Every finding on record at Legacy Nursing and Rehabilitation of Port Allen

Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from neglect for 1 (#1) of 5 residents reviewed for transportation. This was evidenced by: 1. S3TD neglecting to appropriately secure Resident #1 into the facility van; and2. S3TD neglecting to notify the facility when Resident #1 fell out of the moving van. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1, a wheelchair dependent resident, on 02/17/2026 at 12:30 p.m. when S3TD failed to appropriately secure Resident #1 into the facility's transportation van. As S3TD was driving out of the facility's parking lot, the van hit a pothole, the van's back door opened, ramp fell, and Resident #1 rolled out of the van onto the gravel driveway. S3TD stopped the van, assisted Resident #1 back into the van, and drove away without notifying the facility. S3TD's neglect placed Resident #1 at a likelihood for serious injury, harm, impairment, or even death. The facility implemented corrective actions which were completed prior to the State Agency's investigation; thus, it was determined to be a Past Noncompliance citation. S1ADM was notified of the Past Noncompliance Immediate Jeopardy on 03/18/2026 at 11:47 a.m.Review of the facility's policy undated and titled Transportation Policy Acknowledgement Form revealed the following:Emergency occurrence's during transport: Always notify the Administrator and/or DON of any incident or accident that occurs while on the van or during the transportation process. Reporting Incidents and Accidents: All incidents and accidents, no matter how minor or major, must be reported immediately to the administrator- wrecks, resident injury, employee injury, falls. Review of the facility's policy undated and titled Abuse Reporting and Investigation Policy and Procedure revealed the following:E. Neglect is defined as 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. Neglect may include, but is not limited to:Failure to provide timely, consistent, safe, adequate, and appropriate care and services as needed. Review of Resident #1's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Ataxia. Further review revealed the resident required use of a wheelchair for mobility. Review of Resident #1's Quarterly MDS with ARD of 12/09/2025 revealed Resident #1 had a BIMS of 9, which indicated the resident was moderately impaired. Further review revealed Resident #1 required the use of a wheelchair for mobility. Review of Resident #1's current care plan revealed he required staff assistance for all ADLs with use of a wheelchair due to unsteady ataxic gait. Review of the facility's incident report dated 02/17/2026 at 12:30 p.m. revealed the following:Resident: Resident #1Incident Location: OutsidePerson Preparing Report: S2DONIncident Description: As S3TD was leaving the parking lot, the rear door of the van opened which led to Resident #1 rolling backwards into the parking lot.Injury: No injuries Review of S1ADM's written statement dated 02/17/2026 at 12:30 p.m. revealed the following:On 02/17/2026 at 12:30 p.m., S3TD was transporting Resident #1 when he fell out the van. Video footage was reviewed, incident occurred in gravel side of the parking lot. At 12:31 p.m. S3TD put Resident #1 back into the facility van, and at 12:32 p.m. the van left the facility's parking lot. S3TD was observed placing Resident #1 in a regular van seat versus the wheelchair area. S2DON and S8TD met S3TD at Resident #1's appointment. S2DON assessed Resident #1 and no injuries were noted. S2DON brought S3TD back to the facility S3TD was sent home pending investigation. After investigation it was determined S3TD did not follow safety procedures and did not report the incident immediately and was terminated as a result. Review of S3TD's personnel record revealed a termination date of 02/18/2026. Review of the Facilities Vehicle Safety Checklist dated 02/04/2026 revealed the Facility Van was inspected by S11CM. All of the vehicles doors were working properly. All seat belts, including the wheelchair seat belts were working properly and available. Wheelchair straps were available in the vehicle. On 03/17/2026 at 2:54 p.m., a telephone interview was conducted with S11CM. He stated he inspected the Facility Transport Van on 02/04/2026 and completed the Vehicle Safety Checklist at that time. He stated all doors on the van were working properly, the back door latch was not loose, the ramp latches/locks were working properly, and all seat belts and safety straps were available and working appropriately. On 03/17/2026 at 9:03 a.m., a telephone interview was conducted with S3TD. He stated he was responsible for transporting residents in the facility van. He stated he received training on how to safely transport and safely secure wheelchair bound residents in the van. He stated he was driving the facility van on 02/17/2026 when Resident #1 fell out of the van. He stated he loaded Resident #1 in his wheelchair into the back of the van. He stated he did not have the appropriate wheelchair seat belt or safety straps to transport the resident, so he did the best he could. He denied reporting he did not have the appropriate belt or straps to administration prior to loading the resident into the van. He stated he placed the wheelchair between the two back seats. He stated he secured the seat belt from the van seat onto the side of the resident's wheelchair, then wrapped it around the resident. He stated he fastened it to the seatbelt buckle. He stated the seat belt went around Resident #1 but it did not properly secure and lock Resident #1 in place. He stated he knew this wasn't the right way but it was the only way he could secure Resident #1 without having the appropriate wheelchair seat belt and straps. He stated he secured the ramp and the back door. He stated Resident #1 told him he had no injuries or pain. He stated he did not tell Administration since Resident #1 did not complain of pain or injuries at that time. He stated he knew he should have told them at the time the incident occurred. On 03/16/2026 at 1:25 p.m., an interview was conducted with Resident #1. He stated he had to be transported by the facility van to go to doctor's appointments. He stated on 02/17/2026, he fell out of the van when the van was leaving the facility. He stated S3TD loaded him in his wheelchair into the back of the van and placed a seat belt around him. He stated when they were leaving the facility I just fell out the door and I don't know how that happened. He stated he did not have any injuries or pain. He stated S2DON and S9NP checked on him after the incident occurred. On 03/16/2026 at 3:10 p.m., an interview was conducted with S1ADM. She stated she was aware of the incident that occurred with Resident #1 falling out of the facility transport van on 02/17/2026. She stated the facility was made aware of the incident when a passerby, who witnessed the incident, notified the facility. She stated she and S2DON reviewed the video surveillance which showed the facility van exiting the parking lot and it hit a pot hole, causing the back door to open, the ramp to come out and down, and Resident #1 to roll down the ramp, and land on the gravel road. She stated S3TD got out of the van and assisted Resident #1 in getting back into the van in a regular seat, then left the facility. She stated S2DON and S8TD went to meet S3TD and Resident #1 at his appointment. She stated S2DON assessed Resident #1 for any injuries or pain upon arriving to the doctor's office. She stated S8TD drove Resident #1 back to the facility in the facility transport van and S3TD rode back to the facility with S2DON in his private vehicle. She stated S3TD was sent home on suspension upon return to the facility. She stated S3TD was terminated on 02/18/2026 after investigation for not following facility's safe transportation policy of residents and for not reporting the incident immediately to Administration. She stated Resident #1 was assessed by S9NP and no injuries or pain were reported. She stated she called S10MS to request an inspection of the van. She stated she locked the keys to the van in her office drawer to ensure no one was able to use it. She stated the next morning she, S10MS, and S12CM assessed the van and found the latch of the back door to be loose. She stated all seatbelts and safety straps were present and in good repair in the van at that time. She stated S3TD informed her upon return to the facility that he didn't use the wheelchair seat belt or safety straps because they were not available in the van, but they were present in the van. She stated S3TD admitted to her he didn't use the appropriate seat belt or safety straps for the wheelchair. She stated after inspection, a new transport van was ordered and while waiting the facility acquired a van from their sister facility to transport residents and rented a van to accommodate Bariatric residents. She stated starting on 02/18/2026, she began weekly ride alongs with the approved transport drivers which would continue for 6 weeks, in-serviced the transport drivers on securing the residents with the appropriate seat belts and safety straps while in the van, performed a Vehicle Driver In Service Checklist on each approved transport driver, and scheduled a training with a 3rd party person to train all approved transport drivers on wheelchair securement and lift operations. She stated she also added gravel to the exit driveway to fill the pot hole. On 03/16/2026 at 3:10 p.m., an interview was conducted with S2DON. He stated he was made aware of the incident on 02/17/2026 where Resident #1 fell out of the van when a passerby, that witnessed the incident, came into the facility after the incident occurred and informed him of what they witnessed. He stated he reviewed the video surveillance and saw the van exiting the facility, hit a pot hole, causing the back door to open, the ramp come out, and Resident #1 roll down the ramp, and onto the gravel driveway. S2DON stated S3TD exited the van, assisted Resident #1 getting up off the gravel driveway, placed Resident #1 into a regular seat in the van, and drove off. He stated he asked S8TD to ride with him in his private vehicle to the destination the van was going. S2DON stated he assessed Resident #1 when he arrived to the destination. He stated he then had S8TD drive the facility van with Resident #1 back to facility. On 03/17/2026 at 8:05 a.m., an interview was conducted with S9NP. She stated the facility notified her Resident #1 had fallen out of the facility transport van on 02/17/2026. She stated she was informed S2DON assessed Resident #1 and he had no injuries, did not hit his head, and did not complain of any pain. She stated she did a full assessment on 02/18/2026 and noted no injuries and no complaints of pain. On 03/17/2026 at 9:52 a.m., an interview was conducted with S10MS. He stated the facility transport van was inspected monthly to ensure it was in good working condition. He stated part of that check was to ensure all seat belts and safety belts were present and in working condition. He stated the vehicle doors were also inspected to ensure they worked properly. He stated the van was inspected 02/04/2026 and all doors and seat belts were working properly. He stated the wheelchair seat belts and safety straps were in the van and in good repair. He stated no one reported to him an issue with the van door, seat belts, or safety straps prior to the incident on 02/17/2026. He stated no work orders had been placed regarding the van. He reviewed the facility Maintenance Log from 12/01/2025 through 03/17/2026 and confirmed no work orders were reported/listed regarding the facility transport van. He reviewed the facility's Monthly Facility Vehicle Inspection Form dated 01/01/2026 through 03/17/2026 and confirmed no issues were noted related to the doors or seat belts of the van. He stated S3TD never told him the back door to the van was not working properly or that he did not have wheelchair seat belts or safety straps. He confirmed he inspected the van after the incident with S1ADM and S12CM present. He stated he found that the back door latch was completely loose. He stated all seat belts were working properly, the ramp was working properly, and the wheelchair seat belts and safety straps were noted to be present in the van. On 03/17/2026 at 1:13 p.m., a telephone interview was conducted with S12CM. He stated he inspected the van on 02/18/2026, after the incident occurred. He stated himself, S1ADM, and S10MS were also present during the inspection. He stated the back door latch was loose upon inspection. He stated all seat belts were in good repair and the wheelchair safety straps/seat belts were available and in good repair in the vehicle. On 03/16/2026 at 1:30 p.m., an interview was conducted with S7TD. She stated she had been trained on how to load, secure, and safely transport residents in the facility prior to transporting residents. She stated she never had an incident occur when she transported a resident but had she, she would notify Administration immediately. She stated beginning on 02/18/2026 she received additional training on safely securing the residents in the van, the Administrator began performing weekly ride alongs, and a 3rd party company came to the facility to train her on how to properly use the ramp on the van and how to properly use the safety straps/seat belts for wheelchairs. She stated if any equipment needed to safely transport a resident was not working properly or not available she would not transport the resident and she would notify Administration. On 03/16/2026 at 1:40 p.m., an interview was conducted with S8TD. She stated prior to transporting residents, she was trained on how to load, secure, and safely transport residents. She stated she never had an incident occur when she transported a resident but had she, she would notify Administration immediately. She stated if there was a safety concern with the van, seat belt, lift, or any securing devices necessary for the residents safety needs, she would not transport the resident and would notify Administration immediately. She stated the transportation vans were routinely checked to ensure safety of the residents during transport. She stated starting on 02/18/2026 she received additional training by S1ADM on how to safely securing the residents in the van, Administration had been accompanying her for weekly for ride alongs, and a 3rd party company came to the facility and trained on how to properly use the ramp on the van and how to properly use the safety straps/seat belts for wheelchairs. On 03/18/2026 at 2:50 p.m. a telephone interview was conducted with S22MT. He stated he was a 3rd party Master Trainer. He stated he was contracted by S1ADM to come to the facility on [DATE] to train employees on the proper way to secure residents during transportation in the facility van, the appropriate way to secure the wheelchair straps and seat belt, and how to properly open/close/secure the van loading ramp. He stated he demonstrated to all three of the approved facility transport drivers these techniques and had them perform a return demonstration to ensure they performed them correctly. He stated all three individuals perform the return demonstrations appropriately and were given certificates of completion. On 03/17/2026 at 12:38 p.m., an observation was made of a resident being loaded onto the Facility Transport Van by S7TD and S8TD, Resident #R1 was in a wheelchair. No safety concerns were identified. The facility implemented the following actions to correct the deficient practice prior to surveyor entry on 03/16/2026: On 2/17/2026 at 12:30pm, S3TD was transporting Resident #1 when he fell out of the van. A bystander came in off the street around 12:45pm to report that the incident occurred. S2DON, immediately reviewed the video surveillance.12:30 p.m., Resident #1 noted falling out of the van as S3TD exits the parking lot.12:31 p.m., S3TD placed Resident #1 back into the van into a regular van seat.12:32 p.m., Van leaves facility site.12:45 p.m., Bystander notifies staff and S2DON reviews video footage.12:56 p.m., Local Police Department called facility to see if any assistance was needed.Approx. 1:15 p.m., S2DON and S8TD met S3TD at the appointment he was at and assessed Resident #1 and obtained a statement. No injuries noted and no complaints of pain. Resident #1's statement l fell out the van but I'm alright. S9NP notified and attempted to notify the RP multiple times.S1ADM opened SIMS on 3/18/2026 at 2:13 p.m., 1. The following corrective actions were taken: S2DON drove S3TD back to the facility and S8TD drove resident back to the facility on the regular van seat using the van seatbelt. S3TD was suspended pending investigation. On 2/18/2026, Resident #1 was assessed by S9NP with no injuries noted or complaints of pain.2. All residents who ride in their wheelchairs in the facility van had the potential to be effected by the alleged deficient practice:a. Van keys were locked in S1ADM's office on 2/17/2026 for the remainder of the day, and the van was not used again. Corporate Maintenance Coordinator, Maintenance Supervisor, and S1ADM inspected van the next day on 2/18/2026. The latch on the back door closure was missing screws. Wheelchair straps and regular seat seatbelts available and in working order. Wheelchair ramp and latches in good working order. Van was taken out of service and removed from site.b. On 2/18/2026, S1ADM in-serviced transportation staff on Proper restraint for residents transported via wheelchair- demonstration. Notifying Administrator and/or DON immediately of any issues on incidents/Review of van forms/ binder. Residents who can safely transfer to van seat may ride in a traditional seat. The following employees were in attendance: S2DON, S7TD, S17SSD, S18ADON, S19QA, S8TD, S20TTS, S4LPN, and S21ESS.c. S3TD was terminated on 2/18/2026.d. On 2/18/2026, Administrator completed a ride along with S8TD and S7TD and completed Driver In-service Checklist and the Transportation Policy Acknowledgement Form.e. On 03/03/2026, a 3rd party consultant provided training with certificates of completion for: S7TD, S8TD, S1ADM, and S21ESS.f. Administrator ordered items discussed during 3rd party training. On 03/03/2026 seatbelt lock (can be used for residents who may try to remove their seatbelt) was ordered. On 03/04/2026, Q-straint loops which improve wheelchair securement hook attachment were purchased. Items were received on 03/05/2026 and placed into van on 03/06/2026.3. Measures that will be taken to ensure the alleged deficient practice will not recur are:a. On 2/18/2026 transportation monitoring was initiated weekly and will continue for 6 weeks. Administrator and/or Designee complete a weekly ride along with van drivers to ensure resident safety, proper securement, and safe driving.b. Facility borrowed a van from sister facility to continue resident transports and Driver Inservice Checklists were completed.c. Vans were rented so bariatric residents could be safely transported and Driver Inservice Checklists were completed.d. Facility has also scheduled ambulance transfers as needed.4. The facility will monitor to make sure that the solutions were sustained by:a. Administrator and/or Designee also intends to continue training and ride along with each approved van driver approximately every 6 months on going. Initial training completed 2/18/2026. 5. Completion Date: March 4th, 2026 Review of the three approved Facility Transport Drivers training (S1ADM, S7TD, and S8TD) revealed all had Certificates of Completion on Wheelchair Securement and Lift Operations per 3rd party Provider (S22MT), completed Company Owned Vehicle Driver Inservice Checklist, had ongoing weekly ride alongs with Administration since 02/18/2026, and all reviewed and signed Transportation Policy Acknowledgment Form. All department managers were trained and signed off on proper placement of van straps on 02/18/2026.

Based on interviews and record reviews the facility failed to ensure an allegation of neglect was reported to the administrator immediately and to the State Survey Agency within 24 hours for 1(#1) of 5 residents investigated for neglect. Review of the facility's undated policy titled Abuse Reporting and Investigation Policy and Procedure revealed in part, the following:Policy:1. All reports of resident neglect shall be promptly reported to local, state, and federal agencies (as defined by current regulations).Reporting:1. All alleged violations involving neglect will be reported by the facility Administrator, or his/her designee, and in turn they will notify to the following persons or agencies, as applicable:a. The State licensing/certification agency responsible for surveying/licensing the facility.2. An alleged violation neglect will be reported immediately, but not later than:b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.E. Neglect is defined as 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. A facility must report incidents of alleged neglect and all situation in which the facility has cause to believe that the physical or mental health and/or welfare of a resident has been or may be adversely affected by neglect caused by another person. Neglect may include, but is not limited to:-Failure to provide the timely, consistent, safe, adequate, and appropriate care and services as needed. Review of the facility's undated policy titled Transportation Policy Acknowledgment Form revealed in part, the following:All incidents and accidents, no matter how minor or major, must be reported immediately to the Administrator- wrecks, resident injury, employee injury, falls, attempted elopement from facility vehicle, etc. Review of Resident #1's clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Ataxia. Review of the facility's incident report dated 02/17/2026 at 12:30 p.m. revealed the following:Resident: Resident #1Incident Location: OutsidePerson Preparing Report: S2DONIncident Description: As S3TD was leaving the parking lot, the rear door of the van opened which led to Resident #1 rolling backwards into the parking lot.Injury: No injuries Review of S1ADM's written statement dated 02/17/2026 at 12:30 p.m. revealed the following:On 02/17/2026 at 12:30 p.m., S3TD was transporting Resident #1 when he fell out the van. Video footage was reviewed, incident occurred in gravel side of the parking lot. At 12:31 p.m. S3TD put Resident #1 back into the facility van, and at 12:32 p.m. the van left the facility's parking lot. Review of S3TD's Disciplinary Report dated 02/18/2026 revealed S3TD was terminated for carelessness and failure to obey safety rules. Further review revealed S3TD failed to properly restrain resident in van and did not report incident. On 03/17/2026 at 9:03 a.m., a telephone interview was conducted with S3TD. He stated he was responsible for transporting residents in the facility van. He stated he was driving the facility van on 02/17/2026 at 12:30 p.m. when Resident #1 fell out of the van. He stated he did not tell Administration when Resident #1 fell out of the van since Resident #1 did not complain of pain or injuries at that time. He stated he knew he should have told them at the time the incident occurred. On 03/16/2026 at 3:10 p.m., an interview was conducted with S2DON. He stated he was made aware Resident #1 fell out of the van on 02/17/2026 at 12:45 p.m. He stated S3TD did not notify him at the time the incident occurred and should have. S2DON stated he informed S1ADM on 02/18/2026 at 12:50 p.m. after a passerby notified the facility Resident #1 fell out of the van while S3TD was driving. On 03/17/2026 at 12:40 p.m., an interview was conducted with S1ADM. She stated she was responsible for reporting neglect to the state agency. She stated she was informed of the incident, where Resident #1 fell out of the van during transport, on 02/17/2026 at 12:50 p.m. by S2DON. She stated she did not consider the incident to be neglect, and she did not report it to the state agency. She confirmed S3TD's failure to secure Resident #1 in the van prior to transport, which resulted in the resident falling out of the van, was neglect and should have been reported in the 24-hour timeframe.

Based on interviews and record review, the facility failed to ensure the services provided as outlined in the comprehensive care plan met quality professional standards. The facility failed to ensure nursing staff administered supplements per professional standards for 1 (#2) of 3 sampled residents reviewed.Findings: Review of Resident #2's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Chronic Combined Systolic And Diastolic Congestive Heart Failure, Type 2 Diabetes Mellitus With Other Circulatory Complications, Vitamin Deficiency and Generalized Muscle Weakness. On 03/16/2026 at 10:00 a.m., Resident #2's current Physician orders were reviewed and revealed, no current order for the house supplement. An interview was conducted with S15LPN on 03/16/2025 at 2:35 p.m. She stated Resident #2 had a decreased appetite and refused at times to eat his meals. She stated on 03/09/2026, she notified S9NP Resident #2 was not eating. She stated S9NP gave her a verbal order to administer 4 ounces of house supplement to Resident #2 anytime he was refusing to eat a meal. She stated she forgot to enter the verbal order for Resident #2's house supplement. She stated between 03/09/2026 and 03/16/2026, she administered 4 ounces of the house supplement to Resident #2 at least four times, but could not recall when it was administered. She confirmed she should not have administered the house supplement to Resident #2 without entering the order. An interview was conducted with S9NP on 03/17/2026 at 7:50 a.m. She stated Resident #2 had a decreased appetite and recently began refusing to eat some of his meals. She stated sometime last week, she gave a verbal order to S15LPN to administer the house supplement to Resident #2 if he refused to eat and would agree to take it. She stated if Resident #2 was administered the house supplement it should have been entered as an order. An interview was conducted with S16LPN on 03/17/2026 at 12:45 p.m. She stated she was assigned to Resident #2 today from 6:00 a.m. to 6:00 p.m. She stated she administered 4 ounces of the house supplement to Resident #2 this morning with his morning medications. She reviewed Resident #2's clinical record and confirmed there was no order to administer the house supplement. She stated she was not sure if she should have administered the house supplement to Resident #2 without an order. An interview was conducted with S2DON on 03/17/2026 at 3:00 p.m. He reviewed Resident #2's clinical record and confirmed there was no documented evidence the house supplement was ordered for Resident #2. He confirmed nurses' should not have administered the house supplement to Resident #2 without an order entered in the clinical record.

Based on observations, interviews, and record review, the facility failed to ensure a resident at risk for pressure ulcer development received care consistent with professional standards of practice, to prevent pressure ulcers. This deficient practice was evidenced by failing to ensure a resident with orders for a pressure reducing seat cushion intervention was implemented for 1 (#2) of 3 residents reviewed who were at risk for pressure ulcers.Findings: Review of Resident #2's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Chronic Combined Systolic And Diastolic Congestive Heart Failure, Type 2 Diabetes Mellitus With Other Circulatory Complications, Morbid Severe Obesity Due To Excess Calories, and Generalized Muscle Weakness. Review of Resident #2's Quarterly MDS with an ARD of 02/10/2026 revealed a BIMS of 04, which indicated he was severely cognitively impaired. Further review of the MDS revealed he was dependent on staff assistance for chair/bed-to-chair transfers, was at risk for pressure ulcer development, and required a pressure reducing device for his chair. Review of Resident #2's current Physician Orders revealed an order for a pressure reducing seat cushion every shift which started on 07/23/2025. Review of Resident #2's current Care Plan revealed the following, in part:Focus: Resident is at risk for pressure ulcers and other skin impairments related to Obesity, Diabetes Mellitus, occasional incontinence, and impaired mobility. Uses wheelchair.Interventions: 07/23/2025 New Order: Pressure reducing seat cushion. An observation was made of Resident #2 on 03/16/2026 at 8:13 a.m. He was in his room seated in a wheelchair with no pressure reducing seat cushion observed. An interview was attempted with Resident #2, but he was unable to be interviewed due to his cognitive status. An observation was made of Resident #2 on 03/16/2026 at 11:10 a.m. He was in his room seated in a wheelchair with no pressure reducing seat cushion observed. An interview was conducted with S14CNA on 03/16/2026 at 2:20 p.m. She stated Resident #2 required two person total assistance with transfers, incontinent care, and was at risk for pressure ulcers. She stated Resident #2 was out of bed in the wheelchair when she arrived for her shift today. She stated she and S15LPN transferred Resident #2 back to bed after lunch. She confirmed there was no pressure relieving cushion in Resident #2's wheelchair or in his room.An interview was conducted with S15LPN on 03/16/2026 at 2:35 p.m. She stated Resident #2 was at risk for pressure ulcer development and had a physician order for a pressure reducing seat cushion when he was in the wheelchair. She stated she and S14CNA transferred Resident #2 from the wheelchair to his bed after lunch. She confirmed there was no pressure relieving cushion in Resident #2's wheelchair or in his room and there should have been.An interview was conducted with S2DON on 03/17/2026 at 3:00 p.m. He stated Resident #2 was at risk for pressure ulcer development. He reviewed Resident #2's Physician Orders and confirmed a pressure reducing seat cushion should be used anytime Resident #2 was out of bed in the wheelchair.

