DON was asked how did you ensure staff were competent to provide care and 1:1 monitoring of a combative, aggressive resident. The former DON stated, We have a [computer] course on de-escalating patients and our log that they're checking on him to make sure and documenting where he is . The former DON was asked what training was provided to staff regarding how to complete or fill out the 1:1 Monitoring tool. The former DON stated, I think it's pretty self-explanatory . The former DON was asked did you monitor those tools to ensure they were completed. The former DON stated, Truly, honestly I left that to be on the nurses. The former DON was asked were you aware there was no coverage for 1:1 for Resident #1 on 11/10/2022. The former DON stated, No .I did not know about it until after the incident . During an interview conducted on 12/1/2022 at 3:13 PM, the Regional Nurse Consultant (RNC) was asked were you aware there were days Resident #1 did not have 1 on 1 monitoring. The RNC stated, Not until November 10th when I saw a resident to resident be submitted that [named the Interim Administrator] and I had a conversation .that's not a Resident to Resident, that's reportable under neglect because he was care planned for 1 on 1 .if there was a staffing issue .supposed to notify [named interim Administrator] and then [named IDON] to obtain a replacement . During an interview conducted on 12/5/2022 at 9:55 AM, the Interim Administrator confirmed they could not find any de-escalation training that was completed prior to 12/2/2022. During an interview conducted on 12/7/2022 at 9:03 AM, the MDS Coordinator confirmed Resident #1's care plan was updated to include 1:1 monitoring on 9/9/2022 and the care plan was not being followed on 11/10/2022 when the incident between Resident #1 and Resident #2 occurred. The MDS Coordinator was asked should the care plan be followed. The MDS Coordinator stated, Absolutely. The MDS Coordinator was asked should Resident #1 be on continuous 1:1 monitoring. The MDS Coordinator stated, Yes. Refer to F-689 The surveyors verified the removal plan by review of root cause analysis, in-services, audits, and staff interviews conducted: NP educated the 2 CNAs involved with Resident #1 on one-to-one supervision. Surveyors verified by interview. RNC in-serviced RN/IDON and LPN Nurse Manager on Abuse Prevention Program, Recognizing Signs and Symptoms of Abuse/Neglect (Identification) to include notification of Admin (Administrator)/DON when staffing changes occur with 1:1. Nursing staff educated not to leave 1:1 resident without staff replacement. Charge Nurses educated to new protocol for 1:1 and notification. Surveyors verified by review of in-service documentation and interview. DON/Nurse Manager in-serviced staff on Abuse Prevention Program, Recognizing Signs and Symptoms of Abuse/Neglect (Identification) to include notification of Admin/DON when staffing changes occur with 1:1. Nursing staff to be educated not to leave 1:1 resident without staff replacement. Charge Nurses educated to new protocol for 1:1 and notification. Surveyors verified by review of in-service documentation and interview. RNC in-serviced RN/IDON and LPN Nurse Manager on use of crisis intervention technics, tips on managing challenging behaviors, and redirecting a client with challenging behaviors. Surveyors verified by review of in-service documentation and interview. DON/Nurse Manager in-serviced staff on use of crisis intervention technics, tips on managing challenging behaviors, and redirecting a client with challenging behaviors. This training started on 11/23/22. Additional staff will be in-serviced prior to working their next shift. Surveyors verified by review of in-service documentation and interview. Charge Nurse will sign at the end of each shift to verify documentation is complete. Surveyors verified by review of documentation. Medical Records will collect and audit 1:1 sheets routinely and scan into the electric record. Surveyors verified by interview. All new behaviors will be reviewed Monday through Friday during clinical start up for redirection/appropriate intervention and discuss and provide education according to needs. Surveyors verified by interview. DON implemented protocol and placed at NS (Nurses Station). All one-on-one orders for supervision are placed as a doctor's order on POC/PCC MAR (Point of Care CNA Documentation/Point Click Care Medication Administration Record). Surveyors verified by review of protocol and interview. QAPI (Quality Assurance Performance Improvement) was conducted November 18, 2022, with IDT (Interdisciplinary Team) and Medical Provider representative and completed RCA [Root Cause Analysis]. Surveyors verified by review of QAPI minutes. New staff will be educated on 1:1 process, crisis intervention and behavioral training upon hire. Surveyors verified by interview. QAPI will be held again 12/8/22 with Governing Body to discuss deficiency, education, systemic changes, and monitoring moving forward. Surveyors verified by review of QAPI minutes. Audit of Staffing sheets to be done 3 times (x) a week to assess compliance of assignment(s) of 1:1 weekly x 4 weeks then 1 x weekly for 8 weeks. Results of the audits will be submitted to the QAPI Committee for review and recommendation(s). Surveyors verified by review of audits and interview. DON/Nurse Manager will audit staff knowledge regarding behavioral scenarios and how to respond. Choosing 2 staff members 3 times a week x 4 weeks then 2 staff members 1 time a week x 8 weeks. The results of those audits will be sent to QAPI for eval and review. Surveyors verified by review of audits and interview. The facility's noncompliance of F-656 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, job description review, medical record review, observation, and interview, the facility failed to ensure that residents were provided appropriate care and services to meet the residents' physical, mental and/or psychosocial needs in a timely manner for 2 of 18 sampled residents (Resident #5 and #14) reviewed for quality of care. This resulted in Immediate Jeopardy (IJ) when Resident #5 complained of pain and abuse by a staff member and no one addressed this abuse allegation and injury until the next day; and when staff failed to acknowledge and implement an immediate (STAT) physician's order, follow up on radiology results, transfer a resident to the hospital in a timely manner, and provide pain relief for Resident #14. The facility's failure to provide appropriate care and services resulted in Immediate Jeopardy for Resident #5 and #14. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Interim Administrator and Regional Vice-President were notified of the Immediate Jeopardy (IJ) for F-684 on 12/7/2022 at 5:31 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-684. The facility was cited at F-684 at a scope and a severity of J, which is Substandard Quality of Care. A partial extended survey was conducted from 12/12/2022 through 12/13/2022. The Immediate Jeopardy existed from 8/19/2022 through 12/13/2022. An acceptable Removal Plan which removed the immediacy of the jeopardy was received on 12/13/2022 at 10:44 PM, and was validated onsite by the Surveyors on 12/14/2022, through review of root-cause analysis, in-services, audits and staff interview conducted. The findings include: 1. Review of the facility's policy titled, Request for Diagnostic Services . dated 5/2022, revealed, All requests for diagnostic services must be ordered by a physician .Orders for diagnostic services will be promptly carried out as instructed by the physician's order .Emergency requests must be labeled .stat .to assure that prompt action is taken . Review of the facility's policy titled, .Pain Clinical Protocols and Guidelines dated 10/2022, revealed, .Pain management will be provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences .Through established assessments, the nursing staff will identify individuals who have pain or who are at risk for having pain .This includes a review of each person's known diagnoses and conditions that commonly cause or predispose to pain .It also includes a review for any treatments that the resident currently is receiving for pain, including complementary treatments .The nursing staff will assess each individual for pain .whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain .Through the assessment process, the nursing staff will attempt identify the nature (characteristics such as location, intensity, frequency, pattern, etc.) and severity of pain .Staff will assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level .The staff will observe the resident (during rest and movement) for evidence of pain .grimacing while being repositioned .The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated .ambulation .repositioning .Confer with the attending practitioner to help identify the extent to which underlying causes of pain can be addressed or reversed .Obtain orders for appropriate tests .x-rays as needed .Obtain orders for appropriate pain medications based upon the resident's current situation .PRN [as needed] doses should be monitored at time of request .Monitoring .PRN pain management response will be recorded post each dose given . 2. Review of the facility's unsigned Charge Nurse JOB DESCRIPTION dated 6/2021, revealed, .Perform administrative duties such as the documenting of: nurses' notes, doctors' orders .reports, evaluations .charts, resident assessments and care plans .Report accidents and incidents when they occur, including all complaints and grievances made by residents and /or their families, and immediately report any time a resident is observed leaving campus . 3. Review of the medical record, revealed Resident #5 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease, Dementia, Diabetes, Osteoarthritis, Psychosis, Scoliosis, and Anxiety. Review of Certified Nursing Assistant (CNA) #1 witness statement dated 8/20/2022, revealed that she entered Resident #5's room to change her prior to shift change at approximately 7:00 PM on 8/19/2022, and when she turned Resident #5 back toward her the resident yelled out in pain. CNA #1 asked the resident what was wrong and the resident complained of left (L) arm pain. CNA #1 documented in her statement that she reported the complaint to LPN #1, and they both went to the resident's room. CNA #1 documented that when LPN #1 had Resident #5 lift her arm, she cursed him out. CNA #1 documented that LPN #1 told her he would call for an xray. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment, and required extensive assistance for activities of daily living (ADLs). Review of the Nursing Note dated 8/20/2022 at 8:21 AM [over 13 hours after Resident #5 complained of left arm pain], revealed, This nurse [Licensed Practical Nurse (LPN) #2] was called to resident's room by CNA [Certified Nursing Assistant #1] asking me to assess resident arm d/t [due to] complaints of pain. Upon entering room, this nurse observed resident lying in bed with L arm cradled to side of body. Resident stated her arm was hurting real bad when asked where she was hurting resident stated her shoulder while guarding her L arm. Limited ROM [Range of motion] noted. When this nurse asked resident what happened she stated there was 'a girl that worked with them (referring to the CNAs) that was real rough and yanking' on her. This nurse notified unit manager on duty, DON [Director of Nursing] and telehealth contacted at this time. Orders given to STAT x-ray L shoulder and notify telehealth with results. Review of the Nursing Note dated 8/20/2022 at 2:45 PM [over 19 hours after Resident #5 complained of left arm pain], [Named mobile X-ray company] in facility to complete ordered x-rays. Reported to on-coming nurse . Review of the Nursing Note dated 8/20/2022 at 8:39 PM [over 25 hours after Resident #5 complained of left arm pain], revealed, .PRN Administration .Effective Follow-up Pain Scale was: 0. There was no documentation a pain medication had been administered to Resident #5 on the Medication Administration Record (MAR) for this date and time. Review of the Discharge Summary dated 8/20/2022 at 9:20 PM, revealed, .X ray result indicates left shoulder humeral fracture .notified telehealth and got order to transfer resident to hospital for further evaluation .transferred to [named hospital] at 9:20pm [9:20 PM]. Resident #5 was transferred to a hospital for treatment of the left arm fracture over 26 hours after she complained of left arm pain. Review of a Nursing Note created on 8/22/2022 at 8:11 AM, for a late entry note for 8/20/2022 timed at 10:45 AM, revealed, Late Entry .Daily skilled note for [named Resident #5]. See nursing notes, Resident sent to ER [emergency room ] for follow up to STAT x-ray ordered this shift . This Nurses' Note was created two days later, and Resident #5 did not go to the hospital until 8/20/2022 at 9:20 PM, approximately 26 hours after Resident #5 first complained of bad pain. Review of the Nursing Note dated 8/21/2022 at 4:45 AM, revealed, Return with injury to L humeral, swollen, warm to touch, sling placed . Review of the Nursing Note dated 8/21/2022 at 7:13 PM, revealed PRN [as needed Tylenol for pain medication] Administration was: Effective Follow-up Pain Scale was: 0. The August 2022 MAR did not document this Tylenol was given on 8/21/2022. Review of the Nursing Note created on 8/22/2022 at 7:32 AM, for a late entry note for 8/21/2022 revealed, Resident resting throughout shift PRN [as needed] Tylenol given for pain .Sling in place throughout shift . The August 2022 MAR did not document this Tylenol had been administered on this date and time. Review of the Nursing Note created on 8/22/2022 at 8:14 AM, for a late entry for 8/21/2022 at 10:55 AM, revealed .[Resident #5] resting in bed with no apparent distress noted at this time. vitals stable .Able to make wants and needs known This Nurses' Note was created 27 hours and 29 minutes after Resident #5 had been readmitted back to the facility. Review of the Nursing Note dated 8/22/2022 at 7:18 AM revealed, L humeral [upper arm], swollen, warm to touch, sling placed. Review of the Nursing Note dated 8/22/2022 at 7:24 PM, revealed, Resident left arm, swollen, warm to touch, sling intact. Tylenol given for pain . The August 2022 MAR did not document this Tylenol had been administered on this date and time. Review of the Nursing Note created on 8/22/2022 at 10:55 AM, for a late entry note for 8/22/2022 at 9:34 PM, revealed, .[Resident #5] resting in bed left arm in a sling R/T [related to] fractured arm . Review of the statement by LPN #1 dated 9/8/2022 revealed, I did not witness [Resident #5] falling, she has never fell on my shift. Patient had a fracture from X-ray report, I got a report from out going nurse and I transferred patient to [named Hospital]. She returned to facility next day in the morning. Observations in the resident's room on 11/17/2022 at 10:05 AM, 2:53 PM, and on 11/21/2022 at 5:21 PM revealed Resident #5 was lying in bed, her bed was against the wall on the right side, the call light was in reach, no side rails were present, no odors were noted, and the resident appeared thin and frail. Observation on 11/29/2022 at 9:17 AM revealed Resident #5 was in bed, the head of her bed was raised, she was awake and alert, her call light was in reach. During an interview on 12/2/2022 at 1:40 PM, Licensed Practical Nurse (LPN) #2 was asked about the incident with Resident #5's injured arm. LPN #2 stated, I came into work, Saturday morning, the CNA [named Certified Nursing Assistant #1] came to me and stated Resident #5 reported pain in her shoulder. The CNA #1 said resident had complained the previous night and an X-ray was supposed to have been ordered. I went in to assess her. I could see something was going on with her shoulder. I ordered x-ray through [named mobile xray company]. They came that day I believe and did x-ray of her left upper arm. We got an alert sent to us that it was a fracture. I contacted telehealth again that it was a fracture, and they gave order to send her to ER. We contacted the DON let her know fractured. [Named LPN #6] was asked to assess [named Resident #1] also. She was sent back to facility with a brace on left arm with orders to follow up with ortho [orthopedic doctor]. She did do follow up with Ortho. Surgery was not recommended. We did get statements from CNAs. Social usually interviews the residents around the incident. During an interview conducted on 12/5/2022 at 4:15 PM, CNA #1 was asked about Resident #5's incident. CNA #1 stated, I went in to dry [Resident #5] she didn't say nothing when I flipped her toward the wall then I turned her back toward me she said 'oh' I asked her what's wrong. [Resident #5] said 'I'm hurting, my arm.' I asked her what happened to you she said 'that girl beat the [expletive] of me' I ran out of the room for the nurse. I got [LPN #1] and told him [Resident #5] said her arm hurt that a girl beat the [expletive] out of her. So, we went into her room. He asked her and she told him the same thing. I said [named LPN #1] what you going to do before I leave. He said I'm going to order an x-ray. He said for me to go on home he would handle it. The next morning when I came in .I had the same section. I went in and asked [ Resident #5] how you doing today. She said her arm still hurt. I ran got the other nurse, [named LPN #2]. Told her to check on [Resident #5] her arm still hurts. Told her [LPN #1] was supposed to got an x-ray last night. [LPN #2] pulled the cover back and she said, 'I think her arm is broke'. I told her about telling [LPN #1] the night before and evidently didn't order the x-ray he said he was going to order. The left arm was purple in color at the upper arm. [Named LPN #2] went, got 2 other nurses and they came in the room. They said to get x-ray ordered. This was Friday and they ordered the x-ray. [Named Resident #5] stated the white girl beat her. She is sometimes oriented. She recognizes me and I talk with her regularly. This is the first time I ever heard her say something like this had happened. During an interview conducted on 12/6/2022 at 10:15 AM, LPN #2 was asked about the incident with Resident #5. LPN #2 stated, .I came in to work on 8/20/2022 at about 7:30. [Named CNA #1] came to me and stated she had reported to [named LPN #1] the night before that [named Resident #5] had been complaining of arm pain and she told [named LPN #1]. The resident was still complaining the next morning of arm pain and [named CNA #1] came to get me. I assessed the resident's arm. I got [named LPN #6] to come assess resident's arm. Her arm had bruising at bicep area of her arm and shoulder area didn't look right. We contacted telehealth and got order for x-ray and notified the DON and Administrator. It was a STAT order for x-ray. They came and done x-ray. We got a phone call and fax alert with the result of x-ray. I relayed the results to telehealth doctor, and they gave order to send her to ER [emergency room ]. I believe it was on my shift I sent her out to ER. She was complaining of pain . LPN #2 was asked if Resident #5 told her what happened to her arm. LPN #2 stated, [Named Resident #5] told me the 'big white, fat, [expletive] shook' her, a CNA. I wasn't here the day before. [CNA #4] does fit that description. The same Nurse [LPN #1] came in the next day on 8/20 [2022], and I believe she was in the hospital when [named LPN #1], he came in, and I told him she was there . During an interview conducted on 12/6/2022 at 10:49 AM, LPN #6 was asked about the incident with Resident #5. LPN #6 stated, [Named LPN #2] came got me and wanted me to look at her [Resident #5's] arm. Her left arm was bruised and didn't look right. I said you need to call [named former DON] and tell her it's an injury of unknown origin, [named Resident #5] said 'that girl hurt my arm, she was [NAME] as a bull and she hurt my arm' I told [named LPN #2] to call telehealth, family and doctor let them know. They came and did x-ray .I know she did go to hospital .Telehealth gave order for the x-ray. Telehealth will give us pain medicine, they have before . During a telephone interview conducted on 12/8/2022 at 9:35 AM, CNA #4 was asked about the incident with Resident #5. CNA #4 stated, The former DON called me and said she had a bruise on her wrist. She said a white woman had hurt her arm. There are only 2 white CNAs, me and .Possibility, I worked, I don't remember working with her that day . During a telephone interview conducted on 12/8/2022 at 12:40 PM, the former Administrator was asked about the incident with Resident #5. The former Administrator stated, I do remember that. An abuse incident should have been done [named CNA #4] she described, but she didn't work with her in the time frame. The doctor had seen her on Wednesday, and she told us on Friday .I spoke with MD [Medical Doctor] and FNP [Family Nurse Practitioner] one had seen her, and she didn't have any problem of pain. The person she described didn't work in that time frame. We looked at schedule to see what staff worked. Had dx [diagnoses] of fractures in past. We did see that she had comorbidities and we noted she had a turtleneck on. She could have been injured putting on that tight turtleneck. We concluded, unsubstantiated abuse, but she had a fracture from manipulating her arm, instead of intentionally hurting her . During a telephone interview conducted on 12/14/2022 at 8:44 AM, LPN #1 was asked about the incident with Resident #5's injured arm. LPN #1 confirmed his statement was true, as the surveyor read the statement dated 9/8/2022. LPN #1 stated, I was told by the nurse when I came on, she had a fracture per x-ray. No complaint of pain on previous day, I work on Friday, Saturday, and Sunday .The CNA did not mention any arm pain. It was next day I came back, and I sent her out. I think I gave her Tylenol, before sending her out . Resident #5 first said she was in pain and alleged abuse by a staff member on 8/19/2022 at about 7:00 PM, to CNA #1. CNA #1 reported the allegation to LPN #1 that night. LPN #1 did not document an assessment of Resident #5, did not do an incident report, and did not report the allegation of abuse. CNA #1 reported the same to LPN #2 on 8/20/2022 about 12 hours later .X-ray was obtained at 2:45 PM on 8/20/2022 (over 19 hours after the first complaint of pain) results showed left humerus fracture (results obtained over 26 hours after first complaints of pain). Therefore, Resident #5 suffered with the fractured area for over 24 hours with only two doses of Tylenol for pain and then was sent out to the hospital. This resulted in an Immediate Jeopardy for neglect of Resident #5. 4. Review of the closed medical record, revealed Resident #14 was admitted to the facility on [DATE], with diagnoses of COVID-19, Cerebral Infarction, Dementia, Alzheimer's Disease, Osteoporosis, Anxiety, and Vitamin D Deficiency. Review of the quarterly MDS assessment dated [DATE], revealed Resident #14 had a BIMS of 4, which indicated severe cognitive impairment. The medical record revealed Resident #14 sustained unwitnessed falls on 9/26/2022, 9/28/2022, 10/4/2022, 10/6/222, and 10/27/2022. There was no documentation that Neuro Check assessments were completed per the facility's fall protocol. Review of the Incident Report dated 9/26/2022 revealed Resident #14 was found on the floor beside his bed, and the Mental Status and Predisposing Factors sections of the Incident Report were not completed. Review of the fall investigation dated 9/26/2022 revealed Neuro Check assessments were not completed per the facility's protocol. Review of the Incident Report dated 9/28/2022 revealed Resident #14 was found on the floor beside his bed and the Mental Status section of the Incident Report was not completed. Review of the fall investigation dated 9/28/2022, revealed the Skin assessment and Neuro Check assessments were not completed per the facility's protocol for unwitnessed falls. Review of the Incident Report dated 10/4/2022 revealed Resident #14 sustained an unwitnessed fall on 10/4/2022, and the Mental Status and Predisposing Factors sections of the Incident Report were not completed. Review of the fall investigation dated 10/4/2022 revealed the Skin assessment and Neuro Check assessments were not completed per the facility's protocol for unwitnessed falls. Review of the Incident Report dated 10/6/2022, revealed Resident #14 was found sitting on the floor with his bedsheet wrapped around his legs. Review of the fall investigation dated 10/6/2022, revealed the Neuro Check assessments were not completed per the facility's protocol for unwitnessed falls. Review of the Nursing Note dated 10/27/2022 at 6:15 AM revealed, .Resident observed sitting on floor by his wheelchair .stated he was attempting to walk .Staff reeducated resident about att [attempting] to ambulate without asst [assistance] .DON [Director of Nursing] notified . Review of the Incident Report dated 10/27/2022, revealed Resident #14 sustained an unwitnessed fall, and the Mental Status and Predisposing Factors section of the Incident Report were not completed. Review of the Neuro Checks assessment dated [DATE], revealed neuro checks should be completed every 15 minutes times (x) 4, every 30 minutes x 4, every 1 hours x 2, then every shift for 72 hours. Review of the fall investigation dated 10/27/2022, revealed Neuro Check assessments were completed on 10/27/2022 at 7:32 AM, 7:47 AM and 8:02 AM. Neuro check assessments were not completed per the facility's protocol for unwitnessed falls. Review of the Nursing Note dated 10/28/2022 at 7:07 AM, revealed .Therapy .went in res [resident's] rm [room] to perform exercise .Res complained of pain when therapy att [attempted] to get him up .Writer came and did a physical asst [assessment] of residents left hip .did not observe hip to be swollen redden [reddened] or discolored of nature .advised oncoming nurse .MD [medical doctor] notified and bilat [bilateral] x-ray . Review of the telehealth Progress Notes dated 10/28/2022 at 1:48 PM, revealed, .resident c/o [complained of] L [left] hip pain .had a fall on 10/27/2022 at 0630 [6:30 AM] .Patient highly confused. Nurse states patient normally gets up to eat and do activities but refusing to get out of bed .decreased ROM [range of motion] to L hip .ASSESSMENT/DIAGNOSIS PLAN NOTES .Pain in left hip .STAT xray left hip 2 views . Review of the Physician's Order dated 10/29/2022 revealed a bilateral hip x-ray was ordered but was not entered into the electronic health record (EHR) as STAT until the day after the order was given. Review of the Nursing Note dated 10/29/2022 at 3:09 PM, revealed Resident #14's x-ray was completed, and the results were pending. Review of the Nursing Note dated 10/31/2022 at 9:30 AM, revealed the x-ray results were received and Resident #14 had a left subcapital hip fracture (fracture in the neck of the thighbone) with moderate displacement, the provider was made aware and gave an order to send the resident to the emergency room . Review of the Nursing Note dated 10/31/2022 at 10:25 AM, revealed Resident #14 was transported to the emergency room for treatment; 4 days after the unwitnessed fall, and 3 days after the resident complained of pain to the Physical Therapist and was unable to stand on his left leg. During an interview conducted on 11/22/2022 at 12:16 PM, LPN #2 confirmed she worked 10/28/2022, the day following Resident #14's fall. LPN #2 stated, .Friday [10/28/2022] morning I come [came] back in to work and was told .he was complaining of pain and refusing to get up .[named LPN #3] said he had called [named telephonic physician's group], notified the RP [responsible party] .was just needing help getting the x-ray ordered through the mobile x-ray company .he said he needed help calling, and we don't call, we do it all online .left the nurses' station to go to the other one to get our password to be able to do that .the password wasn't valid and I couldn't log on to [named the mobile x-ray site] .when [named LPN #6] come in I asked her for the password so we could get it ordered .[named LPN #6] took over the whole situation . During an interview conducted on 11/23/2022 at 9:39 AM, the Physical Therapist stated, .[On 10/28/2022] went in to do his [Resident #14] treatment, he had been able to sit, stand and transfer .he couldn't stand .because of pain .went and found [named LPN #3] .walked down with me and did assess him .moaned and verbally complained about his left hip which was uncharacteristic of him .he would move his right side and say see no pain here, it's [pain] just right here .indicated his left upper leg . The Physical Therapist confirmed LPN #3 said he was going to notify the physician and obtain an order for an x-ray. During an interview on 12/1/2022 at 12:00 PM, the Medical Director confirmed that facility staff should fully follow physician's orders and should have followed up on Resident 14's STAT x-ray, and not have waited until almost 2 days after the x-ray was obtained. During an interview conducted on 12/2/2022 at 1:28 PM, LPN #2 confirmed that she contacted the telephonic physician's group through a facetime visit and obtained an order for a bilateral hip x-ray. LPN #2 stated, .I let [named LPN #6] know .she facilitated that and ordered it through [named mobile x-ray company] . LPN #2 confirmed she was not sure if she told LPN #6 the bilateral hip x-ray order was supposed to be entered STAT. LPN #2 was asked when came in on 10/29/2022, did she receive in report that the x-rays had not yet been obtained. LPN #2 stated, Yes, [named LPN #10] said .they weren't going to be able to come out .but would be out first thing in the morning [10/29/2022] . LPN #2 was asked what she did next. LPN #2 stated, I administered prn [as needed] pain medication that I didn't document . LPN #2 confirmed that she did not attempt to contact the mobile radiology company, the nurse practitioner, or the doctor when the x-ray was not obtained STAT as ordered. During an interview on 12/5/2022 at 4:09 PM, LPN #4 confirmed the facility's protocol when a resident fell included a fall risk assessment, pain assessment, skin assessment, and if the fall was unwitnessed, neurochecks were required. LPN #4 confirmed every section of the Incident Report should be completed following a resident's fall. During an interview conducted on 12/6/2022 at 9:51 AM, LPN #2 was asked the facility's protocol for resident falls. LPN #2 stated, .That seems like it has changed some over the years, when I first started working it seems like we would complete a pain and skin assessment .seems like it is no longer required .when you ask upper management .I've done my incident report, I've contacted telehealth and ask what else I need to do .they say oh well that's fine . LPN #2 was asked who she meant by upper management and she stated, [Named former Director of Nursing (DON)]. LPN #2 was asked if there was a policy or protocol on falls that instructed staff which assessments should be completed. LPN #2 stated, I don't know. I would like to assume that there is somewhere, where I couldn't tell you. LPN #2 was asked was she was uncertain what protocol to follow when a resident falls. LPN #2 stated, Yes .because it may or may not change depending on our DON or Administrator at the time .we can never keep an Administrator or DON .typically the nurse it happens on should complete all of that .your neurochecks if it's unwitnessed .the nurse here when it happens is responsible for ensuring all of that is complete . LPN #2 was asked the protocol for an unwitnessed fall and stated, Incident report, neurochecks .you start under the assessment tab in the chart .will set up its own schedule you have to follow for 72 hours .the time frames are triggered but you have to trigger it [Neuro Check assessments] initially .a lot of times I try to do the pain assessment even though it may not be required right now. I know that it has been in the past . LPN #2 confirmed that the former DON told her the pain assessment was no longer required when a resident had fallen. LPN #2 confirmed that a pain assessment and skin assessment were required to be completed for each fall prior to the former DON's administration. LPN #2 confirmed that the facility's protocol for Neuro Check assessments should have been followed for Resident #14's unwitnessed falls that occurred on 9/26/2022, 9/28/2022, 10/4/2022, 10/6/2022, and 10/27/2022. Resident #14 fell multiple times, and the post fall protocol was not followed by staff. Then he had a fall on 10/27/2022, complained of pain on 10/28/2022, the xray was not completed STAT as ordered, and xrays results were not obtained until 10/31/2022, revealing a left hip fracture. Therefore, Resident #14 suffered with the untreated fractured hip for 4 days, when the facility failed to follow the fall protocol and plan of care. This resulted in an Immediate Jeopardy for Resident #14. The surveyors verified the Removal Plan through review of root-cause analysis, in-services, audits and staff interview conducted: Governing Body re-educated the DON of notification to Primary Care Physician (PCP) with changes of condition, review of 24/72 Hour Shift Report in Clinical Startup. Surveyors verified by review of in-services and interviews. Governing Body educated community Leadership and Interdisciplinary Team (IDT) on Clinical Start up to be conducted Monday thru Friday DON/Assistant Director of Nursing (ADON)/Staff Development Coordinator (SDC)/Unit Managers (UM). Incidents and changes of condition are to be identified and followed through until stabilized to include PCP and Responsible Party (RP) notification. Surveyors verified staff interviews and in-services. Governing Body/Administrator (Admin)/DON/SDC initiated education and on-going to licensed nurses on Shift Report, Notification of Change in Condition, to include new onset or worsening of pain, on Admission, Quarterly, and Significant Change. Training included licensed staff were educated that residents are to receive treatment and care within professional standards of practice, person-centered care to honor resident's choice. Example: A. An accident involving the resident which results in injury and has the potential for requiring physician intervention; B. A significant change in the resident's physical, mental, or psychosocial status, including a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications ; C. A need to alter the resident's medical treatment significantly; D. A need to transfer the resident to a hospital/treatment center; E. A discharge without proper medical authority; and/or F. Instructions to notify the physician of changes in the resident's condition. STAT orders should be followed within the 4 hour time frame, if provider cannot (lab, xray) perform, licensed nurse to notify provider of delay for further treatment orders. Surveyors verified by review of in-services and interviews. Governing body to educate community leadership and department heads/IDT to include Medical Director re: QAPI and Ad Hoc QAPI related to Quality of Care issues. Surveyors verified by review of QAPI minutes. Surveyors varied by review of QAPI minutes and staff interviews. DON/ADON/SDC/UM and licensed staff re-educated to utilize the PointClickCare Clinical Communication Portal to identify residents requiring follow up documentation, labs, xrays, appointments. Surveyors verified by review of in-services. DON/SDC/ICP/UM/HR will educate new licensed staff regarding Quality of Care concerns F684. Surveyors verified by review of new hire in services. QAPI will be held again 12/8/22 with Governing Body to discuss deficiency, education, systemic changes, and monitoring moving forward. Surveyors verified by review of QAPI minutes and forms for monitoring.

