Every finding on record at Legacy Transitional Care & Rehabilitation

Based on observations, staff and resident interviews, record review, and review of the facility policies titled, Infection Prevention and Control Program and Hand Hygiene and Hand-Washing Policy, the facility failed to use proper infection control measures during catheter care for one of seven sampled residents (R) (R6). This deficient practice had the potential to cause infection. Findings include:Review of the facility policy titled Infection Prevention and Control Program date of issue: June 2025, Policy Statement revealed: Have a comprehensive program that addresses detection, prevention, and control of infections among residents and staff. This facility's infection prevention and control policies/practices are intended to facilitate in maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.Review of the facility policy titled Hand Hygiene and Hand-Washing Policy date of issue: June 19, 2025, Policy Statement revealed: Hand hygiene is the single most effective way of preventing the spread of communicable diseases and infections when performed correctly. Effective hand hygiene reduces the incidence of healthcare-associated infections. The objective revealed, To ensure that the facility complies with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines to effectively reduce the incidence of healthcare-associated infections. Cleanliness and hygiene are critically important in long-term care facilities. Hand soaps, sanitizers and cleaners are designed to reduce the risk of infection, cross-contamination between patients and the spread of germs by visitors. Hand hygiene practices are crucial in long-term care settings to protect residents and staff from infections. Regular training and compliance audits should be conducted to ensure that all healthcare personnel are adequately following these guidelines to maintain a safe environment. Section title, Standard of Practice: Section 2 revealed the following are indications for hand hygiene; immediately before touching a resident, before performing a clean or aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, and after touching a patient or the patient's immediate environment. The section titled, Gloves and Hand Hygiene, revealed Gloves are not a substitute for hand hygiene, if your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment, perform hand hygiene immediately after removing gloves, change gloves and perform hand hygiene during patient care, if gloves become damaged, gloves become visibly soiled with blood or body fluids following a task, moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs, and always clean your hands after removing gloves.Review of the electronic medical record (EMR) revealed R6 was admitted on [DATE] with diagnosis to include but not limited to hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side, major depressive disorder, benign prostatic hyperplasia with lower urinary tract symptoms, urine retention, benign neoplasm of the colon, and atrophy of kidney.Review of the Quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating R6 is cognitively intact. Section H (Bladder and Bowel) indicates indwelling catheter and always incontinent of bowel. Section I (Active Diagnoses) indicates asthma and respiratory failure. Section O (Special Treatments and Programs) indicates oxygen therapy. Review of the care plan revealed R6 has a suprapubic catheter and is at risk for complications from use of indwelling catheter. Dx Obstructive Uropathy, Urine Retention, Neurogenic bladder and BPH (benign prostatic hyperplasia).Observation of catheter care on 04/17/2026 at 1:09 PM with Restorative Aide (RA) AA assisted by Certified Nursing Assistant (CNA) BB. No hand hygiene was observed. Gown and gloves were applied. Double gloves were applied. Placed water in a basin. Pulled several wipes out the pack and placed them on the pad on the bed. Cleansed with wipes. Groin cleaned from inner area to outer with separate wipes. The catheter tubing was cleansed with the wipe started from the top of the catheter and moved away from the catheter. Added soap to water in basin. Cleaned area with soap and water. Rinsed area with wet cloth. Removed gloves and applied clean gloves without hand hygiene.Interview on 04/17/2026 at 1:32 PM with RA AA and CNA BB revealed that they would know if someone was on precautions by looking at the signage on the door. The signage would tell them what PPE (personal protective equipment) they needed to wear. RA AA also stated that if a resident had C-diff (clostridium difficile) you should always wash your hands with soap and water. RA AA stated that she used hand sanitizer when she went back in the hall although surveyor stepped into the hall behind RA AA and did not observe staff use sanitizer. RA AA confirmed that she placed the opened wipes on the resident's draw sheet. RA AA also confirmed that she double gloved and that when she removed the gloves, she did not sanitize her hands prior to putting on new gloves. She stated that it was important to use proper infection control to prevent the spread of infections.Interview on 04/17/2026 at 4:30 PM with the Administrator and Director of Nursing (DON) revealed their expectations of their nursing staff providing peri-care and catheter care was to explain to the residents what they were doing throughout the entire process of care. They stated the staff were required not to double glove but use single gloving process. They stated the staff were expected to clean their hands with hand sanitizer or soap and water, before and after each process of peri care and catheter care.

Based on observations, staff interviews, and review of the facility's policy titled Facility Maintenance Policy, the facility failed to ensure that three of 14 shared bedrooms on the 400 hall (rooms [ROOM NUMBER]) were maintained in good repair. Specifically, rooms [ROOM NUMBER] were not free from chipped and peeling paint, scuffed sheetrock, and damaged or broken electrical outlet. Findings include: Review of the policy titled Facility Maintenance Policy revealed the Maintenance Policy outlines the procedures and responsibilities for ensuring the proper operation and upkeep of the nursing home's facilities. It includes guidelines for plant operations and regular checks of the call light system to ensure the safety and comfort of all residents.Standard of Practice: Plant Operations revealed the plant operations is the maintenance and functionality of all mechanical, electrical, and plumbing within the facility. This includes heating, ventilation, air conditioning (HVAC), water supply, and emergency power systems.Responsibilities include: Conducting daily inspections of all critical systems. Performing routine maintenance as per manufacturer and regulatory guidelines. Documenting all maintenance activities and inspections. Responding promptly to any system failures or malfunctions. Tels task rounds are conducted on a weekly, monthly, and annual basis per system.Resident Rooms: Patient rooms are inspected weekly for cleanliness, functionality of fixtures, and safety compliance. Repairs and maintenance issues are addressed promptly to ensure resident comfort and safety. An observation on 9/30/2025 at 11:36 am during tour and screening of residents revealed in room [ROOM NUMBER], bed two, a damaged and broken outlet. An observation on 9/30/2025 at 11:55 am during tour and screening of residents revealed in room [ROOM NUMBER], next to bed two, wall paint that was peeled and scraped with scuffed sheetrock. An observation on 9/30/2025 at 12:19 pm during tour and screening of residents revealed in room [ROOM NUMBER], bed one, wall paint that was peeled and scraped with scuffed sheetrock, holes in the wall, and an overbed light that was inoperable. An observation on 10/1/2025 at 1:03 pm during tour and screening of residents revealed in room [ROOM NUMBER], bed two, a damaged and broken outlet. An observation on 10/1/2025 at 1:30 pm revealed in room [ROOM NUMBER], next to bed two, wall paint that was peeled and scraped with scuffed sheetrock. An observation on 10/1/2025 at 1:42pm during tour and screening of residents revealed in room [ROOM NUMBER], bed one, wall paint that was peeled and scraped with scuffed sheetrock, holes in the wall, and an overbed light that was inoperable. An interview on 10/1/2025 at 4:05 pm during walking rounds with the Maintenance Director confirmed damaged walls with peeled paint and chipped, scuffed sheetrock, a damaged and broken outlet, and the overbed light to be inoperable. An interview on 10/2/2025 at 2:09 pm with the Administrator revealed that she was aware of the environmental concerns and stated that three Maintenance Personnel would be assigned to round the facility, each responsible for a designated floor. She further indicated that additional tools would be implemented to support daily checks.