Based on interviews and record reviews, the facility failed to ensure Resident #5, a resident identified as High Risk for Falls, remained as free of accident hazards as possible. This deficient practice was evidence by failure to implement an effective Fall Prevention Program which ensured:1. Resident #5's Care Plan was updated to reflect each fall for 1 (#5) of 3 residents reviewed for falls; and2. A new fall prevention intervention was identified, implemented and updated in Resident #5's Care Plan following each fall for 1 (#5) of 3 residents reviewed for falls. Findings: Review of the facility's undated Fall Protocol, as of 12/16/2025 at 3:50 p.m., revealed, in part, the following: Policy: Each resident will be assessed on any significant change in condition, and as needed for potential risk for falls to initiate preventative approaches. Discussion regarding the acceptable level of risk must be based on individual assessment with input from the resident and/or interdisciplinary team. Procedure: All residents: 4. Care Plan will be updated. High Risk: 1. All residents who have been identified as high risk for falls will be discussed in high risk meetings weekly for implementation of preventative approaches, strategies and interventions. Equipment: 6. Care Plan.Review of the facility's undated Incident and Accident Policy and Procedure, as of 12/16/20025 at 3:50 p.m., revealed, in part, the following:Policy: Incidents and accidents are to be reported, investigated, and followed up in a timely manner. Procedure: 4. Investigative Action: d. Resident will be assessed for intervention to prevent further incidents. 9. All incidents will be discussed daily with the Interdisciplinary Team to include intervention and update Care Plan. Review of the facility's undated Fall Prevention Program Policy and Procedure, as of 12/16/20025 at 3:50 p.m., revealed, in part, the following:Procedure: 6. All residents on the program will have Care Plan addressing goals and approaches. Review of the facility's Incident Log, dated 08/27/2025 through 12/15/2025, as of 12/15/2025 at 1:37 p.m., revealed Resident #5 experienced the following unwitnessed falls: 08/31/2025 at 9:30 p.m.; and09/02/2025 at 4:40 p.m 1. Review of Resident #5's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included, in part, the following; Senile Degeneration Of Brain; Other Frontotemporal Neurocognitive Disorder; Unspecified Dementia; Unsteadiness On Feet; and Extrapyramidal And Movement Disorder. Further review revealed, in part, he was classified as High Risk for Falls. Review of Resident #5's Quarterly MDS, with an ARD of 11/13/2025, indicated, in part, a BIMS of 03, which indicated he was not cognitively intact. Review of the facility's Incident Reports involving Resident #5, dated 08/31/2025 through 12/15/2025, as of 12/15/2025 at 2:45 p.m., revealed, in part, the following: 08/31/2025 at 9:30 p.m. - Unwitnessed Fall; and09/02/2025 at 4:45 p.m. - Unwitnessed Fall. Review of Resident #5's Nurses Notes, dated 08/31/2025 through 12/15/2025, as of 12/15/2025 at 3:18 p.m., revealed, in part, the following: 08/31/2025 at 9:30 p.m. - Resident #5 found on the floor by his bed; and09/02/2025 at 4:45 p.m. - Resident #5 found on the floor in his bathroom. Review of Resident #5's Care Plan for Problem: At High Risk for Falls, last revised 12/04/2025, as of 12/15/2025 at 3:40 p.m., revealed, in part, no documented evidence to indicate Resident #5 sustained a fall on 08/31/2025 at 9:30 p.m. and/or 09/02/2025 at 4:40 p.m.An interview was conducted on 12/16/2025 at 3:20 p.m. with S3ADON. S3ADON confirmed she was responsible for the facility's Fall Prevention Program. S3ADON confirmed following a resident fall, the facility's Fall Prevention Program required a resident's Care Plan to be updated to reflect the date and situation of their fall. S3ADON reviewed Resident #5's Care Plan and confirmed it did not reflect his falls on 08/31/2025 at 9:30 p.m. and/or 09/02/2025 at 4:40 p.m., and should. An interview was conducted on 12/16/2025 at 3:40 p.m. with S2DON. S2DON confirmed following a resident fall, he expected the resident's Care Plan to be updated to reflect the date and situation of their fall. S2DON reviewed Resident #5's Care Plan and confirmed it did not reflect his falls on 08/31/2025 at 9:30 p.m. and/or 09/02/2025 at 4:40 p.m., and should. 2. Review of Resident #5's Care Plan Interventions for Problem: At High Risk for Falls (last revised 12/04/2025), as of 12/15/2025 at 3:40 p.m., revealed, in part, no documented evidence of the identification and implementation of a new fall prevention intervention in response to Resident #5's fall on 08/31/2025 at 9:30 p.m. and/or 09/02/2025 at 4:40 p.m.Review of Resident #5's Physician's Order History, dated 08/31/2025 through 12/16/2025, as of 12/16/2025 at 12:52 p.m., revealed, in part, no documented evidence of an order for a new fall prevention intervention in response to Resident #5's fall on 08/31/2025 at 9:30 p.m. and/or 09/02/2025 at 4:40 p.m.Review of Resident #5's Progress Notes, dated 08/31/2025 through 12/16/2025, as of 12/16/2025 at 12:52 p.m., revealed, in part, no documented evidence to indicate a new fall prevention intervention was identified or implemented in response to his fall on 08/31/2025 at 9:30 p.m. and/or 09/02/2025 at 4:40 p.m.Review of Resident #5's Nurses Notes, dated 08/31/2025 through 12/15/2025, as of 12/15/2025 at 3:18 p.m., revealed, in part, no documented evidence to indicate a new fall prevention intervention was identified or implemented in response to his fall on 08/31/2025 at 9:30 p.m. and/or 09/02/2025 at 4:40 p.m.An interview was conducted on 12/16/2025 at 3:20 p.m. with S3ADON. S3ADON confirmed following each resident fall, the facility should identify, implement, and update the Care Plan with a new, resident-specific fall prevention intervention. S3ADON reviewed Resident #5's Care Plan and confirmed the facility had not identified, implemented, and updated his Care Plan with a new, resident-specific fall prevention intervention following his falls on 08/31/2025 at 9:30 p.m. and/or 09/02/2025 at 4:40 p.m., and should have. An interview was conducted on 12/16/2025 at 3:40 p.m. with S2DON. S2DON confirmed following each resident fall, he expected staff to identify, implement, and update the Care Plan with a new, resident-specific fall prevention intervention. S2DON reviewed Resident #5's Care Plan and confirmed the facility had not identified, implemented, and updated his Care Plan with a new, resident-specific fall prevention intervention following his falls on 08/31/2025 at 9:30 p.m. and/or 09/02/2025 at 4:40 p.m., and should have.

Based on observations, interviews, and record reviews, the facility failed to provide services with reasonable accommodation of needs by failing to ensure call lights were in reach for 2 (#82 and #109) of 33 residents reviewed for accommodation of needs in the initial pool.Findings: Review of the facility's undated policy titled, Call Light, Use of Policy and Procedure revealed the following, in part:Policy:2. To assure call system is in proper working order.Procedure:10. When providing care to residents be sure to position the call light conveniently for the resident to use.15. Be sure all call lights are placed on the bed at all times, never on the floor or bedside stand. Resident #82Review of Resident #82's Clinical Record revealed an admission date of 08/09/2024 and diagnoses, which included Hemiplegia and Hemiparesis following Cerebral Infarction. Review of Resident #82's Quarterly MDS with an ARD of 07/08/2025 revealed a BIMS of 13, which indicated intact cognition. Further review revealed she required staff assistance with transfers. Review of Resident #82's current Care Plan revealed she had Hemiplegia and Hemiparesis following a Cerebrovascular Accident. Further review revealed an intervention to place her call light in reach. An observation was made of Resident #82 on 08/25/2025 at 12:50 p.m. She was lying in bed. Her call light was lying on the floor at the foot of her bed and not in reach. An observation was made of Resident #82 on 08/26/2025 at 11:30 a.m. She was lying in bed. Her call light was lying on the floor at the foot of her bed and not in reach. An interview was conducted with Resident #82 at that time. Resident #82 confirmed she was unable to reach her call light. An observation was made of Resident #82 on 08/26/2025 at 1:51 p.m. She was seated on the edge of her bed near the head of the bed. Her call light was lying on the floor at the foot of her bed and not in reach. An interview was conducted with Resident #82 at that time. Resident #82 confirmed she was unable to reach her call light. An observation was made of Resident #82 with S11CNA on 08/26/2025 at 1:54 p.m. An interview was conducted with S11CNA at that time. S11CNA confirmed Resident #82's call light was lying on the floor and not in reach. S11CNA stated Resident #82's call light should have been clipped to her bed linens and in reach. S11CNA confirmed Resident #82 utilized her call light for assistance. Resident #109Review of Resident #109's Clinical Record revealed an admission date of 07/17/2024 and diagnoses, which included Hemiplegia. Review of Resident #109's Quarterly MDS with an ARD of 07/04/2025 revealed a BIMS of 15, which indicated intact cognition. Further review revealed Resident #109 required staff assistance with activities of daily living and transfers. An observation was made of Resident #109 on 08/25/2025 at 1:16 p.m. She was lying in bed. Her call light was lying on the floor and not in reach. An interview was conducted with Resident #109 at that time. Resident #109 confirmed her call light was not in reach. An observation was made of Resident #109 on 08/26/2025 at 8:10 a.m. She was lying in bed. Her call light was lying on the floor under her bed. An interview was conducted with Resident #109 at that time. Resident #109 confirmed her call light was not in reach. An observation was made of Resident #109 with S10CNA on 08/26/2025 at 8:12 a.m. An interview was conducted with S10CNA at that time. S10CNA confirmed Resident #109's call light was lying under her bed and not in reach. S10CNA confirmed Resident #109's call light should have been in reach. S10CNA confirmed Resident #109 utilized her call light for assistance. An interview was conducted with S2DON on 08/26/2025 at 3:50 p.m. He stated each resident's call light should be in reach while they are in their room.

Based on observations, interviews, and record review, the facility failed to protect each residents' right to personal privacy for 2 (#4 and #6) of 9 (#1, #4, #6, #52, #62, #74, #88, #116, and #130 ) residents observed during personal care and treatment procedures. The facility failed to ensure:1. Resident #6 was provided privacy during incontinence care; and2. Resident #4 was provided privacy during medication administration. Findings:Review of the facility's undated policy titled, Quality of Life-Dignity Policy and Procedure revealed the following, in part: Purpose: To ensure each resident shall be cared for in a manner that promotes quality of life, dignity, respect, and individuality. Procedure: 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth including safeguarding their personal privacy and confidentiality. 11. Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. a. Ensure privacy curtains or doors are closed during personal care. 1. Review of Resident #6's Clinical Record revealed an admission date of 06/09/2025 and diagnoses, which included Cerebral Infarction, Anxiety Disorder, Bipolar Disorder, and Major Depressive Disorder. Review of Resident #6's Significant Change MDS with an ARD of 07/08/2025 revealed a BIMS of 15, which indicated she was cognitively intact. Further review revealed Resident #6 was always incontinent of bladder and bowel. An observation was made of S8CNA and S9CNA providing incontinence care for Resident #6 on 08/26/2025 at 2:10 p.m. During incontinence care, S8CNA stated she needed to obtain more gloves. Resident #6 was lying on her bed with her dress pulled up to her abdomen and her perineal area fully exposed. S8CNA exited the room and left the door fully open. Resident #6's body was visible from the hallway. A male resident passed by the room in the hallway while Resident #6 was exposed. An interview was conducted with S9CNA on 08/26/2025 at 2:40 p.m. She confirmed when S8CNA exited Resident #6's room during incontinence care, her perineal area was fully exposed and could have been visualized by anyone in the hallway. She stated Resident #6 should have been fully covered prior to opening Resident #6's room door. She confirmed S8CNA should have closed Resident #6's room door upon exiting. An interview was conducted with S8CNA on 08/26/2025 at 3:33 p.m. She stated Resident #6 always requested privacy. She stated residents should have privacy during care. An interview was conducted with Resident #6 on 08/26/2025 at 3:28 p.m. She stated she always wanted to be provided privacy during incontinence care. She stated she would be embarrassed for someone to see her perineal area. An interview was conducted with S2DON on 08/26/2025 at 3:50 p.m. He stated he expected CNAs to close a resident's door behind them if having to exit the room to obtain supplies during incontinence care. He stated residents should always have privacy during incontinence care. 2. Review of Resident #4's Clinical Record revealed an admission date of 07/10/2020 and diagnoses, which included Cerebral Infarction, Dysphagia, Gastronomy Status, and Depression. An observation was made of S5LPN administering Resident #4's medications through his feeding tube on 08/25/2025 at 9:14 a.m. During treatment, S5LPN left the hallway door fully open and did not pull the privacy curtain. An interview was conducted with S5LPN on 08/25/2025 at 9:18 a.m. She confirmed she did not close the hallway door or pull the privacy curtain prior to administering Resident #4's medications and should have. An interview was conducted with S2DON on 08/26/2025 at 2:42 p.m. He stated he expected all CNAs to close a resident's door and/or pull the privacy curtain prior to the provision of treatment. He stated residents should always have privacy during medication administration.

Based on record review and interviews, the facility failed to ensure an accurate Minimum Data Set assessment for 1 (#19) of 2 (#6 and #19) residents reviewed for falls. The facility failed to ensure falls were accurately coded for Resident #19.Review of Resident #19's Clinical Record revealed an admission date of 12/26/2023. Review of Resident #19's Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/27/2025 revealed the following, in part:Section J: Health ConditionsJ1800-Any falls since admission/entry or reentry or prior assessment. Marked 0. No. J1900-Number of falls since admission/entry or reentry or prior assessment. Marked blank. Review of the facility's incident log dated 02/25/2025 to 08/25/2025 revealed Resident #19 had an unwitnessed fall on 06/26/2025 and 06/27/2025. On 08/27/2025 at 12:45 p.m., an interview was conducted with S15LPN. She stated she was responsible for completing MDS assessments for Resident #19. She reviewed Resident #19's Discharge MDS with an ARD of 06/27/2025. S15LPN confirmed Resident #19 had a fall since his previous MDS assessment. S15LPN confirmed Resident #19's Discharge MDS with an ARD of 06/27/205, section J1800 was coded no and was not correctly coded for falls and should have been. S15LPN confirmed section J1800 and J1900 of Resident #19's discharge MDS was not accurately coded for falls and should have been. On 08/27/2025 at 2:02 p.m., an interview was conducted with S2DON. S2DON reviewed Resident #19's Discharge MDS with an ARD of 06/27/2025 and confirmed it was not accurately coded for his falls on 06/26/2025 and 06/27/2025 and should have been.

Based on interviews and record reviews, the facility failed to ensure a resident with a newly evident or possible serious mental disorder was referred for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required for 1 (#71) of 5 (#2, #7, #38, #71, and #89) sampled residents reviewed for PASRR Level II.Review of the facility's undated policy, titled, Preadmission Screening, PASARR (Resident Review) revealed in part, the following: Procedure: Coordination shall include:2. Referring.all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. Review of the Resident #71's Clinical Record revealed he was admitted to the facility on [DATE]. Further review revealed he was diagnosed with Schizoaffective Disorder on 02/10/2025. On 08/26/2025 at 1:15 p.m., an interview was completed with S14SW. She stated she was responsible for submitting Resident Review Forms for residents. She stated she was aware Resident #71 was newly diagnosed with Schizoaffective Disorder on 02/10/2025, but was unable to provide documentation indicating a PASRR Level II evaluation was submitted to the appropriate authorities. On 08/26/2025 at 1:35 p.m., an interview was conducted with S2DON. He stated if a resident received a new, mental health diagnosis, he expected a PASRR Level II evaluation to be submitted to the appropriate authorities by S14SW. On 08/26/2025 at 2:25 p.m., an interview was conducted with S3CA. She confirmed a PASRR Level II evaluation had not been submitted to the appropriate authorities since Resident #71's diagnosis of Schizoaffective Disorder on 02/10/2025 and should have.

Based on observations, interviews, and record review, the facility failed to ensure interventions for Aphasia were implemented as identified on the care plan for 1 of 1 (#84) residents reviewed for communication difficulty. Review of Resident #84's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Cerebral Infarction, Aphasia, and Major Depressive Disorder. Review of Resident #84's Quarterly MDS with an ARD of 07/01/2025 revealed a BIMS of 10, which indicated his cognition was moderately impaired. Further review of Section B: Speech, Hearing, and Vision, revealed Resident #84 had unclear speech and was sometimes understood by others. Review of Resident #84's current Care Plan revealed the following:Focus: Resident is aphasic related to CVA. Uses a communication board to assist with communicating. Intervention: Resident needs to be provided with a communication tool. On 08/25/2025 at 11:00 a.m., an observation was made of Resident #84's room. No communication tools were observed in his room. On 08/26/2025 at 10:55 a.m., an interview was conducted with S13CNA. She stated she was familiar with Resident #84's care. She stated Resident #84 had difficulty communicating his wants and needs to staff. She stated when he is misunderstood he would yell, curse, and occasionally demonstrate physically aggressive outbursts. She stated he primarily communicated via yes/no responses. She stated he understood others and could follow commands. She stated she had not used the communication board with him recently. She stated she had not seen the communication board in his room. On 08/26/2025 at 11:47 a.m., an interview was conducted with Resident #84. Simple, close-ended questions were presented that required either a yes or no response. Resident #84's responses revealed the following, in part: When staff does not understand you, does that make you mad? YesHave they used a communication board with you before? YesDo you want them to continue using the communication board? YesHave you seen it in your room? No On 08/26/2025 at 11:49 a.m., an observation was made of Resident #84. He opened the top drawer of his night stand, no communication board was observed inside the drawer. On 08/26/2025 at 3:30 p.m., an interview was conducted with S15MDS. She stated she was responsible for implementing Resident #84's interventions as identified on his care plan. She confirmed staff should have attempted to utilize the communication board with him during communication breakdowns. She stated a communication board should have always been available in his room. On 08/26/ 2025 at 3:32 p.m., an observation was made of S15MDS and S16MDS inspecting Resident #84's room for his communication board. S15MDS confirmed the communication board was not in Resident #84's room and should have been. On 08/26/2025 at 3:40 p.m., an interview was conducted with S2DON. He stated he expected all staff to implement interventions as identified on the care plan.

Based on observation, interviews, and record review, the facility failed to ensure services were provided by the facility to meet quality professional standards. The facility failed to ensure nursing staff followed manufacturer instructions for use of an inhaler to prevent side effects of the medication for 1 (#88) of 4 (#52, #74, #88, and #130) residents reviewed for medication administration.Findings:Review of the facility's undated policy, titled Medication Administration Policy And Procedure revealed the following, in part:Purpose: The purpose of this procedure is to provide guidelines for the safe administration of medications.Procedure:8. The individual administering a medication shall be aware of the following information concerning each medication before administration:b. Untoward.side effectsReview of the facility's medication insert for Fluticasone Propionate/Salmeterol Diskus inhalation powder revealed the following, in part:Step 1: Open your Fluticasone Propionate/Salmeterol Diskus.Step 2: Slide the lever until you hear it click.Step 3: Inhale your medicine.Step 4: Close the Diskus.Step 5: Rinse your mouth. Rinse your mouth with water after breathing in the medicine. Spit out water. Do not swallow it.Further review of the step-by-step instructions revealed the following:Rinse your mouth with water without swallowing after each use of Fluticasone Propionate/Salmeterol Diskus. This will help lessen the chance of getting a yeast infection (thrush) in your mouth and throat.Review of Resident #88's Clinical Record revealed she was admitted to the facility on [DATE] with a diagnosis, which included Chronic Obstructive Pulmonary Disease.Review of Resident #88's current Physician Orders revealed the following:Revision Date: 08/21/2025 Advair Diskus Inhalation Aerosol 100-50 mcg take one puff inhale every 12 hours.On 08/26/2025 at 7:50 a.m., an observation was made of S5LPN administering Resident #88's medications. She administered one inhalation of Advair 100-50 mcg to Resident #88. S5LPN exited the room and did not offer or instruct Resident #88 to rinse her mouth out after the inhaler was administered. On 08/26/2025 at 8:05 a.m., an interview was conducted with S5LPN. She confirmed she did not have Resident #88 rinse her mouth out with water after administration of the Advair inhaler and was not aware she should have. She reviewed the Advair medication insert and confirmed she should have had Resident #88 rinse her mouth out after administration of the inhaler and did not. On 08/26/2025 at 11:40 a.m., an interview was conducted with S2DON. He was notified of the above observations during medication administration. He confirmed after a resident was administered an inhaler the nurse should have the resident rinse their mouth out with water.

Based on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out ADLs received the necessary services to maintain good grooming and personal hygiene for 1 (#107) of 5 (#6, #38, #71, #93, and #107) residents reviewed for ADL's. The facility failed to trim and clean fingernails for Resident #107.Review of the facility's undated policy titled, Nail Care Policy and Procedure, revealed the following, in part:5. To promote cleanliness.Procedure: 1. Care of fingernails and toenails is part of the bath.2. Be certain nails are clean.4. Nails are to be clipped and filed smoothly. Review of the Medical Record for Resident #107 revealed the resident was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis Affecting Right Dominant Side and Neuroleptic Induced Parkinsonism. Review of the most recent MDS (Minimum Data Set) for Resident #107 with an ARD (Assessment Reference Date) of 07/16/2025 revealed Resident #107 had a BIMS (Brief Interview for Mental Status) of 15, which indicated the resident was cognitively intact. Review of the current Care Plan for Resident #107 revealed, in part, the following:Problem - The resident has an ADL self-care performance deficit related to Confusion and Diagnosis of Neuroleptic Induced Parkinson's. Interventions - Staff to perform fingernail and toenail care as appropriate.On 08/25/2025 at 9:45 a.m., an observation was made of Resident #107's fingernails. Resident #107's fingernails were observed to be long and had a black and red substance underneath all fingernails. Resident #107's fingernails were observed to be approximately 0.5 cm past the tip of all 10 fingers. On 08/25/2025 at 10:15 a.m., an interview was conducted with Resident #107. Resident #107 stated he had asked staff to cut his fingernails for him. Resident #107 stated he would like his nails to be cleaned and trimmed. On 08/25/2025 at 10:20 a.m., an interview was conducted with S12CNA. S12CNA stated restorative staff and/or CNAs were responsible for cleaning and trimming resident's nails. S12CNA observed and confirmed Resident #107's fingernails were very long and dirty. She further confirmed his nails should be kept clean and trimmed and were not. 08/27/2025 at 12:31 p.m., an interview was conducted with S19LPN. S19LPN stated CNAs were responsible for nail care and should perform with baths or showers or at resident's request. She confirmed staff should keep resident's fingernails clean and trimmed. On 08/26/2025 at 2:18 p.m., an interview was conducted with S2DON. S2DON confirmed staff should keep resident's fingernails clean and trimmed.

Based on observations, interviews, and record review, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards. The facility failed to ensure oxygen tubing was properly labeled for 1 (#89) of 1 (#89) residents reviewed for oxygen therapy.Review of Resident #89's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease, Emphysema, and Chronic Diastolic (Congestive) Heart Failure. Review of Resident #89's current Physician's Orders revealed the following, in part:Start date: 05/27/2025: Administer oxygen at 2 Liters per minute via nasal cannula, every shift for Chronic Obstructive Pulmonary Disease, Emphysema, Congestive Heart Failure, and Shortness of Breath. On 08/25/2025 at 10:15 a.m., an observation was made of Resident #89's oxygen tubing, which was not labeled with the date. On 08/25/2025 at 10:20 a.m., an observation and interview was conducted with S7LPN. S7LPN observed Resident #89's oxygen tubing and confirmed the oxygen tubing was not labeled with the date last changed and stated it should have been. She stated the tubing should have been changed and labeled weekly, and it was the nurse's responsibility to do so. On 08/27/2025 at 2:00 p.m., an interview was conducted with S2DON. He was made aware of the observation of Resident #89's oxygen tubing not being labeled with a date. S2DON confirmed all oxygen tubing should be labeled with the date it was changed.

Based on observations and interviews, the facility failed to ensure garbage and waste were properly contained in the outdoor trash dumpster.Findings: On 08/25/2025 at 9:00 a.m., an observation was made of the facility's two outdoor trash dumpsters with S4DM. One of the dumpsters was observed with the lid open, half full of bagged trash with flies swarming around the dumpster. On 08/25/2025 at 9:02 a.m., an interview was conducted with S4DM. She observed and confirmed the above mentioned observations of the dumpster area. She stated S6HSK was responsible for the dumpster area. She confirmed the dumpster lid was open and should not be.On 08/25/2025 at 9:05 a.m., an interview was conducted with S6HSK. He stated he was responsible for the dumpster area. He stated he had opened the dumpster lid this morning to take out the trash and would close the lid on the dumpster when he was done. He confirmed the dumpster lid should be closed when not in use.On 08/25/2025 at 9:20 a.m., an interview was conducted with S1ADM. She was notified of the observation of the dumpster lid being open. She confirmed the dumpster lid should be kept closed when not in use.

Based on record review and interviews, the facility failed to ensure a resident's MAR (Medication Administration Record) was accurately documented for 1 (#21) of 31 residents included in the final sample. Review of the facility's undated policy titled Documentation and Charting Guidelines, revealed the following, in part:Purpose: The purpose of Charting and Documentation is to provide the following: a complete account to the resident's care.Review of Resident #21's clinical record revealed she was admitted on [DATE] with diagnoses which included Dementia with other Behavioral Disturbance. Review of Resident #21's admission MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 08/19/2025 revealed BIMS of 13, which indicated she was cognitively intact. Review of Resident #21's current Physician's Orders revealed the following:-Contact Precautions - every shift for infection Start date: 08/17/2025-Vancomycin HCl Oral Capsule 125 MG - Give 1 capsule by mouth four times a day for C. Diff (Clostridium Difficile) Start date: 08/17/2025 Review of Resident #21's current Care Plan revealed the following:-Focus: I have an infection C. Diff and I am on contact isolation precautions. Date initiated: 08/17/2025.-Interventions: Provide me treatment as ordered by my physician. Review of Resident #21's current MAR (Medication Administration Record) revealed the following: -Contact Precautions every shift for infection. Start date 08/17/2025. Further review revealed no documentation contact precautions were in place for 08/17/2025 - 08/21/2025. On 08/27/2025 at 9:10 a.m., an interview was conducted with S5LPN. S5LPN stated once Resident #21 received a confirmed diagnosis of C. Diff, she was immediately placed on TBP (Transmission Based Precautions). She stated Resident #21's TBP was ordered to start on 08/17/2025. She reviewed Resident #21's MAR and confirmed there was no documentation isolation precautions were in place from 08/17/2025 - 08/21/2025. She further confirmed Resident #21 was on TBP but the documentation did not reflect this and should have. On 08/27/2025 at 9:53 a.m., an interview was conducted with S17ADON. S17ADON confirmed Resident #21 was placed on TBP on 08/17/2025 after receiving a call from the hospital informing facility staff that resident tested positive for C. Diff. S17ADON reviewed Resident #21's MAR and confirmed there was no documentation to reflect contact precautions were in place from 08/17/2025 - 08/21/2025 and there should have been.