Based on policy review, facility investigation review, review of time detail reports, review of daily assignment sheets, review of Safety Check logs, medical record review, observation, and interview, the facility failed to ensure a safe environment for 5 of 11 sampled residents (Resident #1, #2, #3, #4, and #14) reviewed for resident-to-resident altercations and accident hazards. The facility's failure to ensure a safe environment resulted in Immediate Jeopardy (IJ) when the facility failed to provide 1 on 1 supervision for Resident #1, a severely cognitively impaired resident with known combative and aggressive behaviors, which resulted in resident-to-resident altercations between resident #1 and Residents #2, #3, and #4 on 3 different occasions; and when the facility failed to follow their policy for post-fall assessments when Resident #14 sustained 4 falls with no completion of the post-fall assessments, and then sustained a 5th fall on 10/27/2022, which resulted in a left hip fracture. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Interim Administrator and Interim Director of Nursing (IDON) were notified of the Immediate Jeopardy (IJ) on 11/21/2022 at 5:43 PM, in the Conference Room. The Interim Administrator and Regional [NAME] President were notified of the Immediate Jeopardy (IJ) for a second Immediate Jeopardy (IJ) for F-689 on 12/7/2022 at 5:32 PM, in the Conference Room. The facility was cited F-689 at a scope and severity of J, which is Substandard Quality of Care. A partial extended survey was conducted from 12/12/2022 through 12/13/2022. The IJ was effective from 8/19/2022 through 12/13/2022. An acceptable Removal Plan, which removes the immediacy of the jeopardy, was received on 12/13/2022 at 10:42 PM, and was validated onsite by the surveyors on 12/14/2022, through policy review, review of education records, and staff interviews. The findings include: 1. Review of the facility's policy titled, Unmanageable Residents ., dated 8/2021, revealed .Each resident will be provided with a safe place of residence .Should a resident's behavior become abusive, hostile, assaultive, or unmanageable in any way that would jeopardize his or her safety or the safety of others, the Nurse Supervisor/Charge Nurse must immediately .Provide for the safety of all concerned .Complete documentation of the incident must be recorded in the resident's medical record and an incident report must be filed with the Administrator . Review of the facility's policy titled, Accidents, dated 8/2022, revealed .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes .and a facility-wide commitment to safety at all levels of the organization, including staff, residents, and families .Data will be utilized to the extent available to identify potential hazards, risks, and solutions related to safety issues within the community .staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary .Resident supervision is a core component of the systems approach to safety .type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment .Resident to Resident Altercations .Review as potential abusive situation, including the identification of .willful .Assess for need for additional or adequate supervision based upon a history of aggressive behaviors which may disrupt or annoy others .repetitive behaviors .address potential underlying issues which may lead to such behavior .address community process for appropriate supervision including .adequate staffing levels for services to those with dementia or history of trauma .Providing safe supervision when required . Review of the facility's policy titled, .Assessing Falls and Their Causes ., dated 5/2022, revealed .If a resident has just fallen, or is found on the floor without witness to the event, nursing staff will record vital signs and evaluate for possible injuries to the head, neck, spine, and extremities .If there is evidence of a significant injury such as a fracture or bleeding, nursing staff will provide appropriate first aid .Once an assessment rules out significant injury, nursing staff will help the resident to a comfortable sitting, lying, or standing position, and then document relevant details .Attending Physician and family in an appropriate time frame .a fall results in a significant injury or condition change .Nursing staff will observe for delayed complications of a fall for approximately 48 hours after an observed or suspected fall, and will document findings in the medical record .Documentation will include any observed signs or symptoms of pain .deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function .An incident report must be completed for resident falls . Review of the facility's policy titled, .Behavior Assessment and Monitoring, dated 11/2022, revealed .Problematic behavior will be identified and managed appropriately .The staff will identify, document, and inform the physician about an individual's mental status, behavior, and cognition, including .changes in behavior .Management .The staff will identify and discuss with the practitioner situations where non-pharmacologic approaches are indicated, and will institute such measures to the extent possible . 2. Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE], with diagnoses of Schizophrenia, Dementia with Mood Disturbance/Behavioral Disturbance/Psychotic Disturbance, Chronic Kidney Disease, Conversion Disorder with Seizures, Hypertension, and Chronic Hepatitis C. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment, exhibited wandering behaviors daily, and required extensive to total assistance of staff for all activities of daily living (ADLs) except eating, for which he required supervision with setup help only. A. Review of the Incident Report dated 8/21/2022, revealed .resident [Resident #1] foot accidentally ran over by another resident [Resident #2] who is blind .resident [Resident #1] .[hit] resident [Resident #2] in wheelchair on the back of the head with an open hand . Review of a Nursing Note dated 8/21/2022, revealed .resident [Resident #1] had hit another resident [Resident #2] softly on the head due to being run over by wheelchair. Resident [Resident #2] in wheelchair is blind and didn't see resident [Resident #1] . B. Review of an Incident Report dated 8/28/2022 at 6:56 PM, revealed .nurse was called to dayroom by CNA [Certified Nursing Assistant] stating there was blood on the floor. [Named Resident #1] was observed Lying on floor with hands under head in sleeping position. [Named Resident #2] was observed sitting in WC [wheelchair] with small amount of blood noted from lower lip. [Named Resident #1] had small scratch noted to face L [left] of nose. [Named Resident #1] was assisted to chair by nurse and [named Resident #2] was supervised in dayroom. Residents asked what happened and neither resident was able to say what happened .first aide administered .Abrasion .face . Review of the Staff Interview/Statement Sheet dated 8/28/2022, revealed .Upon come'n [coming] on shift I was looking for CNA to get report. When looking in the dayroom [named Resident #1] was on the floor, [named Resident #2] was in his wheelchair he had [named Resident #1] by the arm, I notify [notified] the nurse that [named Resident #1] was on the floor, and there was blood on the floor. The statement was signed by CNA #4. Review of the Weekly Skin Evaluation for Resident #1 dated 8/28/2022, revealed .small scratch observed to face to L [left] of nose . The facility was unable to provide any additional statements obtained from staff working that shift. The facility was unable to provide evidence that Resident #2 received testing after his possible exposure to a communicable disease following the incident with Resident #1, who has Chronic Hepatitis C. C. Review of the Incident Report dated 9/7/2022, revealed the report was incomplete and did not give any details regarding an incident that occurred between Resident #1 and Resident #3 on 9/7/2022. Review of a Staff Interview/Statement Sheet dated 9/7/2022, revealed .On September 7, 2022 at approximately 6:55 pm [PM] I [CNA #5] was giving end of shift report to [named CNA #6] when the resident [named Resident #3] walked in the direction of resident [named Resident #1]. [Named Resident #1] was sitting in the chair and immediately reach [reached] up with a closed fist and struck [named Resident #3] in the jaw .left side .[named CNA #6] stepped in between [named Resident #1] and [named Resident #3]. I took [named Resident #3] to a safe area. After making sure [named Resident #3] was in a safe area, we both reported the incident to the nurse [named LPN #3] . D. Review of an Incident Audit Report dated 9/7/2022, revealed .Incident Description .09/07/2022 .20:45 [8:45 PM] .Writer [LPN #3] standing at med [medication] cart passing medication when writer observed res [Resident #1] walking up behind res [Resident #4] .Res [Resident #1] struck res [Resident #4] .in the rear right side of his neck with a closed fist. Writer immediately jumped in between the residents and redirected res .[Resident #1] .away from res [Resident #4] .Writer walked down to his [Resident #1] room and put cna [CNA] as one on one with res. Writer went back and assessed resident [Resident #4], Res [Resident #4] had no obvious signs of injury and made no faces of pain or any complaints . Review of the quarterly MDS dated [DATE], revealed Resident #1 had a BIMS of 99, which indicated resident inability to complete the interview, physical behavioral symptoms toward others on 4-6 days, verbal behavioral symptoms toward others on 1-3 days, and behavioral symptoms toward himself on 1-3 days of the 7-day lookback period. Review of the Nursing Note dated 9/8/2022 at 9:00 AM, revealed .Resident [Resident #1] was transported to [named hospital] for a psychiatric evaluation r/t [related/to] physical altercation with another resident . Review of Resident #1's Care Plan revised 9/9/2022, revealed .Potential for injury to self or others r/t [related to] impaired mental and physical status and aggressiveness, combative and resistive behaviors .9/9/22 [2022] .One on one supervision and care . Review of the Nursing Note dated 9/9/2022 at 1:10 AM, revealed .Resident arrived back to facility. Review of the Safety Check Logs for Resident #1 beginning 9/7/2022 through 11/17/2022, revealed 1 on 1 monitoring documentation for following days were missing: a. 9/17/2022-all day b. 9/21/2022-all day c. 9/23/2022-all day d. 9/24/2022-all day e. 9/25/2022-all day f. 9/26/2022-all day g. 10/22/2022-from 7:00 AM through 7:00 PM h. 10/24/2022-from 7:00 AM through 7:00 PM i. 11/1/2022-from 3:00 AM through 7:00 AM j. 11/5/2022-from 7:00 AM through 11:59 PM k. 11/6/2022-all day l. 11/10/2022-all day Review of the outcome of the facility's investigation into the resident-to-resident altercations that occurred between Resident #1 and Resident #3, and Resident #1 and Resident #4, dated 9/15/2022, revealed .Our investigations outcome has revealed that [named Resident #1] needs indefinite 1:1 [1 on 1] monitoring . Review of the Nursing Note dated 9/20/2022 at 5:17 AM, revealed .Res [Resident #1] sleep [asleep] most of shift .Res did get up and wonder [wander] periodically and push on exit door handles. No one on one personnel avail [available] for res and staff safety. DON notified . Review of the Nursing Note dated 9/21/2022 at 12:20 AM, revealed Res [Resident #1] sleep most of shift, no behaviors noted .No one on one personnel avail for res and staff safety. DON notified . Review of the Care Plan revised 11/1/2022, revealed .Potential for injury to self or others r/t [related to] impaired mental and physical status and aggressiveness, combative and resistive behaviors . E. Review of the time punch detail dated 11/10/2022, revealed CNA #2 clocked in at 1:52 PM. Review of the Incident Report dated 11/10/2022 at 2:15 PM, revealed .Resident [Resident #1] observed laying [lying] in hallway floor on back with resident [Resident #2] .laying [lying] on top of him [Resident #1] .while on floor resident [Resident #2] was observed with hands around [named Resident #1] neck .Memory Impaired [checked] .Confused/Disoriented [checked] .Non compliance [checked] .Impulsive [checked] .Hallucinations [checked] .Decreased safety awareness [checked] .Delusions [checked] . Review of the Nurse Practitioner Progress Note dated 11/10/2022 at 3:02 PM, revealed .This writer heard what sounded like something that fell outside office door and upon inspection, resident [named Resident #2] .had his hands around another resident's neck [Resident #1] .[Resident #1] was lying on the floor and [named Resident #2] was .over him .[named Resident #2] stated shortly after that [named Resident #1] hit him on the back of his head .[named Resident #1] has been in supervision due to combative behaviors towards other residents and staff. He was not being monitored at the time of the incident and was in the hallway alone .Nurse .to initiate the process of transferring residents to Psychiatric facility for further evaluations due to behaviors above . Review of the Staff Interview/Statement Sheet dated 11/10/2022, revealed .I [CNA #3] was sitting in front of the dayroom charting when I heard the wheelchair hit the ground. I immediately went over there. I seen [saw] [named Resident #1] on the ground and [named Resident #2] hands were around his [Resident #1] neck hollering he pushed my chair, hit me in my head . The statement was signed by CNA #3. Review of the Staff Interview/Statement Sheet dated 11/10/2022, revealed .I [CNA #2] was just getting to work .putting my belongings up and used the restroom when I heard some fussing .came out the bathroom in the hall and there was [named Resident #2] on top of [named Resident #1] saying he [Resident #1] hit me [Resident #2] . The statement was signed by CNA #2. Review of the Staff Interview/Statement Sheet dated 11/10/2022, revealed .I [CNA #8] was in the breakroom having lunch when I heard a noise in the hallway. I went to see what was going on that is when I noticed [named Resident #2] on [named Resident #1]. [Named Resident #2] was saying that [named Resident #1] had hit him on the back of his head. [Named Resident #2] wheelchair had turned over . The statement was signed by CNA #8. Review of the daily assignment sheet for the secure unit dated 11/10/2022, revealed the staff assigned for 7:00 AM through 7:00 PM on the unit were LPN #6, CNA #2, CNA #3, and CNA #8. At the time the resident-to-resident altercation occurred only LPN #6 was at the Nurses' Station, and CNA #3 was on the unit. CNA #2 and CNA #8 were in the breakroom. No staff member was 1 on 1 with Resident #1. Review of the Physician's Order dated 11/22/2022, revealed .Ensure resident [Resident #1] is receiving 1:1 supervision .Review safety check log to ensure documentation completed as ordered . Review of the laboratory results dated [DATE], revealed Resident #1 was positive for Hepatitis C. Observation in the Resident #1's room on 11/17/2022 at 10:25 AM, revealed Resident #1 lay on top of the bed, was fully clothed, wore nonskid socks, and a staff member provided 1 on 1 monitoring. Observation in the secure unit on 11/21/2022 at 11:09 AM, revealed Resident #1 walked with 1 on 1 staff member, dressed in a gown, pants, and nonskid socks. Observation in the secure unit Day Room on 11/29/20221 at 9:16 AM, revealed Resident #1 sat in a chair, was fully clothed, his left foot was bare and he had a nonskid sock on his right foot. Staff was present for 1 on 1 monitoring. 3. Review of the closed medical record, revealed Resident #2 was admitted to the facility on [DATE], with diagnoses of Diabetes, Dementia with Psychotic Disturbance, Schizoaffective Disorder-Bipolar Type, Hypertension, Epilepsy, Chronic Kidney Disease, Depression, and Mixed Receptive-Expressive Language Disorder. Review of the annual MDS dated [DATE], revealed Resident #2 had a BIMS of 11, which indicated moderate cognitive impairment, with delusions and wandering behaviors on 3 days of the 7-day lookback period, highly impaired vision, and required extensive to total staff assistance for ADLS. Review of the Nursing Note dated 8/21/2022, revealed .resident was hit on the back of the head by other resident [Resident #1] due to accidentally running over his feet in wheelchair. Resident had no pain and just asked who did it. Resident [Residents] was [were] separated and both are calm . Review of the Nursing Note dated 8/28/2022, revealed .This nurse alerted by CNA there was blood in dayroom floor. Upon entering room this nurse observed resident [Resident #2] sitting in WC [wheelchair] with small amount of blood observed on bottom lip. [Named Resident #1] was observed lying on the floor with hands under head in sleeping position witheyes [with eyes] closed, small scratch noted on face to L [left] of nose. Residents separated and supervised at this time . Review of the Weekly Skin Evaluation dated 8/28/2022, revealed .small laceration noted to bottom lip with small amount of blood observed . Review of the quarterly MDS dated [DATE], revealed Resident #2 had a BIMS score of 10, which indicated moderate cognitive impairment, with no behaviors, highly impaired vision, and required extensive staff assistance for ADLs. Review of the Nursing Note dated 11/10/2022, revealed .Resident [Resident #2] observed laying [lying] in hallway on top of resident .[Resident #1] with hands around [Resident #1] neck. Resident noted yelling .he [Resident #1] .hit me in my head . Review of the Nursing Note dated 11/11/2022 at 5:42 PM, revealed Resident #2 was transferred to a psychiatric facility for evaluation. 4. Review of the medical record, revealed Resident #3 was admitted to the facility on [DATE], with diagnoses of Alzheimer's Disease, Hypertension, Depression, and Dementia. Review of the quarterly MDS dated [DATE], revealed Resident had a BIMS of 3, which indicated severe cognitive impairment with no behaviors. Review of the Nursing Note dated 9/7/2022 at 8:33 PM, revealed .Reported by staff this resident [Resident #3] .was observed walking in dayroom towards resident [Resident #1] .as he was sitting in chair. Resident [Resident #1] .was observed hitting resident [Resident #3] in face with closed fist in left jaw .immediately separated. Resident [Resident #3] noted with redness to left side of face .new order given to send to [named hospital] for CT (computed tomography) scan . Review of the Head CT and the Maxillofacial CT dated 9/8/2022, revealed Resident #3 had no acute abnormalities. Review of Nursing Note dated 9/8/2022 at 8:17 AM, revealed .[Resident #3] returned to facility . Observation in the Day Room on 11/17/2022 at 10:21 AM, 11/21/2022 at 11:07 AM, 11/28/2022 at 4:17 PM, and 11/30/2022 at 9:39 AM, revealed Resident #3 sat in her wheelchair, was fully clothed, wore nonskid socks, and watched television (TV) with other residents present. Observation in the resident's room on 11/28/2022 at 10:27 AM, 12/2/2022 at 3:46 PM, and 12/5/2022 at 10:46 AM, revealed Resident #3 was in bed, her eyes were closed, and she appeared to be sleeping. 5. Review of the medical record, revealed Resident #4 was admitted to the facility on [DATE], with diagnoses of Alzheimer's Disease, Dementia with Behavioral Disturbance, Hypertension, and Protein-Calorie Malnutrition. Review of the quarterly MDS dated [DATE], revealed Resident #4 had a BIMS of 99, which indicated resident inability to complete the interview, with physical behavioral symptoms toward others on 1-3 days and rejection of care behaviors on 4-6 days of the 7-day lookback period, and daily wandering behaviors. Review of the Nursing Note dated 9/7/2022 at 8:42 PM, revealed .Writer standing at med cart passing medication when writer observed res [Resident #1] walking up behind res [Resident #4] .Res [Resident #1] struck res [Resident #4] .in the rear right side of his neck with a closed fist. Writer immediately jumped in between the residents and redirected res [Resident #1] .away from res [Resident #4] .Writer walked down to his room and put cna [CNA] as one on one with res [Resident #1]. Writer went back and assessed resident [Resident #4] .no obvious signs of injury and made no faces of pain or any complaints . Observation in the Day Room on 11/17/2022 at 10:25 AM, revealed Resident #4 sat in a chair, was fully clothed, and played with his pants drawstring. Other residents were present. Observation in the Dining Room on 11/21/2022 at 11:03 AM, revealed Resident #4 sat in a chair, was fully clothed, wore a hat, and nonskid socks. Other residents were present. Observation in the Secure Unit Hallway on 11/29/2022 at 9:14 AM, revealed Resident #4 sat in a chair, he was fully clothed, wore nonskid socks, his eyes were closed, and he appeared to be asleep. During an interview conducted on 11/17/2022 at 1:47 PM, CNA #2 confirmed she was scheduled to supervise Resident #1 on 11/10/2022. CNA #2 stated, When I called my supervisor to let her know I was running late .she said I would be in the Gardens [secure unit] with him . CNA #2 confirmed she arrived to work at about 2:00 PM. CNA #2 stated, .clocked in, put my belongings up in the breakroom .used the restroom in the breakroom, and we literally heard the commotion .run [ran] straight out the door .[named Resident #2] was on top of [named Resident #1] saying he [Resident #1] hit me in the back of the head .he [Resident #2] was just protecting himself .[named Nurse Practitioner] was already at the scene .we proceeded to separate them .let our charge nurse know . CNA #2 stated, He will get angry toward me to the point where I'm literally scared, and I have seen him get mean and holler at other residents or staff .I did see him hit one of our other staff members before .like a light switch he will be sweet one second and then just flip, you never know when he will get in that mood . During an interview conducted on 11/17/2022 at 2:12 PM, CNA #8 confirmed she worked the secure unit on 11/10/2022, and no one was assigned to provide 1 on 1 monitoring to Resident #1 until CNA #2 came in around 2:00 PM. During an interview conducted on 11/17/2022 at 2:20 PM, LPN #6 stated, .never know when he's [Resident #1] going to strike out .he hit me .out of the blue . LPN #6 was asked about the resident-to-resident altercation between Resident #1 and Resident #3. LPN #6 stated, .she would walk and cry, she was walking towards him crying, and he hit her. We put a CNA with him, and as they were walking him to go to his room .[named Resident #4] was in his doorway and out of nowhere he punched him in the back for no reason .he will be laughing or singing us a song, then the next minute he does it [hits someone], and it's not a light tap. It's hard for his weight . LPN #6 confirmed she was the Charge Nurse on 11/10/2022, she was at the Nurses' Station when the altercation occurred, and no one was providing 1 on 1 continuous monitoring of Resident #1. LPN #6 stated, .[named CNA #2] had talked to [named the Scheduler], and she said [named CNA #2] was going to be late .we just had to watch out for him as best we could . LPN #6 was asked if she asked for help when she found out CNA #2 would be late. LPN #6 stated, I did, I was like who is coming in .she [Scheduler] said she was going to talk to CNA #1 .to come sit with him until CNA #2 came in . LPN #6 confirmed CNA #1 never came to sit with Resident #1. LPN #6 was asked if Resident #1 was left alone at times. LPN #6 stated, Yes .we would just check [on him] . LPN #6 confirmed no one saw the resident-to-resident altercation between Resident #1 and Resident #2. LPN #6 was asked if Resident #2 was aggressive. LPN #6 stated, No, he's never .I mean he hallucinates and talks to voices, but for him to hit somebody, no .he's blind so he doesn't know who [named Resident #1] is, he can't see him .he's never hit anybody .this is like the 2nd incident between those two . During an interview conducted on 11/17/2022 at 2:37 PM, the Nurse Practitioner confirmed she was the first one on the scene when Resident #1 and Resident #3 had the resident-to-resident altercation on 11/10/2022. The Nurse Practitioner stated, .sitting here at my desk heard some commotion outside the door, sounded like something fell .[named Resident #2] had [named Resident #1] on the floor with his hands around his neck, the wheelchair he [Resident #2] gets around in had been turned over .he was mumbling something .has a speech impediment .but when he finally calmed down and got him back to his chair, he said 'he [Resident #1] hit me on my head .I'm tired of him hitting me' .got [named Resident #1] up and back to his room. Apparently, he had been unsupervised .he was in the hallway by himself .there was no one assigned to him that day . During a telephone interview conducted on 11/18/2022 at 10:59 AM, the Interim Administrator confirmed that Resident #1 had been left unsupervised the morning of 11/10/2022. The Administrator stated, .They did not have a specified person, the CNAs were tag teaming .he technically did not have a quote unquote person for that shift .just wasn't as efficient in making sure he was covered as it should have been . During an interview conducted on 11/21/2022 at 9:37 AM, the Interim Administrator confirmed she started shadowing the former Administrator on 11/7/2022 for half a day, then returned to the facility on [DATE] for the rest of the week. The Interim Administrator stated, I wasn't in the system .let them handle it [the resident-to-resident altercation between Resident #1 and Resident #2] .I was aware of it the day of .both of us [the Former Administrator and the Interim Administrator] were in the office together . During an interview conducted on 11/21/2022 at 9:44 AM, the Interim DON (IDON) presented the 1 on 1 monitoring documentation and stated, .incomplete documentation is here .these are all we have . The IDON was asked if the facility investigation included the incomplete 1 on 1 monitoring documentation. The IDON stated, Not that I'm aware of, I had to go pull them. The IDON was asked if they were all dated. The IDON stated, They are very random .they are not complete .I just collected what we had .obviously saw that was not being done correctly . The IDON confirmed each page should have been dated and signed by the staff completing the documentation. During an interview conducted on 11/21/2022 at 10:10 AM, the Scheduler confirmed that on the day shift there were 3 CNAs scheduled for the secure unit and that included a CNA for 1 on 1 with Resident #1. The Scheduler confirmed that the nurse on the secure unit would make the assignments for the CNAs and designate 1 CNA for 1 on 1 monitoring. The Scheduler confirmed that CNA #2 texted her and told her she would be late on 11/10/2022. The Scheduler confirmed that she told LPN #6 that CNA #2 said she was going to be late. The Scheduler stated, .I was on a cart working . The Scheduler was asked what her plan was for 1 on 1 monitoring on 11/10/2022, when she learned CNA #2 was going to be late. The Scheduler stated, .There's a Unit Manager back there, and there's a nurse, and we can all help out .that's the way it's supposed to be . The Scheduler stated, .Truthfully, I would say the 1 on 1 is not working .he is walking then hits a resident out of the blue .he could end up hurting one of them really bad not meaning to . During a telephone interview conducted on 11/21/2022 at 2:43 PM, LPN #3 confirmed that he was working on 9/7/2022, when the resident-to-resident altercations occurred between Resident #1 and Resident #3, and Resident #1 and Resident #4. LPN #3 stated, .It was right at shift change .one right after the other . LPN #3 confirmed Resident #1 was not in 1 on 1 at the time of the altercations, but was placed in 1 on 1 monitoring following the two altercations that occurred that day [9/7/2022]. LPN #3 stated, It wasn't decided to put him in 1 on 1 until we had to wait so long on him to be transported .I said look this guy can't just keep walking around here hitting people .they said they didn't have the staff . LPN #3 was asked about his documentation stating there was not staff to provide 1 on 1 monitoring of Resident #1. LPN #3 stated, That's correct .that was like my last resort of asking them over and over again and nobody was doing nothing [anything] . LPN #3 was asked if the former DON was aware. LPN #3 stated, She told me she would get somebody, or she would call the staffing person .but nothing ever happened . LPN #3 confirmed that when only 2 CNA's were scheduled, they assigned 1 CNA to the men and 1 CNA to the women, and the CNA assigned to the men was the one who would also provide 1 on 1 monitoring for Resident #1. LPN #3 stated, The rationale was he [Resident #1] was asleep through the night . LPN #3 was asked if there were times Resident #1 was left unsupervised. LPN #3 stated, Oh yeah, absolutely when she was making rounds .it's impossible, because that means she wouldn't have cared for anybody else .I knew that still wasn't adequate, so that's why I started documenting . LPN #3 was asked if it was safe for the other residents for Resident #1 to be left unsupervised. LPN #1 stated, Oh, absolutely not. During an interview conducted on 11/22/2022 at 11:15 AM, LPN #4 was asked how she as the Unit Manager insured the 1 on 1 monitoring documentation was completed. LPN #4 stated, I just went down there and kept checking to be sure they were doing the sheets .made sure [named former DON] was getting the sheets and they were aware . LPN #4 confirmed there were 6 Safety Check Logs that weren't dated, and she could not tell for which days they were documented. LPN #4 confirmed that she was unaware there was not a CNA available to provide 1 on 1 monitoring of Resident #1 on 11/10/2022 until after the altercation occurred between Resident #1 and Resident #2. LPN #4 stated, .I didn't even know the aide had come to work as late as she had .it happened during PAR [Patient At Risk meeting], and the nurse called me down there and told me what had took [taken] place .trying to figure out why it occurred .notified [named LPN #6] that anytime anyone needs to go to the bathroom .they need to find someone to relieve them . LPN #4 confirmed that as Unit Manager she should have been made aware there was no staff available to sit 1 on 1 with Resident #1. LPN #4 confirmed that she was aware of LPN #3's documentation on 9/20/2022 and 9/21/2022 that there was no staff available for 1 on 1 monitoring of Resident #1 on those 2 days, that the documentation was correct, and the former DON was aware of the lack of staffing available. During an interview conducted on 11/22/2022 at 4:54 PM, the IDON confirmed a physician's order was not entered into the electronic health record (EHR) for 1 on 1 monitoring of Resident[TRUNCATED]