Based on staff interviews, record review, and review of Facility policy titled, Preadmission Screening and Annual Review Policy (PASARR), the facility failed to ensure PASARR Level II was submitted for one of five residents (R) (R8). This failure had the potential to prevent R8 from attaining or maintaining the highest practicable level of mental and psychosocial well-being.Findings include:A review of the facility policy titled, Preadmission screening & Annual Resident Review (PASARR) revised 5/15/2025 revealed under Policy statement: It is the policy of the facility to screen all potential admissions on an individualized basis for PASARR. Under Policy Purpose: The Purpose of this policy is to define and set expectations regarding the appropriate preadmission assessment of all individuals with a mental disorder and individuals with intellectual disability. This includes incorporating the recommendations from the PASARR level II determination and evaluation in the residents' assessment, care plan and transition of care, and referring to all level II residents and all residents with new or evident conditions related to Level II review upon significant change in status assessment.Review of the Quarterly Minimum Data Set (MDS) dated [DATE] Section C (Cognitive Patterns) revealed the Resident had a Brief interview for Mental Status (BIMS) score of 8 indicating moderate cognitive impairment. Section E (Behavior) revealed R8 had delusions, Section I (Active Diagnoses) revealed that R8 had a diagnosis of Schizophrenia, Section N (Medications) revealed that R8 was on an antipsychotic medication. Review of R8's care plan dated 7/23/2025 revealed R8 has impaired cognitive function/ impaired thought processes r/t dx of Schizophrenia with interventions including administer medication as ordered. Review of care plan revealed R8 has a risk for behaviors secondary to diagnosis of Schizophrenia. Interventions including Monitoring and documenting behaviors.Review of Physician orders dated 10/1/2025 revealed medications that included: Divalproex Sodium ER Oral Tablet Extended Release 24 Hour 500 mg (Divalproex Sodium) Give 1 tablet by mouth at bedtime related to Schizophrenia.Aripiprazole oral tablet 10 mg, give one tablet at bedtime related to Schizophrenia, unspecified dated 3/16/2024.Interview on 10/1/2025 at 2:20 pm with Social Service Director revealed this resident has not had an application submitted for PASARR Level II.Interview on 10/1/2025 at 10:25 am with Social Worker (BB) revealed that when a resident is admitted they verify the PASARR by approximately the end of the week they are admitted , the package is checked by the Director of Nursing and MDS. BB confirmed that resident R8 did not have a PASARR Level II submission.Interview with MDS Director on 10/2/2025 at 12:45 pm revealed that they check the diagnosis and put the diagnosis into the care plan upon admission, they do not check for PASSAR status. MDS Director revealed that R8 was admitted to the facility with a diagnosis of Schizophrenia.

Based on observations, resident and staff interviews, and review of the facility policies titled, Call light system/Light Policy, and Facility Maintenance Policy, the facility failed to ensure that the call light communication system was functioning adequately to allow residents to call for staff assistance in two out of seven restrooms (200 hall) and two of 14 rooms (301,305) on 300 hall.Findings include:Review of the facility policy titled, Call System/Light Policy, revise date of May 15, 2025, revealed under Policy Statement: The purpose of the Resident Call System shall allow residents to call for staff assistance through a communication system that relays the call directly to a staff member or to a centralized staff work area. Under Standard of Practice: Equipment: 1. Bedside call light in functioning order 2. Emergency call light in working order.Review of the facilities policy titled, Facility Maintenance Policy, dated July 2025, revealed under Standard of Practice: Plant Operations; Responsibilities included: conducting daily inspections of all critical systems. Resident monitoring systems are a critical component for resident safety and communication. Regular checks are necessary to ensure these monitoring systems are always operational.1.Observation on 9/30/2025 at 11:05 am during tour of resident's rooms revealed in room [ROOM NUMBER] the call light system was hanging off the wall and wires were exposed. The button on call system for the room was not functioning. Call light was tested by pushing the button and there was no sound or indicator light illuminating over the doorway. In room [ROOM NUMBER] the call light system was pulled out from the wall and hanging and was not functioning. Call light was tested by pushing the red button and there was no sound or indicator light illuminating over the doorway.Observation on 9/30/2025 at 11:15 am on the 200 hall two bathrooms connecting rooms [ROOM NUMBERS], 203 and 204 revealed the call light system was hanging from the wall and wires were exposed, and the system was not functioning. Walking rounds on 9/30/2025 at 1:24 pm with Maintenance Director verified rooms 301, 305 and bathrooms on 200 hallway had non-functioning call lights.2. During an observation on 9/30/2025 at 11:12 am in the shared bathroom for 201 and 202 revealed the emergency call device was detached from the wall.During an observation on 9/30/2025 at 11:14 am in the shared bathroom for 203 and 204 revealed the emergency call device was detached from the wall.During an observation and interview on 10/1/2025 at 4:07 pm with Maintenance Director confirmed the call devices in the shared bathrooms were detached from the wall. Continued interview also revealed that he does conduct audits for the call devices to ensure they work.

Based on observations and staff interviews, the facility failed to ensure food items in the freezer were labeled and dated and failed to discard the item by expiration date. In addition, the facility failed to maintain sanitary conditions of the ice machine in the kitchen. The deficient practices had the potential to affect all resident receiving an oral diet. Findings include: During the initial kitchen tour of the kitchen on [DATE] at 9:08 am with the Dietary Manager (DM), the following was observed: The interior components of the ice machine, including the wall lining and the dispenser area, were observed to have visible black residue. The reach in freezer had a large box of beef stew with an expiration date of [DATE], with no expiration date or open date written on the box or a label. During an interview on [DATE] at 2:11 pm with DM, it was confirmed that the ice machine was in regular use for the residents and acknowledged the unsanitary ice machine. He stated mold in an ice machine poses several serious health and safety risks such as respiratory issues, foodborne illnesses and posed a risk to immunocompromised residents. He stated the Maintenance Department was responsible for the routine cleaning and servicing of the ice machine. This included adhering to scheduled cleaning to ensure a sanitary ice machine. During an interview on [DATE] at 1:11 pm with the Head Cook, she stated she received in-service education on the proper way to label, store and discard all food items. She also stated that the proper protocol for expired food was for the staff to discard the expired food within 3 days of expiration. During an interview on [DATE] at 10:12 am with Maintenance Director confirmed his staff was responsible for making sure the ice machine was cleaned and sanitized on a regular basis. He stated after each cleaning, he filled out a log that included the date, time, and what was done. Each log was located on the ice machine for anyone to review. The Maintenance Director revealed he followed the manufactures guidelines along with the facilities rules, which required the machine be deep cleaned once a month. He stated going forward, he will implement a system in which whoever cleaned the machine will check for buildup, and mold.

Based on observations, record review, resident and staff interviews, and review of the facility's policy titled, Language Assistance Service, the facility failed to ensure one of two sampled residents (R) (R182) with Limited English skills, was provided with resources to access and understand communications regarding his healthcare regimen. Findings include: Review of the facility's policy titled, Language Access Policy: Use of Language Line Service, dated 1/1/2025 documented under Purpose: To ensure meaningful access to healthcare services for resident with Limited English Proficiency (LEP). Under Policy: All Name of Corporation facility will provide qualified interpretation through Language Line to all resident, family members, or responsible parties who have limited English proficiency or required ASL (American Sign Language) or other communication support services. Under Procedure: 1. Identification of Language Needs: Upon admission and during care, staff will identify individuals who may need language assistance. Resident language preferences will be documented in their medical records. 2. Accessing language line: Staff can access language line via telephone, tablet, or computer. Quick reference information will be located at nursing stations and intake areas.4. Staff must document the use of Language Line in the resident's chart when identified.6. Prohibited Practices: Family members, friends, or untrained staff may not serve as interpreters for clinical or legal matters unless explicitly requested by the resident and documented, and only when appropriate. Review of the clinical record revealed R36 was admitted to the facility on [DATE] with a primary language documented as Tigrinya (spoken in Ethiopia). Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not scored, unable to determine cognitive level, due to unclear speech. Further review revealed R136 is dependent with activities of daily living (ADLs). Review of the care plan dated 3/18/2025 R36 is a risk for a communication problem related to language barrier with an outcome for R36 to be able to make basic needs known on a daily basis. Interventions to anticipate and meet needs, ensure or provide a safe environment such as call lights in reach, adequate low glare light, bed in lowest position and wheel locked and avoid isolation, gestures, family supports and pen and paper when needed. During an observation/interview on 4/8/2025 at 12:58 pm with R36 revealed he was a non-English speaking and utilized pointing gesture as a form of communication. When the Surveyor tried to communicate with R36 he responded saying thank you and pointed to his bedside table. There was no form of communication noted in his room. During an observation on 4/9/2025 at 4:11 pm, the surveyor attempted to have a discussion with R36 and noted him using hand gestures to communicate. R36 started pointing at his leg saying the word nurse. After further conversation, R36 responded in his primary language. There was no form of communication noted in his room. An observation on 4/10/2025 at 8:06 am revealed R36 in his room. R36 waved and responded in a language and speech that was not identified. There was no form of communication noted in his room. During an interview on 4/10/2025 at 1:05 pm with a family member of R36 revealed English was not her or R36's primary language. She said, no translate when asked if she understood R36's medical care and treatment he was receiving at the facility. R36's family member was shown the admission documentation, and she nodded her head yes to being familiar with the paperwork. Continued interview with R36's family member revealed they were not able to understand some of the questions and the surveyor proceeded to utilize a language translator based of the language listed in the clinical records and she responded, thank you, thank you. During an interview on 4/10/2025 at 1:50 pm with Certified Nurse Assistant (CNA) RR, she revealed she worked on the fourth floor and stated they do not have a non-English speaking resident. CNA RR further stated they do not have a communication device or language line on the unit. During an interview on 4/10/2025 at 1:52 pm with CNA SS revealed she worked on the second floor and stated they do not have a language line or a communication device. During an interview on 4/10/2025 at 1:55 pm with Licensed Practical Nurse (LPN) TT, she stated she was new to the job and was not familiar with R36. She stated no one informed her during on-boarding that her floor had a non-English speaking resident. LPN TT continued to state she had not seen a language line or a communication device. During an interview on 4/10/2025 at 2:18 pm with the Social Worker (SW) UU revealed they have an artificial intelligence (AI) translation box for the residents. SW UU believed she had one non-speaking English resident on the fourth floor and knew there was a 1-800 language line. She stated the language telephone lines should be posted, but most people use the device to communicate. SW UU continued to state R36 understood English and will say or repeat one out of three words back in English during assessment and does head nods as communication gestures. While looking through the AI translation device, SW UU confirmed the language listed on R36's clinical record was not offered on the communication device. During an interview on 4/10/2025 at 3:00 pm with the Director of Nursing (DON), they revealed the staff should be aware of the language line and have access to it along with the newly implemented communication device the facility recently purchased.