Based on observations, interviews, and record reviews, the facility failed to implement and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure staff:1. Performed hand hygiene during medication administration for 1 (#88) of 5 (#52, #62, #74, #88 and #130) residents observed during medication administration; and2. Donned the appropriate Personal Protective Equipment (PPE) during medication administration for 1 of 1 (#4) residents reviewed for feeding tube.Findings: Review of the facility's undated policy, titled, Hand Washing/Hand Hygiene Policy and Procedure revealed the following, in part: Policy: All personnel shall perform hand washing/hand hygiene when working with residents. Procedure: Use an alcohol-based hand rub. for the following situations: b. Before and after direct contact with residents; c. Before preparing or handling medications; m. After removing gloves. 1. Review of Resident #62's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #88's Clinical Record revealed she was admitted to the facility on [DATE]. On 08/26/2025 at 7:50 a.m., an observation was made of S5LPN entering Resident #62's room and administering her medications. S5LPN was observed in Resident #62's room placing the empty water cup and medication cup in the trashcan. Without performing hand hygiene, S5LPN was observed exiting Resident #62's room and went to the medication cart. Without performing hand hygiene, S5LPN prepared Resident #88's medication, knocked and entered Resident #88's room and administered her oral medications. Without performing hand hygiene, S5LPN applied gloves and administered Resident #88's inhaler. S5LPN removed her gloves, exited the room, returned to the medication cart and placed the inhaler in the drawer. S5LPN did not perform hand hygiene. On 08/26/2025 at 8:05 a.m., an interview was conducted with S5LPN. She confirmed the above observations of not performing hand hygiene with medication administration. She confirmed she should have performed hand hygiene before and after medication administration and in between residents and did not. On 08/26/2025 at 11:40 a.m., an interview was conducted with S2DON. He stated nurses should perform hand hygiene before and after medication administration and in between residents. 2. Review of the facility's undated policy, titled, Enhanced Barrier Precautions (EBP) revealed the following, in part: Procedure: 1. EBP are indicated for residents with any of the following: b. Wounds and/or indwelling medical devices ii. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. 4. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities g. Device care or use (feeding tube) 5. PPE is to be applied prior to performing the high-contact resident activity. b. Put on gown and gloves Review of Resident #4's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Gastronomy status. Review of Resident #4's current, physician orders revealed the following, in part: Order date: 04/02/2024; Enhanced Barrier Precautions every shift for Feeding Tube. Order date: 09/19/2024; May give medications via Enteral Tube. On 08/25/2025 at 9:13 a.m., an observation was made of Resident #4's door, which revealed a PPE caddy with no EBP signage displayed. On 08/25/2025 at 9:14 a.m., an observation was made of S5LPN entering Resident #4's room, applying gloves, and administering his medications via feeding tube. On 08/25/2025 at 9:18 a.m., an interview was conducted with S5LPN. She confirmed she did not wear a gown while administering medications through Resident #4's feeding tube and should have. On 08/25/2025 at 2:42 p.m., an interview was conducted with S2DON. He stated he expected all staff to utilize PPE while providing care to residents with a feeding tube. On 08/26/2025 at 2:46 p.m., an interview was conducted with S15ADON. She stated she was responsible for the facility's infection prevention program. She confirmed all care staff should wear a gown and gloves while administering medications via feeding tube to be in compliance with EBP.

Based on observations, interviews, and record reviews, the facility failed to ensure each resident received necessary respiratory care consistent with professional standards of practice for 3 of 3 (#1, #2, and #R2) residents reviewed for respiratory care. The facility failed to ensure: 1. A protocol was implemented for cleaning and/or replacing Resident #1's non-invasive ventilation tubing and mask; and 2. Oxygen tubing and humidification bottles were changed in a timely manner for 2 (#2 and #R2) of 3 (#1, #2, and #R2) residents reviewed for oxygen therapy. Findings: Review of the facility's undated policy titled, Nebulizer CPAP Machine Cleaning Policy and Procedure revealed the following, in part: Purpose: To keep nebulizer or CPAP machine and equipment clean. Policy: Resident's Nebulizer or CPAP will be kept clean when in resident room. Procedure: 3. Tubing, mouthpiece, and mask to be changed out weekly and as needed. Review of the Trilogy clinical manual revealed the following, in part: Cleaning the Patient Circuit: Cleaning the reusable circuit is important. Circuits infected with bacteria may infect the user's lungs. Clean the respiratory circuit on a regular basis. Follow your institution's protocol for cleaning the circuit. This company recommends that you perform the cleaning twice a week under normal conditions and more frequently as required. Reusable circuit cleaning instructions: Clean the patient circuit twice a week, or follow your institution's protocol. Review of the facility's undated Policy titled, Oxygen Administration Policy and Procedure revealed the following, in part: Procedure: 5. Prefilled, sealed, disposable humidifiers may be changed per facility policy. g. Label humidifier with date and time opened. Change humidifier and tubing per facility procedure. 9. At regular intervals, check and clean oxygen equipment, masks, tubing, and cannula. 1. Resident #1 Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Morbid Obesity, Acute Pulmonary Edema, Chronic Congestive Heart Failure, Cardiomegaly, and Sleep Apnea. Review of Resident #1's current Physician Orders revealed the following, in part: Start Date: 05/05/2025 - Non-invasive ventilation support in use while lying in bed/asleep. Further review of Resident #1's Physician Orders revealed no orders to clean or replace the non-invasive ventilation support tubing and/or mask. Review of Resident #1's current care plan revealed the following, in part: Problem: I have Sleep Apnea Interventions: Non-invasive ventilation support in use while lying in bed/asleep. Further review of Resident #1's Care Plan revealed no indication to clean or replace the non-invasive ventilation support tubing and/or mask. Review of Resident #1's MARs and TARs dated May through June 2025 revealed Resident #1 utilized his non-invasive ventilation support machine twenty days in the month of May 2025 and 16 days in the month of June 2025. Further review revealed no documentation the tubing and/or mask were cleaned or replaced. Review of Resident #1's Nurses Notes dated May through June 2025 revealed no documentation his non-invasive ventilation support tubing and/or mask were cleaned or replaced. A telephone interview was conducted with S9LPN on 06/17/2025 at 1:25 p.m. She stated she was regularly assigned to Resident #1. She stated Resident #1 utilized a non-invasive ventilation support machine. She stated there was no order or process to clean or replace Resident #1's non-invasive ventilation support mask or tubing. She stated she was unsure of the facility's protocol for cleaning the non-invasive ventilation support tubing and mask. She explained she cleaned the mask if it was visibly soiled but never cleaned or replaced the tubing. An interview was conducted with S10LPN on 06/18/2025 at 9:30 a.m. She stated she was regularly assigned to Resident #1. She stated Resident #1 utilized a non-invasive ventilation support machine. She stated she was unable to recall if there were orders to clean or replace Resident #1's non-invasive ventilation support mask or tubing. She stated she would have cleaned the non-invasive ventilation support mask and tubing when visibly soiled. An interview was conducted with S11LPN on 06/18/2025 at 10:56 a.m. She stated she was regularly assigned to Resident #1. She stated Resident #1 utilized a non-invasive ventilation support machine. She stated there was no order or process to clean or replace Resident #1's non-invasive ventilation support mask or tubing. She stated she would have cleaned the mask when visibly soiled. She stated she had never cleaned or replaced the tubing. She confirmed there was no documentation of cleaning or replacing Resident #1's non-invasive ventilation support mask or tubing. An interview was conducted with S2DON on 06/18/2025 at 9:59 a.m. He reviewed Resident #1's Clinical Record. He confirmed there was no order to clean or replace the tubing and/or mask for Resident #1's non-invasive ventilation support machine and there should have been. He further confirmed there should have been documentation the tubing and mask were cleaned and/or replaced and there was not. An interview was conducted with S1CNO on 06/18/2025 at 10:40 a.m. He stated he expected the nurses to follow the facility's policy and procedure titled, Nebulizer CPAP Machine Cleaning Policy and Procedure for cleaning non-invasive ventilation support masks and tubing. A telephone interview was conducted with S8NP on 06/18/2025 at 9:15 a.m. She confirmed Resident #1 utilized a non-invasive ventilation support machine for breathing assistance. She confirmed the facility should have implemented a protocol to clean the tubing and mask. 2. Resident #2 Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Congestive Heart Failure and Asthma. Review of Resident #2's MDS with an ARD of 05/13/2025 revealed he had a BIMS of 15, which indicated he was cognitively intact. Review of Resident #2's current Physician Orders revealed the following, in part: Start Date: 05/13/2025- Oxygen at 2 to 3 Liters via Nasal Cannula as needed every shift. An observation was made of Resident #2's oxygen concentrator on 06/16/2025 at 11:54 a.m. The oxygen humidifier bottle was observed dated 06/09/2025. An interview was conducted with Resident #2 on 06/17/2025 at 10:35 a.m. The resident's oxygen humidifier bottle was observed dated 06/09/2025. He stated he wore his oxygen as needed, mostly at night. An interview was conducted with S4LPN on 06/17/2025 at 1:40 p.m. She stated resident's oxygen tubing and humidifier bottles should be changed every week. She verified Resident #2 wore oxygen daily as needed. S4LPN observed Resident #2's oxygen humidifier bottle and confirmed it was dated 06/09/2025 and should have been changed prior to 06/17/2025. An interview was conducted with S2DON on 06/18/2025 at 10:59 a.m. He reviewed Resident #2's Clinical Record and verified the oxygen humidifier bottle was ordered to be changed once weekly, on Wednesdays, during the night shift. He was made aware of the above observations. He confirmed Resident #2's oxygen humidifier bottle should have been changed prior to 06/17/2025. Resident #R2 Review of Resident #R2's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Acute Respiratory Failure with Hypoxia, Emphysema, and Unspecified Heart Failure. Review of Resident #R2's admission BIMS assessment dated [DATE] revealed a BIMS of 13, which indicated she was cognitively intact. An observation was made of Resident #R2's oxygen concentrator on 06/16/2025 at 8:13 a.m. An empty humidifier bottle and nasal cannula tubing was observed with no date. An interview was conducted with S4LPN on 06/16/2025 at 9:10 a.m. She observed and confirmed Resident #R2's oxygen humidifier bottle was empty and not dated, and the oxygen tubing was not dated and should have been. She stated oxygen tubing and humidifier bottles should be changed weekly. An interview was conducted with Resident #R2 on 06/16/2025 at 11:15 a.m. She stated she used her oxygen at night as needed. She stated she wore her oxygen last night, on 06/15/2025. An interview was conducted with S2DON on 06/16/2025 at 12:10 p.m. He stated resident's oxygen tubing and humidifier bottles should be changed weekly and labeled with the date. He was notified of the above observations. He confirmed Resident #R2's humidifier bottle and oxygen tubing should have been labeled with the date.

Based on observations, interviews, and record reviews, the facility failed to ensure correct installation, use, and maintenance of bed rails. The facility failed to ensure: 1. The risks and benefits were reviewed with the resident and/or resident representative, and informed consent was obtained prior to bed rail installation for 1 (#1) of 4 (#1, #3, #R1, and #R3) residents reviewed with bed rails; and 2. Each resident was assessed for risk for entrapment prior to bed rail installation for 4 of 4 (#1, #3, #R1, and #R3) residents reviewed with bed rails. Findings: 1. Resident #1 Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Polyneuropathy, Type 2 Diabetes Mellitus, Morbid Obesity, Acute Pulmonary Edema, Chronic Congestive Heart Failure, Cardiomegaly, Essential Hypertension, and Sleep Apnea. Further review of the Clinical Record revealed no documentation pertaining to bed rails, including an entrapment risk assessment, the risks and benefits of bed rails were reviewed with the resident and/or resident representative, and/or informed consent was obtained for bed rails. An observation was made of Resident #1 on 06/16/2025 at 8:14 a.m. He was lying in his bed. He had bilateral one-quarter bed rails on the top of his bed. An interview was conducted with S12CNA on 06/17/2025 at 10:30 a.m. She confirmed Resident #1 had bilateral bed rails on the top of his bed. An observation was made of Resident #1's bed with S1CNO on 06/17/2025 at 2:15 p.m. S1CNO confirmed there were bilateral bed rails on Resident #1's bed. An interview was conducted with S2DON on 06/17/2025 at 3:30 p.m. He confirmed Resident #1 had bilateral bed rails on his bed. He confirmed there was no documentation an entrapment risk assessment was completed, the risks and benefits of bed rails were reviewed with the resident and/or resident representative, or informed consent was obtained for Resident #1's bed rails. 2. Resident #3 Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] and had a diagnosis, which included Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Dominant Side. Further review revealed no documentation of an entrapment risk assessment for bed rails. An observation was made of Resident #3 on 06/17/2025 from 11:10 a.m. She was lying in her bed. She had bilateral one-quarter bed rails raised on the top of her bed. An interview was conducted with S14CNA on 06/18/2025 at 10:00 a.m. She observed and confirmed Resident #3 had bilateral bed rails raised on the top of her bed. She stated when Resident #3 was in bed, the bed rails were raised. Resident #R1 Review of Resident #R1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Paraplegia, Other Reduced Mobility, and Other Chronic Pain. Further review revealed no documentation of an entrapment risk assessment for bed rails. An observation was made of Resident #R1 on 06/16/2025 at 8:40 a.m. He had a left one-quarter bed rail raised on top of his bed. An interview was conducted with S15CNA on 06/18/2025 at 10:10 a.m. She observed and confirmed Resident #R1 had a left bed rail on the top of his bed. She stated when Resident #R1 was in bed, the bed rail was raised. Resident #R3 Review of Resident #R3's Clinical Record revealed she was admitted to the facility on [DATE] and had a diagnosis, which included Cerebral Infarction. Further review revealed no documentation of an entrapment risk assessment for bed rails. An observation was made of Resident #R3 on 06/17/2025 at 11:20 a.m. She was lying in her bed. She had a right one-quarter bed rail raised on the top of her bed. An interview was conducted with S14CNA on 06/18/2025 at 10:02 a.m. She observed and confirmed Resident #R3 had a right bed rail on the top of her bed. She stated when Resident #R3 was in bed, the bed rail was raised. An interview was conducted with S2DON on 06/18/2025 at 10:45 a.m. He confirmed Resident #3, #R1 and #R3 had bed rails on their beds. He confirmed there was no documentation an entrapment risk assessment was completed for Resident #3, #R1 and #R3's bed rails.

Based on observations, interviews, and record review, the facility failed to ensure services were provided by the facility to meet quality professional standards for 1 (#R2) of 3 (#1, #2, and #R2) sampled residents reviewed with oxygen therapy. The facility failed to ensure Physician Orders for oxygen therapy were obtained for Resident #R2 prior to administration. Findings: Review of the facility's undated policy titled, Oxygen Administration Policy and Procedure revealed the following, in part: Procedure: 1. Check Physician's Order for liter flow and method of administration. Review of Resident #R2's Clinical Record revealed she admitted to the facility on [DATE] with diagnoses, which included Acute Respiratory Failure with Hypoxia, Emphysema, and Unspecified Heart Failure. Review of Resident #R2's admission BIMS (Brief Interview for Mental Status) assessment dated [DATE] revealed a BIMS of 13, which indicated intact cognition. Review of Resident #R2's Physician Orders dated June 2025 revealed no orders for oxygen therapy. On 06/16/2025 at 8:13 a.m., an observation was made of Resident #R2's room. An oxygen concentrator with a humidifier bottle and nasal cannula tubing was observed on at 2 liters per minute next to Resident #R2's bed. On 06/16/2025 at 9:10 a.m., an interview was conducted with S4LPN. She reviewed Resident #R2's Physician's Orders and confirmed there was no order for oxygen for Resident #R2. S4LPN observed the oxygen concentrator with humidifier bottle and nasal cannula tubing in Resident #R2's room and confirmed oxygen was not ordered for Resident #R2 and should not have been in the resident's room. On 06/16/2025 at 11:15 a.m., an interview was conducted with Resident #R2. She stated used oxygen at night as needed. She stated she had oxygen in her room to use as needed since she admitted to the facility. She stated she used oxygen last night, on 06/15/2025. On 06/16/2025 at 12:00 p.m., an interview was conducted with S5LPN. She verified she worked on 06/15/2025, from 6:00 p.m. to 6:00 a.m. and was assigned to Resident #R2. She stated Resident #R2 wore oxygen as needed. She confirmed Resident #R2 wore oxygen last night, on 06/15/2025 during her shift. On 06/16/2025 at 12:10 p.m., an interview was conducted with S2DON. He reviewed Resident #R2's clinical record and confirmed there were no Physician's Orders for oxygen. He confirmed a Physician's Order for oxygen was needed for it to be administered to Resident #R2.

Based on interviews and record review, the facility failed to ensure a resident's medical record was complete and accurate by failing to ensure baths were documented as provided for 1 (#1) of 4 (#1, #2, #3, and #4) residents reviewed for activities of daily living. Findings: Review of the facility's undated policy titled, Documentation and Charting Guidelines revealed the following, in part: Purpose: The purpose of charting and documentation is to provide the following: A complete account to the resident's care . Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Polyneuropathy, Type 2 Diabetes Mellitus, Morbid Obesity, Chronic Congestive Heart Failure, and Cardiomegaly. Review of Resident #1's Significant Change MDS with an ARD of 05/20/2025 revealed he was dependent on staff for bathing. Review of Resident #1's Day Shift CNA Assignments dated 05/05/2025, 05/14/2025, 05/19/2025, and 05/23/2025 revealed S13CNA was assigned to Resident #1. Review of Resident #1's Bath Documentation dated May 2025 revealed he was scheduled to receive a bath on Mondays, Wednesdays, and Fridays. Further review revealed no documented bath on 05/05/2025, 05/14/2025, 05/19/2025, and 05/23/2025, which indicated he did not receive a bath. An interview was conducted with S13CNA on 06/17/2025 at 11:56 a.m. He stated Resident #1 was scheduled to receive bed baths every Monday, Wednesday, and Friday. He confirmed he was assigned to give Resident #1 baths on 05/05/2025, 05/14/2025, 05/19/2025, and 05/23/2025. He stated he provided baths to Resident #1 on 05/05/2025, 05/14/2025, 05/19/2025, and 05/23/2025. He reviewed Resident #1's Bath Documentation dated 05/05/2025, 05/14/2025, 05/19/2025, and 05/23/2025 and confirmed there was no bath documented. He confirmed the baths he provided to Resident #1 should have been documented. An interview was conducted with S1CNO on 06/17/2025 at 1:48 p.m. He stated if a bath was provided, it should have been documented on the resident's Bath Documentation.

Based on interviews and record reviews, the facility failed to ensure nursing staff communicated a significant change in status to the resident's physician for 2 (#3 and #R4) of 8 (#1, #2, #3, #R1, #R2, #R3, #R4, and #R5) residents reviewed for notification of change. This deficient practice resulted in an Immediate Jeopardy situation on 05/31/2024 at 4:00 a.m. when S4LPN failed to notify Resident #3's physician when the resident had no urine output. On 05/30/2024 at 2:56 p.m., Resident #3 was observed to be lethargic and weak, which resulted in S6NP ordering 500 cc normal saline via intravenous infusion and lab work in the morning. On 05/31/2024 at 4:00 a.m., S4LPN attempted to collect urine from Resident #3 with an in and out catheter which resulted in no urine. The resident's brief was also observed to be dry at that time. S4LPN did not notify the resident's physician or nurse practitioner that Resident #3 had no urine output. On 05/31/2024 at 7:00 a.m., Resident #3 was lethargic, his body was rigid, and extremities were twitching. On 05/31/2024 at 8:30 a.m., Resident #3 was transferred to the hospital. Resident #3 was diagnosed with Acute Metabolic Encephalopathy, Hypernatremia, and Acute Cystitis with Hematuria. Resident #3 was admitted to the hospital on 05/31/2024 and discharged back to the facility on [DATE]. S1ADM and S2DON were notified of the Immediate Jeopardy situation on 06/21/2024 at 2:41 p.m. The Immediate Jeopardy was removed on 06/23/2024 at 2:53 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. The deficient practice continued at more than minimal harm for any resident residing in the facility. Findings: Review of the facility's undated Resident Rights and Quality of Life Policy and Procedure revealed, in part: Policy: A resident has the right: 11. To be notified, and his or her physician notified of significant changes in condition, of a need to significantly alter treatment, or of a decision to be transferred. Resident #3 Review of Resident #3's medical record revealed Resident #3 was admitted to the facility on [DATE] with the following diagnoses, in part, Unspecified Dementia, Schizophrenia, Benign Prostatic Hyperplasia with lower urinary tract symptoms, Metabolic Encephalopathy, Sepsis, Acute Embolism and Thrombosis of left Peroneal Vein. Review of Resident #3's Progress Note dated 05/30/2024 by S6NP revealed, in part, vital signs: P 99, BP 178/91, T 98, R 18, O2 sat 95% RA. Staff reports that resident stayed in bed most of the day yesterday; today he is weak and required help with eating. BP elevated prior to medications, looks comfortable. Staff reports Resident #3 was weak, requiring assistance with feeding, not talking but tracks people and follows command, poor intake yesterday. Give IV bolus 500cc NS today, check CBC, CMP, UA. Review of Resident #3's Physician Orders dated May 2024 revealed, in part, the following: An order dated 05/30/2024 CBC, CMP, and UA in the morning for diagnoses: lethargy; An order dated 05/30/2024 for 500 cc Normal Saline IV one time only for dehydration for 1 day; An order dated 05/31/2024 for send to emergency room for evaluation. Review of Resident #3's Administration Note dated 05/31/2024 at 4:00 a.m. by S4LPN revealed, in part, Resident #3 was in bed and alert to nurse's voice. Resident #3's adult brief was dry. In and Out catheter attempted, no urine output, abdomen soft and non-tender, resident weak and fatigued more than normal. Report given to oncoming nurse of resident status. Further review revealed the NP and/or physician were not notified that the resident had no urine output. Review of Resident #3's Nurse's Note dated 05/31/2024 at 7:00 a.m. by S3LPN revealed, in part, Resident #3 was in bed with eyes closed, lethargic, body rigid, extremities twitching, refusing any oral fluids, 0.9% sodium chloride infusing at 20 ml/hr in IV noted to right arm. Night shift reported he had no urine output during the night shift and was unable to obtain urine when attempted to catheterize him this a.m. S6NP was informed of resident's condition. Received orders to send to hospital. Review of Resident #3's emergency provider note dated 05/31/2024 revealed, in part, Resident #3's chief complaint was weakness, increased weakness for 2 days, normally walking. Further review revealed, apparently on 05/28/2024 Resident #3 began to become more weak and less talkative, resident is non-communicative, so history was provided through EMS. Further review revealed, diagnoses included encephalopathy, weakness, and acute cystitis with hematuria. Review of Resident #3's hospital history and physical dated 05/31/2024 revealed, in part, acute metabolic encephalopathy-suspect from volume depletion and acute cystitis; hypernatremia- sodium elevated at 148, suspect volume depletion; acute cystitis with hematuria-UA consistent with acute cystitis and patient grossly encephalopathic. Review of Resident #3's hospital discharge summary dated 06/04/2024 revealed, in part, Resident #3 was admitted to the hospital on 05/31/2024 and discharged back to the facility on [DATE]. On 06/20/2024 at 8:10 a.m., an interview was conducted with S6NP. She stated on 05/30/2024 the nurse notified her Resident #3 was weak and lethargic, so she ordered a normal saline bolus via IV with labs to be completed in the morning. She stated she instructed the staff to notify her if there was no improvement or any decline. She stated she was not notified Resident #3 had no urine output, on 05/31/2024 at 4:00 a.m., when the nurse attempted to collect urine for the urinalysis. She stated she should have been notified of no urine output immediately. On 06/20/2024 at 9:20 p.m., an interview was conducted with S4LPN. She stated the provider should be notified of any changes in a resident's status. She stated on 05/31/2024 at 4:00 a.m. Resident #3's brief was dry, and there was no urine output noted when an In and Out catheter was used to collect the urine specimen. She stated she didn't notify the NP of no urine output at 4:00 a.m. on 05/31/2024, and should have. On 06/20/2024 at 11:25 a.m., an interview was conducted with S3LPN. She stated when she arrived to work on 05/31/2024 for the 6:00 a.m. to 6:00 p.m. shift, S4LPN asked her to assess Resident #3 during report since he had no urine output during the night shift. She stated Resident #3 was walking on Tuesday, 05/28/2024 and on 05/31/2024 he was lethargic. She stated Resident #3's blood pressure and heart rate were elevated so she called the S6NP and received orders to send him out. Resident #R4 Review of Resident #R4's medical record revealed Resident #R4 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus with Diabetic Nephropathy, Morbid Obesity, and Chronic Obstructive Pulmonary Disease. Review of Resident #R4's MAR dated May 2024 revealed, in part, the following: Normal Saline Intravenous Solution 1000 ml/hr with a note to see progress note dated 05/02/2024. Review of Resident #R4's Progress Note dated 05/02/2024 by S6NP revealed, in part, Resident #R4 was confused and lethargic. Further review revealed, start IV NS; infuse 1 liter over 4 hours and encourage fluid intake. Review of Resident #R4's Nurse's Note dated 05/02/2024 at 7:03 p.m. by S7LPN revealed, in part, unable to start IV, could not access vein, attempted three times. On 06/21/2024 at 6:00 p.m., an interview was conducted with S7LPN. She stated she confirmed she was not able to obtain IV access on 05/02/2024 and she did not administer the IV fluids as ordered on 05/02/2024. She also stated she did not notify the NP and should have. On 06/21/2024 at 6:15 p.m., an interview was conducted with S6NP. She stated she ordered IV fluids for Resident #R4 on 05/02/2024. She confirmed was not notified of the IV not being able to be obtained and she should have been. On 06/24/2024 at 10:30 a.m., an interview was conducted with S2DON. She confirmed providers should be notified immediately when orders are not able to be followed or for any significant change in a resident's condition.