Based on policy review, job description review, staff personnel file review, Safety Check Logs, medical record review, observation, and interview, the facility failed to ensure nursing staff were competent and proficient in practice to assure resident safety, to maintain residents' highest practicable well-being, to timely assess and report injuries of unknown origin, to supervise an aggressive and combative resident, to follow STAT (urgent, immediate or rush) physician orders, to follow up on radiology results, to administer pain medication, and to timely transfer residents to the hospital. The failure of the facility to ensure competent nursing staff resulted in Immediate Jeopardy for 4 of 18 sampled residents (Resident #1, Resident #2, Resident #5, and Resident #14) reviewed for abuse and accident hazards. Resident #1, a vulnerable resident with severe cognitive impairment, who displayed combative and aggressive behaviors and was care planned for 1 on 1 monitoring, was left unsupervised and had an altercation with Resident #2, who had moderately impaired cognition. Resident #5, who had moderate cognitive impairment, alleged abuse and complained of left upper arm and shoulder pain, the allegation of abuse was not reported until the following day, the injury of unknown origin was not assessed timely, and pain medication was not administered timely. Resident #5 had an oblique left proximal humerus fracture. Resident #14, who had severe cognitive impairment, complained of left leg and hip pain approximately 24 hours following a fall, STAT physician orders for radiology were not followed, the radiology results were not followed up on timely, pain medication was not administered, and the resident was not transferred to the hospital until 72 hours later. Resident #14 had a left Subcapital hip fracture. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Interim Administrator and Regional Vice-President were notified of the Immediate Jeopardy (IJ) on 12/7/2022 at 5:33 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-726. The facility was cited F-726 at a scope and severity of J. A partial extended survey was conducted from 12/12/2022 through 12/13/2022. The Immediate Jeopardy was effective from 8/19/2022 through 12/13/2022. An acceptable Removal Plan, which removes the immediacy of the jeopardy, was received on 12/13/2022 at 10:43 PM, and was validated onsite by the surveyors on 12/14/2022, through policy review, review of education records, review of audit tools, and staff interviews. The findings include: 1. Review of the facility's policy titled, Administering Pain Medications, dated 4/2021 revealed, .The purpose of this procedure is to provide guidelines for assessing the resident's level of pain prior to administering analgesic pain medications .Be familiar with the physiologic and behavioral (non-verbal) signs of pain .Verbal expressions such as groaning, crying, screaming .Facial expressions such as grimacing, frowning, clenching of the jaw .Limitations in his or her level of activity due to the presence of pain .Guarding, rubbing or favoring a particular part of the body .Acute pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated after analgesic relief is obtained .The pain assessment consists of gathering both subjective and objective data .Conduct a pain assessment as indicated. The initial assessment is comprehensive and should follow the facility pain assessment procedure .Conduct an abbreviated pain assessment if there has been no change of condition since the previous assessment .Whether pain has improved or worsened since the last assessment .The general condition of the resident .Verbal and non-verbal signs of pain .Evaluate and document the effectiveness of non-pharmacological interventions .Administer pain medications as ordered .Document the following in the resident's medical record .results of the pain assessment .medication .dose .route of administration .and .results of the medication . Review of the facility's policy titled Staff Competency ., dated 5/2022 revealed, .Nursing staff will demonstrate competency in skills and techniques necessary to care for the resident's needs, as identified through resident assessments and resulting plans of care .In-service training classes are conducted to provide employees with information concerning their position, methods and procedures to follow when implementing assigned duties, and to provide up-to-date information that will assist the employee, as well as the facility, in providing quality health care .At a minimum there should be competency demonstrated, at the appropriate staff level on the following topics .Abuse, neglect and exploitation policies and procedures .Dementia management .infection control .Person Centered Care .Effective Communication .Basic nursing skills .Pain Management .Identification of changes in condition .Staff competency in change of condition will be provided for RN [Registered Nurse], LPN [Licensed Practical Nurse], and Nurse Aides (CNA), which includes an understanding of how to identify, report and intervene based upon licensure category . Review of the facility's policy titled .Abuse Investigations . dated 5/2022 revealed, .Reports of resident abuse, neglect, and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Should an incident or suspected incident of resident abuse .neglect or injury of unknown source be reported, the Administrator .will appoint a member of management to investigate the alleged incident .The individual conducting the investigation will, at a minimum .Review the resident's medical record to determine events leading up to the incident .Interview the person(s) reporting incident; Interview any witnesses to the incident .Interview the resident .as medically appropriate .Interview staff members .on all shifts .who have had contact with the resident during the period of the alleged incident .Review all events leading up to the alleged incident .Post validated allegations of abuse, the QA [Quality Assurance] team should evaluate the following .Immediate and ongoing training needs and staff competency as needed . Review of the facility's policy titled .Abuse Prevention Program, Investigation . dated 8/2022 revealed, .Reports of resident abuse, neglect and injuries of unknown sources shall be promptly and thoroughly investigated by facility management .Post validated allegations of abuse, the QA [Quality Assurance] team should evaluate the following .Changes that may need to be made to prevent further occurrences .Defining how care will be changed or improved to protect residents .Immediate and ongoing training needs and staff competency as needed . Review of the facility's policy titled .Pain Clinical Protocols and Guidelines dated 10/2022 revealed, .Pain management will be provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences .Through established assessments, the nursing staff will identify individuals who have pain or who are at risk for having pain .This includes a review of each person's known diagnoses and conditions that commonly cause or predispose to pain .It also includes a review for any treatments that the resident currently is receiving for pain .The nursing staff will assess each individual for pain .whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain .Through the assessment process, the nursing staff will attempt to identify the nature .characteristics such as location, intensity, frequency, pattern .and severity of pain .Staff will assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level .The staff will observe the resident .during rest and movement .for evidence of pain .grimacing while being repositioned .The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated .ambulation .repositioning .Confer with the attending practitioner to help identify the extent to which underlying causes of pain can be addressed or reversed .Obtain orders for appropriate tests .x-rays as needed .Obtain orders for appropriate pain medications based upon the resident's current situation .PRN [as needed] doses should be monitored at time of request .Monitoring .PRN pain management response will be recorded post each dose given . 2. Review of the facility's Job Description, dated 8/2018 revealed, .Director of Nursing .Coordinates all departments relating to nursing. Accountable for all .training, and education of all nursing employees .Evaluates resident records to assure accuracy .residents are receiving optimal nursing care .Monitors lab, x-ray .services .Coordinates and delegates nursing orientations and on-going education for all nursing staff .Participates in in-service education .Responsible for supervising direction of resident care .Responsible for 24-hour supervisory nursing coverage of the care center by preparing schedules for nursing supervisors .Coordinates and delegates nursing coverage to appropriate personnel as necessary .Report accidents and incidents when they occur, including all complaints and grievances made by residents and/or families .Attend and participate in orientation programs, ongoing training and educational classes .Perform assigned tasks in accordance with facility policies and procedures .Must be able to communicate with all employees and give supervision and management direction .Thorough knowledge of state and federal regulations regarding long term care .Can demonstrate sound judgement, dependability, and good teamwork and communication skills . Review of the facility's Charge Nurse .JOB DESCRIPTION, dated 6/2021 revealed .Perform administrative duties such as the documenting of .nurses' notes, doctors' orders .reports, evaluations .charts, resident assessments and care plans .Report accidents and incidents when they occur, including all complaints and grievances made by residents and /or their families . 3. Review of the medical record, revealed Resident #5 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease, Dementia, Diabetes, Osteoarthritis, Psychosis, Scoliosis, and Anxiety. Review of the significant change Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #5 had a Brief Interview for Mental Status (BIMS) of 8, which indicated moderate cognitive impairment, and required extensive assistance for activities of daily living (ADLs). Review of the Nursing Note dated 8/20/2022 at 8:00 AM revealed Resident #5 was administered Tylenol 1000 milligrams (mg) for her complaint of pain in her arm and shoulder by Licensed Practical Nurse (LPN) #2. There was no documentation LPN #2 conducted a follow-up pain assessment within 30 or 60 minutes following the PRN pain medication per the facility's policy. Review of the Nursing Note dated 8/20/2022 at 8:21 AM revealed CNA #1 asked LPN #2 to come to Resident #5's room to assess the resident's arm after she complained of pain to CNA #1. Resident #5 cradled her left arm to her side, stated that her arm and shoulder hurt real bad, and had limited range of motion (ROM). LPN #2 notified the Unit Manager, former DON, and telehealth, who ordered a STAT x-ray of Resident #5's left shoulder. Review of the CNA #1's witness statement dated 8/20/2022, CNA #1 documented, .I went in to dry [named Resident #5] turn her to the wall first, she didn't say anything turn [turned] her back toward myself, she hollow [hollered] out. I said what's wrong, she said Baby, my arm hurts. [I] Immediately went and found [named LPN #1], [LPN #1] was in the back Dining Room eating. I told him [Resident #5] said somebody jump on her then I told him she said her arm was hurting, so he got up and me and him went to her room. He check [checked] her arm, told her to lift her arm, she started cussing him out. I said what you gonna [going to] do, he said I'm gonna call for xray, so I left . Review of the Staff Interview/Statement Sheet dated 8/20/2022, revealed .This writer [LPN #1] did head to toe assessment on patient [Resident #5] .on 8/19/2022 resident denies pain and was able to raise extremities. No visible injuries noted . The statement was signed by LPN #1. Review of the Physician's Order dated 8/20/2022 at 8:29 AM revealed a STAT order for xrays of Resident #5's left shoulder, humerus, and elbow. Review of the Nursing Note dated 8/20/2022 at 2:45 PM revealed the mobile x-ray company completed the ordered x-rays on Resident #5 six (6) hours and 40 minutes following the time of the STAT physician's order. Review of the Radiology Report dated 8/20/2022 at 4:28 PM revealed Resident #5 had an oblique proximal humerus fracture. Resident #5 was not sent to the hospital for the oblique left proximal humerus fracture until 8/20/2022 at approximately 9:30 PM, over 26 hours after she first complained of severe pain in her arm and shoulder. The facility's hospital Transfer Form was dated 7/30/2022 at 9:30 PM. Review of the Nursing Note dated 8/21/2022 at 4:45 AM revealed Resident #5 returned to the facility with a sling in place to her left arm. Her left upper arm was swollen and warm to the touch. Review of the Nursing Note dated 8/21/2022 at 2:26 PM revealed .[Resident #5] resting throughout shift PRN Tylenol given for pain .Sling in place throughout shift . Review of the Nursing Note dated 8/21/2022 at 7:13 PM revealed .PRN Administration was: Effective Follow-up Pain Scale was: 0 . Review of the Nursing Note dated 8/22/2022 at 7:24 AM revealed .Resident left arm, swollen, warm to touch, sling intact. Tylenol given for pain . Review of the Medication Administration Record (MAR) dated 8/1/2022 through 8/31/2022 revealed Tylenol was only documented as administered to Resident #5 on 8/20/2022 at 8:00 AM and 8/21/2022 at 5:25 AM for the month of August. Tylenol was not documented on the MAR as administered on 8/21/2022 at 2:26 PM or on 8/22/2022 at 7:24 AM. Observations in the Resident #5's room on 11/17/2022 at 10:05 AM, at 2:53 PM, and on 11/21/2022 at 5:21 PM revealed Resident #5 was lying in bed, her bed was against the wall on the right side, the call light was in reach, no side rails were present, no odors were noted, and the resident appeared thin and frail. Observation on 11/29/2022 at 9:17 AM revealed Resident #5 was in bed, the head of her bed was raised, she was awake and alert, her call light was in reach. During an interview conducted on 12/5/2022 at 4:15 PM, CNA #1 confirmed that she worked the 7:00 AM to 7:00 PM shift on 8/19/2022, and when she went in to change Resident #5 shortly before shift change at 7:00 PM, the resident complained of left upper arm and shoulder pain. CNA #1 stated, .I asked her what happened to you, she said, 'that girl beat the shit out of me,' I ran out of the room for the nurse. CNA #1 confirmed that she got LPN #1 and told him what Resident #5 said and they both went into the resident's room. CNA #1 stated, .[Resident #5] told him the same thing .[LPN #1] said 'I'm going to order an x-ray' . CNA #1 confirmed that when she came in on the following morning 8/20/2022 she had the same section of rooms and when she checked on Resident #5 the resident told her that her arm still hurt. CNA #1 stated, .I ran, got the other nurse [named LPN #2] .told her to check on [named Resident #5's] arm .Told her LPN #1 was supposed to got [have gotten] an xray last night . CNA #1 confirmed that she and LPN #2 went to the resident's room and when LPN #2 pulled back the cover she [LPN #2] said she thought the resident's arm was broken. CNA #1 stated, .told her about telling [named LPN #1] the night before and evidently [he] didn't order the x-ray he said he was going to order . CNA #1 confirmed Resident #5's upper arm was purple in color. During an interview on 12/6/2022 at 10:15 AM, LPN #2 was asked about Resident #5's injury of unknown origin. LPN #2 confirmed that on 8/20/2022 at about 7:30 AM, CNA #1 told her that she had reported to LPN #1 the night before that Resident #5 had complained of left arm pain and still complained of pain that morning. LPN #2 stated, .I assessed the resident's arm .got [named LPN #6] to come assess the resident's arm. LPN #2 confirmed that Resident #5 had bruising at the bicep area of her arm and the shoulder area didn't look right. LPN #2 stated, We contacted telehealth and got order for x-ray and notified the DON and Administrator. It was a stat order . During an interview on 12/6/2022 at 1:44 PM, the Administrator was asked about the Transfer Form for Resident #5 which was dated 7/31/2022 at 9:30 PM. The Administrator stated, It [the Transfer Form] self-populates the same date on the next Transfer Form you do. He [LPN #1] did not insert the correct date. It [date of transfer] was 8/20/2022 . During a telephone interview on 12/14/2022 at 8:44 AM, LPN #1 confirmed his written statement from 8/20/2022. LPN #1 stated, .[Resident #5] No complaint of pain on [the] previous day [8/19/2022]. LPN #1 denied that CNA #1 reported to him that Resident #5 had arm pain. LPN #1 stated, .I sent her out [to the hospital]. I think I gave her Tylenol, before sending her out . Resident #5 sustained an injury of unknown origin on 8/19/2022 and complained of pain at approximately 7:00 PM. The nurse was notified of the resident's complaint and did not notify the physician or nurse practitioner of the resident's change in status or obtain an order for an xray, and did not notify the Administrator of the allegation of abuse. The injury of unknown origin was not followed up on by staff until 8/20/2022, the STAT order was not obtained until 6 hours and 40 minutes after it was given, and the resident was not transferred to the hospital until 25 hours after she first complained of pain. Resident #5 sustained an oblique left proximal humerus fracture and received only 1 dose of Tylenol for pain management within the 25 hours following her complaint. The facility's failure to ensure staff were competent to assure resident safety and to maintain residents' highest practicable well-being resulted in Immediate Jeopardy for Resident #5 when staff did not timely assess an injury of unknown origin, did not follow STAT physician's order for radiology, did not transfer Resident #5 to the hospital in a timely manner, and did not provide adequate pain control to a resident who suffered a fractured humerus. 4. Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Schizophrenia, Dementia with Behavioral Disturbance/Psychotic Disturbance, Chronic Kidney Disease, Hypertension, and Chronic Hepatitis C. Review of the Staff Interview/Statement Sheet dated 9/7/2022 revealed CNA #5 was giving shift report to CNA #6 when Resident #3 walked toward Resident #1 who was sitting in a chair. Resident #1 reached up and struck Resident #3 in the left jaw with his closed fist. CNA #6 stepped between the residents, CNA #5 took Resident #3 to a safe area, and the CNAs reported the incident to LPN #3. Review of the Nursing Note dated 9/7/2022 at 8:17 PM revealed LPN #3 was at the medication cart when he observed Resident #1 walk up behind Resident #4 and strike him in the rear right side of his neck with a closed fist. LPN #3 immediately redirected Resident #1 away from Resident #4, put a CNA 1 on 1 with Resident #1, then assessed Resident #4. Resident #4 had no obvious signs of injury and made no faces of pain or had any complaints. Review of the Incident Report dated 9/7/2022 revealed the Incident Report was incomplete and did not provide any details regarding the incident that occurred between Resident #1 and Resident #3 on 9/7/2022. Review of the Nursing Note dated 9/7/2022 at 8:17 PM revealed LPN #3 was at the medication cart when he observed Resident #1 walk up behind Resident #4 and strike him in the rear right side of his neck with a closed fist. LPN #3 immediately redirected Resident #1 away from Resident #4, put a CNA 1 on 1 with Resident #1, then assessed Resident #4. Resident #4 had no obvious signs of injury and made no faces of pain or had any complaints. Review of the Care Plan with a revision date of 9/8/2022 revealed Resident #1 had violent outbursts, altercations with 2 other residents, and was transferred to the hospital for a psychiatric evaluation. Review of the quarterly MDS dated [DATE] revealed Resident #1 had severe cognitive impairment, physical behavioral symptoms toward others on 4-6 days, verbal behavioral symptoms toward others on 1-3 days, and behavioral symptoms not directed toward others on 1-3 days of the 7-day look back period. Review of the Care Plan revised 9/9/2022 revealed Resident #1 had been placed in 1 on 1 supervision as an intervention for hitting other residents. Review of the outcome of the facility's investigation of the altercations that occurred on 9/7/2022 between Resident #1 and #3, and Resident #1 and #4 dated 9/15/2022, revealed facility staff determined Resident #1 should be placed in indefinite 1 on 1 monitoring until more appropriate placement could be found for him. Review of the Safety Check Log for the 1 on 1 monitoring documentation for Resident #1 revealed missing documentation for 8 full days which included 9/17/2022, 9/21/2022, 9/23/2022-9/26/2022, 11/6/2022, and 11/10/2022, and 4 partial days which included 10/22/2022 and 10/24/2022 from 7:00 AM through 7:00 PM, 11/1/2022 from 3:00 AM through 7:00 AM, and 11/5/2022 from 7:00 AM through 11:59 PM. Review of the Nursing Notes dated 9/20/2022 at 5:17 AM and 9/21/2022 at 12:20 AM revealed there was no staff available for 1 on 1 monitoring of Resident #1, and the former DON was notified. Review of the daily staffing assignment sheet dated 11/10/2022, revealed CNA #2 was scheduled from 7:00 AM to 7:00 PM. Review of the time punch detail report dated 11/10/2022, revealed CNA #2 clocked in at 1:52 PM. Review of the Incident Report dated 11/10/2022 at 2:15 PM revealed Resident #1 was found lying on the hallway floor and Resident #2 was on top of him with his hands around Resident #1's throat. Review of CNA #2's Staff Interview/Statement Sheet dated 11/10/2022 revealed she had just arrived at work, put her belongings away, and used the restroom when she heard a commotion in the hallway. CNA #2 confirmed that she observed Resident #1 on the floor in the hallway and Resident #2 was on top of Resident #1, stating that Resident #1 hit him. Review of the Progress Note dated 11/10/2022 at 3:02 PM revealed the Nurse Practitioner heard a noise outside of her office door, went out to inspect, and found Resident #1 lying on his back in the hallway with Resident #2 on top of him. Resident #2's hands were around Resident #1's throat. Resident #2 stated that Resident #1 hit him in the back of the head. The Nurse Practitioner documented that Resident #1, who was supposed to be in 1 on 1 staff supervision, was not being supervised at the time and was in the hallway alone when the incident occurred. Review of the daily assignment sheet for the secure unit dated 11/10/2022, revealed there were 4 staff members scheduled for the 7:00 AM through 7:00 PM shift, LPN #6, CNA #2, CNA #3, and CNA #8. At the time the resident-to-resident altercation occurred LPN #6 was at the Nurses' Station and only CNA #3 was on the hall. CNA #2 and CNA #8 were in the Breakroom. There was no staff member present to provide 1 on 1 monitoring of Resident #1. 5. Review of the closed medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses of Diabetes, Dementia with Psychotic Disturbance, Schizoaffective Disorder-Bipolar Type, Hypertension, Chronic Kidney Disease, Depression, and Mixed Receptive-Expressive Language Disorder. Review of the annual MDS dated [DATE] revealed Resident #2 had a BIMS of 11, which indicated moderate cognitive impairment, with delusions and wandering behaviors on 3 days of the 7-day look back period, highly impaired vision, and required extensive to total staff assistance for ADLs. Review of the Nursing Note dated 8/21/2022 revealed, .resident was hit on the back of the head by other resident [Resident #1] due to accidentally running over his feet in wheelchair. Resident had no pain and just asked who did it. Resident was separated and both are calm . Review of the quarterly MDS dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status of 10, which indicated moderate cognitive impairment, with no behaviors, highly impaired vision, and required extensive staff assistance for ADLs. Review of the Nursing Note dated 11/10/2022 revealed, .[Resident #2] observed laying in hallway on top of [Resident #1] .with hands around [Resident #1] neck. [Resident #2] noted yelling .[Resident #1] hit me in my head . Review of the Nursing Note dated 11/11/2022 at 5:42 PM revealed Resident #2 was transferred to a psych facility for evaluation. During an interview conducted on 11/17/2022 at 9:15 AM, the Interim Administrator confirmed that Resident #1 was supposed to be in 1 on 1 monitoring on 11/10/2022, was left unsupervised, and that's when the altercation between Resident #1 and Resident #2 occurred. During an interview conducted on 11/17/2022 at 1:31 PM, CNA #8 confirmed she was working on 11/10/2022, but was on her lunch break when the altercation between Resident #1 and Resident #2 occurred. CNA #8 was asked who was on the hall with the residents. CNA #8 stated, A nurse was in the break room with me, he came out with me, I think it was another CNA [named CNA #4], I can't think who else was out there . CNA #8 stated, I noticed [named Resident #2] was on top of [named Resident #1], he [Resident #2] was hollering [named Resident #1] had hit him on the back of the head . CNA #8 confirmed she was very familiar with Resident #2. CNA #8 was asked to describe Resident #2's temperament. CNA #8 stated, He will not bother you unless you provoke him. During an interview conducted on 11/17/2022 at 1:47 PM, CNA #2 confirmed that she was running late on 11/10/2022, and did not arrive at the facility until approximately 2:00 PM. CNA #2 was asked what education or training the facility provided for monitoring a combative or aggressive resident. CNA #2 stated, .just to make sure we watched him and prevent any other incidents between him and any other resident . CNA #2 confirmed they had abuse inservices but no specific training or education regarding de-escalation or handling a combative resident. CNA #2 confirmed that when she arrived on the secure unit and went to the break room there was not a staff member sitting outside of Resident #1's room. CNA #2 was asked were there 1:1 monitoring documentation papers on the over bed table. CNA #2 stated, No, it wasn't there I had to ask for it . CNA #2 confirmed the facility staff had told her Resident #1 was never to be left alone, at any time. CNA #2 was asked was anyone in the hall when she entered the break room. CNA #2 stated, .[Named Resident #2] was in his wheelchair at the opposite end . CNA #2 was asked how long she thought she was in the break room. CNA #2 stated, I would say about 5 minutes .went in and put my stuff up, used the bathroom and washed my hands, heard the commotion and run straight out the door .[named LPN #5] .and [named CNA #8] .was on break. We all heard the commotion . CNA #2 confirmed Resident #2 was on top of Resident #1 and Resident #2 was saying he hit me in the back of the head when she arrived in the hallway. During an interview conducted on 11/17/2022 at 2:20 PM, LPN #6 confirmed she was the Charge Nurse and worked the secure unit on 11/10/2022. LPN #6 was asked where she was when the incident between Resident #1 and Resident #2 occurred. LPN #6 stated, I was at the Nurses' desk charting . LPN #6 confirmed that CNA #2 had only been on the hall for 10-15 minutes when the incident occurred and that no one was sitting with Resident #1. LPN #6 stated, .We had to just watch out for him to do the best we could . During an interview conducted on 11/21/2022 at 10:10 AM, the Scheduler confirmed that she had to sit 1 on 1 with Resident #1 at times, when they needed help. The Scheduler was asked did the facility provide any training or inservices on how to handle a resident in 1 on 1 monitoring. The Scheduler stated, No, not that I remember . During a telephone interview conducted on 11/21/2022 at 11:59 AM, LPN #3 confirmed that he worked the secure unit on the 7:00 PM through 7:00 AM shift, and there were several times the facility did not provide him with enough staff to provide 1 on 1 supervision of Resident #1. LPN #3 stated, .They said they didn't have the staff . LPN #3 confirmed the Unit Manager told him they did not have enough staff. LPN #3 was asked did the facility provide staff any special education for 1 on 1 monitoring. LPN #3 stated, No .it was just like grab somebody and sit with him .with [named Resident #1] you need somebody who understands his disability, his dementia, and triggers, and be proactive in stopping triggers .to keep him from becoming violent .if they had taken the time to do it [1 on 1 monitoring] right .they could've .[I] sat down with the DON and talked to her about it .I guess I just [expletive] her off .to me that was paramount . During a telephone interview on 11/23/2022 at 9:56 AM, CNA #3 confirmed that she worked the secure unit on 11/10/2022, when the incident occurred between Resident #1 and #2, that she was not scheduled to provide 1 on 1 monitoring of Resident #1 that day, that she was the only CNA on the hall at the time the incident occurred, and that she did not witness the incident. CNA #3 was asked did the facility provide education to staff on how to provide 1 on 1 monitoring. CNA #3 stated, I don't think so, I use my own judgement . During an interview conducted on 11/23/2022 at 11:38 AM, the Interim DON (IDON) stated, .No .there was no education provided [1 on 1 monitoring education] . The IDON was asked should education for 1 on 1 monitoring and how to complete the Safety Check Log have been provided. The IDON stated, Yes .there was obviously no protocol . During a telephone interview on 11/29/2022 at 4:30 PM, the former DON was asked how she ensured staff was competent to provide 1 on 1 monitoring of a combative and aggressive resident. The former DON stated, We have a [named computer] course on de-escalating patients and our log that they're checking on him to make sure and documenting . The former DON confirmed the de-escalation training would be found in the computer system. The former DON was asked what training was provided to staff regarding how to complete the Safety Check Log. The former DON stated, I think it's pretty self-explanatory . The former DON denied knowledge of missing dates, gaps in time, and missing signatures on the Safety Check Logs for Resident #1's 1 on 1 monitoring. During an interview conducted on 12/5/2022 at 9:55 AM, the Interim Administrator confirmed the facility could not find documentation that de-escalation training was provided to the staff for 1 on 1 monitoring, prior to the training conducted on 12/2/2022. Resident #1, a cognitively impaired resident with combative and aggressive behaviors hit Resident #3 and #4 on 9/7/2022. He was evaluated at a psychiatric hospital and returned to the facility. Facility staff determined to use 1 on 1 monitoring for Resident #1 indefin[TRUNCATED]