Based on observations, staff interviews, and review of the facility policy titled, Cleaning and Disinfection of Environmental Surface, the facility failed to maintain clean Packaged Terminal Air Conditioner (PTAC) units for seven of 56 rooms on the third and fourth floors (Rooms 223, 227, 228, 302, 316, 317 and 323). The deficient practice had the potential to compromise the health and safety of the residents by increasing the risk of infections. Findings include: Review of the facility's policy titled, Cleaning and Disinfection of Environmental Surface dated October 2024 documented Environmental surface will be clean and disinfected according to current Center of Disease Control and Prevention (CDC) recommendations for disinfection of healthcare facilities and the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standards. 1. An observation on 4/8/2025 at 11:11 am in room [ROOM NUMBER] revealed the PTAC unit contained a gray, thick, fuzzy debris on the front dividers of the unit. An observation on 4/9/2025 at 9:06 am in room [ROOM NUMBER] revealed the PTAC unit contained a gray, thick, fuzzy debris on the front dividers of the unit. An observation on 4/11/2025 at 9:24 am in room [ROOM NUMBER] revealed the PTAC unit contained a gray, thick, fuzzy debris on the front dividers of the unit. An observation on 4/8/2025 at 11:15 am in room [ROOM NUMBER] revealed the PTAC unit contained a gray, thick, fuzzy debris on the front dividers of the unit. An observation on 4/9/2025 at 9:07 am in room [ROOM NUMBER] revealed the PTAC unit contained a gray, thick, fuzzy debris on the front dividers of the unit. An observation on 4/11/2025 at 9:24 am in room [ROOM NUMBER] revealed the PTAC unit contained a gray, thick, fuzzy debris on the front dividers of the unit. An observation on 4/8/2025 at 12:14 pm in room [ROOM NUMBER] revealed the PTAC unit contained a gray, thick, fuzzy debris on the front dividers of the unit. An observation on 4/9/2025 at 9:12 am in room [ROOM NUMBER] revealed the PTAC unit contained a gray, thick, fuzzy debris on the front dividers of the unit. An observation on 4/11/2025 at 9:20 am in room [ROOM NUMBER] revealed the PTAC unit contained a gray, thick, fuzzy debris on the front dividers of the unit. An interview on 4/11/2025 at 11:00 am with the Housekeeping Director (HD) stated the maintenance department was responsible for maintaining the units but moving forwards he and maintenance will come up with a schedule together. An interview on 4/11/2025 at 2:44 pm with the Maintenance Director revealed the responsibility was not on one sole person, but it was expected for the HD to ensure the PTAC units were clean. 38154 2. Observation of resident rooms beginning on 4/8/2025 at 12:43 pm revealed PTAC units with surface soil including the grills and dusty filters in rooms 223, 227, 228, and 302. Additional observation of resident rooms on 4/10/2025 beginning at 2:35 pm revealed the PTAC units remained soiled with dusty filters in rooms 223, 227, 228, and 302.

Based on staff interviews, record review, and review of facility's policy titled, Residents Assessments, the facility failed to document a significant change assessment upon re-admittance and change to hospice status for one resident (R) (R 104) and failed to accurately document the discharge status for one of 64 sampled residents R192. This deficient practice had the potential to affect quality of care and resident outcomes. Findings include: A review of the facility's policy titled Resident Assessments reviewed on 2/4/2025 revealed under Policy Statement: Resident Assessments will be completed upon admission, quarterly, annually and with a significant change on status. 1. A review of the Electronic Medical Record (EMR) for R104 revealed he was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of but not limited to adult failure to thrive, malignant neoplasm of oropharynx and malignant neoplasm of tongue. Furthermore, R104 was admitted to the hospital on 1/2/2025. Review of R104's quarterly Minimum Data Set (MDS) dated [DATE] indicated in Section O (Special Treatments, Procedures, and Programs) that hospice services were not selected for the resident. Further review revealed no significant change assessment was done after R104 was admitted to hospice on 12/23/2024. Review of R104's physician orders with a revised date of 1/20/2025 revealed R104 was admitted to Hospice Services due to a diagnosis of tongue cancer. Review of R104's hospice contract revealed a date of 12/23/2024. Review of nurses' notes with a late entry of 12/23/2024 revealed R104 returned from the hospital and admitted to hospice services. 2. Review of the EMR for R192 revealed he was admitted to the facility on [DATE] with the diagnoses of but not limited to dementia, congestive heart failure, delusional disorders, mental disorder, psychotic and mood disturbance and anxiety. Review of R104's discharge return-not- anticipated Minimum Data Set (MDS) dated [DATE] indicated discharge status to short-term general hospital. Review of progress notes dated 3/5/2025 revealed the facility had communication with R192's family representative regarding Personal Care Home (PCH) placement that assisted with behavioral health management. Review of progress notes dated 3/14/2025 stated R192 was discharged to a PCH. Review of R192' discharge summary instructions dated 3/14/2024 revealed R192 to be discharged to a PCH. An interview conducted on 4/11/2025 at 9:05 am with the MDS Manager, MDS Coordinator LL, and MDS Coordinator OO revealed that information for MDS assessments was typically gathered from a variety of sources, including documentation from nursing, rehabilitation, dietary, and nutrition departments, as well as hospital records for new admissions or readmissions. Additional information was obtained verbally from floor staff, Certified Nursing Assistants (CNA), family members during care plan meetings, through point-of-care documentation, physician progress notes, nurse practitioner notes, lab results, and direct input from the resident. The MDS Manager also noted that when contracted personnel were involved in patient care-such as hospice providers-care plans were discussed collaboratively, particularly when preparing for discharge or arranging personal care services. The MDS Manager stated that R104 was admitted to hospice on 12/23/2024. According to the facility census, hospice billing was stopped on 1/1/2025, and the resident re-entered the facility on 1/4/2025, still under hospice care. The MDS Manager confirmed that a progress note dated 12/23/2024 also documented the hospice admission. However, a review of the quarterly MDS assessment dated [DATE] revealed that Section O (Special Treatments, Procedures, and Programs), which pertained to hospice services, was not marked. MDS Coordinator OO, who completed the quarterly assessment, planned to capture hospice services on the next scheduled MDS in May 2025. The MDS Coordinator acknowledged that the omission on the 2/11/2025 assessment was an oversight and noted that this was not typical practice. The MDS Manager stated the resident was discharged to a personal care home based on available documentation. However, MDS Coordinator OO, who completed the MDS, reported that the census indicated a discharge to a hospital, and she relied only on that information when completing the MDS. The MDS Manager emphasized that it was the responsibility of staff to verify discharge destinations by cross-referencing the census with progress notes, consulting nursing staff, and raising discrepancies during clinical meetings. Failure to confirm and accurately document a resident's discharge location may lead to uncertainty about the resident's whereabouts, inaccurate records, and billing issues. During an interview on 4/11/2025 at 9:37 am, the Administrator stated she emphasized the importance of effective communication, stating that collaboration between nursing staff and the MDS team was essential. She noted that residents were reviewed during daily clinical meetings, and any changes in condition should be promptly identified and addressed during these discussions. She further expressed concern that, in this instance, R104 may not have been receiving all necessary care to ensure comfort.