Based on interviews and record reviews, the facility failed to a resident received treatment and care in accordance with professional standards of practice and each resident's physical needs including assess, monitor, and record accurate intake/output for a resident receiving IV therapy for 1 (#3) of 5 (#3, #R1, #R2, #R3, and #R5) residents reviewed for IV therapy. This deficient practice resulted in an Immediate Jeopardy situation on 05/30/2024 at 2:56 p.m., when Resident #3 began receiving IV fluids as ordered for lethargy and weakness. On 05/31/2024 at 4:00 a.m., S4LPN attempted to collect urine from Resident #3 with an in and out catheter which resulted in no urine. The resident's brief was also observed to be dry at that time. There was no documentation of each shift's total intake and output. On 05/31/2024 at 7:00 a.m., Resident #3 was lethargic, his body was rigid, and extremities were twitching. On 05/31/2024 at 8:30 a.m., Resident #3 was transferred to the hospital. Resident #3 was diagnosed with Acute Metabolic Encephalopathy, Hypernatremia, and Acute Cystitis with Hematuria. Resident #3 was admitted to the hospital on 05/31/2024 and discharged back to the facility on [DATE]. S1ADM and S2DON were notified of the Immediate Jeopardy situation on 06/21/2024 at 2:39 p.m. The Immediate Jeopardy was removed on 06/23/2024 at 2:53 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. The deficient practice continued at more than minimal harm for any resident residing in the facility requiring IV therapy residing in the facility. Findings: Review of the facility's undated Documentation and Charting Guidelines Policy revealed, in part, Purpose: The purpose of charting and documentation is to provide the following: A complete account to the resident's care, treatment, response to the care, signs, symptoms, and progress of resident care. Guidance to the physician in prescribing appropriate medication and treatment, assistance in the development of a plan of care for the resident. Procedure: 6. Intake and Output: a. consistent and accurate documentation and measurement of the resident's intake/output. b. each shift's total intake c. each shift's total output d. The 24-hour total intake/output for all shifts. e. Intake/output documentation shall be recorded when a resident has an IV. 7. IV therapy: d. 24-hour intake/output record. Review of Resident #3's medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses, in part, Unspecified Dementia, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Metabolic Encephalopathy, and Sepsis. Review of Resident #3's Physician Orders dated May 2024 revealed, in part, the following: An order dated 05/30/2024 for labs: CBC, CMP, and UA in the morning for diagnosis: Lethargy; An order dated 05/30/2024 for 500 cc Normal Saline IV one time only for Dehydration for 1 day; An order dated 05/31/2024 to send emergency room for evaluation. Review of Resident #3's MAR dated May 2024 revealed, in part, 500 cc normal saline IV one time only for dehydration for 1 day administered on 05/30/2024 at 10:13 a.m. Review of Resident #3's Nurse's Note dated 05/30/2024 by S6NP revealed, in part, Staff reports Resident #3 was weak, requiring assistance with feeding, not talking but tracks people and follows command, poor intake yesterday. Give IV bolus 500cc NS today, check CBC, CMP, UA. Review of Resident #3's Administration Note dated 05/31/2024 at 4:00 a.m. by S4LPN revealed, in part, adult brief dry, In an Out catheter attempted, no urine output, resident weak and fatigued more than normal. Report given to oncoming nurse of resident status. Further review revealed the NP was not notified. Review of Resident #3's medical record failed to reveal documentation of each shift's total intake and output on 05/30/2024 and the facility failed to provide any documentation of each shift's total intake and output. On 06/20/2024 at 9:20 p.m., an interview was conducted with S4LPN. She stated on 05/31/2024 at 4:00 a.m. Resident #3's brief was dry, and there was no urine output noted when an In and Out catheter was used to collect the urine specimen. She stated she was not monitoring intake/output of Resident #3 and should have been. On 06/20/2024 at 11:25 a.m., an interview was conducted with S3LPN. She stated when she arrived to work on 05/31/2024 for the 6:00 a.m. to 6:00 p.m. shift, S4LPN asked her to assess Resident #3 during report since he had no urine output during the night shift. She stated Resident #3 was walking on 05/28/2024 and on 05/31/2024 he was lethargic and not walking. She stated Resident #3's blood pressure and heart rate were elevated, so she called the S6NP and received orders to send him out. Review of Resident #3's Nurse's Note dated 05/31/2024 at 7:00 a.m. by S3LPN revealed, in part, Resident #3 was in bed with eyes closed, lethargic, body rigid, extremities twitching, refusing any oral fluids, 0.9% sodium chloride infusing at 20 ml/hr in IV noted to right arm. Night shift reported he had no urine output during the night shift and was unable to obtain urine when attempted to catheterize him this a.m. S6NP was informed of resident's condition. Received orders to send to hospital. Review of Resident #3's emergency provider note dated 05/31/2024 revealed, in part, Resident #3's chief complaint was weakness, increased weakness for 2 days. Further review revealed, on 05/28/2024 Resident #3 began to become more weak and less talkative, resident was non-communicative. Review of Resident #3's history and physical dated 05/31/2024 revealed, in part, Acute Metabolic Encephalopathy-suspect from volume depletion and Acute Cystitis; Hypernatremia- sodium elevated at 148, suspect volume depletion; Acute Cystitis with Hematuria-UA consistent with Acute Cystitis and patient grossly Encephalopathic. On 06/21/2024 at 10:20 a.m., an interview was conducted with S10CNA. She stated she did not monitor or document intake & output amounts. She stated she did not document how many times a resident had gone to the bathroom. She was only required to document incontinence once a shift. She stated she was not instructed to monitor intake/output for any residents. On 06/21/2024 at 10:35 a.m., an interview was conducted with S8LPN. She stated supplemental fluid with meals was not tracked. She stated the CNAs monitored how many times the resident urinated and was unsure if that was documented. On 06/21/2024 at 10:37 a.m., an interview was conducted with S9LPN. She stated she was not tracking intake/output for residents who may have been dehydrated. She stated she didn't know how urine output was measured for incontinent residents. On 06/21/2024 at 10:50 a.m., an interview was conducted with S5LPN. She stated she did not monitor intake or output for residents receiving IV fluids. On 06/20/2024 at 8:10 a.m., an interview was conducted with S6NP. She stated on 05/30/2024 the nurse notified her Resident #3 was weak and lethargic; she ordered a normal saline bolus via IV with labs to be completed on 05/31/2024 in the morning. She stated she instructed the staff to notify her if there was no improvement or any decline. She stated she expected nursing staff to document and assess a resident's fluid intake and output if she ordered IV fluids for dehydration or if the resident had decreased intake. On 06/21/2024 at 11:40 a.m., an interview was conducted with S2DON. She confirmed the documenting and charting policy indicated to track intake and output for residents receiving IV therapy. On 06/24/2024 at 10:30 a.m., an interview was conducted with S2DON. She stated Resident #3 should have had accurate intake and output monitoring while receiving IV fluids. She also stated the nurse practitioner should have been notified immediately when Resident #3 had no urine output from the in an out catheter attempt.

Based on interviews and record review the facility failed to be administered in a manner that enabled it use its resources effectively and efficiently by failing to implement a system to provide quality care to meet the needs of each resident by failing to: 1. Ensure nursing staff communicated a resident's significant change in condition to the physician after having no urine output while receiving IV therapy for 1 (#3) of 5 (#3, #R1, #R2, #R3, and #R5) residents reviewed for receiving IV therapy; and 2. Ensure a resident received treatment and care in accordance with professional standards of practice and each resident's physical needs including assess, monitor, and record accurate intake/output for a resident receiving IV therapy for 1 (#3) of 5 (#3, #R1, #R2, #R3, and #R5) residents reviewed for IV therapy. This deficient practice resulted in an Immediate Jeopardy situation on 05/30/2024 at 2:56 p.m., Resident #3 was observed to be lethargic and weak, which resulted in S6NP ordering 500 cc normal saline via intravenous infusion and lab work in the morning. On 05/31/2024 at 4:00 a.m., S4LPN attempted to collect urine from Resident #3 with an in and out catheter which resulted in no urine. The resident's brief was also observed to be dry at that time. S4LPN did not notify the physician of this significant change in status for Resident #3. There was no documentation of each shift's total intake and output. On 05/31/2024 at 7:00 a.m., Resident #3 was lethargic, his body was rigid, and extremities were twitching. On 05/31/2024 at 8:30 a.m., Resident #3 was transferred to the hospital. Resident #3 was diagnosed with Acute Metabolic Encephalopathy, Hypernatremia, and Acute Cystitis with Hematuria. Resident #3 was admitted to the hospital on 05/31/2024 and discharged back to the facility on [DATE]. S1ADM and S2DON were notified of the Immediate Jeopardy situation on 06/21/2024 at 2:42 p.m. The Immediate Jeopardy was removed on 06/23/2024 at 2:53 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. The deficient practice continued at more than minimal harm for any resident residing in the facility. Findings: Cross Reference F580 and F684 Review of the facility's In-service Training Record Documentation revealed, in part, the following: Names of Person giving the training: S2DON Date of Training: 01/01/2024 Purpose of Training: Educating nursing staff on notifying physician/nurse practitioner of incident. Attachment: Documentation and Charting Guidelines Name of Person giving the training: S3ADON Date of Training: 04/09/2024 Purpose of Training: Hydration Attachment: Hydration Policy and Procedure Review of the facility's undated Documentation and Charting Guidelines Policy revealed, in part, the following: Purpose: The purpose of charting and documentation is to provide the following: A complete account to the resident's care, treatment, response to the care, signs, symptoms, and progress of resident care. Guidance to the physician in prescribing appropriate medication and treatment, assistance in the development of a plan of care for the resident. Procedure: 6. Intake and Output: a. consistent and accurate documentation and measurement of the resident's intake/output. b. each shift's total intake c. each shift's total output d. The 24-hour total intake/output for all shifts. e. Intake/output documentation shall be recorded when a resident has an IV. 7. IV therapy: d. 24-hour intake/output record. Review of the facility's undated Hydration Policy and Procedure revealed, in part, the following: Purpose: To assure that the resident receives sufficient amount of fluid based on individual needs to prevent dehydration. Procedure: 3. Intake and Output will be done every shift on residents that have: e. Any other condition that warrant possible dehydration or as ordered by the physician. Review of Resident #3's medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses, in part, Unspecified Dementia, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Metabolic Encephalopathy, and Sepsis. Review of Resident #3's Physician Orders dated May 2024 revealed, in part, the following: An order dated 05/30/2024 for labs: CBC, CMP, and UA in the morning for diagnosis: Lethargy; An order dated 05/30/2024 for 500 cc Normal Saline IV one time only for Dehydration for one day; An order dated 05/31/2024 to send emergency room for evaluation. Review of Resident #3's Nurse's Note dated 05/30/2024 by S6NP revealed, in part, Staff reports Resident #3 was weak, requiring assistance with feeding, not talking but tracks people and follows command, poor intake yesterday. Give IV bolus 500cc NS today, check CBC, CMP, UA. Review of Resident #3's Administration Note dated 05/31/2024 at 4:00 a.m. by S4LPN revealed, in part, adult brief dry, In and Out catheter attempted, no urine output, resident weak and fatigue more than normal. Report given to oncoming nurse of resident status. Review of Resident #3's Nurse's Note dated 05/31/2024 at 7:00 a.m. by S3LPN revealed, in part, Resident #3 was in bed with eyes closed, lethargic, body rigid, extremities twitching, refusing any oral fluids, 0.9% sodium chloride infusing at 20 ml/hr in IV noted to right arm. Night shift reported he had no urine output during the night shift and was unable to obtain urine when attempted to catheterize him this a.m. S6NP was informed of resident's condition. Received orders to send to hospital. Review of Resident #3's emergency provider note dated 05/31/2024 revealed, in part, Resident #3's chief complaint was weakness, increased weakness for 2 days. Further review revealed, on 05/28/2024 Resident #3 began to become more weak and less talkative, resident was non-communicative. Review of Resident #3's history and physical dated 05/31/2024 revealed, in part, Acute Metabolic Encephalopathy-suspect from volume depletion and Acute Cystitis; Hypernatremia- sodium elevated at 148, suspect volume depletion; Acute Cystitis with Hematuria-UA consistent with Acute Cystitis and patient grossly encephalopathic. On 06/20/2024 at 9:20 p.m., an interview was conducted with S4LPN. She stated the provider should be notified of any changes in a resident's status. She stated on 05/31/2024 at 4:00 a.m. Resident #3's brief was dry, and there was no urine output noted when an In and Out catheter was used to collect the urine specimen. She stated she didn't notify the NP of no urine output at 4:00 a.m. on 05/31/2024, and should have. On 06/20/2024 at 8:10 a.m., an interview was conducted with S6NP. She stated on 05/30/2024 the nurse notified her Resident #3 was weak and lethargic; she ordered a normal saline bolus via IV with labs to be completed on 05/31/2024 in the morning. She stated she instructed the staff to notify her if there was no improvement or any decline. She stated she expected nursing staff to document and assess a resident's fluid intake and output if she ordered IV fluids for dehydration or if the resident had decreased intake. She stated she was not notified Resident #3 had no urine output, on 05/31/2024 at 4:00 a.m., when the nurse attempted to collect urine for the urinalysis. She stated she should have been notified of no urine output immediately. On 06/21/2024 at 11:40 a.m., an interview was conducted with S2DON. She stated intake and output was only tracked if there was an order from the provider. She confirmed the facility's documenting and charting policy indicated to track intake and output for all residents receiving IV therapy. She stated she expected nursing staff to contact the provider for any change in condition. She confirmed she conducted an in-service for nursing staff to notify the physician/nurse practitioner of any resident incidents which included the Documentation and Charting Guidelines Policy on 01/01/2024 and ADON conducted an in-service on the Hydration Policy on 04/09/2024. She stated she was not monitoring compliance of the in-services conducted on 01/01/2024 and 04/09/2024. On 06/24/2024 at 10:30 a.m., an interview was conducted with S2DON. She stated Resident #3 should have had accurate intake and output monitoring while receiving IV fluids. She also stated the nurse practitioner should have been notified immediately when Resident #3 had no urine output from the in an out catheter attempt.