Based on policy review, job description review, and interview, Administration failed to provide oversight to ensure systems and processes were developed and consistently followed, failed to provide oversight of nursing staff, failed to identify the root cause of concerns identified in the facility, and failed to ensure systems and processes were developed and consistently followed by facility staff. Administration failed to provide oversight that established and implemented policies and procedures to ensure residents were free from verbal, physical, and sexual abuse. Administration failed to provide oversight that established and implemented policies and procedures to ensure residents' Care Plans were followed to ensure safety measures were in place for a resident with a history of aggressive and combative behaviors. Administration failed to provide oversight that established and implemented policies and procedures to ensure facility staff investigated abuse allegations thoroughly. Administration failed to provide oversight that established and implemented policies and procedures to ensure abuse allegations were reported timely to all respective entities. Administration failed to provide oversight that established and implemented policies and procedures to ensure the facility had sufficient numbers of competent staff to provide care and services to residents and to follow doctor's orders. Administration failed to provide oversight that established and implemented policies and procedures to ensure care was provided for Resident #5 who had arm fracture pain and Resident #14 who had hip fracture pain. These failures resulted in Immediate Jeopardy for Resident #1, #2, #3, #4, #5, and #14. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Interim Administrator and the Interim Director of Nursing (IDON) were notified of the Immediate Jeopardy (IJ) for F-600 and F-689 on 11/21/2022 at 5:43 PM, in the Conference Room. The Interim Administrator and Regional [NAME] President were notified of the Immediate Jeopardy for F-684 and a second F-600 on 12/7/2022 at 5:31 PM, in the Conference Room. The Interim Administrator and Regional [NAME] President were notified of the Immediate Jeopardy for a second F-689 on 12/7/2022 at 5:32 PM, in the Conference Room. The Interim Administrator and Regional [NAME] President were notified of the Immediate Jeopardy for F-726 and F880 on 12/7/2022 at 5:33 PM, in the Conference Room. The Interim Administrator was notified of the Immediate Jeopardy for F-656 on 12/8/2022 at 10:07 AM, in the Conference Room. The Interim Administrator was notified of the Immediate Jeopardy for F-835 and F-867 on 12/13/2022 at 3:44 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-600, F-656, F-684, F-689, F-726, F-835, F-837, and F-880. The facility was cited at F-600, F-684, F-689 at a scope and severity of J which is Substandard Quality of Care. An partial extended survey was conducted from 12/12/2022 through 12/13/2022. A Removal Plan which removed the immediacy of the jeopardy was accepted on 12/13/2022 at 10:45 PM, and was validated onsite by the surveyors on 12/14/2022 through review of inservice education, root cause analysis review, review of audit tools, review of QAPI minutes, Interdisciplinary Team (IDT) meeting minutes, and staff interviews on all shifts. The facility's noncompliance at F-835 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction for each deficiency. The findings include: Review of the facility's .Job Description, dated 8/2018, revealed .Director of Nursing .Coordinates all departments relating to nursing. Accountable for all functions, activities, training, and education of all nursing employees .Evaluates resident records to assure accuracy, care plans are current and complete and residents are receiving optimal nursing care .Monitors lab, x-ray .services .Works with administration in interpreting, maintaining, updating, and executing personnel policies, facility manuals and job descriptions .Coordinates and delegates nursing orientations and on-going education for all nursing staff .Participates in in-service education .Responsible for supervising direction of resident care .Responsible for 24-hour supervisory nursing coverage of the care center be preparing schedules for nursing supervisors .Coordinates and delegates nursing coverage to appropriate personnel as necessary .Report accidents and incidents when they occur, including all complaints and grievances made by residents and/or families, and immediately report any time a resident is observed leaving campus .Attend and participate in orientation programs, ongoing training and educational classes .Perform assigned tasks in accordance with facility policies and procedures .Must be able to communicate with all employees and give supervision and management direction .Thorough knowledge of state and federal regulations regarding long term care .Can demonstrate sound judgement, dependability, and good teamwork and communication skills . Review of the facility's Administrator Job Description dated 5/2021, revealed .Supervises, plans, develops, monitors and maintains appropriate standards of care throughout all departments in the nursing home. Manages staff at the facility .Supervise and promote guidance and support to department heads .Meet standard staffing goals and ensure state licensure and certification standards are met .Recruit, employ, and ensure adequate training of personnel in the facility .implement procedures and controls necessary to provide quality resident care .Recognize and respond to changes in residents conditions and report observations to nursing/medical staff .Determine staffing needs of the facility .Develop and improve staff competency through training .Direct various committees of the facility, such as care plan, infection control .quality assessment and assurance .Monitor procedures to assure compliance with the guidelines of state and federal regulations and facility policy .Review, resolve and report complaints and grievances made by residents, families .Develop and authorize the development of established universal precautions and isolation procedures, and review and monitor compliance by staff .Monitor the workplace for possible health and safety hazards .Audit documentation for errors to inconsistencies and make necessary corrections or document reasons for corrections not made . Review of the facility's policy titled, Facility Policies and Procedures dated 5/2022, revealed .To ensure that our facility's operational policies and procedures are maintained on a current basis, the Quality Assurance and Assessment Committee will review our operational policies and procedures and resident care policies .Affected staff will be informed of changes in our policies and procedures. Appropriate in-service training will be conducted when changes in resident care and/or other policies and procedures are introduced . During an interview conducted on 11/21/2022 at 9:44 AM, the IDON confirmed that she became the IDON on 11/14/2022. THE IDON stated, .[My] background is cleaning up nursing homes .not to leave until everything is back in compliance . The IDON provided the Safety Check Logs [1:1 monitoring forms] for Resident #1 and stated, .Incomplete documentation is here, these are all we have. The IDON confirmed that the 1:1 documentation was not included in the facility's investigation of the resident-to-resident altercation between Resident #1 and #2. The IDON confirmed there were dates missing from several of the forms. The IDON stated, They are very random, they are not complete .I just collected what we had .put them in order .obviously saw that [1:1 monitoring documentation] was not being done correctly . During an interview conducted on 11/22/2022 at 10:10 AM, the Interim Administrator stated, .We knew as a whole there was a problem .recognized when we had a morning meeting on Friday [11/11/2022] that 1 on 1 didn't happen in the morning .that was the day the former Administrator and the former DON was leaving .I came in on Monday [11/14/2022] .went back to Alabama on Tuesday [11/15/2022] and wasn't able to get back in the building until 1:30 on Wednesday [11/16/2022] .Thursday [11/17/2022 when the survey team entered the facility] was going to be my first day in the building to tie it all up and bring it all together . During an interview conducted on 11/22/2022 at 11:15 AM, LPN #4 confirmed she was the Unit Manager of the secure unit and that she was aware of LPN #3's documentation on 9/20/2022 and 9/21/2022 that staff were not available for 1 on 1 monitoring. LPN #4 stated, I was aware .and they [Administration] knew that. LPN #4 stated, .Several times I reached out over the weekend [to the former DON] with no response .things weren't getting taken care of .they [former Administrator and former DON] knew they was [were] leaving .at that point nothing mattered I would go in with my concerns . LPN #4 was asked were they aware of the times there was not staff for 1 on 1 monitoring. LPN #4 stated, Yes .they were absolutely aware, and they did nothing to try to get the Staffing Coordinator [Scheduler] to bring in extra people, none of that . During an interview conducted on 11/23/2022 at 11:38 AM, the IDON confirmed no documentation was found that de-escalation education, education on providing 1 on 1 monitoring of a combative and aggressive resident, or education on how to accurately complete the 1 on 1 monitoring form was completed. During a telephone interview conducted on 11/29/2022 at 4:30 PM, the former DON confirmed she became DON in July of 2022. The DON was asked if the Medical Director was made aware that there were times there was not enough staff to provide 1 on 1 monitoring of Resident #1. The DON stated, I don't think so. During an interview conducted on 12/1/2022 at 12:00 PM, the Medical Director confirmed he was never made aware that sometimes the facility did not have enough staff to provide 1 on 1 monitoring of Resident #1. The Medical Director confirmed that he was not made aware of the altercation that occurred on 8/28/2022 between Resident #1 and #2, and Resident #2's possible exposure to a communicable disease. During a telephone interview conducted on 12/1/2022 at 3:13 PM, the Regional Nurse Consultant (RNC) stated, .the 1 on 1 documentation, it should have been in POC [Point of Care, the place where the Certified Nursing Assistants (CNAs) document in the electronic health record (EHR)] .I wasn't aware until sometime in October that he [Resident #1] had been in 1 on 1 for this extended period of time . The RNC confirmed she was not aware that there were gaps, missed days, and missing times in the Safety Check Log (1:1 monitoring form). The RNC was asked if anyone followed up on the Safety Check Logs. The RNC stated, I know on one of my rounds I noticed there were several sheets on a clipboard, addressed with [named former DON] that those needed to be pulled and scanned into PCC [facility's electronic health record] . The RNC confirmed the former DON was supposed to follow up with the mobile radiology company to address the delay in treatment for Resident #14's hip fracture but did not know if the former DON actually did so. The RNC stated, .The communication between me and [named the former DON] was not good .always felt like she thought she knew more than I did . During an interview conducted on 12/1/2022 at 9:53 AM, the Interim Administrator stated, I talked to [named RNC] .They did an Ad Hoc [impromptu Quality Assurance and Performance Improvement (QAPI)] meeting following Resident #14's delay in treatment] .the [former] DON that was here .sitting at her laptop typing notes, there's no notes in Abaqis [Quality Management System] .she's [RNC] going to recreate what they talked about to see what that looks like because they [former Administrator and former DON] screwed up .that STAT order didn't get communicated across the board . During an interview conducted on 12/2/2022 at 1:28 PM, LPN #2 confirmed there was an issue with obtaining STAT radiology services on the weekends. LPN #2 was asked did she make the former Administrator and former DON aware of the problems with radiology. LPN #2 stated, Yes .[they did] absolutely nothing . During an interview conducted on 12/12/2022 at 2:38 PM, the Interim Administrator confirmed that she was finishing the investigation on Resident #12 because the former Administrator and former DON did not conduct a thorough investigation into Resident #12's allegation of abuse. The Administration failed to maintain oversight, establish, and implement policies and procedures to ensure allegations of abuse are thoroughly investigated, and reported. Refer to F-600. The Administration failed to maintain oversight, establish, and implement policies and procedures to ensure adequate staffing. Refer to F-726. The Administration failed to maintain oversight, establish and implement policies and procedures to ensure behavior monitoring for residents. Refer to F-656, F-684, F-689, and F-867. The Administration failed to maintain oversight, establish, and implement policies and procedures to ensure an effective QAPI program was in established in the facility. Refer to F-867. The surveyors verified the Removal Plan through review of inservice education, root cause analysis review, review of audit tools, review of QAPI minutes, Interdisciplinary Team (IDT) meeting minutes, and staff interviews on all shifts: RVP (Regional [NAME] President) reviewed job description with current Admin (Administrator). Governing Body to provide education to new leadership (Admin/DON) for Clinical Startup. Educate and encourage community to utilize PCC (Electronic Health Record) to highest ability to include Clinical Communications portal to communicate resident needs/follow-up. Educate Admin/DON re: safe environment, following physician orders to include STAT (urgent) orders, addressing communicable disease, residents requiring 1:1 monitoring, and following resident's plans of care. The surveyors verified by staff interviews and review of in-services. Educate new clinical leaders for Clinical Startup on hire and as needed. The surveyors verified by review of the in-services, orientation training, and interviews. Educate leadership, Admin/DON, to follow up with Relias (Computer training system) training and new hire Onboarding to ensure training in complete prior to providing direct care. The surveyors verified by review of orientation training program and interviews. QAPI plan and Facility Assessment to be completed annually in December and updated as needed (reviewed quarterly) to assess educational needs. Surveyors verified by review of QAPI minutes and interviews. DON/Staff Development Coordinator (SDC) /Unit Manager (UM) to review 24/72 hour report and follow up with individual licensed staff for documentation improvement to include: safe environment, following physician orders to include STAT, addressing communicable disease, residents requiring 1:1 monitoring. Surveyors verified by review of audits and staff interviews on all shifts. Admin/DON will submit self-reports to Governing Body for review, recommendation, and guidance within 5 days post incident. The surveyors verified by interviews and review of facility self-reports. Admin/DON work will Mission Education Department for assistance in training. The surveyors verified by review of in-services and interviews. Community to work with Home Office for assistance in recruitment of staff. Surveyors verified by interviews. Admin/DON to be on weekly call with Governing Body to discuss issues/concerns and status of regulatory compliance with recent IJs. Surveyors verified by review of call logs and interviews. The facility's noncompliance of F-835 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on job description review, policy review, document review, medical record review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program that identified opportunities for improvement related to resident safety, infection control and competent staffing, and failed to implement performance improvement activities in order to provide a safe environment for residents, prevent the spread of infections and communicable disease, and ensure systems and processes were in place and were consistently followed by staff and administration, and ensure competent staff that practiced in accordance with standards of practice and facility guidelines and followed resident care plan interventions for safety. The QAPI committee failed to provide oversight that established and implemented policies and procedures to assure the facility was administered in a manner to use its resources effectively and efficiently. The QAPI committee program failed to identify the root cause of injuries of unknown origin. The facility failed to ensure cognitively impaired residents (Resident #5 and #14) were properly assessed and treatment was provided following accidents and injuries of unknown origin resulting in a fracture to Resident #14 's hip and a fracture to Resident #5's arm. The QAPI committee failed to provide oversight that established and implemented policies and procedures to ensure that a resident (Resident #2) was properly assessed and monitored following an incident of exposure to a communicable disease and the incident was reported to the Health Department. The QAPI committee failed to provide oversight that established and implemented policies and procedures to ensure that a resident (Resident #1), a cognitively impaired resident with a history of aggressive and combative behaviors, received 1 on 1 monitoring for safety as indicated on his Care Plan. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Interim Administrator and Interim Director of Nursing (IDON) were notified of the Immediate Jeopardy (IJ) for F-600 and F-689 on 11/21/2022 at 5:43 PM, in the Conference Room. The Interim Administrator and Regional [NAME] President were notified of the Immediate Jeopardy for F-684 and a second F-600 on 12/7/2022 at 5:31 PM, in the Conference Room. The Interim Administrator and Regional [NAME] President were notified of the Immediate Jeopardy for a second F-689 on 12/7/2022 at 5:32 PM, in the Conference Room. The Interim Administrator and Regional [NAME] President were notified of the Immediate Jeopardy for F-726 and F880 on 12/7/2022 at 5:33 PM, in the Conference Room. The Interim Administrator was notified of the Immediate Jeopardy for F-656 on 12/8/2022 at 10:07 AM, in the Conference Room. The Interim Administrator was notified of the Immediate Jeopardy for F-835 and F-867 on 12/13/2022 at 3:44 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-600, F-656, F-684, F-689, F726, F-835, F-837, F-867 and F-880 at a severity of J. The facility was cited at F-600 at scope and severity of J, which is Substandard Quality of Care. The facility was cited at F-684 at scope and severity of J, which is Substandard Quality of Care. The facility was cited at F-689 at scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 8/19/2022 through 12/13/2022. A Removal Plan which removed the immediacy of the jeopardy was accepted on 12/13/2022 at 10:45 PM, and was validated onsite by the surveyors on 12/14/2022 through review of inservice education, root cause analysis review, review of audit tools, review of QAPI minutes, Interdisciplinary Team (IDT) meeting minutes, and staff interviews on all shifts. The findings include: The facility's policy titled, QAPI Committee, Program Feedback, Data Systems and Monitoring . revised 10/2022, revealed .This facility shall establish and maintain a Quality Assessment and Assurance Committee (QAPI) that oversees the identification and handling of quality issues. The facility shall establish a system for program feedback, data collection systems, and monitoring, including adverse events .The primary goals of the Quality Assessment and Assurance Committee are .To oversee facility systems and processes related to improving quality of care and services .To promote consistent facility systems and processes and appropriate practices in resident care .To help identify negative outcomes relative to resident care and resolve them appropriately .To coordinate the development, implementation, monitoring, and evaluation of action plans to achieve specified quality goals .To coordinate and facilitate communication regarding the delivery of quality resident care .The committee will meet monthly at an appointed time .The Infection Preventionist shall report on the Infection Prevention and Control Program, include all Health-care associated Infections (HAI's) on a regular basis .The committee will oversee the development and implementation of actions to correct quality concerns and promote overall quality of care and services in the facility .Examples of actions that may be implemented to help address quality issues may include .Adverse Event review including, systematic identification, analysis which lead to corrective action .Educational training programs .Staffing changes .Sources may include .EHR [Electronic Health Records] .Incident Reports .Complaints .If a medical error or adverse event has occurred, initiate feedback and learning throughout the facility by .Education of the staff .The committee shall advise the administration of the need for policy and procedural changes and, as appropriate, monitor to ensure that such changes as implemented . Review of the facility's policy titled, Facility Policies and Procedures dated 5/2022, revealed .To ensure that our facility's operational policies and procedures are maintained on a current basis, the Quality Assurance and Assessment Committee will review our operational policies and procedures and resident care policies .Affected staff will be informed of changes in our policies and procedures. Appropriate in-service training will be conducted when changes in resident care and/or other policies and procedures are introduced . Review of the facility's Administrator Job Description dated 5/2021, revealed .Supervises, plans, develops, monitors and maintains appropriate standards of care throughout all departments in the nursing home. Manages staff at the facility .Supervise and promote guidance and support to department heads .Meet standard staffing goals and ensure state licensure and certification standards are met .Recruit, employ, and ensure adequate training of personnel in the facility .implement procedures and controls necessary to provide quality resident care .Recognize and respond to changes in residents conditions and report observations to nursing/medical staff .Determine staffing needs of the facility .Develop and improve staff competency through training .Direct various committees of the facility, such as care plan, infection control .quality assessment and assurance .Monitor procedures to assure compliance with the guidelines of state and federal regulations and facility policy .Review, resolve and report complaints and grievances made by residents, families .Develop and authorize the development of established universal precautions and isolation procedures, and review and monitor compliance by staff .Monitor the workplace for possible health and safety hazards .Audit documentation for errors to inconsistencies and make necessary corrections or document reasons for corrections not made . Review of the facility's .Job Description, dated 8/2018, revealed .Director of Nursing .Coordinates all departments relating to nursing. Accountable for all functions, activities, training, and education of all nursing employees .Evaluates resident records to assure accuracy, care plans are current and complete and residents are receiving optimal nursing care .Monitors lab, x-ray .services .Works with administration in interpreting, maintaining, updating, and executing personnel policies, facility manuals and job descriptions .Coordinates and delegates nursing orientations and on-going education for all nursing staff .Participates in in-service education .Responsible for supervising direction of resident care .Responsible for 24-hour supervisory nursing coverage of the care center by preparing schedules for nursing supervisors .Coordinates and delegates nursing coverage to appropriate personnel as necessary .Report accidents and incidents when they occur, including all complaints and grievances made by residents and/or families .Attend and participate in orientation programs, ongoing training and educational classes .Perform assigned tasks in accordance with facility policies and procedures .Must be able to communicate with all employees and give supervision and management direction .Thorough knowledge of state and federal regulations regarding long term care .Can demonstrate sound judgement, dependability, and good teamwork and communication skills . Review of the QAPI Immediate Action Plan dated 12/11/2022, revealed, QA Committee not completing AdHO [AdHoc (Impromptu)] [symbol for and] RCA [Root Cause Analysis] as indicated .What are the implications of not taking action .High Risk - Actual harm has occurred .Educate Dept [Department] Heads Re [Related to] QA, RCA, Adhoc .Educate staff about QAPI [symbol for and] how to get data to QAPI .Governing body to support/educate leadership . During a telephone interview conducted on 11/29/2022 at 4:30 PM, the former DON confirmed an Ad Hoc QAPI meeting was not conducted following the resident to resident altercation that occurred between Resident #1 and #2 on 11/10/2022, and the facility's inability to provide staff for 1 on 1 monitoring of Resident #1. During an interview conducted on 12/1/2022 at 12:00 PM, the Medical Director confirmed that a QAPI meeting was not conducted following the resident to resident altercation between Resident #1 and #2 that occurred on 11/10/2022. During a telephone interview conducted on 12/7/2022 at 4:14 PM, the former DON confirmed the incident where Resident #2 had possible exposure to a communicable disease was not taken to the monthly QAPI and an Ad Hoc QAPI meeting was not conducted following the incident. The former DON stated, I didn't know we were supposed to [take the incident to QAPI] . During an interview completed on 12/13/2022 at 12:42 PM, the Interim Administrator was asked how often do you have QA. The Interim Administrator stated, Monthly .in looking at the notes, one month was missed but I prefer monthly . The Interim Administrator was asked who attends the QA meetings. The Interim Administrator stated, Department heads .and the Medical Director and/or the Nurse Practitioner. The Interim Administrator was asked what topics were discussed in QA. The Interim Administrator stated, Each department has their things they bring, the DON looks at wounds, med errors .Infection Control nurse looks at that .nursing talks about weight loss, skin, nursing related, Dietary talks about diets, food preferences, Social .any discharges and reports to the Ombudsman, Activities covers volunteers, and resident council .MDS brings reports and we look at the Quality Measures .we are setting up to do our own inhouse surveys of staff, residents, families .any PIPS [Performance Improvement Plans], and follow up on those . The Interim Administrator was asked do you discuss falls, incidents, and accidents. The Interim Administrator stated, Yes ma'am .that would fall under the DON. The Interim Administrator was asked what would prompt an Ad Hoc meeting. The Interim Administrator stated, The IJs prompted an Ad Hoc meeting .It depends on the extent of the concerns .if a concern is brought up and it's something we feel like the whole team needs to be aware of, we would do it .if a concern that just addresses 1 department, I would probably just make that department aware . The Interim Administrator was asked would you do an Ad Hoc for incidents of abuse. The Interim Administrator stated, I typically haven't in the past, but now I'm second guessing myself .If I feel like if I could investigate it and get a good handle on it, I probably wouldn't .certainly if something substantiated, it would probably be more relevant .what we did with these .behavior related, I've asked my care plan team .talked to CNAs, asked them to go back and do another care plan meeting and reevaluate our interventions, expect our interventions to be more patient related .have put them in there in a way so the CNAs can pull them up and know the interventions . The Interim Administrator was asked if incidents, injuries of unknown origin, and allegations of Abuse were discussed in QA. The Interim Administrator stated, All reportables will be discussed in there .anything from the meeting before .the way QAPI works like December, you're really addressing all of November's stuff. The Interim Administrator was asked when a problem was brought before QA and a plan was put in place, who monitored to make sure the plan was effective, how often was it monitored, and if it was not effective, what do you do next. The Interim Administrator stated, Whoever would monitor would be based on the department the plan is addressed by .that dept head that particular concerns is related to .how often is often determined how that PIP is written .then as an Interim Administrator I would look at each person's PIP and discussing is this working or not working, and do we need to implement something different. The Interim Administrator was asked if the facility had an effective QA program. The Interim Administrator stated, I think the program is effective, so yes .I think it could be utilized more effectively, and that's what I'm hoping to be able to do . The Interim Administrator was asked do you think that QAPI program was being utilized adequately. The Interim Administrator stated, No ma'am . The Interim Administrator was asked who was ultimately responsible for the QAPI program. The Interim Administrator stated, .Me . The Interim Administrator was asked who was ultimately responsible for the safety of the residents. The Interim Administrator stated, Me. The QAPI committee failed to maintain oversight, establish and implement policies and procedures to provide adequate supervision of residents and to properly assess and provide treatment for injuries and reports of pain. Refer to F-600 The QAPI committee failed to maintain oversight, establish, and implement policies and procedures to ensure staff maintained residents' safety by following their plan of care for safety interventions related to aggressive behaviors. Refer to F-656 The QAPI committee failed to maintain oversight, establish, and implement policies and procedures to ensure the facility provided care to residents in accordance with professional standards of practice. Refer to F-684 The QAPI committee failed to maintain oversight, establish, and implement policies and procedures to ensure incidents of resident to resident abuse and accidents were prevented, residents were monitored, and care and treatment was provided timely. Refer to F-689. The QAPI committee failed to maintain oversight, establish, and implement policies and procedures to ensure nursing staff were competent and proficient in practice to assure resident safety, to maintain residents' highest practicable well-being. Refer to F-726. The QAPI Committee failed to maintain oversight, failed to establish and implement policies and procedures, failed to ensure the Administration consistently followed policies and procedures, failed to provide oversight of nursing staff, failed to identify the root cause of concerns identified in the facility, and failed to ensure systems and processes were developed and consistently followed by facility staff. Refer to F-835. The QAPI committee failed to maintain oversight, establish, and implement policies and procedures to ensure residents were properly tested after exposure to Hepatitis C, a communicable disease, and failed to ensure the exposure was reported to the Health Department. Refer to F-880.

Based on the Center for Disease Control (CDC)'s Hepatitis C Questions and Answers for the Public, policy review, medical record review, review of facility emails, and interview, the facility failed to prevent the potential spread of infection and communicable disease for 1 of 1 sampled resident (Resident #2) reviewed. This failure resulted in Immediate Jeopardy when a Hepatitis C-positive resident (Resident #1) was involved in an altercation with another resident (Resident #2), and both residents were bleeding, which exposed staff and Resident #2 to potential contact with Hepatitis C-contaminated blood, when the facility failed to test Resident #2 for Hepatitis C following the exposure, and when the facility failed to report the exposure to the Health Department. Immediate Jeopardy (IJ) is a situation in which a provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, severe injury, harm, impairment, or death to a resident. The Administrator and the Regional [NAME] President were notified of the Immediate Jeopardy on 12/7/2022 at 5:33 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-880. The facility was cited at F-880 at a scope and severity of J. The IJ was effective on 8/19/2022 through 12/13/2022. A partial extended survey was conducted 12/12/2022 through 12/13/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 12/13/2021 at 10:43 PM, and was validated onsite by the surveyors on 12/14/2022 through review of root cause analysis, in-services, audits, and staff interviews conducted. The findings include: 1. Review of the CDC's Hepatitis C Questions and Answers for the Public, dated 7/ 28/2020, revealed .The hepatitis C virus is usually spread when someone comes into contact with blood from an infected person .You should get tested for hepatitis C if you .Have been exposed to blood from a person who has hepatitis C . 2. Review of the facility's policy titled, Exposure Reporting and Investigating, dated 5/2022, revealed Employee exposure incidents to blood .or other potentially infectious materials must be reported to the community management as soon as practical after such incident occurs . Review of the facility's policy titled, Exposure Reports ., dated 5/2022, revealed An occupational exposure report shall be completed for all known employee exposures to blood and/or body fluids .Release of such information will only be on a need-to-know basis .For example, to the Administrator, Director of Nursing Services .and government officials, as required by law . Review of the facility's policy titled, Infection Prevention and Control Program . dated 10/2022, revealed The community Infection Prevention and Control Program is designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The program covers all residents, staff .and others who provide care and services to residents on behalf of the facility .The Infection Control Committee is established to provide the oversight of the program .The Infection Control Committee shall oversee the internal community system for the preventing, identifying, reporting, investigating and controlling of infections and communicable diseases for all staff .and other individuals providing services .The program establishes facility-wide systems for the prevention, identification, reporting, investigation and control of infections and communicable diseases of residents, staff, and visitors .The community program will follow accepted national standards, e.g. [for example] CDC .Components of the program will include .Surveillance system .Reporting requirements .Environmental cleaning .Recording system .The Infection Control Committee may include .Administrator .Director of Nursing .Infection Control Coordinator .The Infection Preventionist will report monthly to the QAPI [Quality Assurance Performance Improvement] Committee . 3. Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Schizophrenia, Dementia with Mood Disturbance/Behavioral Disturbance/Psychotic Disturbance, Seizures, Hypertension and Chronic Hepatitis C. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #1 had severely impaired cognition, physical behaviors directed towards others on 4-6 of 7 days and verbal behaviors directed towards others on 1-3 of 7 days. Review of the Care Plan dated 4/8/2022, revealed .has mood and behavioral problems .displayed as combative behavior towards other resident and staff, agitation, anxiety or restlessness r/t [related to] impaired mental status .has potential for complications r/t hepatitis C . Review of the Nurses Note dated 8/28/2022 at 9:24 PM, revealed .This nurse was notified by CNA [Certified Nursing Assistant] that there was blood on dayroom floor. Upon entering dayroom this nurse observed [named Resident #1] lying on the floor with hands under head in sleeping position with eyes closed. small scratch noted on face to L [Left] side of nose. [Named Resident #2] was sitting in WC [wheelchair] with small amount of blood coming from bottom lip. [Named Resident #1] was assisted into chair in hallway by nurse and [named Resident #2] was supervised in dayroom . 4. Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE], with diagnoses of Diabetes, Dementia with Psychotic Disturbance, Schizoaffective Disorder-Bipolar Type, Depression, and Speech Disturbances. Review of the quarterly MDS dated [DATE] revealed Resident #2 had moderately impaired cognition, was rarely or never understood by and rarely or never understood others, and had highly impaired vision. Review of the Nurses Note dated 8/28/2022 at 10:01 AM, revealed .This nurse alerted by CNA there was blood in dayroom floor. Upon entering room this nurse observed resident sitting in WC with small amount of blood observed on bottom lip. [Named Resident #1] was observed lying on the floor with hands under head in sleeping position with eyes closed, small scratch noted on face to L of nose. Residents separated and supervised at this time . The facility was unable to provide documentation Resident #2 was tested for Hepatitis C following the incident with Resident #1 on 8/28/2022. Review of an email provided by the facility dated 9/4/2022 at 12:02 PM, from the Infection Preventionist to the DON, revealed .Just wanted to follow up with you regarding the incident on the Gardens, notifications and order status for infection control purposes. The DON replied to the email that she had notified the Nurse Practitioner (NP), and the nurses on the floor should have ordered labs on both residents. Review of an email provided by the facility revealed the Infection Preventionist emailed the DON again on 9/5/2022 to report she had not seen any labs related to the incident or a progress note from the NP. The DON replied, I'll look into it. The facility was unable to provide documentation the possible communicable disease transmission was reported to the local health department. During an interview conducted on 11/28/2022 at 2:48 PM, the Infection Preventionist was asked what precautions should be taken for a Resident with Chronic Hepatitis C. The Infection Preventionist stated, Standard Precautions .make sure any blood, if blood is ever drawn, whether it be from lab or an incident, that all precaution and testing is completed, even of staff. The Infection Preventionist was asked if she recalled the incident on August 28th. The Infection Preventionist stated, .I can't recall that one specifically . The Infection Preventionist was asked if she knew if any precautions were completed. The Infection Preventionist stated, .it was not a witnessed incident, there was no explanation as to the source of the injuries, neither party could say what happened .I remember we did discuss assessing hands for breaks in the skin to see if that contact and transferal which there was none .I did not have access to the lab company that we used at that time, but labs were ordered. What all was included I could not tell you off the top of my head .They were supposed to have the same matching lab sets .I want to say [named the former Director of Nursing (DON)] was going to talk to .our Nurse Practitioner, but I can't say for sure .the Nurse Practitioner was supposed to do a follow-up assessment on both residents, post incident assessment and get the orders for the labs . During an interview conducted on 11/28/2022 at 3:45 PM, the Infection Preventionist confirmed no labs to assess for Hepatitis C were collected from Resident #2 following the 8/28/2022 incident. The Infection Preventionist was asked if the DON responded to the email. The Infection Preventionist stated, I didn't see anything, and I should have continued to press her. That's on me. The Infection Preventionist was asked if this incident should have been followed. The Infection Preventionist stated, Absolutely, and the risk of blood being involved. The Infection Preventionist was asked what process should be followed following an exposure to Hepatitis C. The Infection Preventionist stated, We notify our Nurse Practitioner, get the standard lab orders .with his [Resident #1] diagnosis, a hepatitis panel on both residents just to make sure, and just on this incident, I would have asked if she wanted to include RPR [Rapid Plasma [NAME]] .labs as well, anything that could be transmitted via blood especially with the situation being highly suspect, with not having a witness, and having 2 residents that can't tell you what happened . During an interview conducted on 11/29/2022 at 10:01 AM, the Nurse Practitioner (NP) was asked if she recalled the incident on 8/28/2022 involving Resident #1 and #2. The NP stated, I do not remember that .[the nurse] notified Telehealth but didn't notify me . The NP was asked what protocol should be followed when an incident such as this occurred when the resident was Hepatitis C-positive. The NP stated, They should have done a panel for the other resident, should have been taken like as risk management, the whole shebang with blood on the floor, protocol that goes with that .we don't know if there was any contact .protocol as with HIV [Human Immunodeficiency Virus] any blood really .telehealth should have given them those orders as well .even if it's a day I'm off, they're supposed to notify me .if I'm not physically here, they're supposed to notify me .they [the facility] should know that . During a telephone interview conducted on 11/29/2022 at 2:32 PM, CNA #4 was asked to describe the incident between Resident #1 and Resident #2 on 8/28/2022. CNA #4 stated, Coming on shift, they tell us we have to do a walk through .I see [Resident #1] on the floor and the blood on the floor .Right as you come in the room, maybe an inch inside the door .I wasn't sure who's blood but said .He's on the floor .and went and got the nurse and she came and did her assessment. CNA #4 was asked did you see blood on his [Resident #1] face or a scratch or anything. CNA #4 stated, No ma'am, I didn't really know where the blood was coming from. I just knew there was blood on the floor .then [Resident #2] was like in his chair talking about he had to do what he had to do to protect himself .[Resident #2's] wheelchair was facing [Resident #1]. [Resident #2] was knelt forward and he had his hand holding him [Resident #1] down . During a telephone interview conducted on 11/29/2022 at 1:39 PM, the former DON was asked if she recalled the incident on 8/28/2022 involving Resident #1 and #2. The former DON stated, Vaguely, yes . The former DON was asked if labs were collected after that incident. The former DON stated, I don't know. I do know that typically we will call telehealth or the Nurse Practitioner to let them know of an incident .I don't know if telehealth or the NP ordered any labs. The former DON was asked if she was aware Resident #1 was Hepatitis C-positive. The former DON stated, No [adamantly stated] . The former DON was asked what protocol should have been followed considering there was blood on the floor and on both residents, and Resident #1 was Hepatitis C-positive. The former DON stated, Honestly had I known he was Hep [hepatitis] C-positive, even if the physician didn't ask for labs, I would have gotten labs on [named Resident #2]. I would have wanted serial labs .No, I had no idea. The former DON was unable to recall the emails sent by the Infection Preventionist. The former DON was asked if she spoke with the NP regarding this incident. The former DON stated, I'm pretty sure I told her what happened .I typically did, and if we needed anything, I would call [named the NP] or inform her in the morning meeting .if she would have ordered labs, I would have checked with the nurses to see if they were drawn or resulted . During an interview conducted on 11/30/2022 at 9:40 AM, Licensed Practical Nurse (LPN) #6 was asked what protocol should have been followed after the incident on 8/28/2022 involving Resident #1 and Resident #2. LPN #6 stated, Should notify the doctor of the incident and let him know of his [Resident #1] diagnosis, and both of them should have been tested . During an interview conducted on 12/1/2022 at 12:00 PM, the Medical Director was asked if he was notified of the incident that occurred between Resident #1 and #2 on 8/28/2022. The Medical Director stated, No. The Medical Director was asked if a resident had Chronic Hepatitis C, should there be a particular protocol followed by facility staff after possible blood exposure. The Medical Director stated, If it's open wound, yes .check the other resident, labs and screening for other and STD [sexually transmitted diseases]. During an interview conducted on 12/5/2022 at 1:52 PM, the Infection Preventionist was asked what things were reportable to the Health Department. The Infection Preventionist confirmed the potential exposure to Hepatitis C should have been reported to the Health Department. 5. The surveyors verified the Removal Plan through review of root cause analysis, in-services, audits, and conducting staff interviews. Governing Body will educate community leaders, Administrator (Admin) and Director of Nursing, regarding Unmanageable Residents F742 and F743, Lab and Diagnostic Test Results - Clinical Guidelines, and Admission of Residents with Communicable Disease F880. Surveyors verified by review of in-services and interviews. Governing Body/Admin/DON/Staff Development Coordinator (SDC) will educate licensed nurses to Unmanageable Residents F742 and F743, Lab and Diagnostic Test Results - Clinical Guidelines, and Admission of Residents with Communicable Disease F880. Surveyors verified by review of in-services and interviews. DON/SDC/Infection Preventionist (ICP)/Unit Manager (UM) will educate new licensed staff regarding Unmanageable Residents F742 and F743, Lab and Diagnostic Test Results - Clinical Guidelines, and Admission of Residents with Communicable Disease F880. Surveyors verified by interviews. The Interdisciplinary Team will review the 24 Hour Report and resident altercations through the Clinical Startup Process Monday through Friday to assess need for laboratory related to communicable disease and infections. Surveyors verified by interviews. Residents are screened on admission and during change of condition for potential communicable diseases as we follow our policy of Admission of Residents with Communicable Disease F 880, if resident is noted to have flu or COVID, etc. with change of condition, resident is isolated based on necessary precautions and if there is a roommate, roommate is quarantined and tested as indicated until known infection status. Surveyors verified by interviews. Residents with communicable diseases are tracked by The Infection Control Nurse or designee will maintain a log of residents with current evidence of infection or colonization due to multidrug-resistant organisms, including Methicillin-resistant Staphylococcus aureus (MRSA)/Vancomycin-Resistant Enterococci (VRE)/Clostridioides difficile (C. Diff). When considering room assignments the log will be checked to prevent placing a resident with MRSA/VRE/C. Diff infection or colonization with a resident at risk of infection. Surveyors verified by interviews. Residents that have been or could be exposed to a communicable disease will be quarantined and have appropriate testing as indicated. Surveyors verified by interviews. DON/IDON/SDC/UM will assess residents with communicable diseases and infections for potential exposures and appropriate follow up 3 x week for 4 weeks, then 1 x week for 8 weeks. Results of the audits will be submitted to the Quality Assurance Committee for review and recommendations. Surveyors verified by interviews. The facility's noncompliance of F-880 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, review of facility investigations and interview the facility failed to ensure allegations of abuse were reported timely for 2 of 16 (Resident #5 and #13) sampled residents reviewed for abuse. The findings include: 1. Review of the facility's policy titled, Reporting Suspected Cases and/or Incidents of Rape . dated 5/2022, revealed .All suspected cases or incidents of rape musts be reported immediately to the Administrator and Director of Nursing . Review of the facility's policy titled, .Abuse Program: Training, Reporting and Response Covered Individual Responsibilities dated 10/2022, revealed .The facility .will report alleged violations related to mistreatment, exploitation, neglect or abuse including injury of unknown source .to the proper authorities within prescribed time frames .Upon hire and annually, covered individuals will be notified of their obligations to report suspicions of crimes per above .Repeat the training when covered individuals indicate they do not understand their reporting responsibilities .Examples of crimes that should be reported immediately to the Administrator .Rape .Assault and battery .Sexual abuse . 2. Review of the medical record, revealed Resident #5 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease, Dementia, Diabetes, Osteoarthritis, Psychosis, and Anxiety. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment and required extensive assistance for activities of daily living (ADLs). Review of the Progress Note dated 8/20/2022 at 8:05 AM, revealed .notified by nurse: 'resident complains of pain in L shoulder .Will get STAT [urgent] xray of L [left] shoulder. If abnormal pt [patient] will need FTF [Face to face]. Review of the Nursing Note dated 8/20/2022 at 8:21 AM, revealed This nurse was called to residents room by CNA [Certified Nursing Assistant #1] asking me to assess resident arm d/t [due to] complaints of pain. Upon entering room, this nurse observed resident lying in bed with L arm cradled to side of body. Resident stated her arm was 'hurting real bad' when asked where she was hurting resident stated her shoulder while guarding her L arm. Limited ROM [Range of motion] noted. When this nurse asked resident what happened she stated there was 'a girl that worked with them (referring to the CNA at bedside) that was real rough and yanking' on her. This nurse notified unit manager on duty, DON [Director of Nursing] and telehealth contacted at this time. Orders given to STAT x-ray L shoulder and notify telehealth with results. Review of the Nursing Note dated 8/20/2022 at 9:12 PM revealed X ray result indicates left shoulder humeral fracture . During an interview conducted on 12/5/2022 at 4:15 PM, CNA #1 was asked about Resident #5 incident. CNA #1 stated, I went in to dry [named Resident #5] .she said 'oh' I asked her what's wrong. [Named Resident #5] said 'I'm hurting, my arm .that girl beat the [expletive] out of me' I ran out of the room for the nurse. I got [named LPN #1] .she told him the same thing .He said for me to go on home he would handle it. The next morning when I came in and I had the same section .[named Resident #5] said her arm still hurt. I ran got .[named LPN #2] .[Named LPN #2] pulled the cover back and she said, 'I think her arm is broke' . During an interview on 12/6/2022 at 10:15 AM, LPN #2 was asked about the incident with Resident #5. LPN #2 confirmed CNA #1 reported Resident #5's arm pain on 8/20/2022 at about 7:30 AM. LPN #2 was asked if Resident #5 told her what happened to her arm. LPN #2 stated, [Named Resident #5] told me the 'big white, fat, [expletive] shook' her. I wasn't here the day before . 3. Review of the medical record revealed, Resident #13 was admitted on [DATE] with diagnoses of Dementia, Cognitive Communication Deficit, Hypertension and Chronic Kidney Disease. Review of the quarterly MDS dated [DATE], revealed a BIMS score of 9, indicating moderate cognitive impairment, limited assistance was provided by staff with transfers, mobility on the unit, and dressing, and extensive assistance was provided by staff with mobility off the unit. Review of the Care Plan dated 3/12/2021, revealed .impaired cognitive function/impaired thought processes r/t [related to] BIMS score in moderately impaired range and diagnosis of unspecified dementia and age-related cognitive decline. She has difficulty with memory recall and periods of confusion and throughout the day. HX [History]: periods of confusion with increased anxiety [.] Hx of making statements about being raped and someone getting her drunk with liquor .11/30/2022 psych [psychiatric] eval .12/01/22 Medication review with medication adjustment . Review of the Nurses Note dated 11/28/2022 at 1:58 AM, revealed Resident was confused, anxious, and wandering the 105 hallway at approx [approximately] 7:15 pm. She stated, 'somebody got me drunk and put me in a room, they tried to rape me and all of them went back to my house, they keep filling me up with liquor, and I had to douche 3 times afterwards'. Resident became nauseous. She spit up x [times] 2 a scant amount of clear fluid. She stated that she felt no pain at this time. She did mention that she was afraid but could not mention what she was afraid of .Resident took her medication and went to bed at approx. 8:00 pm with no further occurrences. No complications noted at this time. Will continue to monitor for any changes. Review of a Nurses Note dated 11/30/2022 at 1:59 PM, revealed This nurse at 1135am [11:35 AM] along with 100 hall charge nurse and nurse manager completed a head-to-toe skin assessment on resident at this time. Skin pink/pale, warm/dry with no bruising, redness or s/s [signs and symptoms] of trauma witnessed to peri area, trunk or ext [extremities] x 4. No c/o [complaints of] pain or discomfort voiced, witnessed or reported. Skin intact with numerous moles, random sizes over complete body. As placing clothing back in place with assist the res [resident] asked, 'Did I do something wrong, is there something wrong with me?' This nurse voiced to res that we do complete head to toe skin assessments on everyone weekly to make sure nothing we can't see ourselves gets missed. This nurse then asked res if anything was wrong or had happened recently, she would like to talk about. Res voiced 'everything has been okay of course except [AGE] years ago when I was at the hospital, you know for the surgery when they took part of my brain for the surgery when they raped me.' This nurse then asked if she had any sexual trauma since then and res voiced 'no that was a long time ago when they raped me at the hospital, I guess they call it that because that's the only bad thing that happens to women is rape, isn't it?' . Review of a facility investigation initiated 11/30/2022, revealed .On 11/30/2022 around 11:50 am [AM] [named Regional Nurse Consultant] was reviewing resident charts and saw the above note on [named Resident #13] written by [named Licensed Practical Nurse (LPN) #7] on 11/28/22 .[Named Regional [NAME] President (RVP)] contacted [LPN #7] who confirmed her nursing note. Then [named RVP] gave [named LPN #7] a 1:1 [one on one] in-service on identifying and reporting abuse . On 11/30/2022 at 12:00 PM, the Administrator notified surveyors of an allegation of abuse on 11/28/2022 that was discovered during a chart review. The Administrator confirmed staff did not report the incident when it occurred. During a telephone interview conducted on 12/6/2022 at 2:39 PM, LPN #7 confirmed she wrote the nurses note regarding the allegation of sexual abuse by Resident #13 on 11/28/2022. LPN #7 was asked what was her mental and behavioral status prior to the allegation. LPN #7 stated, She was confused. I had worked with her before and she appeared to be at her baseline .I was reading her chart and assumed she had behaviors in the past and so she was having a behavior. Like delusions. I knew she had not been out of the building so nobody took her to her house . LPN #7 was asked did you report the behavior to anyone. LPN #7 stated, Yes, I told my relief that she was having some behaviors earlier but that she [was better]. I gave report on her in shift report. LPN #7 was asked did you write it on a 24 hour report book. LPN #7 stated, I don't know if they had one .I was contract and it was the end of my contract . LPN #7 was asked were you in-serviced on abuse when you were hired. LPN #7 stated, I did an in-service on abuse on [named computer training program]. LPN #7 was asked were you in-serviced on abuse following this incident. LPN #7 stated, They called me .I was just contract and my contract has ended, it was just a 6 week assignment. LPN #7 confirmed she is no longer working at the facility. Review of LPN #7's employee file revealed she signed a 6 week contract on 10/6/2022 and her last day worked was 11/28/2022. During an interview on 12/7/2022 at 9:20 AM, the MDS Coordinator confirmed that allegations of abuse should be reported to administration immediately. During an interview on 12/7/2022 at 4:56 PM, LPN #8 confirmed she relieved LPN #7 on 11/29/2022 and LPN #7 did not report Resident #13's allegation of being gotten drunk and raped when giving report to her on 11/29/2022. During an interview on 12/8/2022 at 9:36 AM, the Administrator was asked did you do any in-services on reporting abuse following the incident. The Administrator stated, We did a 1:1 with the nurse . The Administrator confirmed no other staff in-services on reporting abuse were given related to the allegation by Resident #13.