Based on staff interviews, record review, and review of the facility's policy titled, Care Plan Policy and Language Access Policy: Use of Language Line Service, the facility failed to follow comprehensive person-centered care plan for one of 64 sampled residents (R) (R36). The deficient practice had the potential for R36's needs to go unmet. Findings include: Review of the facility's policy titled Care Plan Policy with a revised date 2/4/2025 documented under Policy Statement: Each resident will have a person centered plan of care to identify problems, needs, and strengths that will identify how the facility staff will provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Under Standard of Practice: .7. The facility must provide the resident and the representative, if applicable, with a written summary of the baseline care plan by the completion of the comprehensive care plan. The summary must be in a language and conveyed in a manner the resident and/or representative can understand. This summary must include but is not limited to: (a) the initial goals of the resident . (c) any service and treatments to be administered by the facility and personnel acting on behalf of the facility and (d) any updated information based on the details of the comprehensive care plan, as necessary. Review of the facility's policy titled Language Access Policy: Use of Language Line Service dated 1/1/2025 documented under Purpose: To ensure meaningful access to healthcare services for resident with Limited English Proficiency (LEP). All Name of facility owner facilities will provide qualified interpretation through Language Line to all resident, family members, or responsible parties who have limited English proficiency or required ASL (American Sign Language) or other communication support services. Under Procedure: 1. Identification of Language Needs: Upon admission and during care, staff will identify individuals who may need language assistance. Resident language preferences will be documented in their medical records. 2. Accessing language line: Staff can access language line via telephone, tablet, or computer. Quick reference information will be located at nursing stations and intake areas.4. Staff must document the use of Language Line in the resident's chart when identified.6. Prohibited Practices: Family members, friends, or untrained staff may not serve as interpreters for clinical or legal matters unless explicitly requested by the resident and documented, and only when appropriate. Review of the care plan dated 3/18/2025 R36 is a risk for a communication problem related to language barrier with an outcome for R36 to be able to make basic needs known on a daily basis. Interventions to anticipate and meet needs, ensure or provide a safe environment such as call lights in reach, adequate low glare light, bed in lowest position and wheel locked and avoid isolation, gestures, family supports and pen and paper when needed. During an interview on 4/10/2025 at 2:57 pm with the MDS LL revealed she was unaware about a communication device and that it was something that should be added to his care plan. During an interview on 4/11/2025 at 11:41 am with the Director of Nursing (DON) if it is on the care plan and it is indicated, then they are expected to follow the resident care.

Based on observations, staff interview, record review, and review of the facility policy titled, Gastrostomy Tube Feeding and Monitoring Policy, the facility failed to follow physician's orders to check residual and gastrostomy tube (G-tube) placement for one of 10 residents (R) (R 243) of ten residents receiving tube feedings. The deficient practice had the potential to cause infection, poor quality of life and negative outcomes for R243. Findings include: Review of the facility policy titled Gastrostomy Tube Feeding and Monitoring Policy revised 4/16/2024 documented under Standards of Practice, Step number 1: Check physicians' orders for nutritional formula, rate of flow, flush amount, medication administration, checking for tube placement and for gastric residual.7. Check placement of feeding tube prior to feeding, medication, or flush administered by slowly injection approximately 30 ml of air through the tube and listening with stethoscope over the abdomen for a swish sound. Review of the electronic medical record (EMR) for R243 revealed he was admitted to the facility with diagnoses including but not limited to gastrostomy status, acute respiratory failure, seizures, encephalopathy. Review of the most recent admission Minimum Data Set (MDS) for R243 dated 4/4/2025 documented a Brief Interview for Mental Status (BIMS) score of 00, indicating resident had severe cognitive impairment. Review of the Care Plan for R243 revealed a care plan dated 3/12/2025 that documented in Section O (Special Treatments, Procedures, and Programs), monitor/document/report to MD PRN (as needed): aspiration-fever, SOB (shortness of breath), tube dislodged infection at tube site, self-extubation (removal of tracheostomy tube), Tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, dehydration. Check for tube placement and gastric/contents/residual volume per facility protocol. Review of the Physician orders for R243 dated 4/4/2025 documented enteral feed order, every shift Nutren 1.5 at 55 ml/hr (milliliters per hour) hold for care. G-tube care daily. Tube checks gastric residuals if greater than 60 ml discard and hold feeding, notify physician of gastric emptying as needed. 4/4/2025 tube: check tube placement before initiation of feeding/flushing and prior to medication administration slowly inject 30 ml of air through tube every shift. Observation on 4/9/2025 at 9:31 am during medication administration observation, it was noted Charge Nurse-Licensed Practical Nurse (LPN) DD did not measure abdominal contents for residual or check for proper placement G-tube as ordered by physician. Charge Nurse LPN DD administered scheduled medications and flushes to R243 without proper tube placement check. Interview on 4/9/2025 at 9:30 am with Charge Nurse LPN DD revealed he did check for residual and placement, sometimes. He confirmed he did not check during this administration. Interview on 4/10/2025 at 8:15 am with LPN CC revealed the first thing she did was tell the resident what she was going to do for medications. The second thing she stated to do was to check for G-tube placement. She stated she obtained a stethoscope and drew up 30 cc of air and pushed it into the G-tube and listened for the swish sound. If the resident got more than one medication, she would mix medications in a medication cup and flush with 30 cc (cubic centimeters) of water and gave medications, then flushed again with 30 cc of water. She stated to check for residual feeding in the stomach, she checked at the same time she checked for proper tube placement. Interview on 4/11/25 8:51 am with the Human Resource Manager revealed she received skills check-off at hire and annually and put them in the staff personnel files. Review of the personnel file for Charge Nurse LPN DD revealed a Medication Administration Skills Checklist dated 10/31/2024. Tube feeding not addressed directly in skills check-offs. Review of staff inservices provided in 2025 revealed an inservice on 3/16/2025 on medication administration, an in-service conducted on 10/10/2024 on G-Tubes, enhanced barrier precaution, tube placement, checking residuals, flushing G-tubes, and administering medications through a G-tube. Interview on 4/10/2025 at 10:41 am with the Director of Nursing (DON) revealed Staff Development performed random audits and observations on the floor with nurses for tube feeding. Medication Techs/Aides cannot administer tube feeding. When the facility saw a need, they implemented education. Interview on 4/11/2025 at 8:46 am with the DON revealed the computer-based education system did not have tube feeding training. She stated it was part of skill checkoffs that were performed by Staff Development and the Infection Control Nurse. Skills checks were done upon hire and annually.