Based on observations, interviews, and record reviews, the facility neglected to provide needed services to residents by failing to ensure: 1. Nursing staff supervised and monitored residents who utilized the outdoor smoker's patio to ensure their safety in accordance with the residents care plan for 9 (#1, #3, #4, #5, R1, R2, R3, R4, R5) of 10 (#1, #2, #3, #4, #5, R1, R2, R3, R4, R5) residents reviewed for supervision; and 2. Staff (S6CNA and S7CNA) did not sleep when responsible for caring for residents during their shift. The deficient practice resulted in an Immediate Jeopardy on [DATE] at approximately 2:00 a.m., when Resident #1, who was moderately cognitively impaired and care planned as requiring supervision when smoking, was last seen by staff (S5CNA). Resident #1 was later found outside behind a storage shed near the smoker's patio on Hall A by another facility resident (R6). R6 notified S5CNA who then found Resident #1 to be lying face down on the ground with no pulse at 5:46 a.m. Resident #1 was pronounced dead at 6:51 a.m. with causes of death listed as Dilated Cardiomyopathy and Hypothermia. On [DATE] at 10:36 p.m. video surveillance revealed 8 residents (#3, #5, #4, R1, R2, R3, R4, R5), who were care planned as requiring staff supervision while smoking, were seen outside smoking without staff supervision on the smoker's patio between the times of 9:00 p.m. and 10:36 p.m. Further review of the video revealed Resident #5, who was severely cognitively impaired, remained outside unsupervised on the smoker's patio on [DATE] from 11:50 p.m. through 2:27 a.m., when the resident independently ambulated into the facility. S1ADM was notified of the Immediate Jeopardy on [DATE] at 5:10 p.m. The Immediate Jeopardy Plan of Removal included the following: 1. Residents identified as having the potential to be affected or have been affected will be monitored and observed every 2 hours to ensure safety by the assigned nurse for every shift for 30 days, and rounds will be documented on a monitoring form, re-evaluated after receipt of the 2567, review of the policies and procedures, review of the smoking risk assessments, and QA identified issues. a. Monitoring forms were observed by surveyors as completed for each hall and resident. 2. DON/designee will review all smoking resident care plans to ensure residents are monitored base on risk assessments as determined by the IDT and residents' needs. 3. Care plan will be updated as needed. 4. Nurses educated by DON/ADON on rounding on residents and monitoring for safety every 2 hours for every shift, beginning [DATE] at 6:00 p.m. for 30 days. Reevaluation will occur when facility receives the 2567. a. In-services/Education started on [DATE] at 6:00 p.m. and will have an expected completed dated of [DATE]. i. In-services started reviewed by surveyors. b. Nurses will be educated before working scheduled assignments. 5. Nurses/CNAs educated by DON/ADON on observing residents while smoking, and to report any resident with cigarettes and/or smoking paraphernalia to administration. Reevaluation will occur when facility receives the 2567. a. In-services/Education started on [DATE] at 6:00 p.m. and will have an expected completed dated of [DATE]. b. In-services started reviewed by surveyors. c. Nurses will be educated before working scheduled assignments. 6. Nurses/CNAs educated by DON/ADON on observing video monitors at nurses station and observing residents to ensure safety. a. Video monitoring initiated [DATE] at 6:00 p.m. and will continue until the receipt of the 2567 when reevaluation will occur. b. Additional rounding documentation by CNAs beginning [DATE] at 6:00 p.m. until [DATE] at 6:00 p.m. c. In-services/Education started on [DATE] at 6:00 p.m. and will have an expected completed dated of [DATE]. In-services started reviewed by surveyors. d. Nurses will be educated before working scheduled assignments. 7. Nurses/CNAs are to document monitoring form when round is complete, and residents are accounted for. a. Nurses will sign the monitoring form next to the time/monitoring complete. b. If any resident is not accounted for, nurses and CNA/designee will make rounds outside the perimeter of the facility. c. In-services/Education started on [DATE] at 6:00 p.m. and will have an expected completed dated of [DATE]. d. Nurses will be educated before working scheduled assignments. 8. Monitoring/documentation of monitoring of resident every 2 hours will be initiated [DATE] at 6:00 p.m. and will continue to for 30 days, and as deemed necessary by the QAPI team after receipt of the 2567. The Immediate Jeopardy was removed on [DATE] at 1:10 p.m., when the facility submitted an acceptable Plan of Removal. Through observations, interviews and record reviews, the surveyors confirmed the Plan of Removal had been initiated and/or implemented prior to exit. The deficient practice continued at more than minimal harm for the 18 residents identified by the facility as ambulatory and requiring supervision when smoking. Findings: Review of the facility's Abuse Prevention and Prohibition policy revealed the following, in part: Neglect is defined as the failure of the facility, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect may include, but is not limited to: Failure to provide adequate supervision and staffing Resident #1 Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses, which included Multiple Subsegmental Pulmonary Emboli without Acute Coronary Pulmonale, Other Symptoms and Signs Involving Cognitive Functions Following Cerebral Infarction, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Cardiac Arrest due to Underlying Cardiac Conditions, Acute and Chronic Combined Systolic and Diastolic Congestive Heart Failure, Chest Pain, Unspecified Convulsions, Paranoid Schizophrenia, Bipolar Disorder, Major Depressive Disorder Recurrent Moderate, Vascular Dementia Moderate with Other Behavioral Disturbances, Generalized Anxiety Disorder, Impulse Disorder, Unspecified Intellectual Disabilities, Other Seizures, Mild Cognitive Impairment of Uncertain or Unknown Etiology, Cardiomyopathy due to Drug and External Agent, and Cerebral Infarction. Review of the Quarterly MDS with an ARD of [DATE] revealed Resident #1 had a BIMS of 12, which indicated the resident was moderately cognitively impaired. Further review revealed Resident #1 was ambulatory without assistive devices. Review of the current Care Plan for Resident #1 revealed the following, in part: Date Initiated: [DATE] Problem: Resident was a smoker. Safe to smoke with staff supervision. At risk for injuries and issues related to smoking. Interventions: Supervise and assist with smoking as needed. Date Initiated: [DATE] Problem: Resident had impaired cognitive functions or impaired thought processes related to vascular dementia, mild neurocognitive disorder. Interventions: Cue, reorient and supervise as needed. Review of Resident #1's smoking assessment dated [DATE] revealed Resident #1 was a smoker and required staff supervision with all smoke breaks. Review of Resident #1 nurse's notes dated [DATE] at 5:34 a.m. revealed the following, in part: Nurse on Hall A doing morning rounds and noticed Resident #1 was not in his room. Staff found the resident lying outside behind a shed unresponsive. Staff initiated CPR and called 911. Response team arrived at 5:59 a.m., CPR was continued. Resident #1's time of death was 6:44 a.m. Signed by S4LPN Review of the Coroner's Fact of Death Letter for Resident #1 revealed the following, in part: Decedent: Resident #1 date of death : [DATE] Time of death: 6:51 a.m. Cause of death: Dilated Cardiomyopathy and Hypothermia. Review of the weather app, Accuweather, revealed the following: [DATE] - Low of 45 degrees Fahrenheit [DATE] - Low of 53 degrees Fahrenheit Review of the police detective's investigation notes of video surveillance from [DATE] revealed the following, in part: 2:18 a.m. Resident #1 was noted to go outside on Hall A smoker's patio and smoke a cigarette. 2:27 a.m. Resident #1 was noted to go behind a storage shed and was no longer seen on camera. 5:41 a.m. R6 was noted to go outside on Hall A smoker's patio. 5:45 a.m. R6 was noted to go inside the facility. 5:46 a.m. R6 was noted to go outside with staff member, S5CNA. They were noted to walk around the storage shed. An interview was conducted on [DATE] at 4:10 p.m. with S3ADON. S3ADON stated the doors to the outside smoking areas stay unlocked at all times to allow residents freedom to go in and out, as they please. She stated Resident #1 was a smoker and was allowed to go outside at all times of the day and night. She stated he did not need to be supervised unless he was smoking, but staff was expected to round on him every 2 hours. An observation was made of Hall A's smoker's patio on [DATE] at 3:45 p.m. The door leading to the smoker's patio was solid with a small rectangular window. It was noted that only a small portion of the patio was visible through the window from inside the facility. About 20 feet and directly in front of the smoker's patio was a storage shed. Immediately outside of the door, the smoker's patio was noted to extend into a large fenced-in perimeter that enclosed all the facility halls smoker's patios. Surveyor was unable to visualize the entirety of the area, including the gazebo area, to see residents from inside the building. An observation was made of Hall B's smoker's patio on [DATE] at 3:50 p.m. The door leading to the smoker's patio was solid with a small rectangular window. It was noted that only a small portion of the patio was visible through the window from inside the facility. About 100 feet to the right of the smoker's patio was a gazebo area. Surveyor was unable to visualize the entirety of the area, including the gazebo area, to see residents from inside the building. An interview was conducted on [DATE] at 12:08 p.m. with the local police detective. He stated dispatch was called at 5:59 a.m. on [DATE]. He confirmed he reviewed the facility's video surveillance from [DATE], which revealed Resident #1 smoking outside unsupervised multiple times prior to 2:18 a.m. He stated at 2:27 a.m. Resident #1 was observed to walk behind the storage shed and out of site of the camera. He said the resident remained behind the shed from 2:27 a.m. to 5:46 a.m. He confirmed staff were not seen on the surveillance video until 5:46 a.m., when R6 and S5CNA walked into view and found Resident #1 behind the shed. He stated the coroner report revealed the resident died of Dilated Cardiomyopathy and Hypothermia. An interview was conducted on [DATE] at 9:45 a.m. with S4LPN. She confirmed being responsible to care for Resident #1 the night of [DATE]. She said Resident #1 was cognitive, could walk on his own with no assistive devices, had no behaviors, was a smoker, and needed supervision when smoking. She stated the facility expected the staff to lay eyes on each resident about every 2 hours during their shift. She stated the last time she saw Resident #1 was approximately 2:00 a.m. on [DATE]. She stated at that time he was in bed. She stated she did not make rounds on Resident #1 until around 5:30 a.m. when she realized he was not in his bed. She stated she began looking for Resident #1 when R6 found her. She stated R6 told her a body was outside. S4LPN said she went outside onto Hall As smoker's patio and walked around the storage shed where saw Resident #1 face down on the ground. She stated Resident #1 did not have a pulse. She explained 2 other nurses helped flip the resident over and began CPR while she called 911. She confirmed she did not make rounds on Resident #1 between the hours of 2:00 a.m. to 5:30 a.m. She said she assumed S5CNA had made rounds and checked on him. An interview was conducted on [DATE] at 9:00 a.m. with R6. R6 stated early every morning he walked outside onto the smoker's patio to see how the weather was. He said on [DATE] around 5:40 a.m., he walked outside and noticed something on the ground behind the storage shed that was located near Hall A's smoking patio. He stated he walked inside and told S5CNA there was something on the ground. He stated they walked outside together and S5CNA said, That's a body. He said he then went inside and told S4LPN there was a body on the ground. He stated S4LPN went outside after that. An interview was conducted on [DATE] at 9:12 a.m. with S5CNA. She confirmed being responsible to care for Resident #1 on the night of [DATE]. She described Resident #1 as polite and cognitive. She stated he was a smoker, which needed supervision when smoking. She stated the facility expected the staff to make rounds on each resident about every 2 hours during their shift. She stated the last time she saw Resident #1 on [DATE] was at 2:00 a.m. and Resident #1 was standing in his bedroom doorway. She stated she did not see Resident #1 again until about 5:46 a.m. when he was found outside on the ground. She explained R6 found her and said something was outside on the ground so she walked outside to see what it was. She stated she saw Resident #1 was on his stomach face down on the ground behind the storage shed. She said she and asked R6 to go get help. She stated S4LPN came outside shortly after and then two other nurses. She stated the nurses began CPR and called 911. An interview was conducted on [DATE] at 11:45 a.m. with the coroner. She confirmed she completed the Fact of Death Letter for Resident #1 dated [DATE]. She stated Resident #1's autopsy showed the causes of death as Dilated Cardiomyopathy with Hypothermia being a contributing factor to his demise. She confirmed the time of death for Resident #1 was 6:51 a.m. on [DATE]. An interview was conducted on [DATE] at 1:48 p.m. with S3ADON. She confirmed she reviewed the video surveillance dated [DATE] with the local police detective. She confirmed Resident #1 exited the building from Hall A onto the smoker's patio at 2:18 a.m. and smoked a cigarette unsupervised. She said Resident #1 then walked behind the shed and out of sight of the surveillance camera at 2:27 a.m. She confirmed no staff were seen to go out of the building to round on Resident #1 from 2:18 a.m. to 5:46 a.m. She confirmed the staff went out at 5:46 a.m. and found the resident on the ground. She confirmed Resident #1 died from Dilated Cardiomyopathy and Hypothermia. She stated the facility encouraged staff to round on residents at least every 2 hours and confirmed on [DATE] the staff did not round on Resident #1 for over 3 hours. She stated staff were in-serviced regarding making rounds on residents every 2 hours after this incident. She stated no new policies, procedures, or monitoring was implemented after Resident #1 died because he died of natural causes. She stated Resident #1 should not have had access to cigarettes or a lighter without supervision. An interview was conducted on [DATE] at 2:11 p.m. with S2DON. He stated the nurses and CNAs were encouraged to round on residents every 2 hours. He stated early on [DATE] he was notified Resident #1 was found outside on the ground. He stated staff reported CPR was started, 911 was called and the time Resident #1 was pronounced dead. He stated he reviewed the video surveillance with the local police detective. He confirmed Resident #1 was outside smoking unsupervised at 2:18 a.m. He verified Resident #1 should have been supervised while smoking. He confirmed at 2:27 a.m., the resident went behind the storage shed and out of sight. He confirmed no staff rounded on the resident until after R6 alerted S5CNA. He confirmed Resident #1 was found outside at 5:46 a.m., over 3 hours later. He stated staff were in-serviced regarding rounding on residents every 2 hours, but nothing new was implemented. He stated he did not investigate the circumstances surrounding the resident's death because this resident was very sick and it was not surprising he had passed. He confirmed nothing new was implemented because the resident had died of natural causes. He confirmed the coroner's report said the cause of death was Dilated Cardiomyopathy and Hypothermia. An interview was conducted on [DATE] at 2:34 p.m. with S1ADM. She stated she encouraged staff to put their eyes on the residents at a minimum of every 2 hours. She stated on [DATE] staff notified her prior to 8 a.m. that Resident #1 was found outside on the ground, behind the storage shed near Hall As smoker's patio. She said staff reported CPR was initiated, the paramedics were called, and staff continued CPR for 45 minutes until Resident #1 was pronounced dead. She stated she did not watch the video surveillance dated [DATE]. She stated she spoke with the nurses and CNAs on duty the night of [DATE] about the series of events, but did not find anything that would make her think the facility did anything wrong. She confirmed there was no further investigation into this event. She stated she did not know Resident #1 was smoking outside and unsupervised at 2:18 a.m. She confirmed he should have been supervised while smoking. She stated during her investigation, she did not specifically ask staff what times they had last seen Resident #1 and did not know none of the staff had laid eyes on him from 2:18 a.m. to 5:46 a.m. She confirmed had she known this she would have considered this as potential neglect. She explained S3ADON in-serviced all staff to round on the residents at least every 2 hours, but there were no new interventions or changes to policies. She denied increasing supervision of residents outside on the smoker's patio or rounding. Resident #5 Review of the Clinical Record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses, which included Type 2 Diabetes Mellitus without Complications, Schizophrenia, Major Depressive Disorder, and Multiple Fractures of Ribs on Left Side. Review of the Quarterly MDS with an ARD of [DATE] revealed Resident #5 had a BIMS of 8, which indicated the resident was moderately cognitively impaired. Further review revealed Resident #5 was able to independently propel when in the wheelchair. Review of the current Care Plan for Resident #5 revealed the following, in part: Date Initiated: [DATE] Problem: The resident was a tobacco smoker and was at risk for complications. Refuses to come inside after smoking at times. Resident requires supervision at all smoke breaks. Date Initiated: [DATE] Problem: At risk for wandering and elopement related to anxiety disorder, schizophrenia, depression. Intervention: monitor behavior/behavior changes, redirect as appropriate Date Initiated: [DATE] Problem: Resident has impaired cognitive function or impaired thought processes related to BIMS 8 Intervention: cue, reorient, and supervise as needed, monitor for change in cognition function. Review of Resident #5's smoking assessment dated [DATE] revealed Resident #5 was a smoker and required staff supervision with all smoke breaks. The facility's video surveillance of Hall B's outdoor smoker's patio dated [DATE] to [DATE] was observed with S3ADON on [DATE] at 1:45 p.m. The following was confirmed by S3ADON. 10:17 p.m. Resident #5 was observed on the patio watching tv. 10:36 p.m. Resident #5 was observed smoking a cigarette on the patio with no supervision. 10:53 p.m. Resident #5 was observed going back into the facility. 11:50 p.m. Resident #5 was observed going back out onto the smoker's patio, and watching tv. 2:27 a.m. Resident #5 was observed going back into the facility. It is noted from 11:50 p.m. to 2:27 a.m. no staff were observed supervising or monitoring Resident #5. An interview was conducted on [DATE] at 4:00 a.m. with S15CNA. She stated was assigned to care for Resident #5 on the night shift of [DATE]. She stated Resident #5 should not be smoking outside alone, nor should he have access to cigarettes without a CNA giving them to him. She stated she was unaware this resident was outside smoking unsupervised on [DATE] and should not had been. She confirmed Resident #5 should not be outside smoking without supervision. Resident #3 Review of the clinical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses, which included Chronic Obstructive Pulmonary Disease, Asthma, Bradycardia, Major Depressive Disorder, Disease of Upper Respiratory Tract, Old Myocardial Infarction, and Tobacco Use Review of the Quarterly MDS with an ARD of [DATE] revealed Resident #3 had a BIMS of 11, which indicated the resident was moderately cognitively impaired. Further review revealed Resident #3 was ambulatory without assistive devices. Review of the current Care Plan for Resident #3 revealed the following, in part: Date Initiated: [DATE] Problem: The resident was a tobacco smoker. Safe to smoke with supervision. Interventions: Resident requires supervision when smoking Date Initiated: [DATE] Problem: The resident has impaired cognitive function and though processes related to Dementia. Interventions: Cue, reorient and supervise as needed Date Initiated: [DATE] Problem: the Resident was at risk for mood and behavior episodes related to diagnosis of bipolar schizoaffective disorder, OCD, anxiety and behavior issues; picks up cigarette butts off of the ground and look for people to light them for him Intervention: staff will encourage resident to not pick up cigarette butts off the ground Review of Resident #3's smoking assessment dated [DATE] revealed Resident #3 was a smoker, and required staff supervision while smoking. The facility's video surveillance of Hall B's outdoor smoker's patio dated [DATE] to [DATE] was observed with S3ADON on [DATE] at 1:45 p.m. S3ADON confirmed Resident #3 was outside smoking without staff supervision at 9:09 p.m. and should not have been. An interview was conducted on [DATE] at 10:56 a.m. with S12CNA. She stated Resident #3 was a smoker and had to be supervised when smoking. Resident #4 Review of the clinical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses, which included Unspecified Dementia, Unspecified Severity without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, Tobacco Use, Major Depressive Disorder, Bipolar Disorder, Atherosclerotic Heart Disease of Native Coronary Artery With Unspecified Angina Pectoris, Angina Pectoris, Schizoaffective Disorder, Unspecified Psychosis not due to a Substance or Known Physiological Condition, and Unspecified Convulsions. Review of the Quarterly MDS with an ARD of [DATE] revealed Resident #4 had a BIMS of 13, which indicated the resident was cognitively intact. Further review revealed Resident #4 was ambulatory without assistive devices. Review of the current Care Plan for Resident #4 revealed the following, in part: Date Initiated: [DATE] Problem; Resident smokes daily. Resident requires staff supervision. Chews on cigarette butts at times. Resident had periods where he quit smoking and then start back again. At risk for injury related to smoking. Interventions: supervise and assist with smoking Date Initiated: [DATE] Problem: Nurse informed MD of my complaint of frequent nausea related to eating cigarette butts. Interventions: staff will encourage not to chew cigarette butts, staff will counsel resident on effects of eating cigarette butts when needed. Date Initiated: [DATE] Problem: At risk for mood and behavioral problems related to Depression, Schizoaffective Disorder, Mood Disorder, Anxiety, Bipolar disorder, and Psychosis; Eats cigarette butts out of ashtray and off ground; Interventions: supervise resident during smoke breaks to ensure resident was not eating cigarette butts. Review of Resident #4's smoking assessment dated [DATE] revealed Resident #4 was a smoker and required staff supervision while smoking. The facility's video surveillance of Hall B's outdoor smoker's patio dated [DATE] to [DATE] was observed with S3ADON on [DATE] at 1:45 p.m. S3ADON confirmed Resident #4 was outside smoking without staff supervision at 9:09 p.m. and should not have been. An interview was conducted on [DATE] at 12:30 p.m. with S13LPN. She stated Resident #4 had a habit of eating cigarette butts. She stated he should be supervised when outside because he has pica and would eat strange things. An interview was conducted on [DATE] at 11:30 a.m. with S14CNA. She stated when Resident #4 goes outside during smoking times; he would pick up cigarette butts and eat them. She confirmed the resident required supervision when smoking. R1 Review of the clinical record revealed R1 was admitted to the facility on [DATE] with diagnoses, which included Venous Insufficiency Chronic Peripheral, Osteonecrosis, Idiopathic Aseptic Necrosis of Right and Left Femur, Idiopathic Aseptic Necrosis of Bone in Multiple Sites, Anxiety Disorder, Borderline Intellectual Functioning, Other Fracture of Upper and Lower End of Right Fibula, Subsequent Encounter for Closed Fracture with Routine Healing, Tobacco Use, Bipolar Disorder, in Partial Remission, Most Recent Manic Episode, Other Schizophrenia, Other Psychoactive Substance Abuse with Psychoactive Substance Induced Mood Disorder, Major Depressive Disorder, Borderline Personality Disorder, Extrapyramidal and Movement Disorder, Peripheral Vascular Disease, Osteoarthritis, and Epilepsy. Review of the Quarterly MDS with an ARD of [DATE] revealed R1 had a BIMS of 15, which indicated the resident was cognitively intact. Further review revealed R1 was able to self-propel with the assistance of a wheelchair. Review of R1's care plan revealed the following, in part: Date Initiated: [DATE] Problem: Resident smokes daily. Intervention: supervise and assist with smoking as needed Date Initiated: [DATE] Problem: The resident has impaired cognitive function or impaired thought processes related to Schizophrenia, borderline intellectual functioning, & Borderline personality disorder. At risk for complications. Interventions: cue, reorient, and supervise as needed Review of R1's smoking assessment dated [DATE] revealed R1 was a smoker and required staff supervision while smoking. The facility's video surveillance of Hall As outdoor smoker's patio dated [DATE] to [DATE] was observed with S3ADON on [DATE] at 1:45 p.m. S3ADON confirmed R1 was outside smoking without staff supervision at 9:00 p.m. and should not have been. R2 Review of the clinical record revealed R2 was admitted to the facility on [DATE] with diagnoses, which included Rheumatic Tricuspid Valve Disease, Opioid Dependence, Other Psychoactive Substance Abuse, Major Depressive Disorder, Biventricular Heart Failure, Dysphagia, Tobacco Use, and Critical Illness Myopathy Review of the Quarterly MDS with an ARD of [DATE] revealed R2 had a BIMS of 13, which indicated the resident was cognitively intact. Further review revealed R2 was ambulatory without assistive devices. Review of the current Care Plan for R2 revealed the following, in part: Date Initiated: [DATE] Problem: The resident was a tobacco smoker. Safe to smoke with supervision. Interventions: the resident required supervision while smoking. Review of R2's smoking assessment dated [DATE] revealed R2 was a smoker and required staff supervision while smoking. The facility's video surveillance of Hall Bs outdoor smoker's patio dated [DATE] to [DATE] was observed with S3ADON on [DATE] at 1:45 p.m. S3ADON confirmed R2 was outside smoking without staff supervision at 9:10 p.m. and should not have been. R3 Review of the Clinical Record revealed R3 was admitted to the facility on [DATE] with diagnoses, which included Hypertensive Heart Disease without Heart Failure, Schizoaffective Disorder, Generalized Anxiety Disorder, Unspecified symptoms and signs involving cognitive functions and awareness, Encephalopathy, Nicotine Dependence, Cigarettes, Other Psychoactive Substance Abuse with Intoxication Delirium, and Stridor. Review of the Quarterly MDS with an ARD of [DATE] revealed R3 had a BIMS of 15, which indicated the resident was cognitively intact. Further review revealed R3 was ambulatory without assistive devices. Review of the current Care Plan for R3 revealed the following, in part: Date Initiated: [DATE] Problem: Resident was active cigarette smoker. Safe to smoke with supervision. Interventions: Supervise and assist with smoking as needed. Date Initiated: [DATE] Problem: The resident has potential for mood and behavioral episodes and issues related to diagnosis of restlessness and agitation, history of psychoactive substance abuse, and brief psychotic disorder. Interventions: intervene as necessary to protect the rights and safety of others. Monitor behavior episodes. Cue, reorient and supervise as needed. Review of R3's smoking assessment dated [DATE] revealed R3 was a smoker and required staff supervision while smoking. The facility's video surveillance of Hall As outdoor smoker's patio dated [DATE] to [DATE] was observed with S3ADON on [DATE] at 1:45 p.m. S3ADON confirmed R3 was outside smoking without staff supervision at 9:15 p.m. and should not have been. R4 Review of the Clinical Record revealed R4 was admitted to the facility on [DATE] with diagnoses, which included Unspecified Psychosis not due to a Substance or Known Physiological Condition, Tobacco Use, Schizophrenia, Anxiety Disorder, Mental Disorder, and Borderline Intellectual Functioning. Review of the Quarterly MDS with an ARD of [DATE] revealed R4 had a BIMS of 4, which indicated the resident was severely cognitively impaired. Further review revealed R4 was ambulatory without assistive devices. Review of the current Care Plan for R4 revealed the following, in part: Date Initiated: [DATE] Problem: Resident request to smoke at facility. Safe to smoke with supervision. Interventions: the resident requires supervision when smoking. Date Initiated: [DATE] Problem: The resident has impaired cognition/thought process related to borderline intellectual functioning, autism, and schizophrenia. Resident was easily distracted at times. Interventions: cue reorient and supervise as needed. Review of R4's smoking assessment dated [DATE] revealed R4 was a smoker and required staff supervision while smoking. The facility's video surveillance of Hall Bs outdoor smoker's patio dated [DATE] to [DATE] was observed with S3ADON on [DATE] at 1:45 p.m. S3ADON confirmed R4 was outside smoking without staff supervision at 9:19 p.m. and 10:30 p.m. and should not have been. R5 Review of the Clinical Record revealed R5 was admitted to the facility on [DATE] with diagnoses, which included Unspecified Dementia, Moderate, with Mood Disturbance, Dysphagia, and Unsteadiness on Feet, Peripheral Vascular Disease, Unspecified, Tobacco Use, Other Seizures, and Personality Change due to Known Physiological Condition Review of the Quarterly MDS with an ARD of [DATE] revealed R5 had a BIMS of 3, which indicated the resident was severely cognitively impaired. Further review revealed R5 was ambulatory without assistive devices. Review of the current Care Plan for R5 revealed the following, in part: Date Initiated: [DATE] [TRUNCATED]

Based on observations, record reviews and interviews, the facility failed to be administered in a manner, which enabled it to use its resources effectively and efficiently by failing to ensure administrative staff had systems in place to identify, prevent and monitor resident neglect for 9 (#1, #3, #4, #5, R1, R2, R3, R4, R5) of 10 (#1, #2, #3, #4, #5, R1, R2, R3, R4, R5) residents reviewed for supervision. The deficient practice resulted in an Immediate Jeopardy on [DATE] at approximately 2:00 a.m., when Resident #1, who was moderately cognitively impaired and care planned as requiring supervision when smoking, was last seen by staff (S5CNA). Resident #1 was later found outside behind a storage shed near the smoker's patio on Hall A by another facility resident (R6). R6 notified S5CNA who then found Resident #1 to be lying face down on the ground with no pulse at 5:46 a.m. Resident #1 was pronounced dead at 6:51 a.m. with causes of death listed as Dilated Cardiomyopathy and Hypothermia. On [DATE] at 10:36 p.m. video surveillance revealed 8 residents (#3, #5, #4, R1, R2, R3, R4, R5), who were care planned as requiring staff supervision while smoking, were seen outside smoking without staff supervision on the smoker's patio between the times of 9:00 p.m. and 10:36 p.m. Further review of the video revealed Resident #5, who was severely cognitively impaired, remained outside unsupervised on the smoker's patio on [DATE] from 11:50 p.m. through 2:27 a.m., when the resident independently ambulated into the facility. S1ADM was notified of the Immediate Jeopardy on [DATE] at 5:10 p.m. 1. Residents #1 and #5, Residents #3, #4, #5, R1, R2, R3, R4, R5 and all resident who smoke outside have the potential to be adversely impacted by the result of the noncompliance. 2. Rounding/monitoring every 2 hours initiated on [DATE] at 6:00 p.m. 3. DON/Designee will monitor all documentation to ensure compliance is maintained. 4. Administration will randomly visit facility monthly during the night shift to ensure compliance. 5. Any identified issues will be addressed with re-education and/or progressive discipline. 6. Corporate Compliance will monitor administration monthly to ensure compliance is maintained. 7. Administrator educated Nursing Administration on monitoring documentation to ensure compliance. a. In-service/Education started on [DATE]; expected completion date Thursday, [DATE]. 8. Administrator educated Nursing Administration on random monthly facility visits during night shift to ensure compliance. a. In-service/Education started on [DATE]; expected completion date Thursday, [DATE]. 9. Chief Operating Office educated administrator on monitoring nursing administration and random monthly facility visits during night shift to ensure compliance. a. In-service/Education completed on [DATE]. 10. Monitoring of administration initiated [DATE] by NFA and will continue for 30 days, and as deemed necessary by the QAPI team. The Immediate Jeopardy was removed on [DATE] at 1:10 p.m., when the facility submitted an acceptable Plan of Removal. Through observations, interviews and record reviews, the surveyors confirmed the Plan of Removal had been initiated and/or implemented prior to exit. The deficient practice continued at more than minimal harm for the 18 residents identified by the facility as unsafe smokers and ambulatory. Findings: Cross Reference F600 Review of the facility's policy titled Safety and Supervision of Residents Policy and Procedure revealed the following, in part: Facility Oriented Approach to Safety 3. When accident hazards are identified, the ID team shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible. 5. The facility staff shall monitor interventions to mitigate accident hazards in the facility and modify, as necessary. Individualized, Resident Centered Approach to Safety c. Ensuing that interventions are implemented; and 5. Monitoring the effectiveness of interventions shall include the following a. Ensuring that interventions are implemented correctly and consistently b. Evaluating the effectiveness of interventions c. Modifying or replacing interventions as needed d. Evaluating the effectiveness of new or revised interventions Systems Approach to Safety 2. Resident supervision is a core component of the systems approach to safety. Review of the facility's Abuse Prevention and Prohibition policy revealed the following, in part: Neglect is defined as the failure of the facility, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A facility must report incidents of alleged neglect and all situations in which the facility has cause to believe that the physical or mental health and/or welfare or a resident has been or may be adversely affected by neglect by another person. Neglect may include, but is not limited to: Failure to provide adequate supervision and staffing. Resident #1 Review of the Quarterly MDS with an ARD of [DATE] revealed Resident #1 had a BIMS of 12, which indicated the resident was moderately cognitively impaired. Further review revealed Resident #1 was ambulatory without assistive devices. Review of Resident #1's smoking assessment dated [DATE] revealed Resident #1 was a smoker and required staff supervision with all smoke breaks. Review of the current Care Plan for Resident #1 revealed the following, in part: Date Initiated: [DATE] Problem: Resident was a smoker. Safe to smoke with staff supervision. At risk for injuries and issues related to smoking. Interventions: Supervise and assist with smoking as needed. Date Initiated: [DATE] Problem: Resident had impaired cognitive functions or impaired thought processes related to vascular dementia, mild neurocognitive disorder. Interventions: Cue, reorient and supervise as needed. Review of Resident #1 nurse's notes dated [DATE] at 5:34 a.m. revealed the following, in part: Nurse on Hall A doing morning rounds and noticed Resident #1 was not in his room. Staff found the resident lying outside behind a shed unresponsive. Staff initiated CPR and called 911. Response team arrived at 5:59 a.m., CPR was continued. Resident #1's time of death was 6:44 a.m. Signed by S4LPN Review of the Coroner's Fact of Death Letter for Resident #1 revealed the following, in part: Decedent: Resident #1 date of death : [DATE] Time of death: 6:51 a.m. Cause of death: Dilated Cardiomyopathy and Hypothermia. Review of the weather app, Accuweather, revealed the following: [DATE] - Low of 45 degrees Fahrenheit [DATE] - Low of 53 degrees Fahrenheit An interview was conducted on [DATE] at 12:08 p.m. with the local police detective. He confirmed he reviewed the facility's video surveillance from [DATE], which revealed Resident #1 smoking outside unsupervised multiple times prior to 2:18 a.m. He stated at 2:27 a.m. Resident #1 was observed to walk behind the storage shed and out of site of the camera. He said the resident remained behind the shed from 2:27 a.m. to 5:46 a.m. He confirmed staff were not seen on the surveillance video until 5:46 a.m., when R6 and S5CNA walked into view and found Resident #1 behind the shed. He stated the coroner report revealed the resident died of Dilated Cardiomyopathy and Hypothermia. Review of the most recent care plans and smoking assessments for Residents #3, #4, #5, R1, R2, R3, R4, and R5 revealed each resident required supervision while smoking. The facility's video surveillance of Hall A and Bs outdoor smoker's patio dated [DATE] to [DATE] was observed with S3ADON on [DATE] at 1:45 p.m. The video revealed the following, in part: 9:00 p.m. R1 was observed on Hall A's smoker's patio smoking with no supervision. 9:09 p.m. Resident #4 and Resident #3 were observed on Hall B's smoker's patio smoking with no supervision. 9:10 p.m. R2 was observed on Hall B's smoker's patio smoking with no supervision. 9:15 p.m. R3 was observed on Hall A's smoker's patio smoking with no supervision. 9:19 p.m. R4 was observed on Hall B's smoker's patio smoking with no supervision. 10:30 p.m. R4 and R5 were observed on Hall B's smoker's patio smoking with no supervision. 10:36 p.m. Resident #5 was observed on Hall B's smoker's patio smoking a cigarette with no supervision. 11:50 p.m. - 2:27 a.m. Resident #5 was observed on Hall B's smoker's patio watching tv on the patio with no supervision. Review of the CNA assignment sheet revealed Hall A was assigned 2 CNAs, S6CNA and S7CNA, on [DATE] at 4:00 a.m. An observation was made on [DATE] at 4:00 a.m. of S6CNA and S7CNA. Both CNAs were observed sitting in chairs midway down Hall A, outside of resident rooms. Both CNAs were observed to be sleeping. Surveyor woke both CNAs. S7CNA and S6CNA both immediately stated they should not have been sleeping during their shift. An interview was conducted on [DATE] at 1:48 p.m. with S3ADON. She confirmed she observed the video surveillance dated [DATE] with the local police detective. She stated in the video, Resident #1 exited the building from Hall A onto the smoker's patio at 2:18 a.m. and smoked a cigarette unsupervised. She said Resident #1 then walked behind the shed and out of sight at 2:27 a.m. She confirmed no staff were seen to go out of the building to round on Resident #1 from 2:18 a.m. to 5:46 a.m. She confirmed the staff went out at 5:46 a.m. and found Resident #1 on the ground and initiated CPR. She confirmed Resident #1 was care planned as requiring supervision with smoking and should not have been smoking alone. She further confirmed staff did not round on Resident #1 for over 3 hours on the night of [DATE]. She stated after the incident, staff were in-serviced to round on the residents at least every 2 hours. She stated the facility did not implement any new interventions or monitoring due to Resident #1 dying of natural causes. She confirmed Resident #1 expired from Dilated Cardiomyopathy and Hypothermia. S3ADON stated during the video surveillance dated the night of [DATE] to [DATE] 8 residents (#3, #4, #5, R1, R2, R3, R4, and R5) were observed outside on the smoker' patio smoking unsupervised. She confirmed all 8 of the residents were care planned as requiring supervision while smoking and should not have been unsupervised. She stated Resident #5 was outside alone from 11:50 p.m. to 2:27 a.m. unsupervised by staff. She confirmed no staff rounded on Resident #5 during that time frame and should have. S3ADON confirmed being notified of 2 (S6CNA and S7CNA) found sleeping during the night shift on [DATE]. She verified staff should not be sleeping while responsible for caring for residents. S3ADON stated no new interventions or monitoring were implemented after the above findings dated the night of [DATE] to [DATE] and [DATE]. An interview was conducted on [DATE] at 2:11 p.m. with S2DON. He stated the nurses and CNAs should round on residents every 2 hours. He stated early on [DATE] he was notified Resident #1 was found outside on the ground. He confirmed Resident #1 was outside smoking unsupervised at 2:18 a.m. He verified Resident #1 should have been supervised while smoking. He confirmed Resident #1 was found outside at 5:46 a.m., over 3 hours later. He stated staff were in-serviced regarding rounding on residents every 2 hours, but nothing new was implemented. He confirmed nothing new was implemented because the resident had died of natural causes. He stated S3ADON reported the findings of the video surveillance dated the night of [DATE] to [DATE] revealed Residents #3, #4, #5, R1, R2, R3, R4 and R5 were outside smoking unsupervised. He confirmed all residents in the facility required supervision while smoking at all times. He also stated he was informed the video revealed Resident #5 outside from 11:50 p.m. to 2:27 a.m. unsupervised. He stated staff were not expected to sit outside with the residents, but they were supposed to be aware of where they were. He confirmed S3ADON told him S6CNA and S7CNA were found sleeping on their shift on [DATE]. He confirmed the facility did not implement new interventions, processes or monitoring in regards to Resident #1's death on [DATE], the video findings on [DATE] to [DATE], nor on [DATE] when the 2 CNAs were sleeping on duty. He stated no overnight monitoring had been implemented by administrative staff, and the last time he was in the building during the night shift was 2 months ago. An interview was conducted on [DATE] at 2:34 p.m. with S1ADM. She stated she encouraged staff to put their eyes on the residents at a minimum of every 2 hours. She stated on [DATE] staff notified her prior to 8 a.m. that Resident #1 was found outside on the ground, behind the storage shed near Hall As smoker's patio. She stated she spoke with the nurses and CNAs on duty the night of [DATE] about the series of events, but did not find anything that would make her think the facility did anything wrong. She stated she did not know Resident #1 was smoking outside and unsupervised at 2:18 a.m. She confirmed he should have been supervised while smoking. She stated during her investigation, she did not specifically ask staff what times they had last seen Resident #1 and did not know none of the staff had laid eyes on him from 2:18 a.m. to 5:46 a.m. She confirmed had she known this she would have considered this as potential neglect. She explained S3ADON in-serviced all staff to round on the residents at least every 2 hours, but there were no new interventions or changes to policies. She denied increasing supervision of residents outside on the smoker's patio or rounding. She reported being aware of the findings from the video dated the night of [DATE] to [DATE] where Residents #3, #4, #5, R1, R2, R3, R4 and R5 were outside smoking unsupervised. She confirmed all residents should be supervised while smoking. She confirmed Resident #5 should have been rounded on while he was outside on [DATE]. She stated she was informed of S6CNA and S7CNA sleeping during their shift on [DATE]. She stated as a result, S6CNA and S7CNA were sent home with suspension. She confirmed the facility did not implement new interventions, processes or monitoring in regards to Resident #1's death on [DATE], the video findings on [DATE] to [DATE], nor on [DATE] when the 2 CNAs were sleeping on duty. She denied any current administrative monitoring in the facility at night.