Based on policy review, medical record review, review of facility investigations, and interview, the facility failed to complete thorough investigations of abuse for 4 of 16 (Residents #1, #4, #12 and #13) sampled residents reviewed for abuse. The findings include: 1. Review of the facility's policy titled .Abuse Prevention Program, Investigation ., dated 8/2022, revealed .Reports of resident abuse, neglect and injuries of unknown sources shall be promptly and thoroughly investigated by facility management .The individual conducting the investigation will, as a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witness to the incident; e. Interview the resident (as medically appropriate); f. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; g. interview the resident's roommate, family members and visitors as able or as appropriate to the situation; h. Review all events leading up to the alleged incident .Witness reports will be obtained in writing. Witnesses will required to sign and date such reports .Post validated allegations of abuse, the QA [Quality Assurance] team should evaluate the following: a. Changes that may need to be made to prevent further occurrences; b. Defining how care will be changed or improved to protect residents; c. Immediate and ongoing training needs and staff competency as needed . 2. Review of the medical record, revealed Resident #1 admitted to the facility on [DATE] with diagnoses of Schizophrenia, Dementia with Behavioral Disturbance/Psychotic Disturbance, Chronic Kidney Disease, Hypertension, and Chronic Hepatitis C. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment, and exhibited wandering behaviors daily. Review of the Nursing Note dated 9/7/2022 at 8:42 PM, revealed .Writer [Licensed Practical Nurse (LPN #3) standing at med cart passing medication when writer observed res [Resident #1] walking up behind res .[Resident #4]. Res [Resident #1] struck res [Resident #4] .in the rear right side of his neck with a closed fist. Writer immediately jumped in between the residents and redirected res [Resident #1] .away from res [Resident #4] .Writer walked down to his room and put cna [Certified Nursing Assistant (CNA)] as one on one with res [Resident #1]. Writer went back and assessed resident [Resident #4] .no obvious signs of injury and made no faces of pain or any complaints . 3. Review of the medical record, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Dementia with Behavioral Disturbance, Hypertension, and Protein-Calorie Malnutrition. Review of the quarterly MDS dated [DATE], revealed Resident #4 had a BIMS of 99, which indicated severe cognitive impairment, with physical behavioral symptoms toward others on 1-3 days and rejection of care behaviors on 4-6 days of the 7-day lookback period, and daily wandering behaviors. Review of the facility's investigation dated 9/7/2022, revealed there were no witness statements obtained for the resident to resident altercation that occurred between Resident #1 and #4. During an interview conducted on 12/12/2022 at 10:34 AM, the Interim Administrator presented the facility's investigation on the resident to resident altercation that occurred between Resident #1 and #2 on 9/7/2022, and stated, I've asked staff to recreate their statements .anybody who was here .his [Resident #1's altercations] stuff was altogether, they were overlapping .so I pulled it out and this is all I've been able to create . The Interim Administrator confirmed there were no witness statements in the facility's investigation, and according to the facility's Abuse policy, witness statements should be obtained following a resident to resident altercation. 3. Review of the medical record, revealed Resident #12 was admitted on [DATE] with diagnoses of Hemiplegia, Cerebrovascular Disease, Diabetes, Depression, and Hypertension. Review of the quarterly MDS dated [DATE], revealed a BIMS of 15, indicating intact cognition. Review of the Care Plan dated 2/18/22, revealed .10/22/2022 refusing showers .has behavior of making false accusations against staff and other residents Examples-forgetting about smoking and ADL care .Hx [History] verbally abusing others at smoke break .Hx refusing care . Review of the facility investigation dated 9/1/2022, revealed .[named Resident #12] .stated that she used her call light a number of times then the CNA [named CNA #7] told her that they were not going to play those games with her tonight .took her glasses off and didn't give them back .asked cna [CNA] to tell nurse that she wanted her medicine, the cna [CNA] exclaimed that 'you ain't the queen of Sheba and she'll get to you when she can' .moved the call light out of her reach . The investigation included statements from 3 day shift and 2 night shift staff, Resident #12, and 7 other residents. The investigation did not include statements from CNA #7, LPN #9 (the nurse working the evening of 8/31/2022), or the Scheduler (who was suspended for the incident). During an interview on 12/7/2022 at 4:14 PM, the former DON confirmed Resident #12 reported the allegation of abuse to her. The former DON stated, I questioned the CNA [CNA #7], she was suspended for 3 days and we had a heart to heart about customer service and how you talk to residents .The nurse did not report it to me. She [the Scheduler] was also suspended . The former DON was asked did you get statements from the CNA (CNA #7) and the nurse (the Scheduler). The former DON stated, I believe so .[named Social Services Assistant (SSA)] usually in charge of getting the statements together. The CNA stated she did .tell her that we have other patients but she denied taking her call light away and taking her glasses away. The nurse was suspended for 1 shift and the CNA was suspended for 3. The former DON was asked was the incident taken to QAPI [Quality Assurance Performance Improvement]. The former DON stated, No ma'am . LPN #9 was actually the nurse who worked the night of the incident, the Scheduler, who did not work that night was suspended, and the DON never acknowledged that she talked to LPN #9 about the incident. During a telephone interview conducted on 12/07/2022 at 9:20 PM, CNA #7 was asked to recall the incident with Resident #12. CNA #7 stated, .I had already put her to bed and set her up the way she likes. She likes everything a certain way. I was in another resident's room and went out to get something and her [Resident #12] light was on again. I went in and turned off the light and told her 'I am helping someone else right now. I will come back. I have other people who want to be put to bed too. CNA #7 was asked did you take her call light away. CNA #7 stated No. I put her glasses, her call light, all her stuff right where she likes it .I took care of her the rest of the night and we didn't have any problems. CNA #7 confirmed she was suspended pending the investigation but was allowed to return to work and is no longer assigned to Resident #12. CNA #7 confirmed LPN #9 was the nurse working the night of the incident. During an interview on 12/8/2022 at 8:39 AM, the SSA was asked who gets witness statements following an incident or allegation of abuse. The SSA stated, If they [the Administrator and DON] don't get them, I get them. The SSA was asked how do you know who to get statements from. The SSA stated, Normally we get statements from people who have an 8 BIMS or above, and get statements from staff who worked the day before and the day of, on that hall . The SSA was asked do you get statements from Nurses. The SSA stated, They usually do theirs on an incident report .If they witness it they do [write a statement], but usually it's on the incident report. I usually get statements from whoever [named former Administrator] tell me to . The SSA was asked did you get statements on the incident related to (Resident #12) and (CNA #7). The SSA stated, The only thing I got was the resident's statements and the CNAs that were here. She [CNA #7] was on vacation. [Named former Administrator] got her statement. The SSA was asked did the former Administrator get a statement from the nurse also. The SSA stated, I'm not sure . During an interview on 12/8/2022 at 12:39 PM, the former Administrator was asked what is the process for a staff-to-resident abuse allegation. The former Administrator stated, .if we have a staff-to-resident we had to make sure the resident was safe .we had to identify that person and make sure the resident and other residents are safe .get them [staff] out of the building. Interviewing people that worked in the last 24 hours. Interviewed residents on that assignment to see if anyone else had anything happen . The former Administrator was asked who did you get statements from. The former Administrator stated, Anyone who worked around that person, anyone that worked that unit, the shift before . The former Administrator was asked do you recall an incident involving Resident #12 and a CNA. The former Administrator stated, Yes . The former Administrator was asked who interviewed the CNA. The former Administrator stated, . I would need the folder to see if I did it or if [named SSA] did it. She [CNA #7] was like 'I didn't mean anything by that' . The former Administrator was asked did you interview the Nurse. The former Administrator stated, [Named the Scheduler] knew that [named Resident #12] was offended by what [named CNA #7] said .when I got those details, they both had to be suspended . The former Administrator was asked did you get a statement from the nurse. The Administrator stated, I know I didn't talk to [named the Scheduler]. Usually if it's a nurse that needs to be talked to, its by her supervisor. To interview it could have been [named the SSA] or the [former] DON, for disciplinary action it would have been the [former] DON. The former Administrator was asked did you have an Ad Hoc [impromptu] QAPI meeting related to this. The former Administrator stated, I'm sure not .I believe with [CNA #7] we thought it was isolated . The former Administrator confirmed the witness statements and investigation documents were kept in a red folder usually initiated by nursing and completed by the SSA. The former Administrator was asked what kind of training did (the SSA) have to do these red folders. The former Administrator stated, I sat down with her and went through . The former Administrator was asked who was responsible for making sure the investigation was complete. The former Administrator stated, She [the SSA] would do the folder and I would review. She, [the former DON], and I would review it. But essentially she [the SSA] would do it and I would review it and put it in the file cabinet . During a telephone interview on 12/12/2022 at 2:04 PM, LPN #9 was asked if she recalled the incident between Resident #12 and CNA #7. LPN #9 stated, I was standing in the hallway right outside the door when the CNA walked in. The CNA did not take away her call light. I was getting her meds [medications] ready and I went in right after the CNA left. She did not take her call light away, she had it in the bed with her. The CNA was in the room answering her call light and told the resident [Resident #12] she was assisting another resident and would be back. LPN #9 was asked if she wrote a statement about the incident. LPN #9 stated, No, they never even contacted me. I heard they had another nurse [named the Scheduler] on suspension. I don't know why they suspended her, it was only for 1 day, but she wasn't even in the building. LPN #9 denied hearing the CNA make any derogatory comments to Resident #12. LPN #9 stated, She [Resident #12] is the type that gets mad if you don't do exactly what you want her to do. She told me she was going to get her [CNA #7] fired . During an interview on 12/12/2022 at 2:19 PM, the Interim Administrator confirmed there was no statement from or documentation in the red folder related to the Nurse who took care of Resident #12 on 8/31/2022. During an interview on 12/12/2022 at 2:39 PM, the Interim Administrator entered the conference room and stated I'm finishing the investigation on [Resident #12]. They didn't get anybody's statements that were directly related to the incident. During an interview on 12/12/2022 at 3:24 PM, the Scheduler confirmed she was suspended for 1 shift related to the incident related to Resident #12 and CNA #7. The Scheduler stated, [Named former DON] .called me, left a message on my phone, and told me they had to suspend me for a day because I didn't report an allegation by [Resident #12] .I told them I did my own investigation and told them it was [named LPN #9] and the [former] Administrator stated 'We had to show that we did something so we suspended you'. The scheduler was asked were you asked to write a statement. The scheduler stated, No ma'am. During an interview on 12/12/2022 at 3:48 PM, the Interim Administrator confirmed the investigation on Resident #12 should have been completed when the incident happened. Review of the medical record, revealed, Resident #13 was admitted on [DATE] with diagnoses of Dementia, Cognitive Communication Deficit, Hypertension and Chronic Kidney Disease. Review of the quarterly MDS dated , 10/7/2022, revealed a BIMS score of 9, indicating moderate cognitive impairment, limited assistance was provided by staff with transfers, mobility on the unit, and dressing, and extensive assistance was provided by staff with mobility off the unit. Review of the Care Plan dated 3/12/2021, revealed .impaired cognitive function/impaired thought processes r/t [related to] BIMS score in moderately impaired range and diagnosis of unspecified dementia and age-related cognitive decline. She has difficulty with memory recall and periods of confusion and throughout the day. HX [History]: periods of confusion with increased anxiety [.] Hx of making statements about being raped and someone getting her drunk with liquor .11/30/2022 psych eval .12/01/22 Medication review with medication adjustment . Review of a Nurses Note dated 11/28/2022 at 1:58 AM, revealed Resident was confused, anxious, and wandering the 105 hallway at approx [approximately] 7:15 pm. She stated, somebody got me drunk and put me in a room, they tried to rape me and all of them went back to my house, they keep filling me up with liquor, and I had to douche 3 times afterwards. Resident became nauseous. She spit up x [times] 2 a scant amount of clear fluid. She stated that she felt no pain at this time. She did mention that she was afraid but could not mention what she was afraid of .Resident took her medication and went to bed at approx. 8:00 pm with no further occurrences. No complications noted at this time. Will continue to monitor for any changes. Review of a Nurses Note dated 11/30/2022 at 1:59 PM, revealed This nurse at 1135am [11:35 AM] along with 100 hall charge nurse and nurse manager completed a head-to-toe skin assessment on resident at this time. Skin pink/pale, warm/dry with no bruising, redness or s/s [signs and symptoms] of trauma witnessed to peri area, trunk or ext [extremities] x 4. No c/o pain or discomfort voiced, witnessed or reported. Skin intact with numerous moles, random sizes over complete body. As placing clothing back in place with assist the res [resident] asked, Did I do something wrong, is there something wrong with me? This nurse voiced to res that we do complete head to toe skin assessments on everyone weekly to make sure nothing we can't see ourselves gets missed. This nurse then asked res if anything was wrong or had happened recently, she would like to talk about. Res voiced everything has been okay of course except [AGE] years ago when I was at the hospital, you know for the surgery when they took part of my brain for the surgery when they raped me. This nurse then asked if she had any sexual trauma since then and res voiced no that was a long time ago when they raped me at the hospital, I guess they call it that because that's the only bad thing that happens to women is rape, isn't it . Review of a facility investigation initiated 11/30/2022, revealed .On 11/30/2022 around 11:50 am [AM] [named Regional Nurse Consultant] was reviewing resident charts and saw the above note on [named Resident #13] written by [named Licensed Practical Nurse (LPN) #7] on 11/28/22 .[Named Regional [NAME] President (RVP)] contacted [LPN #7] who confirmed her nursing note. Then [named RVP] gave [named LPN #7] a 1:1 [one on one] in-service on identifying and reporting abuse . The investigation included statements from the Interim Administrator, the RVP, the Social Services Director, the Activities Director and the Nurses who assessed Resident #13 on 11/30/2022. Review of the statement given by the RVP dated 11/30/2022 revealed I .spoke with [named LPN #7] .She was caring for [named Resident #13] on 11/28/2022, and she reported that she was rapped [raped] and that they give her a lot of alcohol. [Named LPN #7] said she seemed confused, but she was in her room and was safe. Other than the interview included in the RVP's statement, no statements from staff who worked on 11/28/2022 or other residents were included in the investigation. During an interview on 12/5/2022 at 2:46 PM, the Administrator was asking if there was any additional paperwork related to the investigation of Resident #13's allegation. The Administrator stated, I believe that's everything. During an interview on 12/5/2022 at 4:02 PM, the Social Services Director (SSD) was asked who notified you of the allegation involving Resident #13. The SSD stated, The Administrator. The SSD confirmed she attempted to interview Resident #13 on 11/30/2022 when she was notified of the incident. The SSD was asked did you interview the roommate and ask her if anything had happened. The SSD stated, No, we didn't interview the roommate. The SSD was asked did you interview any other residents. The SSD stated, No. The SSD was asked do you usually interview other residents as part of an investigation. The SSD stated, We do. The SSD was asked, do you know why no other residents were interviewed this time. The SSD stated, I don't. During a telephone interview conducted on 12/6/2022 at 2:39 PM, LPN #7 confirmed she wrote the nurses note regarding the allegation of sexual abuse by Resident #13 on 11/28/2022. LPN #7 was asked what her mental and behavioral status was prior to the allegation. LPN #7 stated, She was confused. I had worked with her before, and she appeared to be at her baseline .I was reading her chart and assumed she had behaviors in the past and so she was having a behavior. Like delusions. I knew she had not been out of the building so nobody took her to her house . LPN #7 was asked did you report the behavior to anyone. LPN #7 stated, Yes, I told my relief that she was having some behaviors earlier but that she [was better]. I gave report on her in shift report. LPN #7 was asked did you write it on a 24 hour report book. LPN #7 stated, I don't know if they had one .I was contract, and it was the end of my contract . LPN #7 was asked were you in-serviced on abuse when you were hired. LPN #7 stated, I did an in service on abuse on [named computer training program]. LPN #7 was asked were you in-serviced on abuse following this incident. LPN #7 stated, They called me .I was just contract and my contract has ended, it was just a 6 week assignment. LPN #7 confirmed she is no longer working at the facility. During an interview on 12/8/2022 at 9:36 AM, the Interim Administrator was asked do you usually get statements from staff and residents during an abuse allegation. The Interim Administrator stated, Yes. The Interim Administrator was asked did you get statements from residents related to this allegation (Resident #13). The Interim Administrator stated, I didn't feel like we needed them with the information we had. The Interim Administrator was asked did you do any in-services related to not reporting the incident. The Interim Administrator stated, We did a 1:1 with the nurse . On 12/12/2022 at 10:43 AM, the Administrator brought a folder into the conference room and stated Here is the [named Resident #13] folder .we did additional interviews. Review of the folder revealed 10 residents were interviewed on 12/9/2022 including Resident #13's roommate. During an interview on 12/13/2022 at 12:43 PM the Interim Administrator was asked what a thorough investigation included. The Interim Administrator stated, So, when its reported to me we want to make sure everybody was safe, then I ask them to get statements, they call the family, call the doctor .then I come in , I send in a report to the state and I go ahead and print the face sheet, get the BIMS, get the care plans, they always do pain assessments, skin assessments .look at labs, try to go down every avenue as to how the incident can occur. Call the police and get a case number. Sometimes I call the ombudsman, I haven't done that as much here .interview residents if there are interviewable residents .come together as a team .If there is a possibility of a fracture you want to make sure that is addressed timely. Then if we need to, we will do an ad hoc meeting and we take any of it and all of it to QAPI. Then I do the summary and send that to state . The Interim Administrator was asked do you feel like the investigations completed by the former Administration were completely and thoroughly investigated. The Interim Administrator stated, No, I don't. The Interim Administrator was asked who would you get statements from. The Interim Administrator stated, Certainly anyone who was directly related to the incident, and I try to get statements from the day before . The Interim Administrator was asked who is ultimately responsible for making sure allegations are investigated thoroughly and timely. The Interim Administrator stated, The Administrator. In my findings, she [the former Administrator] passed it off to other people, but I just don't see that as good practice. Ultimately the buck stops with me.

Based on the Centers for Disease Control and Prevention (CDC) guidelines, policy review, review of Employee Screening logs and employee time sheets, observation, and interview, the facility failed to ensure practices to maintain the spread of infection were maintained when 14 of 47 staff (Certified Nursing Assistant (CNA) #1, #2, #3, and #4, Licensed Practical Nurse (LPN) #1, #2, and #3, Housekeeper #1, #2, and #3 and Dietary Aide #1, #2, #3 and #4) failed to complete screening for the prevention and detection of COVID-19 prior to working on 2 of 2 days (5/25/2022 and 5/28/2022) reviewed and when 1 of 4 nurses (LPN #7) failed to properly clean and store enteral feeding syringes after use for 2 of 2 sampled residents (Resident #65 and #75) observed. This had the potential to affect the 90 residents residing in the facility. The findings include: Review of the CDC document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 2/2/2022, revealed .Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic .Establish a process to identify anyone entering the facility, regardless of their vaccination status .options could include (but are not limited to) : individual screening on arrival at the facility . Review of the facility's policy titled, E-007 Emergency Plan: COVID -19 Screening, Staff and Visitors, revised 1/2022, revealed .Staff will be screened at the point of entry into the community .Employees and visitors will be screened for signs and symptoms of COVID-19 and denied entry if they exhibit any signs and symptoms . Review of the facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 7/2020, revealed .Reusable Items are cleaned and disinfected or sterilized between residents . Review of the Employee Screening logs and employee time sheets revealed the following employees worked on the following days and failed to screen for signs and symptoms of COVID-19: a. 5/25/2022-CNA #1, #2, #3 and #4, LPN #1 and #2, Housekeeper #1, #2, and #3 and Dietary Aide #1, #2 and #3. b. 5/28/2022-CNA #4, LPN #3, and Dietary Aide #4. During an interview on 6/9/2022 at 10:13 AM, the Interim Director of Nursing (DON) confirmed staff should screen on arrival to work. The Interim DON stated, .Staff and Visitors .everyone who comes in the door should be screened . During an interview on 6/9/2022 at 12:23 PM, the Staff Development Coordinator/Infection Preventionist Nurse confirmed she was unable to locate COVID -19 screenings for CNA #1, #2, #3 and #4, LPN #1 and #2, Housekeeper #1, #2, and #3 and Dietary Aide #1, #2 and #3 on 5/25/2022 and for CNA #4, LPN #3, and Dietary Aide #4 on 5/28/2022. Observation in the resident's room on 6/8/2022 at 9:30 AM, revealed LPN #7 removed an enteral feeding syringe from a plastic bag, checked placement of an enteral feeding tube, and used the enteral feeding syringe to administer medications to Resident #65 through an enteral feeding tube. LPN #7 entered the bathroom, removed the enteral feeding syringe plunger from the barrel, rinsed the plunger and barrel with water, and used a paper towel to wipe off the plunger and the outside of the barrel. LPN #7 then returned the plunger into the barrel and placed the enteral feeding syringe in the plastic bag and placed the plastic bag on the enteral feeding pole at Resident #65's bedside. LPN #7 failed to completely dry the plunger and barrel before reconnecting them and storing the enteral feeding syringe in the plastic bag. Observation in the resident's room on 6/8/2022 at 4:40 PM, revealed during medication administration LPN #7 removed an enteral feeding syringe from a plastic bag on the bedside table, checked placement of an enteral feeding tube, and used the enteral feeding syringe to administer medications to Resident #75. LPN #7 entered the bathroom, removed the enteral feeding syringe plunger from the barrel, rinsed the plunger and barrel, placed them back in the plastic bag, and returned the plastic bag to Resident #75's bedside table. LPN #7 failed to completely dry the plunger and barrel before reconnecting them and storing the enteral feeding syringe in the plastic bag. During an interview on 6/9/2022 at 11:04 AM, LPN #7 was asked how she should have let the plunger dry before placing it back in the plastic bag. LPN #7 stated, .got to air dry .

Based on policy review, medical record review, observation, and interview, the facility failed to notify the Physician and patient representative for an allegation of abuse for 1 of 7 sampled residents (Resident #11) reviewed for abuse and the facility failed to notify patient representatives of changes in pressure ulcer status for 2 of 3 sampled residents (Resident #36 and Resident #388) reviewed for pressure ulcers/injuries. The findings include: Review of the facility's policy titled, Reporting of Abuse Allegations, revised 11/2017, revealed .All suspected violations and all substantiated incidents of abuse .Should a suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse (including resident to resident abuse .) be reported, the facility Administrator, or his/her designee, will promptly notify the following persons (verbally or written) of such incident .The State Licensing/recertification agency .The resident's Attending Physician .The facility Medical Director . Review of the facility's policy titled, Change in a Resident's Condition or Status, revised 11/2017, revealed .The facility staff shall promptly notify the resident, his or her Attending Physician, and resident representative of changes in the resident's medical/mental condition and/or status .A representative of the community will notify the resident, and the resident representative when .There is a change in the resident's level of care status . Review of the facility's policy titled, Guidelines for Notifying Physicians of Clinical Problems, revised 4/2007, revealed .medical care problems are communicated to the medical staff in a timely, efficient, and effective manner . Review of the medical record, revealed Resident #11 was admitted on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated he was moderately cognitively impaired. Review of the Progress Note dated 5/25/2022, revealed .Resident [#32] heard yelling out random people names .When this nurse asked if resident needed anything or any help .resident [#32] began yelling and cursing .Resident [#32] continued to be agitated and began to argue with roommate [Resident #11] .yelling at roommate .Roommate immediately removed from room .DON [Director of Nursing] notified of situation .NP [Nurse Practitioner] to be notified . The facility's investigation of the allegation of resident-to-resident abuse did not include notification of Resident #11's family or Physician. During an interview on 6/7/2022 at 10:02 AM, the Social Services Director confirmed that the Physician and the family should be notified where there is a resident-to-resident altercation. The Social Services Director confirmed she did not notify Resident #11's family or Physician of the resident-to-resident altercation. During an interview on 6/8/2022 at 5:09 PM, the Unit Manager and Licensed Practical Nurse (LPN) #4 confirmed that Resident #11's Physician and family should have been notified. During an interview on 6/9/2022 at 11:52 AM, the Nurse Practitioner (NP) confirmed the staff did not notify her of the resident-to-resident incident. Review of the medical record, revealed Resident #36 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE] and the quarterly MDS dated [DATE], revealed Resident #36 had a BIMS score of 8, which indicated the resident was severely cognitively impaired and had 1 unstageable pressure ulcer. Review of the facility's Weekly Pressure Injury sheet dated 4/21/2022, revealed .1.1x1.8x0.6 .unstageable .improving . Review of the facility's Weekly Pressure Injury sheets dated 4/25/2022, revealed the pressure injury was now a Stage 4 and was improving. There was no documentation that the patient representative was notified of the wound status. Review of the facility's Weekly Pressure Injury sheet dated 5/16/2022, revealed .5/16/2022 .0.3x0.4x0.3 .stage 4 .improving .Notified Family .3/28/2022 . Review of the facility's Weekly Pressure Injury sheet dated 5/31/2022, revealed .5/31/2022 .0.4x0.7x0.7 .stage 4 .declined .Notified Family .3/28/2022 . There was no documentation that the patient representative was notified of the wound status. Observation in the resident's room on 6/8/2022 at 3:12 PM, revealed the Treatment Nurse removed the dressing to the Resident #36's left heel and revealed an open wound. During an interview on 6/8/2022 at 3:34 PM, the Treatment Nurse confirmed that patient representatives should be notified when there is a change in a resident's wound condition and when the Physician changes the treatment orders. The Treatment Nurse confirmed the family should have been notified when Resident #36's wound had a change in status on 4/25/2022 and 5/31/2022. The Treatment Nurse confirmed that she was behind on her documentation and that all families were notified and given wound updates on 5/25/2022. Review of the medical record, revealed Resident #388 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed Resident #388 had a BIMS of 14, indicating the resident was cognitively intact and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Weekly Pressure Injury Sheet dated 1/24/2022, revealed the following: a.L Heel .Previous Measure .4.0 x 3.0 x 0.1 .Current Measure 4.1 x 6.4 x 0.1 .100% Eschar .Declined .Notified Family .1/11/2022 . b.R Heel .Previous Measure .3.9 x 3.6 x 0.1 .Current Measure .6.8 x 7.6 x 0.1 .100 % Eschar .Declined .Notified Family .1/11/2022 . c.L Out (Outer) Mid Foot .Previous Measure .2.6 x 1.9 x 0.1 .Current Measure .6.8 x 2.0 x 0.1 .100% Eschar .Declined .Notified Family .1/11/2022 . d. L Foot Great Toe .Previous Measure .4.4 x 2.4 x 1.3 .Current Measure .4.4 x 2.7 x 2.2 .80% Slough 20% Gra [Granulation] .Declined .Notified Family 1/11/2022 . There was no documentation the family was notified of the decline in status of the pressure injuries on 1/24/2022. During an interview on 6/8/2022 at 1:30 PM, the Interim Director of Nursing (DON) was asked when a patient representative should be informed of a resident's wound status. The Interim DON stated, .well what I expect them to do is let them [representative] know when they [pressure injuries] are found and when they heal . During an interview on 6/8/2022 at 3:42 PM, the Treatment Nurse was asked should the patient representative be notified of any changes in the wound and/or treatments. The Treatment Nurse stated, Yes, they should .

Based on policy review, facility investigation review, medical record review, and interview, the facility failed to timely and thoroughly investigate an incident of resident-to-resident abuse for 2 of 7 sampled residents (Resident #11 and #32) reviewed for abuse. The findings include: Review of the facility's policy titled, Abuse Investigations, revised 11/2017, revealed .Reports of resident abuse .shall be promptly and thoroughly investigated by facility management .The individual conducting the investigation will, as a minimum .Review the completed documented forms .Interview any witnesses to the incident .Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .Interview the resident's roommate .Witness reports will be obtained in writing . Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 10, indicating he was moderately impaired. Review of the medical record, revealed Resident #32 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS dated [DATE], revealed Resident #32 had BIMS of 11, indicating he was moderately impaired and had wandering behaviors. Review of the Progress Note dated 5/25/2022, revealed .Resident [#32] heard yelling out random people names .When this nurse asked if resident needed anything or any help .resident [#32] began yelling and cursing .Resident [#32] continued to be agitated and began to argue with roommate [Resident #11] .yelling at roommate .Roommate immediately removed from room .DON [Director of Nursing] notified of situation .NP [Nurse Practitioner] to be notified . The facility's investigation of the allegation of resident-to-resident abuse by Resident #32 did not include a completed Incident Report, interviews from residents, and interviews/statements from all staff members working on the morning of the incident. The Investigation did not include 1 on 1 monitoring of Resident #32 (the aggressor). During a telephone interview on 6/8/2022 at 9:41 AM, Licensed Practical Nurse (LPN) #5 confirmed she did not complete an Incident Report, did not complete a witness statement, and did not have all staff members on that shift complete a witness statement. During an interview on 6/8/2022 at 10:40 AM, the Interim Director of Nursing (DON) confirmed there was no documentation of 1 on 1 observation of Resident #32 and no written witness statements from staff members. During an interview on 6/8/2022 at 11:03 AM, the Administrator confirmed the facility did not complete a thorough investigation of the resident-to-resident altercation. The Administrator confirmed there was no Incident Report completed, no witness statements completed, and no documentation of 1 on 1 monitoring for Resident #32. During an interview on 6/8/2022 at 5:09 PM, the Unit Manager was asked what the process was for a resident-to-resident incident. The Unit manager stated .we complete an Incident Report .document what happened .what was done .and who you notified .if there is a witnesses .have all staff on the unit write a witness statement .separate the resident .the aggressor is placed on 1 on 1 observation .document the 1 on 1 observations on the safety check log .