Based on observations, staff interviews, and review of facility's policies titled, Water Supply, Infection and Control Committee, and Laundry and Bedding, Soiled, the facility failed to maintain a Water Management Program, failed to prevent the spread of infections by not properly securing and storing one clean linen rack of five racks, to ensure the laundry area was maintained in a clean and sanitary condition, and to disinfect a gastronomy tube (G-tube) site per physician orders for one resident (R) (R243). The deficient practices had the potential to spread infection throughout the facility. Findings include: Review of the facility's policy titled Water Supply reviewed October 20, 2022, revealed under Purpose: To maintain a sanitary water supply and control the spread of waterborne microorganisms. Review of the facility's policy titled Infection Prevention and Control Committee reviewed 2/4/2025 revealed under Practice Guidelines: The Infection Control Committee shall oversee the surveillance, investigation, reporting, control and prevention of infections; occupational exposures to blood, body fluids, or other potentially infectious materials; and monitoring for proper implementation of and adherence to infection control policies and procedures. Review of the facility's policy titled Laundry and Bedding, Soiled reviewed October 2024 revealed under Policy Interpretation and Implementation: .2. Place contaminated laundry in a bag or container at the location where it is used and do not sort or rinse at the location of use. 3. Place and transport contaminated laundry in bags or containers in accordance with the established policies governing the handling and disposal of contaminated items. 1. Interview on 4/10/2025 at 9:19 am, the Maintenance Director (MD) stated the City of Atlanta tested the facility's water every other month. When asked for documentation or test results, the MD stated the city does not provide results, and he had never seen any official documentation. The MD noted that the last test for Legionella conducted by the city was in 2024, which was also the first time he had heard of Legionella. When asked about the facility's Water Management Program (WMP), MD confirmed there was none. He also stated that he did not perform routine water system flushing and only flushed the water heaters. Interview on 4/10/2025 at 12:20 pm, the Administrator confirmed that the facility does not have a Water Management Program. She acknowledged that facilities were expected to understand their water system design, ensure water safety, and maintain supporting documentation. She recognized the potential negative outcomes of not having a documented WMP to be that residents could be exposed to water that was not healthy. Observations on 4/9/2025 at 4:51 pm and 4/10/2025 at 8:54 am revealed one clean linen rack was unsupervised and uncovered on the first floor of the facility. There were no residents' rooms located on the first floor of the facility. During an interview and observation conducted on 4/10/2025 at 2:13 pm, the Housekeeping Director (HD) observed that a clean linen cart had been placed on the first floor uncovered, which he stated should not have happened. He confirmed that the facility's expectation was for all clean linen to always be covered to prevent the spread of infection. An interview on 4/10/2025 at 10:00 am with the Administrator revealed the clean linen rack should not be left uncovered outside in the hallway. She stated a possible negative outcome could be risk for infection. An interview and observation on 4/10/2025 at 9:23 am with the HD, the following was observed in the laundry: Puddles of water and brown, rust-like stains on the floor surrounding the washing machine. Grey, fuzzy debris throughout the laundry room, including floor, walls, and ceilings. ] White residue, possibly spilled detergent on and around the washing machines. Grey, fuzzy debris on the washing machines side filters and a sign indicating that filters should be cleaned daily. Debris in between and behind the washing machines which included spoons, wrappers, rags and unidentified objects. Dirty resident clothing piled up in the corner, on the floor, uncovered. The HD stated he realized the leak behind the washing machines a week or two ago. He revealed that the machine manufacturer came into the facility to clean the washing machine filters located on the side of the machine. Observation of the washing machine filter read, Notice Clean Filter Daily. The HD stated the washing machine manufacturer was aware of the leak and they were the ones who could repair it. The HD then stated he called the machine manufacturer a month ago, and they came out to fix the leaking hose, but wasn't sure of where the leak was coming from currently. The MD then stated he had not called them back again since the last time they came out. The MD confirmed that the dirty linen should not be on the floor and that he would bring another blue bin for the laundry aides to use for dirty linen. The MD confirmed that the laundry room was full of gray, fuzzy debris, and stated normally he came in and used a blower for the dust. The MD stated it was the Laundry Aide's responsibility to keep the laundry room clean. Interview on 4/10/2025 at 2:13 pm, the HD stated there should be no leaks on the floor, as this poses a slip hazard. Additionally, he confirmed that dirty linen should not be left on the floor due to hygiene and safety risks. Regarding the washing machine filters, he explained that they were expected to be cleaned daily to ensure that laundry was properly sanitized; failure to do so could result in improperly cleaned clothes. When asked about the presence of dust in the laundry room, he acknowledged that there was dust and agreed that the amount was excessive, which could lead to respiratory issues such as coughing. He also noted that there was often debris between the washing machines, which should not occur, and stated that Laundry Aides were expected to keep the area clean and tidy. If not maintained, this could result in foul odors and a poor appearance, and pose a fire hazard. An interview on 4/10/2023 at 9:40 am, Laundry Aide (LA) QQ stated each shift was responsible for cleaning the laundry room. She stated she noticed the washing machine leak on Monday and informed the HD. An interview on 4/10/2025 at 10:00 am, the Administrator stated that her expectation was for the laundry area to be clean and maintained without needing to be reminded. She emphasized that cleanliness should be standard practice and not something that required constant instruction. She acknowledged personally observing dust accumulation and noted the need for more consistent dusting. The Administrator stated that clothes and other items should never be on the floor, as this can trigger allergies and compromise sanitation. She also reported seeing debris on the floor, and should be removed. 51853 2. A review of the electronic medical record (EMR) for R243 revealed he was admitted to the facility with diagnoses including but not limited to gastrostomy status, acute respiratory failure, seizures, encephalopathy. Review of the most recent admission Minimum Data Set (MDS) dated [DATE] documented R423 had a Brief Interview for Mental Status (BIMS) score of 00, indicating resident was severely cognitively impaired. Review of the Care Plan for R243 revealed a care plan dated 3/12/2025 that documented the resident to Monitor/document/report to MD PRN (as needed): aspiration- fever, SOB, tube dislodged, Infection at tube site, self-extubation, Tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, dehydration. Provide local care to gastrostomy site (G-Tube) as ordered for signs and symptoms of infection. Review of the Physician orders for R243 dated 4/4/2025 documented Enteral feed order every shift-Nutren 1.5 at 55 ml/hr (milliliters per hour) hold for care. G-tube care daily. Observation on 4/9/2025 at 9:31 am of R243 gastrostomy site during medication administration with Licensed Practical Nurse (LPN) DD revealed the site to have a brown, crusty looking substance at the insertion site. Tape for the G-tube was loose and hanging from the tube. Observation on 4/11/2025 with LPN AA Unit Manager revealed R243's G-tube insertion site to have brown, crusty material remaining at the insertion site. The G-tube was not secured with tape hanging from the tube. LPN AA confirmed the site had not been cleansed. Interview on 4/11/2025 at 8:13 am with LPN DD revealed as LPN charge nurse he was responsible for all the tube feedings on his unit. He revealed he had one resident with a G-tube feeding on the unit at this time. LPN DD stated that he did clean the G-tube sites, sometimes. Interview on 4/11/2025 at 08:17 am with LPN AA revealed she typically tried to check behind on the G-tubes if she could on her unit, but the nurse was responsible for the G-tube care. LPN AA confirmed that R423's G-tube site had not been addressed since the first observation. LPN AA stated that G-tube sites were to be cleansed daily.

Based on observations, staff interviews, and review of the facility's policy titled Dating, Labeling, and Discarding Food, the facility failed to discard food items by the expiration or use-by date, failed to discard food items with a fuzzy green substance on it, and failed to ensure dietary staff wore beard coverings while in the kitchen. The deficient practice had the potential to place the 176 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. Findings include: Review of the facility's policy titled Dating, Labeling, and Discarding Food, revised January 2023, included Dating, labeling, food stored in the coolers, dry storage and freezers ensure the safety of the food that will be served to the residents. According to the 2022 Food Code, food that is RTE (Ready to Eat), Refrigerated and/or Time/Temp Control Food (food that contains ingredients that may cause food poisoning) MUST have an OPEN (or Prepared) Date and a USED BY (or DISCARD) date on each of these foods. The USED BY date that the FOOD CODE is referring to is not the use by or expiration date from the manufacturer, rather, how soon the facility must either use or throw away before it becomes unsafe to eat. All boxes, packages, containers must be dated with the delivery date that the food was delivered to the facility. This ensures food is being used and rotated out quickly and safely. During the initial walk-through of the kitchen on 11/5/2025 at 9:00 am, observation revealed Kitchen Aid (KA) CCC was not wearing a beard net. Observation on 11/5/2024 at 9:12 am of the walk-in cooler revealed a pan of salad (lettuce mixture) was not discarded by the used-by date and had brown discoloration. Observation on 11/7/2024 at 1:45 pm of packaged bread revealed a green fuzzy substance on the bread. In an interview on 11/5/2024 at 10:01 am, the Dietary Manager (DM) confirmed she did not know why there were no dates on the identified food items. In an interview on 11/8/2024 at 2:32 pm, the Administrator revealed she expected the DM to be aware of the responsibilities and duties in the dietary department. She explained improper food handling is a concern and food items should have a three-day lifespan. The Administrator continued to confirm the dietary staff was responsible for ensuring items were properly stored and discarded in the kitchen storage areas.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Administration of Medications, the facility failed to ensure one of 60 sampled residents (R) (R684) was assessed to safely self-administer medications. The deficient practice had the potential to allow access to medications otherwise not prescribed by a physician to other residents. Findings include: Review of the policy titled Administration of Medications reviewed October 2024 revealed under Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Revealed under Procedure: All medications are administered accurately and safely, and free of errors. 1. Only licensed nurse or person permitted by the state to prepare, administer, and document the administration of medications may do so.14. Patient may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. A self-administration assessment will be completed. Review of the electronic medical record (EMR) revealed R684 was admitted to the facility with diagnoses including but was not limited to surgical amputation right leg, gangrene, diabetes mellitus type two and chronic kidney disease. Review of R684 quarterly/annual/significant change Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicates R684 was cognitively intact. Section GG, functional status, revealed R684 required moderate assistance for activities of daily living (ADLs) with one or more-person assistance. Review of R684's care plan dated 10/24/2024 indicated a problem of mood, problem related to adjustment to placement. Goals included but not limited to will have improved mood state happier, calmer appearance, no signs or symptoms of depression, anxiety, or sadness, through the review date during adjustment process. Interventions included but not limited to administer medications as ordered. Monitor/document for side effects and effectiveness. Behavioral health consults as needed (psycho-geriatric team, psychiatrist etc.) Monitor/record mood to determine if problems seem to be related to external causes, i.e. medications, treatments, concern over diagnosis. Review of the Physician's Orders for R684 included but was not limited to order dated 10/22/2024 for metformin oral tablet 500 milligrams (mg) give one tablet by mouth one time a day for diabetes. Order dated 10/24/2024 for NovoLog injection solution 100 units per milliliter (ml) as per sliding scale. Review R684's of clinical assessments revealed no assessment for self-medication administration was completed. Observation and interview on 11/5/2024 at 11:05 am with R684 revealed he was awake and alert, lying in bed, bed in low position, call light within reach. Medicine cup noted on overbed table with white tablet in the cup. R684 stated he forgot it was there adding they leave my pills, and I just take them, but I forgot that one. R684 was unable to state what this medication was for. An interview on 11/05/2024 at 11:10 am with Licensed Practical Nurse (LPN) BB at R684's bedside confirmed medication cup was present with a white pill in the cup on the overbed table. LPN BB further confirmed no residents were assessed for self-medication administration and she will talk with the medication aide. An interview on 11/5/2024 at 11:30 am with LPN BB revealed the tablet was a metformin, diabetes medication, and the Certified Medication Aide (CMAT) thought he swallowed it. LPN BB did talk with her about the requirement to watch medication being taken before leaving the room. An interview on 11/5/2024 at 2:36 pm with CMAT GGG revealed R684 had the pills in his mouth and thought he had swallowed them. CMAT GGG stated they never left medication with him or anyone else. An interview on 11/7/2024 at 3:00 pm with the Director of Nursing (DON) confirmed the facility did not do self-med administration assessment. No medication should ever be left or kept at the bedside, this included over the counter items. The DON had expectations that the nursing supervisors should research and find a nurse or a medication tech to provide education and if appropriate move forward with corrective action and notify the DON. The DON also confirmed she was notified of this incident by the supervisor.