Based on record reviews, interviews and observations, the facility failed to identify and implement appropriate interventions/measures to ensure 3 (#1, #2, and #3) of 5 (#1, #2, #3, #4, and #5) sampled residents were free from resident to resident physical abuse. This deficient practice resulted in an actual harm on 09/07/2019 at 11:30 a.m. for Resident #3 when the resident was punched in the face by Resident #1 during a physical altercation. During the physical altercation, Resident #3 sustained an injury to the right eye which resulted in the resident having to be transported to a local hospital on [DATE] at 9:35 a.m. where he was diagnosed with [REDACTED]. Prior to the incident on 09/07/2019, the facility was aware of Resident #1's history of physical abusive behaviors towards other residents, however, the interventions identified by the facility to address the resident's behaviors were not effective. The facility implemented corrective actions, which were completed prior to the State Agency's investigation; thus, it was determined to be a Past Noncompliance citation. Findings: Review of the facility's Abuse Policy included the following: 1.1 Purpose All residents of the facility will be treated with dignity and respect and will be free from all types of abuse. 1.3 Policy and Procedure Abuse is defined as any mental, sexual, or physical mistreatment of [REDACTED]. Abuse includes, but is not limited to, the willful infliction of pain, injury, mental anguish, sexual statements, inappropriate unwanted touching, forceful sexual activity, harassment, threatening statements, yelling derogatory or racial statements with specific intent of hurting a resident, unexplained bruises, burns, pinch marks, fractures, lacerations, or involuntary seclusion. Procedures: 3. Prevention: Preventing resident abuse is a primary concern for this facility. It is our goal to achieve and maintain an abuse free environment. Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: -Assessing and care planning and monitoring of residents with needs and behaviors that may lead to conflict and neglect. -Identifying areas within the facility that may make abuse and/or neglect more likely to occur and monitor these areas on a regular basis. 4. Identification: This facility will not condone any form of resident abuse or neglect. 6. Protection: During abuse investigations, residents will be protected from harm by the following measures: -If the alleged abuse involves another resident, immediate interventions are to be implemented at the Director of Nursing and/or Administrator's discretion. Residents #1 and #3 Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses, which included Anxiety Disorder, Major [MEDICAL CONDITION], Paranoid Personality Disorder, [MEDICAL CONDITION], and Cognitive Communication Disorder. Review of the MDS with ARD, dated 09/12/2019, revealed Resident #1's BIMS score was 8, which indicated moderate cognitive impairment. Review of the Care Plan dated 09/20/2019 for Resident #1 included the following: I have the potential for mood and behavior problems related to my [DIAGNOSES REDACTED]. My mood is up and down, one minute I am happy and talking and the next I am angry. I holler/threaten and have a history of aggression to staff and other residents. I am delusional. I am easily agitated. 08/17/2019: Physical aggression initiated. 08/21/2019: Physical aggression initiated. 09/07/2019: Physical aggression initiated. Interventions: 08/17/2019: Resident moved to another room where there was less noise and activity due to recent behavioral disturbances. 08/21/2019: Resident removed from environment and placed on one to one supervision. Resident became verbally aggressive and attempted to get physical shortly after incident. Resident was separated and redirected. Notified Facility Nurse Practitioner, received PEC to be transported to a local Behavioral Hospital. 09/07/2019: Residents separated. Nurse counseled resident about not hitting other residents. Goal: I will have improved mood state with happier, calmer appearance, no signs and symptoms of depression, anxiety, or sadness through the review date of 12/18/2019. I will cause no harm to myself or others through my next review date of 12/18/2019. Review of the clinical record revealed Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS with ARD, dated 08/08/2019, revealed Resident #3's BIMS score was 3, which indicated severe cognitive impairment. Review of Care Plan dated 09/07/2019 for Resident #3 included the following: Resident is at risk for behavior problems related to impaired cognition secondary to [DIAGNOSES REDACTED]. Resident wanders around facility and goes into other resident's rooms. Goal: Resident will have fewer episodes of negative behavior through the next assessment period. Interventions/Tasks: 08/14/2019 - staff will continue to re-direct as needed 09/07/2019 - Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Review of the facility's Investigative Report dated 09/07/2019 at 11:30 a.m. included the following: Mental Status: Alert oriented x 2. Staff witnessed Resident #3 being physically aggressive toward another staff on the back of the a hallway after the smoke break. This nurse called for his nurse and CNA to come and assist with removing Resident #3 off the hall when Resident #1 came out of his room and walked towards that direction and punched him in the face. Notes IDT Investigation: S2DON and S1ADM asked Resident #1 what happened. Resident #1 stated this man (Resident #3) was about to hit her (S3CNA). I felt like I had one minute to stop a killing. Review of Resident #3's Radiology Report dated 9/9/2019 revealed the following: CT Sinus/Facial Bones with Contrast: Impression: Acute traumatic fracture right medial orbital wall. An interview was conducted on 09/23/2019 at 9:30 a.m. with S2DON. She reported on the day of the incident on 09/07/2019, Resident #3 was calm and having no behavior issues. She said Resident #3 had a history of [REDACTED]. Review of Resident #1's Nurses Notes dated 09/07/2019 at 11:30 revealed the following: Witnessed Resident #3 being physically aggressive toward staff on the back of a Hallway after the smoke break. This nurse called for staff to come and assist with removing resident off the hall when Resident #1 came out of his room, walked towards Resident #3 and punched him in the face. Resident #1 informed the nurse he was a man and he was not going to let him hurt S3CN[NAME] Review of Resident #3's nurses notes dated 09/07/2019 at 11:30 a.m. included the following: Note Text: a hall nurse witnessed Resident #3 being physically aggressive to staff on the back of a hallway after smoke break. Nurse stated she called for Resident #3's CNA and nurse to come and redirect and remove him off of the hall. Before this nurse could get there, Resident #1 came out of room, walked toward Resident #3 and then punched Resident #3 the face. Resident noted with right eye red and slightly swollen. Resident #3 had 3 superficial skin tears underneath right eye and an abrasion to the top of right eyelid. Residents were separated after incident occurred. Skin tears cleansed with wound cleanser and a bandage applied. Nurse practitioner was called and notified of incident and of resident's aggression to staff. An interview was conducted on 09/23/2019 at 1:15 p.m. with S2DON. She said on 09/07/2019, Resident #1 was protecting S3CNA when Resident #3 pushed her against the wall with the cigarette cart. She said Resident #1 walked up to Resident #3 and punched him in the right eye. She said after the incident, Resident #3 was treated with antibiotic ointment and a bandage was applied to a small cut under his right eye. She said it was not swollen, and he did not complain of pain. On 9-9-019, S2DON said the resident was sent out to the emergency room . She said his right eye had some bruising and swelling, but he did not complain of pain. An interview was conducted on 09/23/2019 at 10:20 a.m. with S3CN[NAME] She reported one day Resident #3 was down a Hall and she asked him to step aside so that she could pass with the cigarette cart. She reported he became agitated and pushed the cigarette cart into the wall and pinned her between the cart and the wall and put up his fist to punch her. She said another resident rushed over to help her and punched Resident #3 in the right eye. She reported Resident #3 had never complained of pain to the right eye after the incident. She reported the facility put interventions in place since this last altercation to decrease the amount of violence in the facility. She said they have started bringing the residents on field trips such as shopping, the park, and to the snowball stand. An interview was conducted on 09/23/2019 at 11:00 a.m. with S7ADON. She reported Resident #3 no longer resided at the facility. She reported an incident occurred where Resident #3 pushed an employee against the wall with a cigarette cart. She reported after this incident the resident was placed on one to one observation. She reported he was on one to one observation until going to the hospital. She reported Resident #3 never complained of pain to the right eye after being punch, but he had a few little lacerations under the eye which had been treated by wound care. An interview was conducted on 09/23/2019 at 4:15 p.m. with S8CN[NAME] She reported Resident #3 did have an occasion when he pushed a CNA against the wall with the cigarette cart. She reported another resident threw a punch to his right eye. She reported he was placed on one to one observation after this event until he went to the hospital. She reported the resident sustained [REDACTED]. She said he did not have a lot of swelling. An interview was conducted on 09/23/2019 at 4:35 pm with S9CN[NAME] She said she worked on the a' Hall and was familiar with Resident #3. She reported the resident never complained that his right eye hurt after the incident on 09/07/2019. Further record review revealed Resident #1 had a history of [REDACTED]. --Review of the facility's investigative report dated 08/03/2019 at 8:55 a.m. revealed Resident #1 was observed wrestling with Resident #3 when Resident #3 wandered into his room. Resident #1 was observed to be extremely agitated and verbalized that he wanted to kill Resident #3. Resident #1 was sent to a local hospital for evaluation and on the next day, 08/04/2019, the resident was admitted to a local behavioral health hospital. --Review of the facility's investigative report dated 08/21/2019 at 9:20 a.m. included, Resident #1 was involved in a physical altercation with Resident #2 when the residents were outside smoking. Resident #1 was observed to hit Resident #2 after Resident #2 hit him first. Resident #2 sustained multiple abrasions to the head, left forearm and left elbow. An observation was conducted on 09/23/2019 4:00 p.m. of Resident #1 who remained seated in front of the television in the dining room. There were 4 staff in the dining room. Resident #1 continued to watch television. An interview was conducted on 09/23/2019 at 4:41 p.m. with S6CN[NAME] She said Resident #1 did not bother anyone unless he witnessed another resident get angry with the staff. She said he would get mad with the staff when he could not smoke whenever he wanted to smoke. She said he wanted to smoke all night. She said whenever the resident would begin to have a behavior, he would tie a scarf on his head, and tie his shirt in the front. She said when he did these behaviors she immediately reported this to the nurse. She said she had been his one to one staff. She said she sat with him one to one and he walked all night and whenever he moved, she moved with him. She said Resident #1 was quiet and would be calm and cooperative most of the time, but liked to walk. She said when Resident #1 was not on one to one, she said she visualized the resident at least every two hours. Resident #2 Review of the clinical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses, which included Alcohol Induced Persisting Dementia, Major [MEDICAL CONDITION], Impulse Disorder, [MEDICAL CONDITION], Cognitive Communication Deficit, [MEDICAL CONDITION], Dementia with Behavioral Disturbances, and ADHD. Review of the MDS with ARD, dated 07/29/2019, revealed Resident #2's BIMS score was 12, which indicated moderate cognitive impairment. Review of the Care Plan 08/02/2019 included the following: Resident #2 was at risk for behavioral problems related to [DIAGNOSES REDACTED]. Goal: Resident to have fewer episodes of behavioral disturbances through the next assessment period. Target date: 08/02/2019. Interventions: Administer medications as ordered, Anticipate and meet the residents needs, Intervene as necessary to protect the rights and safety of others. Review of the facility's investigative report dated 08/21/2019 at 9:20 a.m., revealed Resident #2 was involved in physical altercation with Resident #1. While the residents were outside smoking, Resident #2 was observed to hit Resident #1 in the face. During this altercation, Resident #2 sustained multiple abrasions to the head, left forearm and left elbow. Review of the Nurse Notes dated 08/21/2019 at 12:46 p.m. revealed the following: Summoned to the back patio to break up a fight. Resident #2 was bleeding on forehead, left and right elbow, and left forearm. Resident #2 stated, Resident #1 asked me a question. I could not understand him. I told him I could not understand him. Resident #2 stated he put his hands up to protect himself from Resident #1. Separated Residents immediately. Per further investigation, Resident #2 was found to be the aggressor. On 08/23/2019 at 11:30 p.m. Resident # 2 completed neuro checks and had no further behaviors. Review of the facility's investigative report dated 08/27/2019 at 5:09 p.m. revealed Resident #2 hit another resident while in the dining room. The Resident #2 was observed to put the resident's head on a table and punched the resident in the face. Review of the Nurse Notes dated 08/27/2019 at 5:09 p.m. revealed the following: This nurse summoned to dining room and informed by staff that Resident #2 had struck another resident in face. Resident #2 was removed from the dining room and placed on one-on-one supervision. The facility NP was notified of the incident. On 08/28/2019 at 5:19 p.m. the resident was seen by the facility medical doctor and ordered [MEDICATION NAME] 2 mg po BID. An observation was conducted on 09/24/2019 at 11:56 a.m. of Resident #2 ambulating down the hall. There were no concerns. Observations of Resident #1 and Resident #2 were conducted throughout the survey from 09/23/2019 through 09/25/2019 with no behavioral concerns. After the incident dated 09/07/2019, Resident #1 was calm and quiet and did not require one on one supervision or emergency room transfer. Review of the facility's Outing Monitoring Sheets revealed residents went on outings on 09/12/2019, 09/13/2019, 09/18/2019 and 09/19/2019. Staff documented each resident's behavior/demeanor before, during and after the outing. The type of outings were documented as were interventions used for any behaviors which occurred. An interview was conducted on 09/25/2019 at 11:04 a.m. with S4AD. She said she was familiar with the recent training on resident behaviors and handling aggressive residents. She said she was familiar with Resident #1 and Resident #2. She said since the residents' outings were started, she had not seen any incidents with Resident #1 and Resident #2. She said she reported any behaviors to S2DON for these outings. An interview was conducted on 09/25/2019 at 2:50 p.m. with S1ADM. She verified she was responsible for ensuring residents were free from abuse. She stated the clients had been sent out to the hospital and evaluated as well as being placed on one to one supervision as interventions. She said after a while when the resident would calm down, she said the one to one supervision was removed because it was not needed anymore. She said keeping the residents on a continued one to one supervision was not good for the resident. The facility has implemented the following actions to correct the deficient practice: Performance Improvement (QA) Plan dated 09/10/2019 included the following: Opportunity for Improvement: Resident physical altercations between other residents and staff. Improvements will include activities to be more involved with doing outings with resident, revamp the admission process and music therapy for appropriate residents. Intervention Details included in-servicing staff and a new slide presentation which gave examples of how to deal with difficult residents. Resident #1 - Music therapy initiated to help decrease noise stimuli from other residents. Resident #1 given radio and a digital music player. The resident admissions referral process has been changed to include the interdisciplinary team. The new process included S2DON reviewed paperwork of referrals and S1ADM signed off on denials. Facility will have Transportation, Activities, and Direct Care staff monitor how resident behaviors were before, during or after the resident weekly outings. If resident exhibits negative behavior, immediate intervention should be put in place and notification of administrative staff should occur. If resident behaviors becomes out of control during outing, 911 should be called. Residents will discuss the weekly outings during monthly Resident Council meetings. Administration will monitor program on a weekly basis. On 09/10/2019, all direct care staff were in-serviced by the Assistant Director of Nursing on How to Handle Difficult Residents and Help Frontline Staff. The information was presented through a slide presentation, demonstration and lecture. On 09/10/2019, department heads were in-serviced by S2DON on the monitoring sheet with outings weekly, notifying Administration if behaviors are present, and dealing with difficult residents. On 09/10/2019, CNA and Nursing staff were in-serviced by S4AD on music therapy - Digital music player, radio, etc. - as interventions for Resident #1's behaviors.

Based on observation, record reviews and interviews, the facility failed to ensure 1 (#96) of 4 (#61, #78, #91, #96) residents reviewed for abuse was free from physical abuse by a licensed practical nurse. An Immediate Jeopardy situation occurred on 03/13/2019 at 10:54 p.m. when S10FLPN approached Resident #96 after discovering the resident was eating a pudding he had taken off S10FLPN's medication cart. S10FLPN aggressively knocked the pudding out of Resident #96's hands, slapped him across the face, kicked him twice, picked up the pudding from the floor and attempted to shove the pudding in the resident's face. This incident was witnessed by S9LPN who did not take immediate action to protect the resident from the physical abuse by S10FLPN. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings Review of the facility's Policy on Abuse revealed in part Purpose All residents of the facility will be treated with dignity and respect and will be free from all types of abuse. Policy and Procedure Abuse is defined as any mental, sexual, or physical mistreatment of [REDACTED]. Abuse includes but is not limited to the willful infliction of physical pain injury, mental anguish, sexual statements, inappropriate unwanted touching, forceful sexual activity, harassment, threatening statements, yelling derogatory or racial statements with specific intent of hurting a resident, unexplained bruises, welts, burns, pinch marks, fractures lacerations, or involuntary seclusion. Procedures: Identification: This facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor or Director of nursing immediately. An interview was conducted with Resident #96 on 04/01/2019 at 9:35 a.m. When questioned about any abuse, he denied any staff hitting or hurting him. Review of the clinical record revealed Resident #96 was an [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of the annual MDS with 01/10/2019 ARD revealed a BIMS of 03, which indicated Resident #96 had severe cognitive impairment. Review of a Progress Note for Resident #96 written by S9LPN revealed 03/13/2019 at 11 p.m. - I was standing on b hall charting. Resident was leaning against the split hall med cart eating. Suddenly S10FLPN came aggressive charging at resident, yelling, Get away from that f-----g cart, m---f. When S10FLPN get to resident, he then proceeds to punch food out of resident's arm/hands and push him away from cart. Resident stood there in shock for a second. He then begins walking toward S10FLPN screaming, You can't touch me like that m---f. When resident was approximately a foot away from S10FLPN, S10FLPN then picks his foot up and kicks resident in chest, causing him to fall backwards. Resident then walks toward S10FLPN again and S10FLPN pushes resident back. After altercation, resident and S10FLPN both go their separate ways. 03/14/2019 at 12:06 a.m. S10FLPN calls S2DON to tell her about altercation with resident. The story S10FLPN told S2DON was NOT AT ALL what happened and he had fabricated his story to make it seem as resident attached him, when he was the one who stated and initiated altercation. Review of a Progress Note for Resident #96 written by S11LPN revealed 03/13/2019 2330 (11:30 p.m.)- Notified by S7CNA that I was summoned to room c. As entering CNA started to check on Resident #96. Resident #96 stated the bigger guy had no reason to beat up on me. Resident in tears and full head to toe assessment done by nurse in room. Resident reported to nurse and CNA on duty that other male beat him and pushed him. CNA and nurse noted bruising to left arm, wrist, forearm, and elbow. Also on top of leg had big bruise that was red also. Also 11:45 p.m. - 12:00 p.m. - Myself and other nurse on duty went and approached S10FLPN accused. S10FLPN was in resident's room on a hall. I told S10FLPN what was going on and he said I'll call S2DON now. He called S2DON in front of us 2 nurses on speaker and told a different story. S10FLPN stated resident was digging on carts and trying to eat pudding and he can't do that. So I just left out after and monitored residents and told S7CNA and S8CNA to just watch resident also til further notice. Review of the statement written by S7CNA dated 03/14/2019 revealed Around 11 p.m., I heard commotion. I look up and S10FLPN and Resident #96 was at the med cart. We call Resident #96 to come down the hall. When he came in and said that S10FLPN push him down and hit him. On his left arm, there was a bruise, so I told the nurse what, he told me. Review of a statement written by S8CNA dated 03/14/2019 revealed On last night S10FLPN and Resident #96 had an altercation at the nursing station. I call Resident #96 down the hall. We ask him what happened. He stated that S10FLPN hit and push him down. The nurse was notified about what had happen. On 04/02/2019 at 10:00 a.m., this surveyor along with another surveyor viewed the facility's video recording of the incident between S10FLPN and Resident #96 on 03/13/2019 at approximately 10:55 p.m. The video recording was viewed with S1ADM and S2DON present. The visual of the camera angle was the beginning of b hall where S10FLPN medication cart was observed on the right side of the hall. The following were viewed: 03/13/2019 at 10:53 p.m.: Resident #96 ambulated into the camera's view and paused by S10FLPN's med cart. He grabbed a Styrofoam drink cup from the cart, took a sip then placed the cup back on the cart. 03/13/2019 at 10:54 p.m.: Resident #96 grabbed a pudding cup off S10FLPN's med cart and immediately started eating the pudding cup with a tongue blade. 03/13/2019 at 10:54 p.m.: S10FLPN came back around to the med cart from the a hall. He was noted to be holding an object (S2DON identified the objects as medication cards.) He approached Resident #96 in an aggressive manner, grabbed the pudding out of Resident #96's hand where it falls to the floor and slapped Resident #96 in the face with enough force to knock the resident's hat off his head. Resident #96 stared at S10FLPN for a moment, then charged at S10FLPN. S10FLPN kicked at Resident #96 three times of which two of those kicks connected with Resident #96. 03/13/2019 at 10:55 p.m.- S10FLPN picked up the pudding that had fallen to the floor during the incident and attempted to shove it in Resident #96's face. An interview was conducted S2DON on 04/02/2019 at 10:41 a.m. She stated she was notified by S10FLPN of an incident between him and Resident #96 a little after midnight on 03/14/2019. She stated Resident #14, which was the wrong resident, became really upset with him and started going after him but he had medications in hand and could not protect himself. She stated S10FLPN stated he lifted his leg to protect himself but did not make contact with Resident #96. She stated she explained to him she was going to look at the camera system. She stated S10FLPN said that would be fine. She stated she asked S3ADON to review the video recording later that morning. She stated S3ADON called her and told her the incident didn't look good. She stated after she arrived at work, she reviewed the video and determined the resident was not Resident #14 but Resident #96. She stated she was appalled at what she watched. She stated S10FLPN had clearly abused Resident #96. She stated since S11LPN was Resident #96's nurse, she called S11LPN first to see if she saw or heard anything. She stated S11LPN stated she didn't see anything but S9LPN had seen everything. She stated S9LPN and S11LPN were together at that time, so S11LPN handed her phone to S9LPN so they could talk. S2DON stated S9LPN said S10FLPN had approached Resident #96 while he was standing at the med cart eating pudding and S10FLPN aggressively hit the food out of the resident's hand, hit him in the face, and kicked him. S2DON stated she asked S9LPN why she hadn't called to report what S10FLPN had done. She stated S9LPN stated she was scared. She stated S9LPN stated she and S11LPN overheard S10FLPN on the phone telling her (S2DON) about the incident with Resident #96 but S10FLPN did not tell the truth. She stated S9LPN stated she had planned to call S2DON and tell her what really occurred. She stated she told S9LPN and S11LPN to report to the facility immediately so she could obtain their statements about the incident. She stated she reached S10FLPN by phone and asked him to come to the facility. She stated he came to the facility around 2:00 p.m. She stated she asked him what happened and he gave the same statement he had given her when he first called to report the incident. She stated she showed S10FLPN the video. She stated S10FLPN stated he did not remember the incident happening. She stated he said he only remembered just taking the pudding away from Resident #96 and trying to protect himself by putting his leg up. She stated she suspended him at the point. She stated she received statements from the b hall CNAs, S7CNA and S8CNA. She stated both CNAs stated they had not witnessed the incident between S10FLPN and Resident #96 but just heard commotion. She stated S1ADN notified the local police of the incident on 03/14/2019 around 1:00 p.m. She stated she spoke with Resident #96 and he stated he was ok, just didn't know why S10FLPN hit him. She stated during his skin audit, he had new bruising to his left hand and forearm. She stated he also had bruising to his left side from a previous fight. She stated on 03/17/2019, S10FLPN called and left a message stating that he was on an appetite suppressor and he felt like that was what caused him to black out. A telephone interview was conducted with S7CNA on 04/03/2019 at 9:04 a.m. She stated on the night of 03/13/2019 at approximately 11:00 p.m., she was down the b hall charting. She stated she heard a commotion up the hall by the nurse's station. She stated she looked up the hall and saw S10FLPN and Resident #96 standing by a cart. She stated Resident #96 was visibly upset and she called Resident #96 down the hall. She stated when Resident #96 made it to her, he stated S10FLPN had hit him and also pushed him down. She stated she left Resident #96 with S8CNA and went immediately to report the incident to S9LPN. She stated she and S9LPN assessed him and found a very small scratch on his left arm. A telephone interview was conducted with S8CNA on 04/03/2019 at 9:18 a.m. She stated on the night of 3/13/19 at about 11:00 p.m., she and S7CNA were sitting on the a hall. She stated she heard a commotion and overheard Resident #96 fussing at S10FLPN. She stated she and S7CNA called Resident #96 down the hall. She stated when he walked to them, he explained S10FLPN had hit and pushed him. She stated he showed them his left arm. She stated he had a small spot of blood on his shirt. She stated she stayed with him while S8CNA went to go get S11LPN. She stated S11LPN arrived immediately. She stated S7CNA and S11LPN brought him into his room and assessed him. A telephone interview was conducted with S9LPN on 04/03/2019 at 8:39 a.m. She stated she was assigned to three residents that resided on b hall. She stated on the night of 03/13/2019 at approximately 11:00 p.m., she heard S10FLPN yelling and cursing at Resident #96, who was standing by S10FLPN's medication cart. She stated S10FLPN told Resident #96, Get off my cart m---f! She stated S10FLPN then charged Resident #96, knocking food out of Resident #96's hand as he hit his left arm. She stated Resident #96 stepped backed and just looked at S10FLPN for a few seconds. She stated Resident #96 walked towards S10FLPN yelling, You can't hit me like that. She stated S10FLPN kicked Resident #96 in the chest, causing him to stumble backwards again. She stated Resident #96 regained his footing and walked toward S10FLPN again and S10FLPN pushed Resident #96 again. She stated after the last push, the confrontation ended. She stated she and S11LPN approached S10FLPN. She stated S11LPN told him he needed to call S2DON. She stated S10FLPN placed the phone on speaker and called S2DON. She stated S10FLPN reported Resident #96 was acting aggressively toward him and he raised his foot up to protect himself. S9LPN stated S10FLPN told a lie about what happened. She stated she knew she was supposed to call S2DON and inform her of the incident but she was in shock and could not talk. She stated S10FLPN acted psychotic. She stated he clicked on then, then clicked off and acted as if nothing had happened. She stated around 10:00 a.m. on 03/14/2019, she was with S11LPN, when S2DON called her. She stated S2DON asked S11LPN about the incident. She stated S11LPN told S2DON she had not witnessed the incident but S9LPN had. She stated she spoke with S2DON and told her what she had witnessed. She stated S2DON instructed her and S11LPN to report to the facility as soon as possible to write their statements. She stated S7CNA and S8CNA were the aides working b hall. She stated they were further up the hall and had not witnessed the incident but they did hear a commotion. Review of local hospital's After Visit Summary dated 03/14/2019 revealed Resident #96 was diagnosed with [REDACTED]. Review of the Care Document revealed an x-ray of the left hand showed mild [MEDICAL CONDITION] at the third metacarpophalangeal joint but there was no evidence of traumatic fracture. Throughout the survey from 04/01/2019 to 04/04/2019, random staff interviews revealed staff received training on the facility's abuse policies and procedures, and that they were aware of what to do in the event of any observed resident abuse. Interviews with sampled and unsampled residents revealed they were aware of abuse and that they knew who to report any abuse to. The facility has implemented the following actions to correct the deficient practice: 1. Immediate action: 2 nurses in serviced about the importance of reporting abuse to DON Administrator immediately- done 03/14/2019. 2. In-serviced Full time, PRN, and Part time nurses/CNAs about abuse and burnout; a. Full time nurses/CNAs done- 03/14/2019; facility in-service- 03/28/2019. b. Part-time, PRN nurses/CNAs prior to/on next day at work; started- 03/19/2019. 3. Audit: a. Administrative staff will come during the weekend x 4 weeks if no abusive accusations occur and then once a month afterward- started 03/23/2019. b. Will interview residents randomly during the week at least once a week. Will interview for 6 months if no accusations of abuse are made- started 03/18/2019. Monitor: 1. Will speak with staff members randomly 1-2 times per week during Administrative staff unannounced rounds to fill in an abuse/concerns/issues sheet to see if any type of burn out occurred. Will monitor x 4 weeks then once a month afterward. - started 03/23/2019. 2. Will fill out resident interviews randomly 1-2 times weekly during unannounced rounds and once during the week. Will monitor x 4 weeks then once a month afterward. - started 03/23/2019 3. Will try to get IT to put video on Administrator and/or DON phones to watch video at times at night or weekends while administrative staff isn't present.