Based on policy review, medical record review, and interview, the facility failed to develop a comprehensive Care Plan for Dementia for 2 of 4 sampled residents (Resident #10 and #62) reviewed. The findings include: The facility's policy titled, Care Plans - Comprehensive, revised 11/2017, revealed .And individualized comprehensive person centered care plan that includes measurable objectives and time frames to meet the resident medical, nursing, mental and psychological needs is developed for each resident . Review of the medical record, revealed Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #10 had Non-Alzheimer's Dementia. Review of the Care Plan dated 2/28/2022, revealed there was no comprehensive Care Plan for Dementia. Review of the medical record, revealed Resident #62 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the admission MDS dated [DATE], revealed Resident #62 had a BIMS score of 2, indicating he was severely cognitively impaired and had Non-Alzheimer's Dementia. Review of the Care Plan dated 5/1/2022, revealed there was no comprehensive Care Plan for Dementia. During an interview on 6/8/2022 at 2:39 PM, the Social Services Director confirmed Resident #10 and Resident #62 did not have a comprehensive Care Plan for Dementia.

Based on policy review, medical record review, and interview, the facility failed to ensure the completion of a discharge summary that included a recapitulation of the resident's stay, the disposition status of the resident at the time of discharge, and a post discharge plan of care for 1 of 1 sampled residents (Resident #388) reviewed for discharge. The findings include: Review of the facility's policy titled, Discharge Summary and Plan, revealed .When a resident's discharge is anticipated, a discharge summary and post-discharged plan will be developed .The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of discharge .The recapitulation will include .diagnoses, Course of illness, treatment or therapy, Pertinent lab, radiology and consultation results, reconciliation of all pre-discharge medications with the resident's post discharge medications .a final summary paragraph . Review of the medical record, revealed Resident #388 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Social Services Note dated 1/28/2022, revealed the patient representative was in the facility and informed staff she would be taking resident home on 1/29/2022 at 2:00 PM, transporting the resident in a private vehicle and the resident would be living with her and receiving Hospice and Home Health services. Review of a Transfer Note dated 1/29/2022, revealed .residents family picked up resident at 4:50 PM .in suv (Sport Utility Vehicle) . Review of the medical record, revealed the facility failed to complete a discharge summary to recapitulate the resident's stay at the facility, his disposition, and post discharge plan of care. During an interview on 6/8/2022 at 11:30 AM, the Interim Director of Nursing (DON) was asked who should complete the discharge summary when a resident is discharged home. The Interim DON stated, .Well that is something we just discovered we will need to work on .

Based on policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 4 nurses (Licensed Practical Nurse (LPN) #7) followed policies and procedures for the administration of medication through a Percutaneous Endoscopic Gastrostomy (PEG) tube for 1 of 2 sampled residents (Resident #65) observed and the facility failed to ensure Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the facility's policy titled, Administering Medication Through an Enteral Tube, revised 2/2018, revealed .The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube .Dilute powdered, crushed, or split (capsule) medications at the bedside . Review of the medical record, revealed Resident #65 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] Capsule 500 MG [milligrams] Give 1 capsule via [by way of] PEG-Tube four times a day .for 10 Days . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] Tablet 5 MG .Give 1 tablet .two times a day . Observation at the 300 Hall Medication Cart on 6/8/2022 at 9:30 AM, revealed LPN #7 sanitized her hands, crushed the [MEDICATION(S)] tablet, placed it in a plastic medication cup, then opened the [MEDICATION(S)] capsule and put the granular in a medication cup. LPN #7 entered Resident #65's room, washed her hands, donned clean gloves and began to administer the medication via PEG tube. LPN #7 flushed the PEG tube with 30 milliliters (ml) of water, poured the crushed [MEDICATION(S)] into the peg tube, then flushed the PEG tube with 30 ml of water. LPN #7 poured the [MEDICATION(S)] into the PEG tube, then flushed the PEG tube with 30 ml of water, reconnected the enteral feeding, disposed of the trash, sanitized her hands, and exited the room. LPN #7 did not to dilute each medication with 5-10 ml of water prior to administering the medications through the PEG tube. During an interview on 6/9/2022 at 10:04 AM, the Interim Director of Nursing (DON) was asked if medications should be diluted before they are administered through a PEG tube. The DON stated, Of course .supposed to be with 10 milliliters of water or it will clog the tube . During an interview on 6/9/2022 at 11:04 AM, LPN #7 confirmed she should have diluted both medications before administering them through the PEG tube. Review of the medical record, revealed Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Registered Dietician note dated 4/21/2022, revealed .weight is down 1.4 pounds x [times] 1 week .Last week added magic cup to lunch trays daily. Today recommending MD [Medical Doctor] review for weight loss .requesting full lab work-up to include CMP [Complete Metabolic Panel] .for continued weight decline . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .CBC [Complete Blood Count] [is a set of medical laboratory test that provide information about the cells in a person's blood] .CMP [is a blood sample that measures 14 different substances in your blood] . Review of the medical record, revealed a CBC and CMP were not collected until 5/22/2022. During an interview on 6/9/2022 at 9:24 AM, the Interim Director of Nursing (DON) confirmed the CBC and CMP were not performed until 5/22/2022, and stated, .no excuse lab was not done in April .no excuse .

Based on policy review, medical record review, and interview the facility failed to ensure a resident was free from neglect when Licensed Practical Nurse (LPN) #1 neglected to provide adequate treatment when a resident had a significant decline in his condition for 1 of 4 sampled residents (Resident #1) reviewed for neglect, which resulted in Immediate Jeopardy (IJ) for Resident #1. Certified Nursing Assistant (CNA) #1 and CNA #2 notified LPN #1 of Resident #1's change in condition. LPN #1 did not assess Resident #1, and later Resident #1 was found without respirations and LPN #1 failed to initiate life saving measures (CPR). Resident #1 expired. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The facility had a total of 48 residents that were a Full Code status (residents who would require Cardiopulmonary Resuscitation). The Administrator, Director of Nursing (DON), and the Regional Director of Operations (RDO) were notified of the Immediate Jeopardy on [DATE] at 7:15 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-600. The facility was cited Immediate Jeopardy at F-600 at a scope and severity of J, which is Substandard Quality of Care (SQC). The IJ existed from [DATE] through [DATE]. The facility's corrective action plan, which removed the immediacy of the jeopardy, was received and corrective actions were validated onsite by the surveyors on [DATE] through [DATE]. The facility was cited for past noncompliance and is not required to submit a plan of correction. The findings include: Review of the facility's policy titled, Resident Rights, revised ,d+[DATE], revealed .resident's right to exercise his or her rights . choose .treatment and participate in decisions . Review of the facility's policy titled, Recognizing Signs and Symptoms of Abuse/Neglect (Identification) F 607, revised ,d+[DATE], revealed .Neglect is defined as failure to provide goods and services as necessary to avoid physical harm .Signs of/Actual Physical Neglect .inadequate provision of care. Caregiver indifference to resident's personal care and needs . Review of the facility's policy titled, Abuse Prevention Program Policy, revised ,d+[DATE], revealed .residents have the right to be free from abuse, neglect . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the order summary revealed a Physician's written order dated [DATE] of .Code Status (full code) and a Physician's Verbal Order dated [DATE] for CPR. Review of the Care Plan dated [DATE], revealed Resident #1 requested that CPR measures were to be performed (FULL CODE STATUS), staff were to respect the wishes and rights of the resident regarding having CPR performed. The interventions included .Communicate my choice to all appropriate staff members. Initiate CPR when appropriate and continue until Paramedics arrive to take over . Review of the Progress Note dated [DATE] at 10:52 PM, revealed .respirations shallow color pale . Review of the Progress Note dated [DATE] at 11:22 PM, revealed .while checking on resident, resident appears comfortable. Noted breathing stop [stopped]. Ems [Emergency Medical Services] called to pronounce . Review of the vital sign summary sheet dated [DATE], revealed there were no vital signs documented after 3:29 PM. Review of the Progress Notes dated [DATE] at 11:24 PM, revealed .Telemedicine activated awaiting call from MD [Medical Doctor] . During a telephone interview on [DATE] at 9:21 AM, LPN #1 was asked, when CNA #1 notified him that Resident #1's skin color had changed and the resident had shallow respirations, were any vital signs checked at that time. LPN #1 stated, .No I did not . LPN #1 was asked, when Resident #1's breathing stopped was CPR initiated and LPN #1 stated, .No I did not . LPN #1 confirmed he was CPR certified. During an interview on [DATE] at 11:40 AM, CNA #1 stated, .I notified LPN #1 that [Named Resident #1]'s skin color was changing .he was pale looking .he [LPN #1] came to the room and did not do vital signs or check his oxygen .I notified [Named LPN #1] that he was restless and he did not do anything .didn't see the nurse do vital signs, check his oxygen saturation, listen to him or start CPR .I told [Named LPN #1] that he was transitioning .he didn't do anything . During a telephone interview on [DATE] at 5:40 PM, CNA #2 stated, .I knew he was transitioning because his color had changed, his skin was mottled, respirations were shallow, skin was cool .reported it to the nurse [LPN #1] .did not do vitals, he did not do CPR .when EMS arrived, they did not do CPR either . During an interview on [DATE] at 5:15 PM, the DON confirmed LPN #1 was negligent in providing care for Resident #1 when vital signs were not obtained once he was notified by CNA #1 and CNA #2 that the resident had a change in status, and he did not assess the resident and did not provide CPR. The DON stated, .He should have gotten vital signs .and should have started CPR immediately . During an interview on [DATE] at 6:03 PM, the Administrator confirmed LPN #1 was negligent in providing appropriate care to Resident #1 when he failed to assess the resident when there was a change in condition and did not provide CPR. The facility's corrective action plan included the following: 1. On [DATE], an investigation of the incident was started by the DON, including interviews with staff, obtaining written statements, reviewing the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyors reviewed the facility's investigation, interviewed the DON, and facility staff. 2. On [DATE], the Administrator suspended LPN #1 pending the outcome of the investigation. The surveyors interviewed the Administrator, DON, and LPN #1. 3. On [DATE], the DON and Administrator initiated education for facility staff regarding notification of resident's change of status/condition, following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyors interviewed facility staff on all shifts and reviewed the in-service sign in sheets. 4. On [DATE], the Unit Manager audited the crash cart to ensure all needed equipment and materials were present. The surveyors reviewed the audit forms for the crash cart and interviewed the Unit Manager. 5. The unit managers completed an audit for all residents related to the presence of POLST form and a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 6. Starting on [DATE], the Minimum Data Set (MDS) Coordinator and Director of Social Services reviewed and updated the POLST binders, ensured a POLST binder was placed at each Nurses' Station and a bright pink label was added to the binder. The surveyors observed the binders at each Nurses' Station, interviewed the MDS Coordinator, the Director of Social Services, and interviewed staff on all shifts. 7. On [DATE] at 2:58 PM and at 7:15 PM, the DON initiated a mock code drill with education provided by the DON related to procedure for Code Blue. The surveyors interviewed the DON, Administrator, and the facility staff on all shifts, and reviewed the sign in sheet for the mock code drill. 8. On [DATE], an Adhoc (as needed)/QAPI (Quality Assurance Performance Improvement) meeting was conducted with the Medical Director, Administrator, DON, ADON, and Director of Social Services participating in the meeting. The meeting directive was to notify and discuss the incident and receive input from the Medical Director. The surveyors reviewed the AdHoc sign in sheet and interviewed the Administrator, DON, and the Social Worker. 9. Education for facility staff by the Administrator, DON and Staff Development Coordinator continues as of [DATE] for Resident Code/POLST status, assessing a resident, Documentation of information when a resident expires. The surveyors interviewed the Administrator, reviewed the education provided, sign in sheets, and interviewed staff on all shifts. 10. On [DATE], the MDS Coordinator completed an audit of all current residents about the POLST Form, presence of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyors reviewed the audit tool, reviewed the medical records, and interviewed the MDS Coordinator. 11. In-services continues with all staff on [DATE]. Any licensed staff (per-diem/FMLA/Vacation) will be required to complete the in-service before they can return to work. The surveyors interviewed the Administrator and DON. 12. LPN #1 was terminated by the facility on [DATE]. The surveyors verified this through interview with the Administrator, DON, and LPN #1. 13. The facility will continue to monitor the Plan of Correction by conducting mock code drills weekly for 4 weeks and then as needed. The new hire process for Licensed nursing staff will include education on the role of the nurse during the dying phase; following code status/Physician Orders; documentation of information needed when a resident passes away; assessing the resident before and after the resident passes away. The Director of Social Work or their designee will review resident POLST forms for doctor signature and that the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Social Work or their designee will be responsible for ensuring that the resident POLST binders are current and will update the POLST binders upon a change being made to the resident's code status and upon re-admission, and monthly. The surveyors interviewed the Director of Social Work.

Based on policy review, medical record review, review of the facility's investigation, and interview, the facility failed to ensure a resident's wishes for Cardiopulmonary Resuscitation (CPR-an emergency procedure consisting of chest compressions and artificial ventilation to preserve brain function and restore blood circulation and breathing in a person in [CONDITION(S)]) were followed for 1 of 4 sampled residents (Resident #1) reviewed for Resuscitation Status, which resulted in Immediate Jeopardy (IJ) when Resident #1 was found without respirations and staff did not comply with Resident #1's wishes to have life saving measures of Cardiopulmonary Resuscitation (CPR) performed. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The facility had a total of 48 residents that were a Full Code status (residents who would require Cardiopulmonary Resuscitation). The Administrator, Director of Nursing (DON), and the Regional Director of Operations (RDO) were notified of the Immediate Jeopardy on [DATE] at 7:15 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-678. The facility was cited Immediate Jeopardy at F-678 at a scope and severity of J, which is Substandard Quality of Care (SQC). The IJ existed from [DATE] through [DATE]. The facility's corrective action plan, which removed the immediacy of the jeopardy, was received and corrective actions were validated onsite by the surveyors on [DATE] through [DATE]. The facility was cited for past noncompliance and is not required to submit a plan of correction. The findings include: Review of the facility policy titled, Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS) F 678, revised ,d+[DATE], revealed .the community staff, certified in CPR, will provide basic life support, including CPR, to a resident requiring such an emergency prior to the arrival of emergency medical personnel and subject to related physician orders .CPR Status .verify the presence of advanced directives in regards to CPR upon admission .the goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advanced Life Support (ALS) .individual is found unresponsive and not breathing normally .a licensed staff person who is certified in CPR/BLS shall initiate CPR . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician Orders for Life Sustaining Treatment (POLST) form dated [DATE], revealed .Cardiopulmonary Resuscitation (CPR) patient has no pulse and is not breathing Resuscitate (CPR) . Review of the order summary revealed a Physician's written order dated [DATE] that documented, Code Status (full code) . and revealed a Physician's Verbal Order dated [DATE] that CPR was to be initiated. Review of the Care Plan dated [DATE], revealed Resident #1 requested CPR measures be performed (FULL CODE STATUS) and .staff would respect the wishes and rights of the resident regarding having CPR performed . The interventions included Communicate my choice to all appropriate staff members. Initiate CPR when appropriate and continue until Paramedics arrive to take over . Review of the Admission Note dated [DATE], revealed .Social Service admission note .resident is a full code .resident does not have any end-of-life concerns . Review of the Progress Note dated [DATE] at 11:22 PM, revealed .while checking on resident, resident appears comfortable. Noted breathing stop [stopped]. Ems [Emergency Medical Services] called to pronounce . LPN #1 confirmed he was CPR certified. Review of the facility's investigation dated [DATE], revealed the medical record was reviewed and interviews were conducted with multiple staff members. The conclusion of the investigation revealed Licensed Practical Nurse (LPN) #1 was made aware Resident #1 had a change in color of skin by Certified Nursing Assistant (CNA) #2. LPN #1 did not assess Resident #1. Later, Resident #1 was found with no respirations. LPN #1 checked the electronic medical record and Resident #1 was a full code status. LPN #1 went to get assistance and another LPN told him Resident #1 was a DNR. The facility concluded LPN #1 failed to initiate CPR and follow Physician Orders. LPN #1 acknowledged that he confirmed Resident #1's code status in the electronic medical record and Resident #1 was a full code status. When the LPN was questioned why he did not initiate CPR, he replied The other nurse told me he was a DNR and within a span of 2 minutes the daughter also stated that she did not want anything done for her dad. The DON told the LPN it was his obligation to follow Physician Orders. During a telephone interview on [DATE] at 9:21 AM, LPN #1 stated, .not breathing I looked in the computer for his code status and seen [saw] he [Resident #1] was a Full Code . LPN #1 was asked if CPR was initiated and LPN #1 stated, .no . LPN #1 was then asked if he called 911 and he stated, .yes, to pronounce . During an interview on [DATE] at 11:40 AM, CNA #1 confirmed she had notified LPN #1 of the change in the resident's skin color, that the resident was becoming restless and when he (LPN #1) was notified, she (CNA) #1 .didn't see the nurse do vital signs, check his oxygen saturation, listen to him, or start CPR . CNA #1 stated, .he [LPN#1] didn't do anything . During a telephone interview on [DATE] at 5:40 PM, CNA #2 confirmed she had notified LPN #1 that the .his [Resident #1] skin color had changed, his skin was mottled . She had told the nurse he was .transitioning, his respirations were shallow, and his skin was cool . CNA #2 confirmed she did not see LPN #1 check any vital signs, or do CPR and when EMS arrived, they did not do CPR either. During an interview on [DATE] at 5:15 PM, the DON stated, .the resident was a Full Code .he [LPN #1] .should have started CPR .and he did not follow MD [Medical Doctor] orders . During an interview on [DATE] at 6:03 PM, the Administrator stated, .he [LPN #1] did not start CPR .did not do vital signs .did not follow MD orders and did not honor his [Resident #1] wishes or desires . The facility's corrective action plan included the following: 1. On [DATE], an investigation of the incident was started by the DON, including interviews with staff, obtaining written statements, reviewing the Physician's Orders, and reviewing Resident #1's Progress Notes. The surveyors reviewed the facility's investigation, interviewed the DON, and facility staff. 2. On [DATE], the Administrator suspended LPN #1 pending the outcome of the investigation. The surveyors interviewed the Administrator, DON, and LPN #1. 3. On [DATE], the DON and Administrator initiated education for facility staff regarding notification of resident's change of status/condition, following Physician's Orders, initiation of CPR, review of emergent treatment, resident assessments, and Abuse/Neglect. The surveyors interviewed facility staff on all shifts and reviewed the in-service sign in sheets. 4. On [DATE], the Unit Manager audited the crash cart to ensure all needed equipment and materials were present. The surveyors reviewed the audit forms for the crash cart and interviewed the Unit Manager. 5. The unit managers completed an audit for all residents related to the presence of POLST form and a Physician's order. The surveyors verified this through review of the audit tool, medical record review, and interview with the unit managers on [DATE] and [DATE]. 6. Starting on [DATE], the Minimum Data Set (MDS) Coordinator and Director of Social Services reviewed and updated the POLST binders, ensured a POLST binder was placed at each Nurses' Station and a bright pink label was added to the binder. The surveyors observed the binders at each Nurses' Station, interviewed the MDS Coordinator, the Director of Social Services, and interviewed staff on all shifts. 7. On [DATE] at 2:58 PM and at 7:15 PM, the DON initiated a mock code drill with education provided by the DON related to procedure for Code Blue. The surveyors interviewed the DON, Administrator, and the facility staff on all shifts, and reviewed the sign in sheet for the mock code drill. 8. On [DATE], an Adhoc (as needed)/QAPI (Quality Assurance Performance Improvement) meeting was conducted with the Medical Director, Administrator, DON, ADON, and Director of Social Services participating in the meeting. The meeting directive was to notify and discuss the incident and receive input from the Medical Director. The surveyors reviewed the AdHoc sign in sheet and interviewed the Administrator, DON, and the Social Worker. 9. Education for facility staff by the Administrator, DON and Staff Development Coordinator continues as of [DATE] for Resident Code/POLST status, assessing a resident, Documentation of information when a resident expires. The surveyors interviewed the Administrator, reviewed the education provided, sign in sheets, and interviewed staff on all shifts. 10. On [DATE], the MDS Coordinator completed an audit of all current residents about the POLST Form, presence of a Physician's Order for code status, residents' Care Plan for code status, code status on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyors reviewed the audit tool, reviewed the medical records, and interviewed the MDS Coordinator. 11. In-services continue with all staff on [DATE]. Any licensed staff (per-diem/FMLA/Vacation) will be required to complete the in-service before they can return to work. The surveyors interviewed the Administrator and DON. 12. LPN #1 was terminated by the facility on [DATE]. The surveyors verified this through interview with the Administrator, DON, and LPN #1. 13. The facility will continue to monitor the Plan of Correction by conducting mock code drills weekly for 4 weeks and then as needed. The new hire process for Licensed nursing staff will include education on the role of the nurse during the dying phase; following code status/Physician Orders; documentation of information needed when a resident passes away; assessing the resident before and after the resident passes away. The Director of Social Work or their designee will review resident POLST forms for doctor signature and that the Physician Order matches the POLST form weekly for 4 weeks, then monthly for 2 months and then regularly thereafter. The Director of Social Work or their designee will be responsible for ensuring that the resident POLST binders are current and will update the POLST binders upon a change being made to the resident's code status and upon re-admission, and monthly. The surveyors interviewed the Director of Social Work.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure a safe environment to prevent an incident of elopement for 1 of 7 sampled residents (Resident #3) reviewed for elopement, wandering behaviors, and safe smoking. The facility's failure resulted in Immediate Jeopardy (IJ) when Resident #3, a visually impaired resident with short term memory loss walked away from the designated smoking area unsupervised. Resident #3 was found by a Police Officer near an intersection and was returned to the facility approximately 10 minutes later. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Regional Director of Operations (RDO), Administrator, and Director of Nursing (DON) were notified of the Immediate Jeopardy on 11/18/2021 at 6:40 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-689. The facility was cited F-689 at a scope and severity of J, which is Substandard Quality of Care. The IJ existed from 11/12/2021 through 11/19/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 11/20/2021 at 10:35 AM, and was validated onsite by the surveyors on 11/20/2021 through review of assessments, medical record reviews, review of elopement assessments, behavior monitoring documentation, in-service training records, auditing tools, observations, and interviews. The findings include: Review of the facility's policy titled, Elopement F-689, revised 8/2020, revealed .Elopement occurs when a resident leaves the premises or a safe area without authorization .and/or any necessary supervision to do so . Review of the medical record, revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, [CONDITION(S)], [CONDITION(S)], Muscle Weakness, Protein-Calorie Malnutrition, Fracture of the Base of the Skull on the Right Side, [MEDICATION(S)] Dependence, Anxiety Disorder, [CONDITION(S)], Intracranial Bleed, Traumatic Brain Injury, Depression, and Suicidal Attempt. Review of the Nursing Admission Evaluation dated 7/30/2021, revealed Resident #3's vision was moderately impaired, wore an eye patch on his right eye, and wore corrective lenses. Review of the Physician's History and Physical dated 8/3/2021, revealed Resident #3 was admitted following a hospitalization after a horrific road traffic accident last year. He was apparently hit by a car and sustained multiple injuries which included facial and skull fractures (broken bones), lower extremity fractures, an intracranial bleed (bleeding inside the skull), and Traumatic Brain Injury (a head injury caused by an outside force that caused damage to the brain) with a skull fracture. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact for decision making, wore corrective lenses, required limited assistance of one staff member for activities of daily living (ADLs), used a wheelchair for mobility, and had impairment of the lower extremity (leg) on one side. Review of the Physician's Progress Note dated 8/11/2021 revealed Resident #3 had a fracture at the base of the skull, had a past suicidal attempt, had [CONDITION(S)], and Depression. Review of a quarterly MDS dated [DATE], revealed Resident #3 was assessed to have impaired vision, wore corrective lenses, and was cognitively intact with a BIMS of 15. Resident #3 was assessed to be feeling down, depressed, or hopeless several days, feeling bad about himself, and had trouble concentrating nearly every day. Resident #3 required supervision for bed mobility, help for transfers, was independent to walk in the room, required supervision for walking in the corridor, supervision of one staff member for dressing, extensive one person assistance for toilet use and personal hygiene, and total dependence of staff for bathing. Resident #3 was assessed to have impairment on one side to the upper and lower extremities (arm and leg) and used a wheelchair for mobility. Resident #3 was assessed as having no wandering behaviors. Review of the Occupational Therapy Note dated 10/31/2021 through 11/12/2021, revealed Resident #3 was struck by a car which resulted in an open fracture (a bone fracture that is accompanied by breaks in the skin, causing the broken ends of the bone to protrude outside the skin) of the left lower extremity and a fracture of the right upper extremity. Resident #3 had a history of alcohol withdrawal, had attempts to harm himself, and was homeless. Resident #3 had barriers which were likely to impact discharge and included exacerbation of cognitive impairment, multiple medications, addiction to alcohol, and lacked stable employment which could impact treatment. Resident #3 had impaired motor control deficits (partial or full loss of functioning of a body part, usually legs), strength impairments, and limitations in range of motion. Review of the Elopement Incident Report dated 11/12/2021, revealed Resident #3 went outside on a smoke break with a staff member and other residents and walked away from the group. Resident #3 was away from the group approximately 10 minutes. Resident # 3 stated he was having such a good day, he felt .liberated and wanted to go for a walk . Review of the Care Plan revised 11/13/2021, revealed Resident #3 was at moderate to high risk for elopement while going out to smoke. Review of a Psychotherapy Progress Note dated 11/16/2021, revealed Resident #3 had short-term memory problems and had a setback regarding anxiety and desperation with regards to the process of searching for housing after discharge. During an interview on 11/16/2021 beginning at 10:22 AM, the Administrator confirmed the incident occurred on 11/12/2021 at night when the staff stated the resident walked away from the smoke break unsupervised and was later found on the sidewalk. During an interview on 11/16/2021 at 11:15 AM, Resident #3 confirmed he walked away from the smoking area as he just wanted to take a walk, and he didn't remember where he walked when he left the facility. During an interview on 11/16/2021 at 11:45 AM, the Social Worker confirmed 11/12/2021 was an emotional day, the resident was tearful that afternoon in the activity and that may be an explanation for his elopement. During an interview on 11/16/2021 at 1:08 PM, the RDO stated, .we went back and forth about reporting it because technically he wasn't off the property .we decided we better report it because of the previous incident [elopement in August 2021], Corporate doesn't feel this is a reportable incident because the resident is alert and oriented .it's a matter of resident's rights .this is not a jail .because he has a BIMS of 15 we cannot hold him against his will . During an interview on 11/16/2021 at 1:10 PM, the DON stated, .I was notified about 7:50 PM that [Named Resident #3] had left the facility during the smoke break and staff was [were] out looking for him .he was brought back to the facility by the police .I interviewed the CNA [Certified Nursing Assistant] who was assisting with the smoke break, he said it was so dark, that as he walked toward the edge of the building, he could not see him [Resident #3] anymore . During an interview on 11/16/2021 at 1:55 PM, the Police Officer stated, .I saw a staff member walking up the drive in the back parking lot near the road, he told me that a resident was missing. During my rounds I checked the back of the facility because it's so dark because the streetlights are not working. I drove around the housing complex and the street behind the facility, I did not see anyone walking. I returned back to the facility and that's when I saw him [Resident #3] standing on the corner of [Named] road and [Named] street .he told me he belonged in the nursing home .he got in the car .brought him back to the facility .he was dressed in regular clothes . During an interview on 11/16/2021 at 3:01 PM, CNA #1 confirmed that on 11/12/2021 at the 7:00 PM smoke break, Resident #3 had finished smoking. CNA #1 was supervising Resident #4 smoking, he turned around, did not see Resident #3, and it was very dark. CNA #4 stated, .I walked to the end of the building and did not see him [Resident #3] anywhere. After securing [Named Resident #4] in the building, I got in my car and drove through the back parking lot and around the community searching for him [Resident #3] and did not see him . During a telephone interview on 11/17/2021 at 11:42 AM, Licensed Practical Nurse (LPN) #2 stated, .I was notified [Named Resident #3] had walked off from the smoke break .I went to the back parking lot looking for him .yelling his name .it is very dark out there .we've reported the lighting being out but hasn't been fixed yet .I had to use my cell phone flashlight .[Named CNA #1] and [Named LPN #3] were out looking for [Named Resident #3] in the back parking lot and around the building but could not find him .it was very cold that night .a Police Officer brought him back to the building .the resident stated, 'I was feeling good .just wanted to walk' . During an unannounced off-hour observation and interview in the facility's designated smoking area on 11/17/2021 at 7:00 PM, revealed there were 2 residents (Resident #3 and #4) and 2 staff members (CNA #1 and LPN #1) in the smoking area. There were four streetlights which could provide lighting to the back of the facility, the back parking lot, and the smoking area but the four streetlights were not in working order. During interviews with CNA #1 and LPN #1 while supervising the smoke break, they confirmed there was inadequate lighting to provide safe supervision of residents the night of the elopement if they left the designated smoking area unsupervised. There was no lighting on the pathway from the smoking area to the back parking lot. During a telephone interview on 11/18/2021 at 10:56 AM, LPN #3 stated, .[Named CNA #1] took [Named Resident #3] out to smoke and he [Resident #3] took off. I went down the left side of the building .did not see the resident anywhere .I saw a Police Officer, I told the officer we had a resident missing .he went looking for the resident .the police pulled up and the resident was in the car .it was very cold that night, I did not see the resident when I walked down the side of the building .it is very dark on that side of the building . During an interview on 11/18/2021 at 5:45 PM, Resident #3 and the Social Worker requested to speak with the surveyors. Resident #3 stated, .I'm not a nursing home resident .I have emotional issues, chemical dependence .I've been on my feet and in the gutter off and on my whole life .Friday [11/12/2021] I had a moment .a meltdown .I'm in that room all the time .I've suffered a brain injury and lost my eye .I have visual issues .I take anxiety medications .I still have panic attacks . During a telephone interview on 11/19/2021 at 8:29 AM, the Psychologist stated, .he [Resident #3] is desperate for a transfer to an apartment .he was smoking .walking outside the facility .desperate to leave .has issues with depression and anxiety . During a telephone interview on 11/19/2021 at 8:53 AM, the Medical Director stated, .I was notified of the incident .was told staff did not know immediately that the resident had walked off .darkness was an issue .absolutely not safe for him [Resident #3] .he could get hit by a car .when I spoke to him, he could not tell me where he went . During an interview on 11/19/2021 at 10:55 AM, LPN #4 stated, .when they brought him [Resident #3] back to the facility, he was mad .the Police Officer said he found him down the street .the lights were not working out back around the patio and parking lot when he walked off . During an interview on 11/20/2021 at 4:49 PM, CNA #2 stated, .around 6:30 PM [11/12/2021] he [Resident #3] asked me to let him out. I told him to wait until smoke break .he started cussing me out .became very angry, pacing up and down the hall, I work with him often he has never been upset with me like that .I went to the Nurses' Station and told the nurse that he was acting different .he is usually quiet .I figure it was because of the alcohol they'd had during the activity that day .I told them I wasn't doing the 7:00 PM smoke break because he was acting weird and I don't like going out there because it is so dark .[Named Resident #3] was saying things like my name is [Resident #3's last name] for a reason .I'm going to show you .it was like he was planning to do something .I talked to the Administrator and the DON that night about how he was acting .the police found him not too far from the facility .when he got back to the facility he was still acting different .he had dark clothes on so it would be hard to see him as dark as it was . During an interview on 11/20/2021 at 7:26 PM, the Administrator confirmed she knew the lighting was subpar in the parking lot and the smoking area . The Administrator was asked if she was notified that Resident #3 was exhibiting behaviors prior to the incident. The Administrator stated, .no not aware until today . During an interview on 11/20/2021 at 8:45 PM, the RDO stated, .we just got caught up in that he had a BIMS of 15 [cognitively intact] . The surveyors verified the Removal Plan: 1. On 11/12/2021, interviews were started by the Director of Nursing based on the employees that were working at the time of the event. The surveyors reviewed the statements and the investigation. 2. On 11/12/2021, Resident #3 was assessed by the DON with no indication of emotional, mental and/or physical harm/injury. The surveyors reviewed the assessment and interviewed the DON. 3. On 11/12/2021, a skin assessment was completed by the DON and Resident #3's skin was noted to be intact. The surveyors reviewed the skin assessment. 4. On 11/12/2021, Staff in-services were initiated by the DON on Elopement; Smoking Times/schedules; Resident Rights; and Elopement Prevention Tips. The surveyors reviewed the education and interviewed staff on all shifts. 5. On 11/12/2021, the Administrator made external rounds of the exit doors and the doors were found to be secure. The surveyors interviewed the Administrator and observed the doors. 6. On 11/12/2021, the Maintenance Department changed the door code alarm pad leading to the smoking patio area. The surveyors observed the alarm pad and interviewed the Maintenance Director. 7. On 11/12/2021, the DON completed an Off Grounds Evaluation. The evaluation was reviewed with the Administrator, and it was determined that Resident #3 may walk the community grounds. The surveyors reviewed the assessment. 8. On 11/12/2021, an order for psychiatric evaluation was obtained for Resident #3. The surveyors reviewed the evaluation. 9. On 11/13/2021, a new Wandering & Elopement evaluation was completed on Resident #3 by the DON. The surveyors reviewed the evaluation. 10. On 11/13/2021, Resident #3's Care Plan was reviewed by the DON and Administrator with revisions made. The surveyors reviewed the Care Plan. 11. On 11/13/2021, the Director of Maintenance installed motion sensor lights to the smoking patio area and the east side/facade of the building of the smoking area. The surveyors observed the lights. 12. On 11/14/2021, an Elopement drill was conducted. The surveyors reviewed the Elopement drill documentation. 13. On 11/14/2021, In-services continued related to Elopement; Smoking Times/schedules; Resident Rights; and Elopement Prevention Tips by the Director of Nursing. Staff will be in-serviced prior to working their first shift. The surveyors reviewed the education and interviewed staff on all shifts. 14. On 11/15/2021, an outside grounds contractor installed light bulbs in the parking lot perimeter lights. The surveyors observed the lights. 15. On 11/15/2021, Wandering & Elopement re-evaluations were completed by Unit Manager on residents who currently smoke. The surveyors reviewed the evaluations. 16. On 11/15/2021, Elopement books were reviewed and validated by the Unit Manager; no new residents were identified through the new assessment. The surveyors reviewed the Elopement books and assessments. 17. On 11/15/2021, an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held to address the event and the facility's action plan. In attendance were the DON, the ADON, the RDO, the Social Worker, the Business Office Manager, the Unit Manager, Human Resources Director, the Activities Director, and the Maintenance Director. The surveyors reviewed the QAPI minutes. 18. On 11/17/2021, the DON reviewed the facility policy for signing in and out with Resident #3. The resident verbalized understanding. Resident #3 has expressed no desire to leave the facility until his discharge, at this time. The resident has been educated and expressed an understanding that he must sign out of the facility prior to leaving. The surveyors reviewed the education and interviewed Resident #3. 19. Elopement drills will be conducted monthly for 2 months then as needed. The surveyors reviewed the drills. 20. This plan will be monitored by completing Elopement assessments on residents who smoke upon admission. Monthly Elopement assessments will be completed for 2 months on residents who currently smoke. The surveyors reviewed the assessments and interviewed the DON. 21. On 11/22/2021, work will begin on an enclosed smoking area. 22. The facility completed assessments on all similar residents as part of the facility's plan of correction as indicated in the abatement and Elopement. Assessments on all other residents will be completed. The surveyors reviewed the assessments. The facility's noncompliance at F-689 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, facility investigation review, medical record review, and interview, the facility failed to prevent neglect and provide the necessary supervision for a cognitively impaired resident with a history of elopement and exit seeking behavior for 1 of 5 sampled residents (Resident #1) reviewed for elopement, wandering behaviors, and neglect. The facility's failure to provide care and services to prevent neglect resulted in Immediate Jeopardy when Resident #1, a cognitively impaired vulnerable resident, exited the facility unsupervised and walked to a house that was approximately 100 yards from the facility. Resident #1 was returned to the facility by the neighbor. The facility staff were unaware Resident #1 had left the facility unsupervised until Resident #1 was escorted back to the facility by the neighbor. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm and impairment or death to a resident. The Interim Administrator, Administrator, Regional Nurse Consultant, and Regional Director of Operations were notified of the Immediate Jeopardy for F-600 on 8/20/2021 at 12:35 PM, in the Administrator's Office. The facility was cited Immediate Jeopardy at F-600. The facility was cited at F-600 at a scope and severity of J, which is Substandard Quality of Care. The IJ was effective from 8/9/2021 through 8/15/2021. The facility's corrective action plan, which removed the immediacy of the jeopardy, was received and corrective actions were validated onsite by the surveyors on 8/17/2021 through 8/20/2021. 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, Recognizing Sign and Symptoms of Abuse/Neglect (Identification) F 607 revised 11/2017, revealed .Neglect is defined as failure to provide goods and services as necessary to avoid physical harm .some examples of actual abuse/neglect .leaving someone unattended who needs supervision . Review of the facility's policy titled, Elopement F-689 revised 4/2021, revealed .Elopement occurs when a resident leaves the premise or a safe area without authorization . Review of the medical a record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment for decision making, had behaviors of inattention and disorganized thinking, rejected care, and had behaviors which included wandering behaviors that put the resident at significant risk of going to a potentially dangerous place. The resident was documented as being unsteady when walking, required limited assistance with transfer, and extensive assistance with locomotion. Review of the [Named] Initial Psychiatric Evaluation dated 8/4/2021, revealed Resident #1 had .Dementia .with unpredictable behavior .is delusional, paranoid at times .hx [history] of significant cognitive decline . Review of the facility's investigation summary revealed on 8/10/2021 during a department manager morning meeting a lady came to the facility to speak with the Administrator and Director of Nursing (DON). The lady stated that a resident from the facility was in her kitchen on 8/9/2021 around 7:55 PM. She walked with the resident back to the facility and spoke with an employee in the front parking lot who escorted the resident into the facility. The last time Resident #1 was observed by staff on 8/9/2021 was at 7:15 PM when the resident was administered medication by the staff. It was undetermined which door Resident #1 had exited, the emergency alarms on 3 of the 4 exit doors on the secured unit had been turned off, and the alarm on those doors did not sound when the door was opened. During an interview on 8/18/2021 at 3:49 PM, Licensed Practical Nurse (LPN) #2 stated, .I did not know she [Resident #1] was gone until another nurse yelled down the hall and asked is someone missing .I observed [Named Resident #1] earlier in the shift aggressively shaking and pulling at the exit door holding her shoes in her hands, pacing back and forth .I left the unit and when I returned a nurse called and said that she had gotten out of the building and was being returned to the front lobby .I don't know how she got out of the building .I checked the exit doors after she returned 3 of the 4 doors' emergency alarms were turned to the off position . During an interview on 8/19/2021 at 11:45 AM, the homeowner stated, .my husband observed a lady [Resident #1] walking across the lawn headed toward the back of the house. We went into the kitchen at the back of our home .she [Resident #1] was entering our home through the back door. I assumed she was a nursing home resident by her clothing, her shoes were not matching, and her shirt was turned inside out. I escorted the lady back to the facility .I saw a staff member in the parking lot, I yelled and asked the staff member if they were missing someone and why she was out of the building. He said he didn't know and took her back into the building . During an interview on 8/19/2021 at 1:32 PM, LPN #1 stated, .I do not know how she [Resident #1] got out of the building, all I know is that she was out. As the lady [homeowner] and her [Resident #1] were walking toward the parking lot, the lady was yelling asking if we were missing someone and how she got out of the building .I recognized that she was our resident I met the lady and the resident .then assisted the resident back into the facility . During an interview on 8/19/2021 at 5:44 PM, Certified Nursing Assistant (CNA) #1 was asked if she was aware Resident #1 had eloped from the building. CNA #1 stated, .No, I did not know she [Resident #1] had gotten out of the building until I was told by [Named LPN #2] .I noticed earlier in the shift [Named Resident #1] was agitated, pulling at the exit door, pacing back and forth .I went to lunch and was not on the unit when she got out . On 8/9/2021-8/16/2021, the facility implemented the following: 1. On 8/9/2021 the facility implemented the following: a. Staff checked exit doors in the Garden Secure Unit every 30 minutes to ensure the Emergency alarms were in the on position and secure until 7:00 AM. Surveyors reviewed safety check sheets, in-service logs, and interviewed staff on all shifts. b. A head count of all residents in the Garden Secure unit was conducted every 30 minutes until 7:00 AM. Surveyors reviewed the count documentation, in-service logs, and interviewed staff on all shifts. 2. On 8/10/2021 the facility implemented the following: a. A pain assessment, body audit, and updated elopement/wandering assessment was completed for Resident #1. The surveyors reviewed the assessments, audits, and elopement/wandering assessments. a. The Director of Nursing notified the Medical Director and family. Surveyor reviewed the medical record and interviewed the Medical Director. b. Fire drills were conducted on 2nd and 3rd shifts and continued for all shifts. The surveyors reviewed the fire drill in-service log and interviewed staff all shifts. c. Elopement drills were conducted on 2nd shift and 3rd shift and continued for all shifts. The surveyors reviewed the elopement drill in-service log and interviewed staff on all shifts. d. Maintenance Director and an outside contractor checked all the door keypads to ensure they were operational. The codes were changed. The surveyors reviewed maintenance logs, interviewed the Maintenance Director and staff, and observed the keypads and checked the doors. e. The key to the Emergency alarms were removed for the Garden nursing staff. The surveyors interviewed nursing staff on all shifts. f. An Ad Hoc (as needed) Meeting was held to discuss the incident. The Quality Assurance Performance Improvement (QAPI) Ad Hoc immediate action plan was entered into Abaqis. The surveyors reviewed the facility's QAPI plan of correction and interviewed administration. g. Wandering assessments were completed for all residents in the Garden Secure Unit, the elopement book was reviewed and validated, and Care Plans were updated. The surveyors reviewed the wandering assessments, the elopement book and Care Plans, and interviewed staff on all shifts. h. In-services were started and will continue until all staff have been in-serviced on these topics: definition of elopements, incident reporting, emergency alarms are to be checked each shift, incident reporting process, ethical, honesty, and detailed communication. The surveyors interviewed and reviewed staff in-services and interviewed staff on all shifts. 3. On 8/11/2021 the facility Director of Nursing (DON) was placed on Administrative leave. The surveyor interviewed the administrative staff and reviewed personnel files. 4. On 8/13/2021 the facility implemented the following: a. LPN #2, LPN #3, and LPN #4 were disciplined based on their actions based on the findings of the investigation, namely changing the documentation (upon direction of the DON) and not reporting the incidents appropriately. The surveyors reviewed the personnel files and statements. b. Doors were checked by maintenance. Maintenance tightened all screws, checked the latches, and checked door closures on doors 18, 19, 20, and Smoke Door. Maintenance installed new door closures on doors 19 and the Smoke Door. The surveyors reviewed the Maintenance log and nursing safety check documentation. c. In-services were conducted for all staff to educate on the code of conduct. Surveyors interviewed staff on all shifts and reviewed the in-service education. d. In-services were conducted for all staff on reporting unusual occurrences and incidents to the Administrator, 1-800 compliance number when there is unethical, illegal, or intimidating requests. Surveyors interviewed nursing staff and reviewed the in-service education. 5. On 8/16/2021 the facility implemented the following: a. Maintenance repaired the small fence board. The surveyor observed the fence and reviewed the maintenance log. b. An outside contractor installed a new keypad and a new magnetic lock on the Gardens Courtyard gate. The surveyors reviewed the maintenance log, service receipt, observed the gate, and interviewed the Maintenance Director and staff. c. The outside contractor continued troubleshooting the fire doors and installed a new keypad on the door and checked the other doors to determine they were functioning properly. Surveyors reviewed the maintenance log, service receipt and interviewed the Maintenance Director and staff to determine the doors had been repaired.