Based on record reviews, staff and resident interviews, and review of the facility's policy titled, Advance Beneficiary Notice Policy, the facility failed to appropriately provide the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to one of 60 sampled residents (R) (R125). This failure had the potential for R125 not to be able to express her right to make an informed choice about Medicare services as well as being provided with appeal instructions. Findings include: Review of the facility's policy titled Advance Beneficiary Notice Policy revised May 2018 revealed under Policy Statement: It is the policy of this facility to issue Advance Beneficiary Notices (ABN) per CMS Guidelines to inform Medicare Beneficiaries of items or services that Medicare may not pay. Review of the electronic medical record (EMR) for R125 revealed she was admitted to the facility with diagnoses of but not limited to orthopedic aftercare following surgical amputation. Review of the initial Minimum Data Set (MDS) assessment dated [DATE] documented that R125 had a Brief Interview for Mental Status (BIMS) score of 8, indicating R125 had moderately impaired cognition. Section GG (Functional Abilities) documented that R125 requires maximal assistance with mobility and personal hygiene. Review of the NOMNC for R125 revealed no resident signature indicating acceptance and understanding of the notice. Review of the SNF ABN for R125 revealed a signature not R125's name in the signature field indicating acceptance and understanding of the notice. According to the NOMNC and SNF ABN, the Medicare Part A start date was 9/17/2024 and the last covered day of Part A service was 10/23/2024. Interview on 11/7/2024 at 1:05 pm with R125, she stated about a week or two ago, she was verbally notified by the facility that her Medicare Part A coverage was ending. When showed the NOMNC form and SNF ABN form, R125 stated that she has never seen the forms and that the facility had not asked her to sign anything regarding the Medicare non-coverage. R125 indicated she was upset regarding her Medicare benefit running out. R125 stated, the facility is not helping me regarding this matter. They only verbally told me that my benefits were ending but did not give me a number to call for an appeal or provide any further instructions. Telephone Interview on 11/7/2024 at 2:48 pm with a family member of R125 revealed that she did not handle any finances for R125 and stated that the resident handled everything herself. She stated that she was unaware of R125's Medicare Part A coverage expiring. Interview on 11/8/2024 at 10:34 am with the Social Services Director (SSD) confirmed that she was responsible for providing the NOMNC and SNF ABN to the residents. She stated that if a resident cannot sign or refused to sign the forms, she documented it on the form. When asked about R125's NOMNC and SNF ABN forms, the SSD confirmed the resident's signature line on the NOMNC was blank and the SNF ABN form contained the signatures of herself and an assistant. The SSD further stated, I probably need to be more consistent about documenting if the residents cannot sign for themselves.

Based on observations and staff interviews, the facility failed to maintain a safe, clean, comfortable, homelike environment for two rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) on two of four units. Specifically, room [ROOM NUMBER] contained a circulating fan with gray substances on its blades and a privacy curtain caught in the fan blades, and room [ROOM NUMBER] had a dirty, damaged bathroom ceiling with black stains. The facility census was 181 residents. Findings include: 1. Observations during initial screening on 11/5/2024 at 11:05 am and on 11/6/2024 at 3:28 pm revealed a personal circulating fan blowing towards bed A in room [ROOM NUMBER], with thick, gray substances on its blades and a privacy curtain caught in the fan blades. Interview and observations during walking rounds on 11/8/2024 at 12:30 pm and 2:30 pm with the Maintenance Director (MD) and Administrator confirmed a circulating fan with gray substances on its blades and a privacy curtain caught in the fan blades in room [ROOM NUMBER], and a dirty, damaged bathroom ceiling with black stains in room [ROOM NUMBER]'s shared bathroom. The Administrator mentioned the MD will immediately correct and address the removal of personal circulating fan, and the damaged/stained items in each room. The Administrator confirmed the facility does not have an Environmental Maintenance policy. 50170 2. Interview on 11/5/2024 at 10:30 am with R60 revealed that R60 mentioned that staff didn't clean the bathroom or the room. R60 stated that they will come in and take the trash out but that's it. R60 stated that they rarely mop in his room or bathroom. R60 said that they need to do something about the mold in the bathroom. R60 said a couple of months ago they sprayed bleach on the ceiling to treat the mold, but it didn't help. Observation on 11/5/2024 at 10:30 am revealed the bathroom had a urine like smell. On the ceiling there was a black, brown substance, and a distinctive, musty smell, a smell similar to mildew.

Based on record review and staff interview, the facility failed to attempt to obtain fingerprint checks for four of 10 files reviewed and reference checks for two of 10 employee files reviewed. Findings include: Review of the employee files on 11/7/2024 at 1:00 pm with the Assistant Nursing Home Administrator and the Assistant Director of Nursing (ADON) revealed that there were no fingerprint results for staff who required completion of the GCHEXS (Georgia Criminal History Check System) (fingerprint background check). In addition, there were also no reference checks completed for staff who did not require GCHEXS fingerprint of the 10 staff reviewed. 1. The Administrator was hired on 9/18/2023, no evidence of reference checks performed. 2. Certified Medication Aide (CMA) GGG was hired on 1/16/2024, no evidence of GCHEXS fingerprint results and no references checked. 3. Certified Medication Aide (CMA) HHH was hired on 8/9/2024, no evidence of GCHEXS fingerprint results and no references checked. 4. Certified Nursing Assistant (CNA) III was hired on 7/16/2024, no evidence of GCHEXS fingerprint results and no references checked. 5. Dietary Manager (DM) NN was hired on 7/24/2024, no evidence of GCHEXS fingerprint results and no references checked. 6. The DON was hired on 10/11/2022, no evidence of reference checks performed. During an interview on 11/7/2024 at 1:45 pm, the Administrator revealed the Human Resources Representative was recently terminated and she was not aware of the missing information in the employee files.