Based on record reviews and interviews, the facility failed to ensure that all alleged violations involving abuse, were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse, to the administrator of the facility and to other officials in accordance with State law through established procedures for 1 (#96) of 4 (#61, #78, #91, #96) residents reviewed for abuse. An Immediate Jeopardy situation occurred on 03/13/2019 at 10:54 p.m. when S10FLPN approached Resident #96 after discovering the resident was eating a pudding he had taken off S10FLPN's medication cart. S10FLPN aggressively knocked the pudding out of Resident #96's hands, slapped him across the face, kicked him twice, picked up the pudding from the floor and attempted to shove the pudding in the resident's face. After being approached by S9LPN and S11LPN, S10FLPN called S2DON by phone at 12:03 a.m. on 03/14/2019. While the phone was on speaker and overheard by S9LPN and S11LPN, S10FLPN failed to accurately report the incident between he and Resident #96. S9LPN and S11LPN failed to notify S2DON that S10FLPN did not accurately report the incident and had physically abused Resident #96. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings Review of the facility's Policy on Abuse revealed in part Purpose All residents of the facility will be treated with dignity and respect and will be free from all types of abuse. Policy and Procedure Abuse is defined as any mental, sexual, or physical mistreatment of [REDACTED]. Abuse includes but is not limited to the willful infliction of physical pain injury, mental anguish, sexual statements, inappropriate unwanted touching, forceful sexual activity, harassment, threatening statements, yelling derogatory or racial statements with specific intent of hurting a resident, unexplained bruises, welts, burns, pinch marks, fractures lacerations, or involuntary seclusion. Procedures: Identification: This facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor or Director of nursing immediately. An interview was conducted with Resident #96 on 04/01/2019 at 9:35 a.m. When questioned about any abuse, he denied any staff hitting or hurting him. Review of the clinical record revealed Resident #96 was an [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of the annual MDS with 01/10/2019 ARD revealed a BIMS of 03, which indicated Resident #96 had severe cognitive impairment. Review of a Progress Note for Resident #96 written by S9LPN revealed 03/13/2019 at 11 p.m. - I was standing on b hall charting. Resident was leaning against the split hall med cart eating. Suddenly S10FLPN came aggressive charging at resident, yelling, Get away from that f----g cart, m----f. When S10FLPN get to resident, he then proceeds to punch food out of resident's arm/hands and push him away from cart. Resident stood there in shock for a second. He then begins walking toward S10FLPN screaming, You can't touch me like that m----f. When resident was approximately a foot away from S10FLPN, S10FLPN then picks his foot up and kicks resident in chest, causing him to fall backwards. Resident then walks toward S10FLPN again and S10FLPN pushes resident back. After altercation, resident and S10FLPN both go their separate ways. 03/14/2019 at 12:06 a.m. S10FLPN calls S2DON to tell her about altercation with resident. The story S10FLPN told S2DON was NOT AT ALL what happened and he had fabricated his story to make it seem as resident attached him, when he was the one who stated and initiated altercation. Review of a Progress Note for Resident #96 written by S11LPN revealed 03/13/2019 2330 (11:30 p.m.)- Notified by S7CNA that I was summoned to room c. As entering CNA started to check on Resident #96. Resident #96 stated the bigger guy had no reason to beat up on me. Resident in tears and full head to toe assessment done by nurse in room. Resident reported to nurse and CNA on duty that other male beat him and pushed him. CNA and nurse noted bruising to left arm, wrist, forearm, and elbow. Also on top of leg had big bruise that was red also. Also 11:45 p.m. - 12:00 p.m. - Myself and other nurse on duty went and approached S10FLPN accused. S10FLPN was in resident's room on a hall. I told S10FLPN what was going on and he said I'll call S2DON now. He called S2DON in front of us 2 nurses on speaker and told a different story. S10FLPN stated resident was digging on carts and trying to eat pudding and he can't do that. So I just left out after and monitored residents and told S7CNA and S8CNA to just watch resident also til further notice. Review of the statement written by S7CNA dated 03/14/2019 revealed Around 11 p.m., I heard commotion. I look up and S10FLPN and Resident #96 was at the med cart. We call Resident #96 to come down the hall. When he came in and said that S10FLPN push him down and hit him. On his left arm, there was a bruise, so I told the nurse what, he told me. Review of a statement written by S8CNA dated 03/14/2019 revealed On last night S10FLPN and Resident #96 had an altercation at the nursing station. I call Resident #96 down the hall. We ask him what happened. He stated that S10FLPN hit and push him down. The nurse was notified about what had happen. On 04/02/2019 at 10:00 a.m., this surveyor along with another surveyor viewed the facility's video recording of the incident between S10FLPN and Resident #96 on 03/13/2019 at approximately 10:55 p.m. The video recording was viewed with S1ADM and S2DON present. The visual of the camera angle was the beginning of b hall where S10FLPN medication cart was observed on the right side of the hall. The following were viewed: 03/13/2019 at 10:53 p.m.: Resident #96 ambulated into the camera's view and paused by S10FLPN's med cart. He grabbed a Styrofoam drink cup from the cart, took a sip then placed the cup back on the cart. 03/13/2019 at 10:54 p.m.: Resident #96 grabbed a pudding cup off S10FLPN's med cart and immediately started eating the pudding cup with a tongue blade. 03/13/2019 at 10:54 p.m.: S10FLPN came back around to the med cart from the a hall. He was noted to be holding an object (S2DON identified the objects as medication cards.) He approached Resident #96 in an aggressive manner, grabbed the pudding out of Resident #96's hand where it falls to the floor and slapped Resident #96 in the face with enough force to knock the resident's hat off his head. Resident #96 stared at S10FLPN for a moment, then charged at S10FLPN. S10FLPN kicked at Resident #96 three times of which two of those kicks connected with Resident #96. 03/13/2019 at 10:55 p.m.- S10FLPN picked up the pudding that had fallen to the floor during the incident and attempted to shove it in Resident #96's face. An interview was conducted S2DON on 04/02/2019 at 10:41 a.m. She stated she was notified by S10FLPN of an incident between him and Resident #96 a little after midnight on 03/14/2019. She stated Resident #14, which was the wrong resident, became really upset with him and started going after him but he had medications in hand and could not protect himself. She stated S10FLPN stated he lifted his leg to protect himself but did not make contact with Resident #96. She stated she explained to him she was going to look at the camera system. She stated S10FLPN said that would be fine. She stated she asked S3ADON to review the video recording later that morning. She stated S3ADON called her and told her the incident didn't look good. She stated after she arrived at work, she reviewed the video and determined the resident was not Resident #14 but Resident #96. She stated she was appalled at what she watched. She stated S10FLPN had clearly abused Resident #96. She stated since S11LPN was Resident #96's nurse, she called S11LPN first to see if she saw or heard anything. She stated S11LPN stated she didn't see anything but S9LPN had seen everything. She stated S9LPN and S11LPN were together at that time, so S11LPN handed her phone to S9LPN so they could talk. S2DON stated S9LPN said S10FLPN had approached Resident #96 while he was standing at the med cart eating pudding and S10FLPN aggressively hit the food out of the resident's hand, hit him in the face, and kicked him. S2DON stated she asked S9LPN why she hadn't called to report what S10FLPN had done. She stated S9LPN stated she was scared. She stated S9LPN stated she and S11LPN overheard S10FLPN on the phone telling her (S2DON) about the incident with Resident #96 but S10FLPN did not tell the truth. She stated S9LPN stated she had planned to call S2DON and tell her what really occurred. She stated she told S9LPN and S11LPN to report to the facility immediately so she could obtain their statements about the incident. She stated she reached S10FLPN by phone and asked him to come to the facility. She stated he came to the facility around 2:00 p.m. She stated she asked him what happened and he gave the same statement he had given her when he first called to report the incident. She stated she showed S10FLPN the video. She stated S10FLPN stated he did not remember the incident happening. She stated he said he only remembered just taking the pudding away from Resident #96 and trying to protect himself by putting his leg up. She stated she suspended him at the point. She stated she received statements from the b hall CNAs, S7CNA and S8CNA. She stated both CNAs stated they had not witnessed the incident between S10FLPN and Resident #96 but just heard commotion. She stated S1ADN notified the local police of the incident on 03/14/2019 around 1:00 p.m. She stated she spoke with Resident #96 and he stated he was ok, just didn't know why S10FLPN hit him. She stated during his skin audit, he had new bruising to his left hand and forearm. She stated on 03/17/2019, S10FLPN called and left a message stating that he was on an appetite suppressor and he felt like that was what caused him to black out. A telephone interview was conducted with S7CNA on 04/03/2019 at 9:04 a.m. She stated on the night of 03/13/2019 at approximately 11:00 p.m., she was down the b hall charting. She stated she heard a commotion up the hall by the nurse's station. She stated she looked up the hall and saw S10FLPN and Resident #96 standing by a cart. She stated Resident #96 was visibly upset and she called Resident #96 down the hall. She stated when Resident #96 made it to her, he stated S10FLPN had hit him and also pushed him down. She stated she left Resident #96 with S8CNA and went immediately to report the incident to S9LPN. She stated she and S9LPN assessed him and found a very small scratch on his left arm. A telephone interview was conducted with S8CNA on 04/03/2019 at 9:18 a.m. She stated on the night of 03/13/2019 at about 11:00 p.m., she and S7CNA were sitting on the a hall. She stated she heard a commotion and overheard Resident #96 fussing at S10FLPN. She stated she and S7CNA called Resident #96 down the hall. She stated when he walked to them, he explained S10FLPN had hit and pushed him. She stated he showed them his left arm. She stated he had a small spot of blood on his shirt. She stated she stayed with him while S8CNA went to go get S11LPN. She stated S11LPN arrived immediately. She stated S7CNA and S11LPN brought him into his room and assessed him. A telephone interview was conducted with S9LPN on 04/03/2019 at 8:39 a.m. She stated she was assigned to three residents that resided on b hall. She stated on the night of 03/13/2019 at approximately 11:00 p.m., she heard S10FLPN yelling and cursing at Resident #96, who was standing by S10FLPN's medication cart. She stated S10FLPN told Resident #96, Get off my cart m----f! She stated S10FLPN then charged Resident #96, knocking food out of Resident #96's hand as he hit his left arm. She stated Resident #96 stepped backed and just looked at S10FLPN for a few seconds. She stated Resident #96 walked towards S10FLPN yelling, You can't hit me like that. She stated S10FLPN kicked Resident #96 in the chest, causing him to stumble backwards again. She stated Resident #96 regained his footing and walked toward S10FLPN again and S10FLPN pushed Resident #96 again. She stated after the last push, the confrontation ended. She stated she and S11LPN approached S10FLPN. She stated S11LPN told him he needed to call S2DON. She stated S10FLPN placed the phone on speaker and called S2DON. She stated S10FLPN reported Resident #96 was acting aggressively toward him and he raised his foot up to protect himself. S9LPN stated S10FLPN told a lie about what happened. She stated she knew she was supposed to call S2DON and inform her of the incident but she was in shock and could not talk. She stated S10FLPN acted psychotic. She stated he clicked on then, then clicked off and acted as if nothing had happened. She stated around 10:00 a.m. on 03/14/2019, she was with S11LPN, when S2DON called her. She stated S2DON asked S11LPN about the incident. She stated S11LPN told S2DON she had not witnessed the incident but S9LPN had. She stated she spoke with S2DON and told her what she had witnessed. She stated S2DON instructed her and S11LPN to report to the facility as soon as possible to write their statements. She stated S7CNA and S8CNA were the aides working b hall. She stated they were further up the hall and had not witnessed the incident but they did hear a commotion. Throughout the survey from 04/01/2019 to 04/04/2019, random staff interviews revealed staff received training on the facility's abuse policies and procedures, and that they were aware of what to do in the event of any observed resident abuse. Interviews with sampled and unsampled residents revealed they were aware of abuse and that they knew who to report any abuse to. The facility has implemented the following actions to correct the deficient practice: 1. Immediate action: 2 nurses in serviced about the importance of reporting abuse to DON Administrator immediately- done 03/14/2019. 2. In-serviced Full time, PRN, and Part time nurses/CNAs about abuse and burnout; a. Full time nurses/CNAs done- 03/14/2019; facility in-service- 03/28/2019. b. Part-time, PRN nurses/CNAs prior to/on next day at work; started- 03/19/2019. 3. Audit: a. Administrative staff will come during the weekend x 4 weeks if no abusive accusations occur and then once a month afterward- started 03/23/2019. b. Will interview residents randomly during the week at least once a week. Will interview for 6 months if no accusations of abuse are made- started 03/18/2019. Monitor: 1. Will speak with staff members randomly 1-2 times per week during Administrative staff unannounced rounds to fill in an abuse/concerns/issues sheet to see if any type of burn out occurred. Will monitor x 4 weeks then once a month afterward. - started 03/23/2019. 2. Will fill out resident interviews randomly 1-2 times weekly during unannounced rounds and once during the week. Will monitor x 4 weeks then once a month afterward. - started 03/23/2019 3. Will try to get IT to put video on Administrator and/or DON phones to watch video at times at night or weekends while administrative staff isn't present.