Based on policy review, facility investigation review, medical record review, and interview, the facility failed to provide a safe secure environment that provided adequate supervision to prevent elopement of a cognitively impaired, wandering resident with exit seeking behaviors for 1 of 5 sampled residents (Resident #1) reviewed for elopement and wandering/exit seeking behaviors. The facility's failure to provide adequate supervision resulted in Immediate Jeopardy when Resident #1, a cognitively impaired vulnerable resident exited the facility, walked to a neighboring residential home, and entered the home, which was approximately 100 yards from the facility's front entrance door, unsupervised. The facility was unaware Resident #1 was missing from the facility until the resident was returned to the facility by the homeowner. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm and impairment or death to a resident. The Interim Administrator, Administrator, Regional Nurse Consultant, and Regional Director of Operations were notified of the Immediate Jeopardy for F-689 on 8/20/2021 at 12:39 PM, in the Administrator's Office. The facility was cited Immediate Jeopardy at F-689. The facility was cited at F-689 at a scope and severity of J, which is Substandard Quality of Care (SQC). The IJ was effective from 8/9/2021 through 8/15/2021. The facility's corrective action plan, which removed the immediacy of the jeopardy, was received and corrective actions were validated onsite by the surveyors on 8/17/2021 through 8/20/2021. 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, Elopement F-689, revised 4/2021, revealed .Staff shall evaluate, investigate and report all cases of missing residents .Elopement occurs when a resident leaves the premise or a safe area without authorization .For residents requiring increased monitoring of wandering, the licensed Nurse will initiate Elopement/Wandering supervision for a specific period .Examples of resident behavior requiring such action are: a. Attempted elopement .Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Traumatic Subdural Hemorrhage, Dementia, Displaced Fracture of the Right Humerus, Malnutrition, Muscle Weakness, Repeated Falls, and [CONDITION(S)]. Review of the Nursing Wander & [and] Elopement Evaluation, dated 7/19/2021, revealed Resident #1 was a new admission, was oriented to person only, had wandering and exit seeking behaviors, had a history of wandering at home, had a history of exit seeking behavior at home, lacked safety awareness, had a diagnosis of Dementia, and ongoing interventions implemented were required increased supervision by staff and placement on the secured unit. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment for decision making, had behaviors of inattention and disorganized thinking, had rejection of care behaviors and wandering behaviors that placed the resident at significant risk for getting into a potentially dangerous place. Resident #1's functional status documented the resident was unsteady with walking, required limited assistance with transfers and bed mobility, extensive assistance with locomotion, dressing, toilet use, and personal hygiene. Review of the [Named Facility] Initial Psychiatric Evaluation, dated 8/4/2021 revealed .Dementia .with unpredictable behavior .is delusional, paranoid at times .hx [history] of significant cognitive decline . Review of the facility's investigation summary of the elopement that occurred on 8/9/2021, revealed that during a department manager morning meeting on 8/10/2021, a lady came to the facility and reported to the Administrator and Director of Nursing (DON) that a resident from the facility had come to her home and entered her kitchen around 7:55 PM on 8/9/2021. The lady stated she accompanied the resident back to the facility and spoke with an employee in the front parking lot. The investigation revealed the home was approximately 100 yards from the facility and 3 of the 4 Emergency Alarms on the Garden's Secure Unit were in the off position when Resident #1 was returned to the facility. The Administrator was not contacted about this incident. Interviews with staff revealed the DON was contacted and instructed staff to check the doors, contact Maintenance to check the doors, and only treat this incident as an elopement attempt. During the investigation, it was also discovered that Resident #1 had exited the building on 7/21/2021. At that time the alarm sounded, staff immediately responded and brought the resident back into the building. The Administrator was not called about the incident on 7/21/2021 and interviews with staff revealed the DON instructed staff to change the original documentation, including the progress notes and incident reports. Review of the Nursing Wander & [and] Elopement Evaluation, dated 8/10/2021, revealed Resident #1 had a risk score of 19 which indicated the resident was a moderate risk, stayed near the exit door, would exhibit forgetfulness or a short attention span, had a history of wandering at home, had exit seeking behavior, stayed near exit doors, and wandered at night. Review of the Nursing Wander & [and] Elopement Evaluation, dated 8/17/2021 revealed Resident #1 had a risk score of 20 which indicated a high risk, had recent medication changes, exhibited a current state of paranoia, had a diagnoses of Dementia, Anxiety, Depression, Schizo-Affective Disorder, and interventions included secured doors, increased supervision, and placement on a secure unit. During an interview on 8/18/2021 at 3:49 PM, Licensed Practical Nurse (LPN) #2 was asked when she became aware that Resident #1 had eloped from the facility. LPN #2 stated, .I did not know she [Resident #1] was gone .I observed [Named Resident #1] earlier in the shift aggressively shaking and pulling at the exit door holding her shoes in her hands, pacing back and forth .I left the unit and when I returned a nurse called and said that she had gotten out of the building .when I checked the exit doors after she returned 3 of the 4 doors' emergency alarms were turned to the off position .I did not hear an alarm going off .I don't know how she got out of the building or which door .the door could have come open when she was jerking on the door, I don't know but she had gotten out of the building . During an interview on 8/19/2021 at 11:45 AM, the homeowner stated, .my husband observed a lady [Resident #1] walking across the lawn headed toward the back of the house .she [Resident #1] was entering our home through the back door .I escorted the lady back to the facility .I saw a staff member in the parking lot, I yelled and asked the staff member if they were missing someone and why she was out of the building. He said he didn't know and took her back into the building . During an interview on 8/19/2021 at 1:32 PM, LPN #1 stated, .I do not know how she [Resident #1] got out of the building, all I know is that she was out. As the lady [homeowner] and her [Resident #1] were walking toward the parking lot, the lady was yelling asking if we were missing someone and how she got out of the building .I recognized that she was our resident I met the lady and the resident .then assisted the resident back into the facility . During an interview on 8/19/2021 at 5:44 PM, Certified Nursing Assistant (CNA) #1 was asked if she was aware Resident #1 had eloped from the building. CNA #1 stated, .No, I did not know she [Resident #1] had gotten out of the building until I was told by [Named LPN #2] .I noticed earlier in the shift that [Named Resident #1] was agitated, pulling at the exit door, pacing back and forth .last time I saw her she was in the day room .I went to lunch and was not on the unit when she got out . On 8/9/2021-8/16/2021, the facility implemented the following: 1. On 8/9/2021 the facility implemented the following: a. Staff checked exit doors in the Garden Secure Unit every 30 minutes to ensure the Emergency alarms were in the on position and were secure until 7:00 AM. Surveyors reviewed safety check sheets, in-service logs, and interviewed staff on all shifts. b. A head count of all residents in the Garden Secure unit was conducted every 30 minutes until 7:00 AM. Surveyors reviewed the head count documentation, in-service logs, and interviewed staff on all shifts. 2. On 8/10/2021 the facility implemented the following: a. A pain assessment, body audit, and updated elopement/wandering assessment was completed for Resident #1. The surveyors reviewed the assessment, audits, and elopement/wandering assessment. a. The DON notified the Medical Director and family. The surveyor reviewed the medical record and interviewed the Medical Director. b. Fire drills were conducted on 2nd and 3rd shifts and continued for all shifts. The surveyors reviewed the fire drill in-service log and interviewed staff all shifts. c. Elopement drills were conducted on 2nd shift and 3rd shift and continued for all shifts. The surveyors reviewed the elopement drill in-service log and interviewed staff on all shifts. d. The Maintenance Director and an outside contractor checked all the door keypads to ensure they were operational. The codes were changed. The surveyors reviewed maintenance logs, interviewed the Maintenance Director and staff, observed the keypads and checked the doors. e. The keys to the Emergency alarms were removed from the Garden nursing staff access. The surveyors interviewed nursing staff on all shifts. f. An Ad Hoc (as needed) Meeting was held to discuss the incident. The Quality Assurance Performance Improvement (QAPI) Ad Hoc immediate action plan was entered into Abaqis, the facility Quality Assurance program. The surveyors reviewed the facility's QAPI plan of correction and interviewed administration. g. Wandering assessments were completed for all residents in the Garden Secure Unit, the elopement book was reviewed and validated, and Care Plans were updated. The surveyors reviewed the wandering assessments, the elopement book and Care Plans, and interviewed staff on all shifts. h. In-services were started and will continue until all staff have been in-serviced on these topics: definition of elopements, incident reporting, emergency alarms to be checked each shift, incident reporting process, ethical, honesty, and detailed communication. The surveyors reviewed the staff in-services and interviewed staff on all shifts. 3. On 8/11/2021 the facility DON was placed on Administrative leave. The surveyors reviewed the DON's personnel files and interviewed Administration. 4. On 8/13/2021 the facility implemented the following: a. LPN #2, LPN #3, and LPN #4 were disciplined regarding their actions based on the findings of the investigation, namely changing the documentation (upon direction of the DON) and not reporting the incidents appropriately. The surveyors reviewed the personnel files and statements. b. Doors were checked by maintenance. Maintenance tightened all screws, checked the latches, and checked door closures on doors 18, 19, 20, and the Smoke Door. Maintenance installed new door closures on doors 19 and the Smoke Door. The surveyors reviewed the Maintenance log and nursing safety check documentation. c. In-services were conducted for all staff to educate them on the code of conduct. Surveyors interviewed staff on all shifts and reviewed the in-service education. d. In-services were conducted for all staff on reporting unusual occurrences and incidents to the Administrator and the 1-800 corporate compliance number when there is unethical, illegal, or intimidating requests. Surveyors interviewed nursing staff and reviewed the in-service education. 5. On 8/16/2021 the facility implemented the following: a. Maintenance repaired the small fence board. The surveyor observed the fence and reviewed the maintenance log. b. An outside contractor installed a new keypad and a new magnetic lock on the Gardens Courtyard gate. The surveyors reviewed the maintenance log, service receipt, observed the gate, and interviewed the Maintenance Director and staff. c. The outside contractor continued troubleshooting the fire doors, installed a new keypad on the door, and checked the other doors to determine they were functioning properly. Surveyors reviewed the maintenance log, service receipt and interviewed the Maintenance Director and staff to determine the doors had been repaired.

Based on medical record review, kardex review and interview, the facility failed to implement care plan interventions to prevent falls and injury for 1 of 18 (Resident #3) sampled residents reviewed of 32 residents included in the stage 2 review. The failure to provide two person assist with care resulted in actual harm when Resident #3 sustained a fall which resulted in an [MEDICATION NAME] hemorrhage (an emergency condition in which a ruptured blood vessel caused bleeding inside the brain) that formed a subdural hematoma (a blood clot) on the brain and a left clavicular fracture (broken collar bone). The findings included: Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] revealed Resident #3 was severely cognitively impaired, required extensive assistance with 2 person physical assist with bed mobility, transfer and was total dependent for bathing with two person assist. The care plan dated 7/11/17 documented, Focus .has an ADL (activity of daily living) Self Care Performance Deficit r/t (related to) Stroke, Dementia .Interventions .BED MOBILITY: requires, extensive assist of 2 with turning and repositioning in bed .BATHING: Requires extensive to total assist with bathing .TRANSFERS: Requires ext (extensive) to total assist with all transfers, hoyer lift . The Visual/Bedside Kardex Report documented, .Bathing: Requires extensive to total assist with bathing .Transferring .Two-person assist with transfer and positioning .Mobility: requires, extensive assist of 2 with turning and repositioning in bed . The Progress Notes dated 9/16/17 at 0600 (AM) documented, .called to resident's room at approx. (approximately) 0540 (5:40 AM) by CNA (Certified Nursing Assistant) who stated resident had fallen out of her bed while CNA was providing care .resident noted to be laying supine, in her bed, with bed at waist high. Resident was assessed by this nurse .Resident guarding R (right) side of body, specifically R upper arm and R hip . The computerized tomography (CT) report dated 9/16/17 documented, .[MEDICATION NAME] Hemorrhage (an emergency condition in which a ruptured blood vessel causes bleeding inside the brain) . The comparative CT dated 9/16/17 documented, .There is .small bilateral posterior Subdural hematomas measuring a maximum of 3 mm (millimeters) in thickness on the right and 5 mm on the left .These are non significant change compared to the prior study . The Radiology report dated 9/16/17 documented, .Left arm pain post fall .AP (anterior and posterior) .lateral views of the left humerus were obtained .IMPRESSION: Acute left clavicular fracture . Interview with CNA #2 on 9/19/17 at 11:22 AM, in the conference room, CNA #2 was asked what happened that morning when Resident #3 fell . CNA #2 stated, .I went in to give her a bed bath .I turned her over to wash her .I had reached back with one hand and had one hand on her (I) was reaching back to get the diaper and I kind of loose (loosened) the hand I had on her .her legs was positioned off the bed when I turned her .I didn't have her tight .she flipped off the bed on to the floor . CNA #2 was asked if Resident #3 was a one or two person assist for her baths. CNA #2 stated, She is a two (two persons assist) for anything. CNA #2 was asked if anyone was helping her give Resident #3 a bath that morning. CNA #2 stated, No, ma'am. CNA #2 was asked if she had given Resident #3 a bath by herself before. CNA #2 stated, Yes. CNA #2 was asked how the facility lets the staff know if a resident is a one or two person assist. CNA #2 stated, It's in the ADLs we have to do . CNA #2 was asked if Resident #3 was mobile or could she turn herself. CNA #2 stated, No, ma'am . Interview with the Director of Nursing (DON) on 9/20/17 at 8:33 AM, in the DON's office, the DON was shown Resident #3's care plan and was asked if Resident #3 was a one or two person assist with bathing, transfer and turning. The DON stated, She is an assist of two. The DON was asked if on the morning of the fall, did Resident #3 have one or two people assisting her with her bath. The DON stated, It was just (named CNA #2) .she was alone . The DON was asked if CNA #2 followed the care plan. The DON stated, No. The failure to provide two person assist with care resulted in actual harm when Resident #3 sustained a fall which resulted in an [MEDICATION NAME] hemorrhage that formed a subdural hematoma on the brain and a left clavicular fracture.

Based on policy review, medical record review, kardex review and interview the facility failed to implement interventions to prevent falls and injury for 1 of 6 (Resident # 3) sampled residents reviewed for accidents. The failure to provide two person assist with care resulted in actual harm when Resident #3 sustained a fall which resulted in an intracerebral hemorrhage (an emergency condition in which a ruptured blood vessel caused bleeding inside the brain) that formed a subdural hematoma (a blood clot) on the brain and a left clavicular fracture (broken collar bone). The findings included: 1. The facility's Assessing Falls and Their Causes Guidelines policy documented, .Falls are a leading cause of morbidity and mortality among the elderly in nursing homes .If a resident has just fallen .nursing staff will record vital signs and evaluate for possible injuries to the head, neck, spine and extremities .Once an assessment rules out significant injury, nursing staff will help the resident to a comfortable sitting, lying or standing position . 2. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] and quarterly MDS dated [DATE] revealed Resident #3 was severely cognitively impaired, required extensive assistance with 2 person physical assist with bed mobility, transfer and was total dependent for bathing with two person assist. The care plan dated 7/11/17 revealed Resident #3 was an extensive assist and required two persons assist with bathing, bed mobility and transfers. Review of the Visual/Bedside Kardex Report revealed Resident #3 was extensive to total assist with bathing, transferring and two persons assist with transferring, turning, and positioning. Review of the Fall Risk Evaluation dated 8/8/17 revealed Resident #3 was a high fall risk. The Progress Notes dated 9/16/17 documented, .called to resident's room at approx. (approximately) 0540 (5:40 AM) by CNA (Certified Nursing Assistant) who stated resident had fallen out of her bed while CNA was providing care .resident noted to be laying supine, in her bed, with bed at waist high. Resident was assessed by this nurse .Resident guarding R (right) side of body, specifically R upper arm and R hip . Resident #3 was transferred to the hospital, later transferred to a higher level of care hospital and was admitted to the neurocritical care stepdown unit for every 2 hour monitoring. The computerized tomography (CT) report dated 9/16/17 documented, .Intracerebral Hemorrhage . The comparative CT dated 9/16/17 documented, .There is .small bilateral posterior Subdural hematomas measuring a maximum of 3 mm (millimeters) in thickness on the right and 5 mm on the left .These are non significant change compared to the prior study . The Radiology report dated 9/16/17 documented, .Left arm pain post fall .AP (anterior and posterior) .lateral views of the left humerus were obtained .IMPRESSION: Acute left clavicular fracture . Interview with Certified Nursing Assistant (CNA) #2 on 9/19/17 at 11:22 AM, in the conference room, CNA #2 was asked what happened that morning when Resident #3 fell . CNA #2 stated, .I went in to give her a bed bath .I proceeded to give her a bath .I turned her over to wash her bottom, I washed her up .I had reached back with one hand and had one hand on her, (I) was reaching back to get the diaper and I kind of loose (loosened) the hand I had on her .her legs was positioned off the bed when I turned her .I didn't have her tight .she flipped off the bed on to the floor I panicked and I looked on to the hall way there was an aide and a housekeeper that was standing in the hallway and I let both of them know that she had fell and to go get the nurse .I went back in there .she wasn't talking was awake .visible left side of her head a bump .no bleeding .I was waiting on the nurse she was laying on cold floor I picked her up . CNA #2 was asked did you pick her up by yourself. CNA #2 stated, Yes ma'am . CNA #2 was asked what happened then. CNA #2 stated, The nurse came in called the doctor . CNA #2 was asked if Resident #3 was one or two person assist for her bathing. CNA #2 stated, She is a two (two persons assist) for anything. CNA #2 was asked if anyone was helping her give Resident #3 a bath that morning. CNA #2 stated, No, ma'am. CNA #2 was asked how the facility lets the staff know if a resident was a one or two person assist. CNA #2 stated, It's in the ADLs (activity of daily living) we have to do . CNA #2 was asked if Resident #3 was mobile or could she turn herself. CNA #2 stated, No, ma'am . Interview with Registered Nurse (RN) #1 on 9/19/17 at 4:38 PM, in the conference room, RN #1 was asked if she could describe what happened to Resident #3. RN #1 stated, It was about 5:40 in the morning .one of the CNA working that night .yelled for me .said we need you in this room .walked into room Resident #3 was in her bed, there was one CNA in her room (named CNA #2) .she (Resident #3) was lying on her back on her bed .I saw she had a bruise on her forehead with swelling .asked what had happened .she (CNA #2) told me that she was giving (named Resident #3) a bed bath (named Resident #3) was on her right side of the bed naked and her words (CNA #2's explanation) the next thing she knew she fell out of the bed on the floor .when I started to do head to toe (assessment) on her that's when she started guarding her right upper arm, shoulder area .and right hip .I called the Nurse Practitioner .received orders for x-ray. RN #1 was asked if Resident #3 was one or two person assist. RN #1 stated, She is two person Hoyer lift and max assist for ADL .two (two persons assist) . RN #1 was asked how the CNAs are made aware what assistance residents need. RN #1 stated, It's put in their care plan and it shows up on the CNAs' P(NAME) (plan of care) . RN #1 was asked if a resident falls out of bed, what should happen. RN #1 stated, The nurse is supposed to immediately get notified before the resident gets moved .the resident has to be assessed by the nurse. RN #1 was asked how did Resident #3 get back in the bed. RN #1 stated, The CNA (referring to CNA #2) put her back in the bed by herself . A phone interview with Nurse Practitioner (NP) #1 on 9/20/17 at 7:15 AM, NP #1 was asked about the incident concerning Resident #3's fall. NP #1 stated, .I was on call .family wanted her to go to the hospital .ordered transfer . Interview with the Director of Nursing (DON) on 9/20/17 at 8:33 AM, in DON's office, the DON was asked how Resident #3 fell . The DON stated, .I questioned (named CNA #2) over the phone .said she was giving Resident #3 care and she was on her right side, had one hand on her hip, reached back with the other hand to get the adult brief, raised the other hand off the hip area and she fell . She did say her left leg was dangling off the bed . The DON was shown Resident #3's care plan and was asked if Resident #3 was one or two person assist with bathing, transfers and turning. The DON stated, She is an assist of two. The DON was asked if that morning, Resident #3 had one or two people assisting with Resident #3's bath. The DON stated, It was just (named CNA #2) .she was alone . The DON was asked did she follow the care plan. The DON stated, No .said she just panicked .I asked why she moved her .said she was naked and didn't want her on the cold floor .and she was scared . Interview with the Administrator on 9/20/17 on 10:21 AM, in the Administrator's office, the Administrator was asked about Resident #3's fall on September 16th 2017. The Administrator stated, .had a bowel movement .had one hand on her side and turned to reach for something and legs were crossed over .and rolled off .said she panicked .she said she picked her up and put her back on the bed. I asked her why she picked her up and she said she (Resident #3) was laying there naked on the floor . The Administrator was asked what should have been done. The Administrator stated, Should have called for the nurse. The Administrator was asked if the facility's fall policy was followed. The Administrator stated, No, ma'am. A telephone interview with Resident #3's attending physician on 9/20/17 at 1:20 PM, the attending physician was asked if Resident #3 had a head injury or fracture before the 9/16/17 incident. The attending physician stated, Not that I'm aware of .don't think so The attending physician was asked would her falling from the bed contribute to Resident #3 having a subdural hematoma and a clavicular fracture. The attending physician stated, Yes of course . The failure to provide two person assist with care resulted in actual harm when Resident #3 sustained a fall which resulted in an intracerebral hemorrhage that formed a subdural hematoma on the brain and a left clavicular fracture.