Based on observations, record review, resident and staff interviews, and review of the facility policy titled, Preadmission Screening and Annual Resident Review (PASRR) (Preadmission Screening and Resident Review), the facility failed to refer a Level Il PASRR to the appropriate state-designated authority for evaluation and determination of specialized services for one of 60 sampled residents (R) R171) reviewed with serious mental illness. The deficient practice had the potential to affect the appropriate level of care and services provided for R171. Findings include: Review of the facility's policy titled, Preadmission Screening and Annual Resident Review (PASRR), revised November 2017 states that Annually and with any significant change of status, the facility will complete the PASRR Level I screen for those individuals identified per the Level II screen requiring specialized services. The facility will report any changes as identified via the screen to the state mental health authority or state intellectual disability authority promptly. In subsection titled, Definitions Applicable to the PASRR Process, number 1 states that an individual is considered to have a serious mental illness if the individual meets a diagnosis of schizophrenic, mood, paranoid, panic or other severe anxiety disorder. Review of the electronic medical record (EMR) for R171revealed diagnoses that included but not limited to post traumatic stress disorder (PTSD). Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] documented that R171 had a Brief Interview for Mental Status (BIMS) score of 15, indicating R171 had intact cognition. Section N (Medications) documented that R171 is taking an antidepressant medication. Section I (Active Diagnoses) coded yes for PTSD. There was no documented Level 2 PASRR following the diagnosis. R171 had a Level 1 PASRR completed on 08/19/2024. Review of physician orders revealed R171 was on Cymbalta (duloxetine HCl) (an anti-depressant), oral capsule delayed release particles 30 mg (milligrams). Review of the care plan dated 9/4/2024 revealed R171 uses psychotropic medications R171 will be/remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. Interview on 11/8/2024 at 11:17 am with R171 revealed she had been shot, stabbed, etc. She stated she had been through a lot growing up in the projects. She said that when she first arrived here, she had anger issues and would yell at people. She mentioned she was diagnosed with PTSD prior to admission. When she was at the hospital, her primary doctor gave her medication to help her with her mental health. She believed that she was still taking that medication. She says that the facility wasn't doing anything to address her mental health concerns. She said that she was doing better. She said most of the guys she plays cards talked to her. She found comfort in talking to some of the residents that have been through some of the same things she's been through. Interview on 11/8/2024 at 10:38 am with the Social Services Director revealed she was responsible for making the PASRR referrals. She reviewed them within the first 72 hours of admission. If the PASRR didn't seem consistent with the resident or if the diagnosis changed while the resident was here, she notified the state authority for PASRR 2 on admission, diagnosis change, quarterly or comprehensive assessment change, and looked at the mental illness diagnosis to see if a level 2 was needed. Bipolar, anxiety, schizophrenia, and major depression were the major diagnoses that she looked at. She further stated that for the admission process, Nursing and Admissions review the hospital documents. She stated she gets the PASRR prior to admission from the hospital. She stated that the hospital was not always honest about their time at the hospital. The facility staff would question if something did not seem right from the hospital. She went on to state that they would look at the situations of the residents if there was a change in daily behaviors, sometimes a resident needed grief counseling. She stated there were behavior management binders on each floor. When asked if she agreed that the resident would need a PASRR 2, she stated she didn't have a history of knowing if PTSD would require a level 2 PASRR.

Based on observations, staff and resident interviews, record review, and review of the facility policy titled, Activities of Daily Living (ADLs), the facility failed to ensure that ADLs were provided for two of 60 sampled residents (R) (R65 and R154) related to nail care. Specifically, nail care was not provided for R65 and R154. Findings include: Review of the policy titled Activities of Daily Living (ADLs) dated November 2022, the intent of policy indicated based on the comprehensive assessment of a resident and consistent with resident's needs and choices this facility will provide necessary care and services to ensure that a resident's ability in activities of daily living will not diminish unless the circumstances of the individual's clinical and medical condition demonstrate that such diminution was unavoidable. Also, the bath will be given for cleanliness, increased circulation, and comfort of the residents at least weekly, the skin will be observed during bath. 1. Review of the electronic medical record (EMR) revealed R65 was admitted to the facility diagnoses of but not limited to atrial fibrillation, intracardiac thrombosis, type 2 diabetes mellitus with unspecified complications, muscle weakness, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed R65 had a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident had moderate cognitive impairment. Section GG (Functional Status) revealed R65 had impairment on one side, assistance needed is partial to moderate for toileting, maximum with showering, and dressing. Section J (Pain Assessment) revealed R65 was on a pain management regiment and received scheduled pain medication. Review of the care plan for R65 revealed R65 has an ADL Self Care Performance Deficit and required participation from staff with bathing. Record review revealed no shower logs to indicate nail care was provided. Observation on 11/5/2024 at 11:38 am with R65 revealed resident sitting up in bed watching television, with long fingernails with a dark substance underneath. Observation and interview on 11/7/2024 at 1:45 pm with Licensed Practical Nurse (LPN) CC revealed R65 sitting up in bed, alert, watching television, with fingernails long and jagged with a dark substance underneath. LPN CC confirmed that R65's fingernails were dirty and jagged with a dark substance underneath. 50526 2. Review of the EMR revealed R154 was admitted to the facility with diagnoses including but not limited to peripheral vascular disease, chronic congestive heart failure, coronary artery disease, unspecified open wound left leg, pressure ulcer left heal. Review of R154's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, which indicates intact cognition. Section GG (Functional Status) revealed R154 has one side impairment and uses wheelchair, assistance needed is partial to moderate for toileting, maximum with showering, and dressing. Transfer substantial max assistance. Section J (Pain Assessment) revealed average pain rating of three. Review of R154's care plan dated 6/14/2024 documented focus related to ADLs requiring full staff assistance. Observation and interview on 11/5/2024 at 11:14 am with R154 revealed resident lying in bed, bed in low position, responding to verbal stimuli, bandage noted to left lower leg dated for 11/4/2024. R154 asked about his toenails, stated they had been needing to be cut since he was admitted to the facility, adding he had not seen a podiatrist. The toenails were extremely overgrown, especially both great toes. The great toenail on the right foot was extremely thick and twisted laterally. Record review revealed no consultation notes from Podiatry for R154. Review of a Nursing skin assessment dated [DATE] for R154 indicated that a foot assessment was not competed. Review of a Nursing skin assessment dated [DATE] for R154 indicated that a foot assessment was not completed. Interview 11/7/2024 11:24 am with Certified Nursing Assistant (CNA) AA revealed that for those who can, he would hand residents a washcloth and see what they could do. CNA AA confirmed shower sheets were completed and if they noted any skin abnormalities such as bruising or possible injuries, they brought them to the attention of the nurse. Nail care was also provided currently. CNA AA revealed if a resident refused a shower, we waited and asked again and if the resident still refused, the nurse would ask, and then a bed bath would be offered. An interview on 11/7/2024 at 2:30 pm with LPN BB confirmed she had not seen R154's feet recently. LPN BB reviewed R154's EMR for the presence of a Podiatry visit and none was found. LPN BB placed a call to Social Services to have him added to the list for a Podiatry visit. LPN BB stated that the CNAs gave bed baths daily unless it was on shower days, CNAs should tell the nurse if any issues came up, including nails being overgrown. LPN BB confirmed staff should complete shower sheets with skin and nail evaluation each time the resident has a shower. Review of R154's shower sheet dated 10/12/2024 revealed no indication of nail concerns. Interview on 11/7/2024 at 3:03 pm with the Director of Nursing (DON) revealed the facility provided nail care during ADL care and several residents refused and if so, they were care planned. Toenails were cut by nurses unless the nurses felt they were too overgrown, then we would refer them to Podiatry. She revealed her expectation of the CNAs was that they should notify the nurse if nails were overgrown, then the nurse would notify Social Services to get podiatry to see the resident. The DON also added, when nurses did skin assessments, nail condition should be noted.

Based on observations and staff interviews, the facility failed to ensure the dumpster area was maintained in sanitary conditions. The deficient practice had the potential to attract pests and rodents and transfer harmful microorganisms to food, leading to foodborne illness. Findings include: During the initial observation on 11/5/2024 at 8:15 am, the dumpster area had discarded items such as gloves, plastic forks, cardboard, a chair, and combs on the ground surrounding the two dumpsters. In an interview on 11/5/2024 at 9:15 am, during the observational walk-through with the Dietary Manager (DM), the DM confirmed the dumpster area had discarded items on the ground. The DM stated that everyone used the dumpsters, but the maintenance department was responsible for overseeing the site to make sure the area was maintained in a sanitary manner. In an interview on 11/8/2024 at 9:07 am, the Maintenance Director stated everyone shared the responsibility of ensuring the dumpster area was clean and maintained in sanitary conditions. He stated no one department or person was responsible for overseeing the dumpster site.