Based on interviews and record reviews, the facility failed to ensure 1 (#5) of 5 (#1, #2, #3, #4, and #5) sampled residents was free from physical abuse. The facility failed to protect Resident #5 from willful physical abuse by Residents #1 and #4, who each had a history of [REDACTED]. This resulted in an actual harm for Resident #5 when the resident was physically attacked by a resident on 4/21/2018 and 5/2/2018. On 4/21/2018, Resident #4 punched Resident #5 in the face during an altercation in the dining room. Resident #5 was transported to the emergency room and diagnosed with [REDACTED].#1 pushed Resident #5 in the dining room, causing Resident #5 to fall and hit his head. Resident #5 sustained a head injury and was unresponsive for three minutes. Resident #5 was transported to the emergency room and treated for [REDACTED]. Findings: Review of facility's Abuse Policy included: Purpose: All residents of the facility will be treated with dignity and respect and will be free from all types of abuse. Policy and Procedure for Prevention: Our abuse prevention/intervention program includes but is not necessarily limited to the following: Assessing and care planning and monitoring of residents with needs and behaviors that may lead to conflict or neglect. Identifying areas within the facility that make abuse and/or neglect more likely to occur and monitor these areas on a regular basis. Policy and Procedure for Protection: During abuse investigations, residents will be protected from harm by the following measures: If the alleged abuse involves another resident, that resident will not be permitted to visit other areas of the nursing home unsupervised. Resident #5 Review of the Medical Record for Resident #5 revealed an admitted [DATE]. The [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 8. This indicated Resident #5 had moderate cognitive impairment. Review of Care Plan for Resident #5 revealed: Potential for Mood/Behavior Problems related to Chronic Paranoid [MEDICAL CONDITIONS] Disorder. Resident hollers, screams, and hits at staff and other residents (Initiated 10/13/2016) 4/9/2018 Physical aggression initiated. Review of the Incident Report dated 4/9/2018 revealed Resident #5 was struck by Resident #R1. - Interventions: (No interventions documented.) 4/21/2018 Physical aggression received. - Interventions: Separated by staff and sent to the emergency room for evaluation. 5/2/2018 Physical aggression received. - Interventions: Physician ordered a psychiatric evaluation. Resident sent to emergency room for a hematoma on his right forehead. At risk for impaired thought processes related to [DIAGNOSES REDACTED]. (Initiated 12/1/2016). - Interventions: No new interventions were noted since initiated. Original interventions included to cue, reorient, and supervise as needed. Review of Incident Reports for Resident #5 revealed: 4/9/2018 at 8:30am: While in the dining room, Resident #5 approached Resident #R1 with vulgar language; Resident #R1 then raised his fist and began yelling and screaming. S6LPN stood between the residents and Resident #R1 reached around her and hit Resident #5. Resident #5 refused physical assessment and vital signs until the ambulance arrived to transport him to the hospital for treatment. No injuries observed. 4/21/2018 at 5:52am: Resident #R5 came to the nurses' station and reported to S7LPN that there was an altercation occurring in the dining room. Resident #5 was found lying on his back in the dining area actively bleeding from the right side of his face and nose. Resident #5's nose appeared to be discolored and disfigured. Resident #5 stated he was hit hard and hurting under his right arm. Resident #5's agitation was noted and he stated I was hit hard, that man didn't have to do that to me. Resident #5 refused to have his vital signs taken or the blood cleansed from the right side of his face and underneath his nose; he was highly agitated at this time. Resident #5 went to the emergency room and diagnosed with [REDACTED]. - Follow-up notes indicated the video footage had been reviewed and Resident #4 had stepped on Resident #5's foot, Resident #5 responded to Resident #4 verbally, and then the fight took place. Resident #5 had recent medication changes and will continue to be monitored on current psychiatric medication dosages. Review of Nurses Notes for 4/21/2018 revealed: - 5:52am Resident #R5 came to nurses' station to report there was an altercation in the dining area. Resident #5 was found lying on his back in the dining area actively bleeding from the right side of his face and nose. His nose appeared to be discolored and disfigured. He stated he was hit hard and he was hurting under his right arm. Resident stated I was hit hard, that man didn't have to do that to me. Immediately assessed injuries. Two large lightly bleeding abrasions noted to right side of face. His nose was also lightly bleeding, discolored, and disfigured. Skin tear noted to right hand, and redness noted under his right armpit on ribcage. Resident refused vitals. -1:15pm Resident returned to facility awake, alert and agitated. Resident noted with two large red abrasions to the right side of his face below his cheekbone. Resident's nose noted with [MEDICAL CONDITION], bruising, redness and asymmetrical. Resident noted with skin tear to right knuckle. Multiple scars, bruising and redness noted to bilateral forearms. Two areas noted to left clavicle with [MEDICAL CONDITION]. Resident noticed grimacing when changing position. Review of the hospital records dated 4/21/2018 included a CT (computed tomography) Scan of Resident #5's sinus and facial bones with results of a mildly comminuted fracture to the nasal bridge, which was more prominent on the right with slight displacement. Review of the Incident Report dated 5/2/18 and timed for 4:50am revealed: S7LPN was called to the dining room by a resident that stated Resident #5 was pushed on the floor and hit his head. Upon arrival to the dining area, Resident #5 was lying on the floor with his eyes closed. He did not respond to verbal or tactile stimulation for approximately three minutes and then opened his eye and yelled out I am the victim, he did this to me, that man pushed me. Resident #5 refused vital signs. Hematoma was noted to the right side of his forehead. MD was notified and Resident #5 was sent to the emergency room and for psychiatric evaluation. Resident #5 returned to the facility shortly after with no new orders. Review of the Nurses Notes dated 5/2/2018 revealed: 4:50am: S7LPN was called to the dining room by a resident that stated Resident #5 was pushed on the floor and hit his head. Upon arrival to the dining area, Resident #5 was lying on the floor with his eyes closed. He did not respond to verbal or tactile stimulation for approximately three minutes and then opened his eyes and yelled out I am the victim, he did this to me, that man pushed me. Resident #5 refused vital signs. He was assessed for injuries and relocated for safety concerns. Hematoma was noted to the right side of his forehead. MD was notified and Resident #5 was sent to the emergency room for treatment. Review of hospital records dated 5/2/2018 revealed Resident #5 was treated for [REDACTED]. Resident #4 Review of the Medical Record for Resident #4 revealed an admitted [DATE]. The [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed a BIMS of 15. This indicated the resident was cognitively intact. Review of Care Plan for Resident #4 revealed: Potential to be physically aggressive related to his [DIAGNOSES REDACTED]. 3/21/2018: Became agitated and was verbally aggressive when he saw his CNA assisting another resident with combing his hair. He was hollering and went after them until another CNA redirected him. - Interventions included: Give meds, monitor side effects, give choices, psych consult as needed; when the resident becomes agitated intervene before agitation escalates/guide away from source of distress/engage calmly in conversation/if response is aggressive then walk calmly away and approach later. 3/30/2018: Aggressive/threatening behavior towards another resident when he asked Resident #4 if he smoked. - No interventions noted. 4/1/2018: Physical aggression initiated. - Intervention: On 4/2/2018 was referred to day program to address aggression. 4/21/2018 Physical Aggression initiated. - Intervention: Residents were immediately separated, transferred Resident #4 to the emergency room for psychiatric evaluation per the physician's orders [REDACTED]. At risk for Impaired Thought Processes related to his [DIAGNOSES REDACTED]. - Interventions included: Cue, reorient and supervise as needed. Monitor/document/report any changes in cognitive function, specifically changes in: decision-making ability, memory, recall and awareness, difficulty expressing self, difficult understanding others, L[NAME], mental changes. At risk for significant side effects of antidepressant medication related to taking [MEDICATION NAME] for depression (initiated 7/12/2017). - Interventions included: Observe/document/report adverse reactions to antidepressant therapy: change in behavior/mood/cognition, hallucination/delusions, social isolation, suicidal thoughts, and withdrawal. At risk for episodes of depression related to a [DIAGNOSES REDACTED]. - Interventions included: Monitor/document/report as needed any s/s (signs/symptoms) of depression, including anxiety, repetitive anxiousness; monitor/record/report to MD as needed for risk of harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons. Review of Incident Reports for Resident #4 revealed: 4/1/2018 at 2:55pm: S8LPN was summoned to the dining room by S10CNA who reported she observed Resident #4 push/hit Resident #R7 which caused Resident #R7 to fall down. When entering the dining room, Resident #4 was noted sitting in a chair at the table, rocking back and forth. While staff was assisting Resident #R7 to get up, he said he did not want to sit in the chair because of Resident #4. Resident #4 then stood up and picked up the chair and attempted to hit Resident #R7 with it. Resident #4 was redirected and then sat down. No injuries were observed. 4/21/2018 at 5:52am: Resident #R5 came to the nurses' station to report that there was an altercation occurring in the dining area. Resident #4 was sitting at a table close to Resident #5. Resident #5 was lying on the floor actively bleeding and with apparent injuries to his face. When asked what happened, Resident #4 stated I beat his ass, I put my foot on his foot under the table right here and he told me something; so I punched him and pulled him out that chair and I'll do it again. Agitation noted. No injuries noted to Resident #4. No witnesses for this incident. Follow up notes: While assisting Resident #5 away from the dining area, Resident #4 attempted to attack Resident #5 again. S7LPN held back Resident #5 and a CNA held back Resident #4. Both residents were separated and prevented from attacking each other again. Contacted MD-transfer resident to hospital for psychiatric evaluation. Resident was admitted and diagnosed with [REDACTED]. Review of Nurses Notes for Resident #4 revealed: 4/1/2018 at 3:15pm: S8LPN was summoned to the dining room by S10CNA who reported Resident #4 pushed/hit Resident R7 because he accidently bumped his chair. When entering dining room, Resident #4 was noted sitting on chair at table, rocking back and forth. While trying to help Resident #R7 get up, Resident #R7 mentioned he did not want to sit in the chair because of Resident #4. Resident #4 stood up and picked up the chair and attempted to hit the resident with it. Resident #4 was redirected to put the chair down and calm down. Resident #4 then sat back down. 4/3/2018 at 5:00pm: Resident #4 noted with aggression and staff member redirected the resident. On list to see psychiatrist. 4/21/2018 at 5:52am: Resident #R5 came to the nurses' station and reported to S8LPN that there was an altercation in the dining area. Resident #4 was sitting at the table close to Resident #5. Resident #5 was on the floor actively bleeding with apparent injuries to his face. Resident #4 stated I beat his ass, I put my foot under the table right there and he told me something; so I punched him and pulled him out that chair and I'll do it again. Resident #4's agitation was noted. While assisting Resident #5 away from the dining area, Resident #4 attempted to attack Resident #5 again. S8LPN held back Resident #5 and a CNA held back Resident #4. Note: Resident #4 was admitted to a psychiatric hospital on [DATE] and returned to the facility on [DATE]. 5/5/2018 at 5:51pm: Resident #4 noted in day room arguing with Resident #R8 in the hallway. Resident #4 was redirected to sit down. Resident #4 became agitated saying I am going knock her out. Resident #R8 was redirected to another seat. Review of Psychiatric Evaluation for Resident #4: 4/9/2018 Admitting Diagnoses: [REDACTED]. Resident here for treatment of [REDACTED]. Resident says he's fine. Treatment Plan included individual and family therapy as well as resident education. Resident said he didn't know why he was there. Prognosis good. Review of Day Program's Documentation Note for Resident #4: 4/18/2018 Resident still appeared restless and anxious but cooperative. Resident #1 Review of the Medical Record for Resident #1 revealed an admitted [DATE]. The [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed a BIMS of 15. This indicated the resident was cognitively intact. Review of Care Plan for Resident #1 revealed: Potential for Mood/Behavior problems related Depression, [MEDICAL CONDITIONS], Conduct Disorder and History of Suicidal Ideation. 5/2/18: Aggression initiated. - Interventions included: Education on inappropriate behavior towards other residents and encouraged to get a staff member for help in these situations. Resident referred to day program. Review of the Incident Report for Resident #1 revealed: 5/2/2018 at 4:50am: S15LPN was summoned to the dining room by another nurse who stated Resident #1 had pushed Resident #5 onto the floor. Upon assessment, Resident #1 was sitting upright at the dining room table. Resident #1 stated that Resident #5 was trying to sit at his table in the dining room and he told him not to sit there. He stated Resident #5 began yelling at him so he pushed him. Resident #1 had no apparent injuries. Resident #1 was referred to a day program and refused to attend. Review of Nurses Notes for Resident #1 revealed: 5/2/2018 at 4:50am: S15LPN was summoned to dining room by another nurse who stated Resident #1 had pushed Resident #5 onto the floor. Upon assessment, Resident #1 was sitting upright at the dining room table. Resident #1 stated that Resident #5 was trying to sit at his table in the dining room and he told him not to sit there. He stated Resident #5 began yelling at him so he pushed him. No injuries observed for Resident #1. On 5/29/18 at 1:21pm, an interview was conducted with S18LPN who said Resident #1 does have a short temper and will raise his voice. She said he will stand his ground. On 5/29/2018 at 1:25pm, an interview was conducted with S9LPN who was familiar with Resident #4. S9LPN said the resident was a very nice person until someone made him mad. On 5/29/2018 at 1:35pm, an interview was conducted with S11CNA who said she was familiar with the Resident #4. She said he was aggressive and does not like to be told much. She said he usually left the other residents alone until someone aggravated him and then he would be very ready to fight. She said other people irritate him by talking too much or fussing a lot, like Resident #5. She said if Resident #5 started talking too much, then Resident #4 would start exchanging words with him. On 5/29/18 at 1:51pm, an interview was conducted with S19CNA who said Resident #1 has a temper sometimes and will argue with other residents. On 5/29/2018 at 2:00pm, an interview was conducted with S13SS who said she was familiar with Resident #4. She said he was sent to a behavioral hospital on [DATE] after an altercation with Resident #5. S13SS stated that in her opinion, Resident #4's behaviors occurred because he was taken off of one of his psychiatric medications ([MEDICATION NAME]) and he began to exhibit more aggressive behaviors. On 5/29/2018 at 2:30pm, an interview was conducted with Resident #5. He said he was hit by another resident about a month ago. He said he was just sitting down at the dining room table and trying to eat. He said the next thing he knew he was being helped by one of the nurses. He said he did not know what happened. On 5/30/2018 at 5:46am, an interview was conducted with S7LPN who said she was familiar with Resident #4 and Resident #5. She said she was at the facility on the morning of 4/21/2018 when the incident occurred between Resident #4 and Resident #5. She said Resident #1 and Resident #4 were at a table in the dining room and Resident #5 wanted to sit with them so he sat down. Resident #4 and Resident #5's feet touched. She said Resident #4 got highly agitated, which was not his normal behavior, and smacked Resident #5 so hard that he hit the ground and was out for a few minutes. Resident #R5 came to the nurses' station and told her that Resident #5 was on the floor. S12CNA was holding Resident #4 back because when Resident #5 regained consciousness, he was still saying something that was agitating to Resident #4. She said she then assessed and sent both residents out; Resident #5 had a broken nose. On 5/30/18 at 5:49am, an interview was conducted with S17LPN who said it takes another resident to start being aggressive with Resident #4 before he becomes aggressive. On 5/30/2018 at 5:55am, an interview was conducted with S12CNA. She said she was at the facility on 4/21/2018 when the incident occurred between Resident #4 and Resident #5 in the dining room. She said she got between the residents after it started; she did not see what actually happened but by the time she got in the dining room Resident #4 was still trying to hit Resident #5 because he was still saying something agitating to Resident #4. She said staff separated them. She said Resident #4 talks a lot and hollers sometimes but did not have any unusual behaviors that day; he was just being himself. She said the CNAs were not in the dining room until they were finished with their rounds. She said the residents go in and out of the dining room in the morning until staff were finished making rounds. When asked if there was staff in the dining room when it happened, she said no. On 5/30/2018 at 5:58am, an interview was held with Resident #1. He stated he had altercations with other residents a couple of times. He said the altercations were not major and were nothing to really talk about. On 5/30/2018 at 6:10am, an interview was conducted with S2DON, who said she was familiar with Resident #4 and Resident #5. She said Resident #4 had aggressive behaviors. She said on 4/1/2018, Resident #4 pushed Resident #R7 down in the dining room because he bumped his chair. She said Resident #4's [MEDICATION NAME] had been discontinued as part of his gradual dose reduction. She said he was referred to the day program on 4/2/2018 and admitted to the day program on 4/9/2018. He attended the program three days a week. She said the psychiatrist at the day program had not changed his medications or care plan and deemed him appropriate to return to the facility. She said staff continued to round on the residents every 2 hours and monitor their behaviors every shift as usual and there were no other interventions made to Resident #4 and Resident #5's care at that time. She said Resident #4 also had a physically aggressive behavior towards Resident #5 on the morning of 4/21/2018. She said she was notified right after it happened and was later informed that Resident #5's nose was broken. She said Resident #5 did not initiate this altercation. She said no one actually saw the incident; the video was reviewed. She said the video showed the residents come into the dining room of their own free will before coffee pass and that was when the incident occurred. She said that based on the video, Resident #4 stepped on Resident #5's foot and Resident #5 said something to Resident #4 who then hit Resident #5 in the face. Resident #4 was sent for a psychiatric evaluation with medication adjustments and Resident #5 was sent to the emergency room . On 5/30/2018 at 6:15am, an interview was conducted with Resident #4. During the interview he said one time he had to push a fell ow and hit him to get him out of his face and stop him from talking. He said he gets along fine with everyone and then appeared to want to end the conversation. On 5/30/2018 at 12:53pm, an interview was conducted with S8LPN who said she was familiar with Resident #4. She described Resident #4's behaviors as being easily agitated when other residents talked to him or accidently bumped him. She said he became aggressive by hitting or pushing the other residents. She said Resident #4 threatened to beat up an aide because he was upset about her brushing another resident's hair. She said Resident #4 pushed Resident #R7 down and then tried to hit him with a chair because Resident #R7 accidently bumped his chair. She said other than his medication changes and starting the day program, there had been no changes in the care he received. She said staff made rounds at least every two hours and monitored behaviors every shift. She said monitoring was not increased before or after he went to the hospital that she was aware of. S8LPN also said she was familiar with Resident #5. She said Resident #5 sometimes screamed and argued without any cause. She said Resident #5 had altercations with Resident #4 and Resident #R1. She said Resident #5 had just gotten back from the psychiatric hospital about a week before he got into it with Resident #4 and got his nose broken. On 5/31/2018 at 10:45am, an interview was conducted with S3MDS who said she was familiar with Resident #4 and Resident #5. She said she witnessed Resident #4 becoming agitated with his CNA on 3/21/2018 and was shocked because that was not his normal behavior. She said he kept going down the hall after the CNA and had to be redirected multiple times. She said after the incident with Resident #5 in the dining room on 4/21/2018, he was sent to a psychiatric facility. She said when he returned on 4/27/2018, the psychiatric facility had deemed the resident able to return to the facility and he was placed on behavior monitoring every shift, which meant behaviors were monitored and recorded at least every eight hours. On 5/31/2018 at 4:10pm, an interview was conducted with S2DON. She said when residents were placed on the 'Psych List', it meant they would be seen by a psychiatric practitioner the next time they come to the facility, which was once a month. She said Resident #4's [MEDICATION NAME] was discontinued on 12/16/2017 and restarted on 4/21/2018 during his inpatient psychiatric stay after the incident in the dining room with Resident #5. She said for behaviors on 3/30/2018 she called the day program, but could not produce documentation. She said for Resident #4's aggressive behaviors on 4/1/2018 of pushing Resident #R7 and then trying to hit him with a chair, Resident #4 was referred to the day program on 4/2/2018 and began attending the program on 4/9/2018. He also began seeing the psychiatrist weekly at the day program. He was referred to the Psych List to be seen by a psychiatric provider at the facility on the next round, which occurred monthly. She said he went out of the facility on 4/21/2018 before he saw the psychiatric provider in the facility. Resident #4 returned to the facility on [DATE] with a change in his medications; [MEDICATION NAME] was prescribed again. S2DON said she felt the facility had done all they could to monitor, redirect, and supervise the residents.

F689 Based on interviews and record reviews the facility failed to ensure residents with aggressive behaviors received adequate supervision to prevent altercations that resulted in injuries for 1 (Resident #5) of 5 (Residents #1, #2, #3, #4, and #5) sampled residents. The total census was 118. This resulted in an actual harm for Resident #5 on 4/21/2018 and 5/2/2018. On 4/21/2018, Resident #5 was punched in the face by Resident #4 during an altercation in the dining room. Resident #5 was transported to the emergency room , treated for [REDACTED]. Resident #4 had escalating behaviors prior to this incident. On 5/2/2018, Resident #1 pushed Resident #5 in the dining room, causing Resident #5 to fall and hit his head. Resident #5 sustained a head injury and was unresponsive for three minutes. He was transported to the emergency room and discharged back to the facility on [DATE], after receiving treatment for [REDACTED]. Both incidents were unwitnessed and occurred in the dining room of the facility. Findings: Resident #5 Review of the Medical Record for Resident #5 revealed an admitted [DATE]. The [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) for Resident #5 dated 4/27/2018 revealed a Brief Interview for Mental Status (BIMS) of 8. This indicated the resident was moderately cognitively impaired. Resident #4 Review of the Medical Record for Resident #4 revealed an admitted [DATE]. The [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed a BIMS of 15. This indicated the resident was cognitively intact. Resident #1 Review of the Medical Record for Resident #1 revealed an admitted [DATE]. The [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed a BIMS of 15. This indicated the resident was cognitively intact. Review of Incident Reports for Resident #5 revealed: 4/21/2018 at 5:52am: Resident #R5 came to the nurses' station and reported to S7LPN that there was an altercation occurring in the dining room. Resident #5 was found lying on his back in the dining area actively bleeding from the right side of his face and nose. Resident #5's nose appeared to be discolored and disfigured. Resident #5 stated he was hit hard and hurting under his right arm. Resident #5's agitation was noted and he stated I was hit hard, that man didn't have to do that to me. Resident #5 refused to have his vital signs taken or the blood cleansed from the right side of his face and underneath his nose; he was highly agitated at this time. Resident #5 went to the emergency room and found to have a broken nose. There were no witnesses for this incident. Follow-up notes indicated the video footage had been reviewed and Resident #4 had stepped on Resident #5's foot, Resident #5 responded to Resident #4 verbally, and then the fight took place. Resident #5 had recent medication changes and will continue to be monitored on current psychiatric medication dosages. 5/2/2018 at 4:50am: S7LPN was called to the dining room by a resident that stated Resident #5 was pushed on the floor and hit his head. Upon arrival to the dining area, Resident #5 was lying on the floor with his eyes closed. He did not respond to verbal or tactile stimulation for approximately three minutes and then opened his eyes and yelled out I am the victim, he did this to me, that man pushed me. Resident #5 refused vital signs. Hematoma was noted to the right side of his forehead. The physician was notified and Resident #5 was sent to the emergency room for treatment and for psychiatric evaluation. Resident #5 returned to the facility shortly after with no new orders. Review of Nurse Notes for Resident #5 revealed: 4/21/2018 at 5:52am: Resident #R5 came to nurses' station to report there was an altercation in the dining area. Resident #5 was found lying on his back in the dining area actively bleeding from the right side of his face and nose. His nose appeared to be discolored and disfigured. He stated he was hit hard and he was hurting under his right arm. Resident stated I was hit hard, that man didn't have to do that to me. Immediately assessed injuries. Two large lightly bleeding abrasions noted to right side of face. His nose was also lightly bleeding, discolored, and disfigured. Skin tear noted to right hand, and redness noted under his right armpit on ribcage. Resident refused vitals. 4/28/2018 at 5:10am: Resident threw a chair at the front glass door saying he was looking for his army jacket. 5/2/2018 at 4:50am: S7LPN was called to the dining room by a resident that stated Resident #5 was pushed on the floor and hit his head. Upon arrival to the dining area, Resident #5 was lying on the floor with his eyes closed. He did not respond to verbal or tactile stimulation for approximately three minutes and then opened his eyes and yelled out I am the victim, he did this to me, that man pushed me. Resident #5 refused vital signs. He was assessed for injuries and relocated for safety concerns. Hematoma was noted to the right side of his forehead. MD (medical doctor) was notified and Resident #5 was sent to the emergency room treatment and for a psychiatric evaluation. Review of Incident Reports for Resident #4 revealed: 4/1/2018 at 2:55pm: S8LPN was summoned S10CNA who reported she observed Resident #4 push/hit Resident #R7 which caused Resident #R7 to fall down. When entering the dining room, Resident #4 was noted sitting in a chair at the table, rocking back and forth. While staff was assisting Resident #R7 to get up, he said he did not want to sit in the chair because of Resident #4. Resident #4 then stood up and picked up the chair and attempted to hit Resident #R7 with it. Resident #4 was redirected and then sat down. No injuries were observed. 4/21/2018 at 5:52am: Resident #R5 came to the nurses' station to report that there was an altercation occurring in the dining area. Resident #4 was sitting at a table close to Resident #5. Resident #5 was lying on the floor actively bleeding and apparent injuries to his face. When asked what happened, Resident #4 stated I beat his ass, I put my foot on his foot under the table right here and he told me something; so I punched him and pulled him out that chair and I'll do it again. Agitation noted. No injuries noted to Resident #4. No witnesses found were found for this incident. Follow up notes: While assisting Resident #5 away from the dining area, Resident #4 attempted to attack Resident #5 again. S7LPN held back Resident #5 and a CNA held back Resident #4. Both residents were separated and prevented from attacking each other again. Contacted MD-transfer resident to hospital for psychiatric evaluation. Resident was admitted and diagnosed with [REDACTED]. Review of Nurses Notes for Resident #4 revealed: 4/1/2018 at 3:15pm: S8LPN was summoned to the dining room by S9CNA who reported Resident #4 pushed/hit Resident R7 because he accidently bumped his chair. When entering dining room, Resident #4 was noted sitting on chair at table, rocking back and forth. While trying to help Resident #R7 get up, Resident #R7 mentioned he did not want to sit in the chair because of Resident #4. Resident #4 stood up and picked up the chair and attempted to hit the resident with it. Resident #4 was redirected to put the chair down and calm down. Resident #4 then sat back down. 4/21/2018 at 5:52am: Resident #R5 came to the nurses' station and reported to S8LPN that there was an altercation in the dining area. Resident #4 was sitting at the table close to Resident #5. Resident #5 was on the floor actively bleeding with apparent injuries to his face. Resident #4 stated I beat his ass, I put my foot under the table right there and he told me something; so I punched him and pulled him out that chair and I'll do it again. Resident #4's agitation was noted. While assisting Resident #5 away from the dining area, Resident #4 attempted to attack Resident #5 again. S8LPN held back Resident #5 and a CNA held back Resident #4. Review of Incident Report for Resident #1 revealed: 5/2/2018 at 4:50am: S15LPN was summoned to the dining room by another nurse who stated Resident #1 had pushed Resident #5 onto the floor. Upon assessment, Resident #1 was sitting upright at the dining room table. Resident #1 stated that Resident #5 was trying to sit at his table in the dining room and he told him not to sit there. He stated Resident #5 began yelling at him so he pushed him. Resident #1 had no apparent injuries. Resident #1 was referred to a day program and refused to attend. Review of Social Services Note dated 5/2/18 revealed Resident #1 was counseled S13SS on temper and altercations. She encouraged a day program and he declined. On 5/29/18 at 1:21pm, an interview was conducted with S18LPN who said Resident #1 does have a short temper and will raise his voice. On 5/29/2018 at 1:25pm, an interview was conducted with S9LPN who said she was familiar with Resident #4. S9LPN said the resident was a very nice person until someone made him mad. On 5/29/2018 at 1:35pm, an interview was conducted with S11CNA who said she was familiar with Resident #4. She said he was aggressive and did not like to be told much. She said he usually left the other residents alone until someone aggravated him and then he would be very ready to fight. She said other people irritate him by talking too much or fussing a lot, like Resident #5. She said if Resident #5 started talking too much, then Resident #4 would start exchanging words with him. On 5/29/18 at 1:51pm, an interview was conducted with S19CNA who said Resident #1 has a temper sometimes and would argue with other residents. On 5/29/2018 at 2:00pm, an interview was conducted with S13SS who said she was familiar with Resident #4. She said he was sent to a behavioral hospital on [DATE] after an altercation with Resident #5. She said that in her opinion, Resident #4's behaviors occurred because he was taken off of one of his psychiatric medications ([MEDICATION NAME]) and he began to exhibit more aggressive behaviors. On 5/29/2018 at 2:30pm, an interview was conducted with Resident #5. He said he was hit by another resident about a month ago. He said he was just sitting down at the dining room table and trying to eat. He said the next thing he knew he was being helped by one of the nurses. He said he did not know what happened. On 5/29/18 at 2:41pm, an interview was conducted with S20CNA. She stated she was not routinely assigned to Resident #1, but she did know that he had a temper when he was eating. On 5/30/2018 at 5:46am, an interview was conducted with S7LPN who said she was familiar with Resident #4 and Resident #5. She said she was at the facility on the morning of 4/21/2018 when the incident between Resident #4 and Resident #5 occurred. She said Resident #1 and Resident #4 were at a table in the dining room and Resident #5 wanted to sit with them so he sat down. Resident #4 and Resident #5's feet touched. She said Resident #4 got highly agitated, and hit Resident #5 so hard that he fell to the ground and was out for a few minutes. Another resident, Resident #R5 came to the nurses' station and told her that Resident #5 was on the floor. S12CNA was holding Resident #4 back because when Resident #5 regained consciousness he was still saying something that was agitating to Resident #4. She said she then assessed and sent both residents out; Resident #5 had a broken nose. On 5/30/2018 at 5:55am, an interview was conducted with S12CNA. She said she was at the facility on 4/21/2018 when the incident occurred between Resident #4 and Resident #5 in the dining room. She said she got between the residents after it started; she did not see what actually happened but by the time she got in the dining room Resident #4 was still trying to hit Resident #5 because he was still saying something agitating to Resident #4. She said staff separated them. She said Resident #4 talked a lot and hollered sometimes but did not have any unusual behavior that day; he was just being himself. She said she was coming into the dining room when it happened. She said the CNAs were not in the dining room until they were finished with their morning rounds. She said the residents go in and out of the dining room in the morning until staff were finished making rounds. When asked if there was staff in the dining room on 4/21/2018 when the incident between Resident #4 and Resident #5 occurred, she said no. On 5/30/2018 at 6:10am, an interview was conducted with S2DON, who said she was familiar with Resident #4 and Resident #5. She said Resident #4 had aggressive behaviors. She said on 4/1/2018 in the dining room, he pushed Resident #R7 down because he bumped his chair. She said Resident #4's [MEDICATION NAME] had been discontinued as part of his gradual dose reduction. She said he was referred to the day program on 4/2/2018 and admitted to the day program on 4/9/2018. He attended the program three days a week and was seen by the psychiatrist weekly. She said staff continued to round on the residents every 2 hours and monitor their behaviors every shift as usual and there were no other interventions made to Resident #4 and Resident #R7's care at that time. She said Resident #4 also had a physically aggressive behavior towards Resident #5 on the morning of 4/21/2018. She said she was notified right after it happened and was later informed that Resident #5's nose was broken. She said Resident #5 had a tendency to fight frequently. She said the video showed the residents come into the dining room of their own free will before coffee pass and that was when the incident occurred. She said that based on the video, Resident #4 stepped on Resident #5's foot and Resident #5 said something to Resident #4 who then hit Resident #5 in the face. Resident #4 was sent for a psychiatric evaluation with medication adjustments and Resident #5 was sent to the emergency room . S2DON verified there were no staff present to witness this incident. On 5/30/2018 at 6:15am, an interview was conducted with Resident #4. During the interview he said one time he had to push a fell ow and hit him to get him out of his face and stop him from talking. He said he gets along fine with everyone and then appeared to want to end the conversation. On 5/30/2018 at 12:53pm, an interview was conducted with S8LPN. She described Resident #4's behaviors as being easily agitated when other residents talked to him or accidently bumped him, then he became aggressive by hitting or pushing the other residents. She said Resident #4 threatened to beat up an aide because he was upset about her brushing another resident's hair. She said Resident #4 pushed Resident #R7 down and then tried to hit him with a chair because Resident #R7 accidently bumped his chair. She said other than his medication changes and starting the day program, there had been no changes in the care he received. She said staff rounds at least every two hours and monitored behaviors every shift. She said monitoring was not increased before or after he went to the hospital that she was aware of. S8LPN also said she was familiar with Resident #5. She said Resident #5 sometimes screams and argues without any cause. She said Resident #5 had altercations with Resident #4 and Resident #R1. She said Resident #5 had just gotten back from the psychiatric hospital about a week before he got into it with Resident #4 and Resident #5 got his nose broken. She said changes made in Resident #4's care after 4/21/2018 were his medication adjustments and he continued to attend the day program. On 5/30/2018 at 5:49am, an interview was conducted with S17LPN who said it takes another resident to start being aggressive with him before he becomes aggressive. On 5/30/2018 at 5:58am, an interview was conducted with Resident #1 who said he has only had altercation with other residents a couple of times. He said the altercations were not major and were nothing to really talk about. On 5/31/2018 at 10:45am, an interview was conducted with S3MDS who said she was familiar with Resident #4 and Resident #5. She said she witnessed Resident #4 becoming agitated with his CNA on 3/21/2018. She said he kept going down the hall after the CNA and had to be redirected multiple times. On 5/31/2018 at 11:06am, an interview was conducted with S4MDS who said with regards to the incident of Resident #R3 punching Resident #5 in the nose, both residents had a history of [REDACTED]. She confirmed there were no new interventions on the care plan for Resident #5 related to this occurrence of behavior. She confirmed on 10/13/2016 there was an intervention to intervene as needed to protect the rights of others. She said Resident #5 had an inpatient stay at a psychiatric facility with medication changes following to the incident on 4/9/2018 involving Resident #R1. She said Resident #5 approached Resident #R1 with vulgar language and Resident #R1 reached around the nurse and struck Resident #5. She verified there were no further changes to Resident #5's care plan for this incident requiring increased supervision. On 5/31/2018 at 4:10pm, an interview was conducted with S2DON. She said Resident #4 had not been placed on increased supervision since (YEAR). S2DON indicated that increased supervision meant that the staff would visually assess the resident every hour. S2DON also said Resident #5 was on hourly supervisory monitoring since 5/16/2017. She verified there was no staff present in the dining room on 12/20/2017 when Resident #5 was punched in the nose by Resident #R3. She verified there were no staff present in the dining room on 4/21/2018 when Resident #4 punched Resident #5 in the face and broke his nose. She verified there were no staff present in the dining room on 5/2/2018 when Resident #1 pushed Resident #5 onto the floor causing a hematoma to his right forehead. S2DON said she felt the facility had done all they could to monitor, redirect, and supervise the residents.