Based on medical record review, observation, and interview, the facility's Quality Assessment and Assurance Committee (QAA) failed to have an effective ongoing quality program that identified, developed, implemented, and monitored appropriate plans of action to correct issues. The failure to provide two person assist with care resulted in actual harm when Resident #3 sustained a fall which resulted in an [MEDICATION NAME] hemorrhage (an emergency condition in which a ruptured blood vessel causes bleeding inside the brain) that formed a subdural hematoma (a blood clot) on the brain and a left clavicular fracture (broken collar bone). The findings included: 1. The QAA Committee failed to ensure that care plan interventions were implemented to prevent falls and injury for residents. The failure to provide two person assist with care resulted in actual harm when Resident #3 fell and sustained a bilateral parietal subdural hematoma and left clavicular fracture. Refer to F282 and F323. 2. The QAA Committee failed to ensure that a comfortable and sanitary environment was maintained in resident rooms. Refer to F253 The deficient practice of F253 is a repeat deficient practice for failure to ensure housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. The facility was cited F253 on the recertification survey on 6/30/16. 3. The QAA Committee failed to ensure monitoring for behaviors and side effects for residents. Refer to F329. The deficient practice of F329 is a repeat deficient practice for failure to ensure that each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used without adequate monitoring. The facility was cited F329 on the recertification survey on 6/30/16. Interview with the Administrator on 9/21/17 at 2:56 PM, in the Administrator's office, the Administrator stated they had recognized falls as a problem, and were not following through. The Administrator stated, we have a DON (Director of Nursing) now, she stays on the floor, the falls have gotten much better The Administrator was asked if she had identified anything regarding repeat deficiencies like environment. The Administrator confirmed this repeat deficiency and stated, We have like painting . The Administrator was asked should the beds have rust on them. The Administrator stated, No, ma'am .we have been ordering beds .ordering two a month .we will fix that . The Administrator was asked if there had been any concerns identified in QA with staff not following care plans. The Administrator stated, No, not that I am aware. The Administrator was asked when were falls identified in the QA committee as a concern. The Administrator stated, .May (2017) . The Administrator was asked if the facility had repeat deficiencies, would the QA program have been effective. The Administrator stated, No, I don't think so .

Based on policy review, medical record review, review of fall reports, observation, and interview, the facility failed to ensure interventions were in place to prevent falls and injury for 1 of 18 (Resident #22) sampled residents reviewed of the 59 residents included in the stage 2 review. The failure of the facility to implement care plan interventions after two falls from a wheelchair (w/c) resulted in actual harm when Resident #22 had a third fall from a w/c, in the hall, sustaining a hematoma and a laceration to her forehead that required sutures. The findings included: The facility's Falls - Clinical Guidelines policy documented, 1. Upon admission and quarterly a Fall Risk Evaluation will be completed for each resident. As part of the initial assessment, the interdisciplinary team should attempt to identify individuals with a history of falls and risk factors for subsequent falling. 4. If a fall should occur (witnessed or un-witnessed), the staff will complete the Falls Investigative Worksheet as well as an Incident Report. The plan of care will be updated at that time with a review of current interventions. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 14 day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/8/15 and the quarterly MDS with an ARD of 5/21/15 documented, Resident #22 was cognitively severely impaired for daily decision making. The fall report dated 2/17/15 documented, .fell forward. Injuries Observed at Time of Incident was hematoma to scalp. There was no care plan intervention put in place after this fall. The fall report dated 4/4/15 documented, .resident lying on floor. Injuries Observed at Time of Incident was hematoma to scalp. There was no care plan intervention put in place after this second fall. The fall report dated 6/14/15 documented, resident. fell forward hitting forehead. MD (Medical Doctor) made aware and order given to send to. ER (emergency room ) for eval (evaluation). Injuries Observed at Time of Incident: Laceration to face. A telephone order dated 6/14/15 documented, 1) Send to (named ER) s/p (status [REDACTED]. The care plan dated 6/16/15 documented, Resident is at risk for falls. Impaired mental and physical status. Unaware of safety needs. 6/14/15 fall. sent to er. no medication change at this time. Be sure call light is within reach and encourage to use it for assistance as needed. appropriate Non-skid shoes. non-skid socks when out of bed. Fall. Small laceration to forehead. Send to ER foe (for) evaluation. needs a safe environment with dry floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light. Keep personal items within reach. Resident #22's falls were while she was sitting in her wheelchair in the hall and did not occur in her room. The facility failed to put care plan interventions in place after falls from the w/c, in the hall, to prevent further falls. Observations in the restorative dining room on 6/16/15 at 5:37 PM and 6/17/15 8:06 AM, revealed Resident #22 seated in wheelchair with sutures noted in her forehead. Interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 6/17/15 beginning at 3:50 PM, in the conference room, the DON and ADON were asked, if the interventions were appropriate for a severely impaired resident? The ADON stated, Call light in reach, that just gets pulled over automatically for everybody. I would say yes they are appropriate for her except for the call light. Interview with the DON and the ADON on 6/17/15 beginning at 3:50 PM, in the conference room, the DON and the ADON were asked, what has been done to prevent Resident #22 from falling out of the wheelchair. The ADON stated, No, we haven't put anything in place to keep her from falling out the chair. The failure of the facility to implement care plan interventions after two falls from a w/c resulted in actual harm when Resident #22 had a third fall from a w/c, in the hall, sustaining a hematoma and a laceration to her forehead that required sutures.

Based on policy review, medical record review, review of fall reports, observation and interview, the facility failed to ensure interventions were in place to prevent falls and injury for 1 of 4 (Resident #22) sampled residents reviewed of the 4 residents with falls. The failure of the facility to implement care plan interventions after two falls from a wheelchair (w/c) resulted in actual harm when Resident #22 had a third fall from a w/c, in the hall, sustaining a hematoma and a laceration to her forehead that required sutures. The findings included: The facility's Falls - Clinical Guidelines policy documented, 1. Upon admission and quarterly a Fall Risk Evaluation will be completed for each resident. As part of the initial assessment, the interdisciplinary team should attempt to identify individuals with a history of falls and risk factors for subsequent falling. 4. If a fall should occur (witnessed or un-witnessed), the staff will complete the Falls Investigative Worksheet as well as an Incident Report. The plan of care will be updated at that time with a review of current interventions. The facility's Falls - Clinical Protocol policy documented, .Falls should be categorized as: a. Those that occur while trying to rise from a sitting or lying to an upright position; b. Those that occur while upright and attempting to ambulate; and c. Other circumstances such as sliding out of a chair or rolling from a low bed to the floor. Falls should be identified as witnessed or unwitnessed events. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. If interventions have been successful in preventing falling, staff will continue with current approaches or reconsider whether these measures are still needed. If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling. The facility's Falls and Fall Risk, Managing policy documented, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 14 day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/8/15 and the quarterly MDS with an ARD of 5/21/15 documented, Resident #22 was cognitively severely impaired for daily decision making. The Fall Risk Assessments dated 3/26/15 and 5/19/15 documented a score of twelve which indicated the resident was a high risk for falls. The fall report dated 2/17/15 documented, .fell forward. Injuries Observed at Time of Incident was hematoma to scalp. There was no care plan intervention put in place after this fall. The fall report dated 4/4/15 documented, .resident lying on floor. Injuries Observed at Time of Incident was hematoma to scalp. There was no care plan intervention put in place after this second fall. The fall report dated 6/14/15 documented, resident. fell forward hitting forehead. MD (Medical Doctor) made aware and order given to send to. ER (emergency room ) for eval (evaluation). Injuries Observed at Time of Incident: Laceration to face. A telephone order dated 6/14/15 documented, 1) Send to (named ER) s/p (status [REDACTED]. The care plan dated 6/16/15 documented, Resident is at risk for falls. Impaired mental and physical status. Unaware of safety needs. 6/14/15 fall. sent to er. no medication change at this time. Be sure call light is within reach and encourage to use it for assistance as needed. appropriate Non-skid shoes. non-skid socks when out of bed. Fall. Small laceration to forehead. Send to ER foe (for) evaluation. needs a safe environment with dry floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light. Keep personal items within reach. Resident #22's falls were while she was sitting in her wheelchair in the hall and did not occur in her room. The facility failed to put care plan interventions in place after falls from the w/c, in the hall, to prevent further falls. Observations in the restorative dining room on 6/16/15 at 5:37 PM and 6/17/15 8:06 AM, revealed Resident #22 seated in wheelchair with sutures noted in her forehead. Interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 6/17/15 beginning at 3:50 PM, in the conference room, the DON and ADON were asked, if the interventions were appropriate for a severely impaired resident? The ADON stated, Call light in reach, that just gets pulled over automatically for everybody. I would say yes they are appropriate for her except for the call light. The ADON were asked, what was the facility's fall protocol. The ADON stated, Put immediate intervention in place so it doesn't happen again. I encourage nurses to investigate then, to find the root cause. You can't just have an intervention thrown into the care plan. The DON and the ADON were asked, what had been done to prevent Resident #22 from falling out of the wheelchair. The ADON stated, We haven't put anything in place to keep her from falling out the chair. The failure of the facility to implement care plan interventions after two falls from a w/c resulted in actual harm when Resident #22 had a third fall from a w/c, in the hall, sustaining a hematoma and a laceration to her forehead that required sutures.

Based on medical record review, review of meal tray cards, observation and interview, it was determined the facility failed to follow the plan of care intervention of supplements for unplanned weight loss for 2 of 18 (Residents #105 and 98) sampled residents reviewed of the 31 residents included in the stage 2 review. The facility's failure to timely implement the Registerd Dietician's (RD) recommendations and the physician's orders [REDACTED].#105. The findings included: 1. Medical record review for Resident #105 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The dietary progress notes dated 11/1/13 documented Resident #105's admission weight was 120.2 pounds (#) and height of 63 inches. Review of the care plan dated 12/2/13 documented, "...Potential for weight loss r/t (related to) impaired mental and physical status and disease process... provide and serve supplements as ordered..." Review of the "Weights and Vitals Summary" for Resident #105 documented an admission weight of 120.2 # on 10/31/13, a weight of 121.4# on 11/1/13, a weight of 119.4# on 12/8/13, a weight of 114.4# on 1/8/14 and a weight of 103.6# on 2/18/14, resulting in a significant weight loss of 9 percent (%) in 6 weeks; a weight of 104.4# on 2/25/14 and a weight of 95.6# on 3/4/14, resulting in a significant weight loss of 8% in 1 week. Review of a physician's orders [REDACTED]. Review of the February and March, 2014 Medication Administration Records (MAR) documented that the physician's orders [REDACTED]. There was no documentation the resident received Health Shakes from 2/14/14 until 3/1/14. During an interview in the Director of Nursing's (DON) office on 4/2/14 at 4:05 PM, the DON was asked where staff documented that Resident #105 received the Health Shakes from 2/14/14 through (-) 2/28/14. The DON stated, "I can't find it. The nurse noted the order in her nurse's note but it never got transcribed on the MAR." During a telephone interview on 4/2/14 at 6:15 PM, Resident #105's attending physician, who is the Medical Director, was asked if she had any knowledge about the resident's status and weight loss. Resident #105's attending physician stated, "I know she had some weight loss issues, but the FNP (Family Nurse Practitioner) sees them for me." Resident #105's attending physician was informed that an order was written on 2/14/14 for Health Shakes, but there was no documentation on the February MAR indicated [REDACTED]. Resident #105's attending physician stated, "We write the order and if it doesn't get done, we write it again." The facility's failure to timely implement the RD's recommendations and the physician's orders [REDACTED].#105. 2. Medical record review for Resident #98 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of the care plan dated 1/18/14 documented, "...Potential for weight loss r/t (related to) impaired thought process... provide and serve supplements as ordered..." Review of the meal tray cards that arrived with the resident's breakfast and dinner trays on 4/1/14 documented, "...Magic Cup BID with all meals X 30 Days... Health Shake." Observations in the meadows dining room on 4/1/14 at 8:05 AM, 11:55 AM and 6:20 PM and on 4/2/14 at 12:00 PM, revealed the resident being assisted with his meals that included Health Shakes but no Magic Cups. During an interview in the meadows hallway on 4/1/14 at 6:25 PM, the Dietary Manager (DM) was asked if the resident received his Magic Cup as ordered with his dinner tray. The DM stated, "No." During an interview in the meadows dining room on 4/2/14 at 12:00 PM, Certified Nursing Assistant (CNA) #4 was asked if Resident #98 received his Magic Cup with his noon meal. CNA #4 stated, "No."

Based on medical record review, review of the person at risk (PAR) meeting minutes, observation and interview, it was determined the facility failed to timely implement interventions recommended by the Registered Dietician (RD) and ordered by the Family Nurse Practitioner (FNP) for 1 of 3 (Resident #105) sampled residents of the 6 residents reviewed who experienced weight loss. The facility's failure to timely implement RD recommendations and physician's orders [REDACTED].#105. The findings included: Medical record review for Resident #105 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The dietary progress notes dated 11/1/13 documented Resident #105's admission weight was 120.2 pounds (#) and height of 63 inches. Review of the care plan dated 12/2/13 documented, "...Potential for weight loss r/t (related to) impaired mental and physical status and disease process... provide and serve supplements as ordered..." Review of the "Weights and Vitals Summary" for Resident #105 documented an admission weight of 120.2 # on 10/31/13, a weight of 121.4# on 11/1/13, a weight of 119.4# on 12/8/13, a weight of 114.4# on 1/8/14 and a weight of 103.6# on 2/18/14, resulting in a significant weight loss of 9 percent (%) in 6 weeks; a weight of 104.4# on 2/25/14 and a weight of 95.6# on 3/4/14, resulting in a significant weight loss of 8% in 1 week. Review of the PAR meeting minutes dated 2/12/14 documented, "ST (Speech Therapy) to eval (evaluate) to possible downgrade diet (Pocketing food) Health Shakes tid (three times a day) between meals." Review of a physician's orders [REDACTED]." The care plan dated 12/2/13 for potential for weight loss had no new interventions added to reflect the new orders. Review of the February and March, 2014 Medication Administration Records (MAR) documented that the physician's orders [REDACTED]. There was no documentation of any interventions implemented for the weight loss from 2/14/14 until 3/1/14. Review of a RD progress note dated 2/19/14 documented, "Wt. (weight) 105.6 (2/10/14), 103.6# (2/18/14), (Symbol for decrease) 7.6% X (times) 1 month & (and) 1.9% X 1 week... ST to eval diet d/t (due to) some pocketing. HS (Health Shake) added tid b/w (between) Meals..." Review of a physician's progress note dated 2/24/14 documented, "...She (Resident #105) has intermittent decreased appetite. Health shakes ordered tid on 2/14/14 c (with) Speech Therapy evaluating... low [MEDICATION NAME] and total protein on 2/20/14... total protein 5.1, [MEDICATION NAME] 3.1..." The normal range value for total protein is 6.0 to 8.3 grams per deciliter (g/dl) and [MEDICATION NAME] is 3.4 to 5.4 g/dl. Medical record review revealed no documentation that a Speech Therapy evaluation was done during the month of February, 2014. Review of a physician's progress note dated 3/4/14 documented, "...Staff request speech eval or diet downgrade d/t food falling out of pts (patient's) mouth when eating... " Review of the physician's orders [REDACTED]. Review of a physician's orders [REDACTED]. Observations in the meadows dining room on 4/1/14 at 8:05 AM, revealed Resident #105 seated in a chair with her head in a downward position. Certified Nursing Assistant (CNA) #3 was assisting with her meal. Resident #105 consumed 100% of her pureed diet including a Health Shake. Observations in Resident #105's room on 4/1/14 at 6:20 PM, revealed Resident #105 in her room with her 2 daughters. Resident #105 was in an upright position, head tilted downward, and her daughters were assisting her with her meal. Resident #105 consumed 100% of her meal. Observations in the meadows dining room on 4/2/14 at 12:00 PM, revealed Resident #105 was seated in a chair with her head in a tilted downward and was being assisted with her meal. Resident #105 consumed 100% of her meal. During an interview in the meadows dining room on 4/1/14 at 11:25 AM, CNA #2 was asked what type of assistance Resident #105 required. CNA #2 stated, "She's total care for everything. We have to assist her with eating, she's a poor eater and spits out a bunch of her food. She does better drinking." During an interview in the meadows nurses' station on 4/1/14 at 11:35 AM, Nurse #2 was asked what type of assistance Resident #105 required. Nurse #2 stated, "She's a poor eater and requires feeding. She usually only eats 50 to 70% of her meals." During an interview in the therapy room on 4/1/14 at 11:45 AM, the Director of Rehabilitation (Rehab) was asked what type of progress the resident made with therapy. The Director of Rehab stated, "She didn't do very well because she was very poor at following commands. Speech Therapy did change her diet due to swallowing problems." During an interview in the restorative dining room on 4/1/14 at 10:45 AM, the Speech Language Pathologist (SLP) was asked about the care she provided for Resident #105. The SLP stated, "The staff referred her to help prevent weight loss. The staff was concerned. We tried to keep her on her regular diet, but determined that due to the resident's forward flexed neck and tongue thrust movements, we weren't able to keep food leakage from occurring. She couldn't tolerate having her head in an upright position. We downgraded her diet to Pureed." The SLP was asked when she began treating the resident. The SLP stated, "We started seeing her sometime in March (2014)." During an interview in the meadows hall on 4/1/14 at 12:25 PM, the FNP was asked if she had any concerns regarding Resident #105's weight. The FNP stated, "Yes, I've been very concerned." During an interview in the restorative dining room on 4/2/14 at 3:37 PM, the RD was asked if she knew of specific recommendations/interventions for Resident #105. The RD stated, "I know she was targeted for significant weight loss, and we started her on Health Shakes and recommended ST (Speech Therapist) to evaluate." The RD was asked if the resident received Health Shakes in February 2014. The RD stated, "Maybe, I didn't notice, there wasn't a clear order on it so I clarified it." During an interview in the Director of Nursing's (DON) office on 4/2/14 at 4:05 PM, the DON was asked what the process was for physician's orders [REDACTED]. Therapy orders are placed in their (therapy) doors. We go over the orders in clinical meeting. If it's for supplements, we notify dietary." The DON was asked who is responsible for transcribing the order onto the MAR. The DON stated, "The nurse that signed the order off." The DON was asked where staff documented that Resident #105 received the Health Shakes from 2/14/14-2/28/14. The DON stated, "I can't find it. The nurse noted the order in her nurse's note but it never got transcribed on the MAR." During a telephone interview in the DON's office on 4/2/14 at 6:15 PM, Resident #105's attending physician, who is the Medical Director, was asked if she had any knowledge about the resident's status and weight loss. Resident #105's attending physician stated, "I know she had some weight loss issues, but the FNP sees them for me." Resident #105's attending physician was informed that an order was written on 2/14/14 for Health Shakes and ST evaluation, but there was no documentation on the February MAR indicated [REDACTED]. Resident #105's attending physician stated, "We write the order and if it doesn't get done, we write it again. Even if I was there, I wouldn't be able to prove she got it. If they didn't do it, they didn't do it. That's not good, if it's not there, they didn't do it. There's no way to prove it. The order had to be rewritten." The facility's failure to timely implement the RD recommendations and the physician's orders [REDACTED].#105.

Based on medical record review, review of the person at risk (PAR) meeting minutes, observation and interview, it was determined the facility failed to timely implement the PAR recommendation and physician orders [REDACTED].#105) sampled residents of the 30 residents reviewed receving therapy. The facility's failure to timely implement physician's orders [REDACTED].#105. The findings included: Medical record review for Resident #105 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The dietary progress noted dated 11/1/13 documented Resident #105's admission weight was 120.2 pounds (#) and height of 63 inches. Review of the care plan dated 12/2/13 documented, "...Potential for weight loss r/t (related to) impaired mental and physical status and disease process... provide and serve supplements as ordered..." Review of the "Weights and Vitals Summary" for Resident #105 documented an admission weight of 120.2 # on 10/31/13, a weight of 121.4# on 11/1/13, a weight of 119.4# on 12/8/13, a weight of 114.4# on 1/8/14 and a weight of 103.6# on 2/18/14, resulting in a significant weight loss of 9 percent (%) in 6 weeks; a weight of 104.4# on 2/25/14 and a weight of 95.6# on 3/4/14, resulting in a significant weight loss of 8% in 1 week. Review of the PAR meeting minutes dated 2/12/14 documented, "ST (Speech Therapy) to eval (evaluate) to possible downgrade diet (Pocketing food) Health Shakes tid (three times a day) between meals." Review of a physician's orders [REDACTED]." Review of a RD progress note dated 2/19/14 documented, "Wt. (weight) 105.6 (2/10/14), 103.6# (2/18/14), (Symbol for decrease) 7.6% X (times) 1 month & (and) 1.9% X 1 week... ST to eval diet d/t (due to) some pocketing. HS (Health Shake) added tid b/w (between) Meals..." Review of a physician's progress note dated 2/24/14 documented, "...She (Resident #105) has intermittent decreased appetite. Health shakes ordered tid on 2/14/14 c (with) Speech Therapy evaluating..." Medical record review revealed no documentation that a Speech Therapy evaluation was done during the month of February, 2014. Review of a physician's progress note dated 3/4/14 documented, "...Staff request speech eval or diet downgrade d/t (due to) food falling out of pts (patient's) mouth when eating... " Review of the physician's orders [REDACTED]. Review of the speech therapy plan of care dated 3/4/14 documented, "Reason for referral... she receives a mechanical soft diet with regular liquids and requires full assistance for all po intake... report and observation from SLP (Speech Language Pathologist), pt (patient) sits upright with her head held down, with her chin almost touching her chest. Food is observed to spill anteriorly and also to push food out of mouth anteriorly, using her tongue. Shafety (safety) awareness is decreased, as judged from SLP observation... therapy necessary for dysphagia (difficulty swallowing) (oral phase). Without therapy patient at risk for decreased po intake and weight loss/poor nutrition..." Observations in the meadows dining room on 4/1/14 at 8:05 AM, revealed Resident #105 seated in a chair with her head in a downward position. Certified Nursing Assistant (CNA) #3 was assisting with her meal. Resident #105 consumed 100% of her pureed diet including a Health Shake. Observations in Resident #105's room on 4/1/14 at 6:20 PM, revealed Resident #105 in her room with her 2 daughters. Resident #105 was in an upright position, head tilted downward, and her daughters were assisting her with her meal. Resident #105 consumed 100% of her meal. Observations in the meadows dining room on 4/2/14 at 12:00 PM, revealed Resident #105 was seated in a chair with her head in a tilted downward and was being assisted with her meal. Resident #105 consumed 100% of her meal. During an interview in the therapy room on 4/1/14 at 11:45 AM, the Director of Rehabalitation (Rehab) was asked what type of progress the resident made with therapy. The Director of Rehab stated, "She didn't do very well because she was very poor at following commands. Speech Therapy did change her diet due to swallowing problems." During an interview in the restorative dining room on 4/1/14 at 10:45 AM, the SLP was asked about the care she provided for Resident #105. The SLP stated, "The staff referred her to help prevent weight loss. The staff was concerned. We tried to keep her on her regular diet, but determined that due to the resident's forward flexed neck and tongue thrust movements, we weren't able to keep food leakage from occurring. She couldn't tolerate having her head in an upright position. We downgraded her diet to Pureed." The SLP was asked when she began treating the resident. The SLP stated, "We started seeing her sometime in March (2014)." During an interview in the meadows hall on 4/1/14 at 12:25 PM, the FNP was asked if she had any concerns regarding Resident #105's weight. The FNP stated, "Yes, I've been very concerned." During an interview in the restorative dining room on 4/2/14 at 3:37 PM, the RD was asked if she knew of specific recommendations/interventions for Resident #105. The RD stated, "I know she was targeted for significant weight loss, and we started her on Health Shakes and recommended ST (Speech Therapist) to evaluate." During an interview in the Director of Nursing's (DON) office on 4/2/14 at 4:05 PM, the DON was asked what the process was for physician's orders [REDACTED]. Therapy orders are placed in their (therapy) doors. We go over the orders in clinical meeting..." The DON was asked who is responsible for transcribing the order. The DON stated, "The nurse that signed the order off." During a telephone interview in the DON's office on 4/2/14 at 6:15 PM, Resident #105's attending physician, who is the Medical Director, was asked if she had any knowledge about the resident's status and weight loss. Resident #105's attending physician stated, "I know she had some weight loss issues, but the FNP sees them for me." Resident #105's attending physician was informed that an order was written on 2/14/14 for ST evaluation, but there was no documentation of the evaluation in February, and a second order was written on 3/4/14 for ST to evaluate. Resident #105's attending physician stated, "We write the order and if it doesn't get done, we write it again. Even if I was there, I wouldn't be able to prove she got it. If they didn't do it, they didn't do it. That's not good, if it's not there, they didn't do it. There's no way to prove it. The order had to be rewritten." The facility's failure to timely implement the recommendations and the physician's orders [REDACTED].#105.

Complaint investigation for TN 449 Based on review of the "National Pressure Advisory Panel Pressure Ulcer Prevention QUICK REFERENCE GUIDE", policy review, medical record review, and interview, it was determined the facility failed to prevent and identify the development of pressure sore/ulcer and/or failed to accurately assess pressure ulcers for 2 of 3 (Resident #2 and 3) sampled residents with a pressure ulcer. The failure to identify and prevent skin breakdown prior to the development of an unstageable pressure ulcer resulted in actual harm to Resident #2. The findings included: 1. Review of the "National Pressure Advisory Panel Pressure Ulcer Prevention QUICK REFERENCE GUIDE" documented, "p. (page) 9...Unstageable / Unclassified: Full thickness skin or tissue loss-depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. p. 12... 3. Inspect skin regularly for signs of redness... Ongoing assessment of the skin is necessary to detect early signs of pressure damage. 4. Skin inspection should include assessment for localized heat, [MEDICAL CONDITION], or induration (hardness), especially in individuals with darkly pigmented skin... Suspected Deep Tissue Injury (SDTI) - depth unknown... Purple or maroon localized area of discolored area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear... Evolution may include a thin blister over a dark wound bed... Evolution may be rapid exposing additional layers of tissue even with optimal treatment..." 2. Review of the facility's "Pressure Ulcers/Skin Breakdown - Clinical Protocol" policy documented, "...the nurse shall assess and document/report the following... Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue... The following information should be recorded in the resident's medical record... Wound appearance, including wound bed, edges, presence of drainage... All assessment data (i.e., (example) wound bed color, size, drainage...) obtained when inspecting the wound..." Review of the facility's Pressure Ulcer Risk Assessment" policy documented, "...Nurses will conduct skin assessments at least weekly to identify changes..." 3. Medical record review for Resident #2 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. (dressing) QOD (every other day)..." Review of the nurses' progress notes documented the following: a. "...1/21/13 F/U (follow up) area to R Knee dressing Dry/Intact..." b. "1/24/13 5 AM... F/U area to R Knee. Dsg (dressing) clean, dry, and intact... 1000 A (AM) Skin assessment done... area noted to R knee tx (treatment nurse) notified..." There was no assessment or description of this wound and no mention of this wound prior to 1/21/13. The wound to the R knee was not identified until it was unstageable which resulted in actual harm. Review of the weekly skin assessments did not document an area to the R knee, until 2/7/13. Review of the "WEEKLY SKIN INTEGRITY REVIEW" dated 2/7/13 documented, "...drsg to... R Knee dry & intact open area to R knee..." Review of the medical record documented Resident #2 was hospitalized from [DATE] to (-) 2/5/13. Review of the "WOUND TREATMENT & PROGRESS RECORD" assessment form dated 2/5/13 documented wounds to the left (L) hip, R lateral foot, L foot, L foot 1st metatarsal, L lateral thigh, R lower extremity, and R knee. There were no further assessments documented after 2/12/13 until 4/4/13. Review of the "WOUND TREATMENT & PROGRESS RECORD" assessment form dated 4/4/13 documented an unstageable wound to the R lateral foot and a stage 3 to the R knee. These wounds did not worsen from 2/12/13 through 4/4/13. (On 2/12/13 the R lateral foot had been unstageable SDTI and the R knee had been Unstageable wound). Observations in Resident #2's room on 4/16/13 at 10:40 AM, the treatment nurse performed a dressing change to Resident #2's R inner knee. The wound was approximately 2 centimeters (cm) in diameter, pink to the center, with a small amount of yellow to the edge of the wound. The R lateral foot was approximately 1cm in diameter, with brown scabbed area to center, yellow scabbed area surrounding, and appeared to be drying. There were no other wounds present. During an interview in the conference room on 4/16/13 at 12:00 PM, the treatment nurse stated, "This is all the documentation I have, or that I can find, the treatment nurse resigned, and I took over treatments in April (2013)." During an interview in the conference room on 4/16/13 at 1:00 PM, the treatment nurse stated these wounds (L hip, L foot, L foot 1st metatarsal, L lateral thigh, and R lower extremity) healed, were marked off the assessment form and the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview in the conference room on 4/16/13 at 2:55 PM, the Director of Nursing (DON) was asked about the unstageable wound to the R inner knee. The DON stated, "Yes, should be something present on the skin, DTI or something, prior to the wound being unstageable... were issues with previous treatment nurse following through... did not doubt her doing treatments, documentation was missing... there were documentation issues... she chose to resign..." During an interview in the conference room on 4/17/13 at 12:15 PM, the DON stated, "...We QA'd (quality assurance) the issues with with wound care in February (2013), that is why she (previous treatment nurse) is no longer here..." The failure to identify and prevent skin breakdown prior to the development of an unstageable pressure ulcer resulted in actual harm to Resident #2. 4. Medical record review for Resident #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the "WEEKLY SKIN INTEGRITY REVIEW" dated 4/1/13 documented, DTI - sacrum; heels boggy... New (checked)..." Review of the "WOUND TREATMENT & PROGRESS" assessment form dated 4/4/13 documented, "DTI... pink blanchable intact..." to the sacrum. The assessment of the wound as being DTI was inaccurate, it is actually a stage 1 according to the Nurse Consultant. During an interview in the conference room on 4/16/13 at 5:10 PM, the Nurse Consultant was asked what she would consider to be a DTI. The Nurse Consultant stated, "...a purple or dark red blister..." The Nurse Consultant was asked would she consider a pink, blanchable, intact area to be. The Nurse Consultant stated, "Would consider that a Stage 1, not a Deep Tissue Injury."