Based on observations and staff interviews, the facility failed to ensure reusable medical equipment was cleaned between use for residents. The deficient practice had the potential lead to the spread of infection and illness. The facility census was 181 residents. Findings include: Observation on 11/6/2024 at 8:05 am during medication administration revealed Certified Medication Aid (CMA) DD obtained a blood pressure machine from the hallway, checked a resident's blood pressure with the machine, and returned the blood pressure machine to the hallway without cleaning the cuff or equipment. Observation on 11/6/2024 at 8:44 am during medication administration revealed CMA EE checked a resident's blood pressure with the unit blood pressure cuff and returned the blood pressure cuff to the medication cart drawer without cleaning the equipment. Continued observation revealed CMA EE used the same blood pressure cuff to check another resident's blood pressure without cleaning the equipment. In an interview on 11/6/2024 at 8:05 am, CMA DD revealed all reusable medical equipment should be cleaned between use on different residents. In an interview on 11/6/2024 at 8:05 am, CMA EE confirmed infection prevention includes the cleaning of shared medical equipment. In an interview on 11/7/2024 at 2:45 pm, the Director of Nursing (DON) confirmed all infection prevention policies were to be followed when passing out medications, including cleaning reusable medical equipment cleaning.

Based on observations, interviews, and record review, the facility failed to ensure eight of 30 sampled residents (R) (R16, R17, R19, R12, R1, R18, R30 and R22) were free from abuse. On 2/28/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy (IJ) on 2/28/2024 at 3:05 pm. The noncompliance related to the IJ was identified to have existed on 9/30/2023. An Acceptable Removal Plan was received on 3/4/2024. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 3/2/2024. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing abuse in the facility. Findings included: A review of the facility Abuse Prevention Policy dated 9/5/2016 and last revised 11/1/2021 documented the following: The resident has the right to be free from verbal, sexual, physical, and mental abuse including corporal punishment and involuntary seclusion. The resident has the right to be free from mistreatment, neglect, and misappropriation of property. The facility has a zero-tolerance abuse standard regarding all proven allegations of verbal, sexual, physical, mental, neglect, misappropriation of resident property and involuntary seclusion. Abuse means, willful infliction of injury unreasonable confinement intimidation or punishment including physical harm pain or mental anguish. And this also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being abuse maybe resident to resident, staff to resident, family to resident, or visitor to resident. 1. A review of the clinical record for R16 revealed that the resident was admitted to the facility on [DATE] with diagnosis including but not limited to alcohol abuse dependence, vascular dementia with psychotic disturbance, and adjustment disorder. A review of the discharge Minimum Data Set (MDS) assessment dated [DATE] revealed R16 presented with a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident was cognitively intact. 2. A review of the clinical record for R17 revealed that the resident was admitted to the facility on [DATE] with diagnosis including but not limited to mood disorder due to known physiological diagnosis, delusional disorder, and anxiety disorder. A review of the quarterly MDS assessment dated [DATE] revealed R17 presented with a BIMS score of 15, indicating that the resident was cognitively intact; R17 required staff supervision and oversight for dressing, eating, bathing and toileting; and R17 was independent in mobility. 3. A review of the clinical record for R19 revealed that the resident was admitted to the facility on [DATE] with diagnosis including but not limited to adjustment disorder, a history of alcohol abuse, and a history of falling. A review of the quarterly MDS assessment dated [DATE] revealed R19 presented with a BIMS score of 15, indicating that the resident was cognitively intact. 4. A review of the clinical record for R12 revealed that the resident was admitted to the facility on [DATE] with diagnosis including but not limited to major depressive disorder, schizoaffective disorder, and dementia without behavioral disturbance. A review of the annual MDS assessment dated [DATE] revealed R12 presented with a BIMS score of 13, indicating that the resident had mild cognitive impairment; R12 required staff supervision and oversight for dressing, eating, bathing and toileting; and R12 was independent in mobility. 5. A review of the clinical record for R1 revealed that the resident was admitted to the facility on [DATE] with diagnosis including but not limited to adjustment disorder with depressed mood, psychotic disorder with delusions due to known physiological diagnosis, and dementia with agitation. A review of the quarterly MDS assessment dated [DATE] revealed R1 presented with a BIMS score of 3, indicating that the resident had severe cognitive impairment; R1 required staff supervision and oversight for dressing, eating, bathing and toileting; and R1 was independent in mobility. 6. A review of the clinical record for R18 revealed that the resident was admitted to the facility on [DATE] with diagnosis including but not limited to vascular dementia, psychotic disturbance, mood disturbance, and difficulty walking. A review of the discharge MDS assessment dated [DATE] revealed R18 presented with a BIMS score of 3, indicating that the resident had severe cognitive impairment; and R18 required staff assistance with activities of daily living. 7. A review of the clinical record for R30 revealed that the resident was admitted to the facility on [DATE] with diagnosis including but not limited to spinal stenosis (when the space inside the backbone is too small), unsteadiness on feet, repeated falls, and cognitive communication deficit. A review of the quarterly MDS assessment dated [DATE] revealed R30 presented with a BIMS score of 7, indicating that the resident had severe cognitive impairment; and R30 required staff assistance with activities of daily living and used a wheelchair. 8. A review of the clinical record for R22 revealed that the resident was admitted to the facility on [DATE] with diagnosis including but not limited to cognitive communication deficit, liver disease, and difficulty walking. A review of the discharge MDS assessment dated [DATE] revealed R22 presented with a BIMS score of 12, indicating that the resident had mild cognitive impairment; and R22 was independently mobile and did not require assistance with activities of daily living. A review of the clinical record, observations, and interviews revealed the following incidents of resident-to-resident abuse: A review of the progress notes documented by Licensed Practical Nurse (LPN) KKKK dated 9/30/2023 revealed that R17 was involved in a resident-to-resident altercation. It was documented that R17 was slapped by R1, a male resident; R17 was removed from immediate danger; and LPN KKKK observed redness to right of R17's face. A review of the progress notes documented by LPN FFFF dated 9/30/2023 revealed R1 slapped R17. When R18 attempted to intervene, R1 hit R18 and R19. Staff intervened. A review of the written statement of Certified Nursing Assistant (CNA) LLLL dated 9/30/2023 revealed that she observed R1 being physically aggressive towards other residents. She stated that R1 picked up a chair and an unknown resident grabbed the chair from R1, R1 fought R18 outside the breakroom, and that R1 was the aggressor. A review of the written statement of CNA MMMM dated 9/30/2023 revealed that she heard residents shouting in the dining room. She stated that some residents were stating that R1 grabbed R17's hair and slapped her. CNA MMMM stated that she was unable to calm R1 and R1 continued fighting, striking R18 before he was subdued and placed in his room. A review of the facility investigation summary written by the Director of Nursing (DON) dated 9/30/2023 revealed that R17 was seated in the common area in her wheelchair; R1 walked up to R17 and slapped R17 across her face unprovoked; and R18 and R19 attempted to intervene and R1 struck R18 and R19. The DON documented R1 directed his aggression towards staff when staff intervened and was not redirectable. Police were notified and R1 was hospitalized for three days. A review of the written statement of LPN GGGG dated 10/23/2023 revealed that R1 wandered into R12's room, and an argument occurred; and R1 was scratched by R12 on his hands. LPN GGGG documented that she cleansed R1 with nontoxic cleansing solution and notified the Unit Manager. A review of the progress notes documented by LPN IIII dated 11/13/2023 revealed he notified the police department following a verbal altercation between R1 and R16. LPN IIII documented he heard R16 yelling at R1 to get out of R16's room. A review of the facility incident report dated 11/19/2023 revealed that LPN YY documented R1 was exhibiting aggressive behavior; R22 came to get a snack at the nurses' station; and R1 slapped R22, stating that R22 got too close. A review of the progress notes documented by LPN IIII dated 12/13/2023 revealed R1 wandered into R12's room and attempted to pull R12 out of bed by her wrists. Staff immediately intervened and assisted R1 out of the room. A review of the progress notes documented by LPN JJJJ dated 1/25/2024 revealed R1 wandered into R12 room and R12 pushed R1. R1 fell and sustained a fracture of the left elbow. During an observation and interview on 2/20/2024 at 1:30 pm, R17 was observed in her room. When interviewed, she was unable to recall the events on 9/30/2023. R17 stated she does not want male residents in her room. During an observation on 2/20/2024 at 2:30 pm, R1 was observed unsupervised and independently ambulating back and forth in the hallway on the third-floor secured memory unit with his head facing down. During an interview on 2/21/2024 at 2:55 pm, R31 revealed that he is afraid of R1 and that R1 always comes into his room and sits on his bed without his permission. He stated that he has to wait for several hours before staff come in to redirect R1. During an interview on 2/26/2024 at 1:44 pm the DON stated R1 was not cognitively intact and wanders into other resident rooms. The DON stated that staff must constantly redirect R1 and confirmed that R1 has been involved in multiple resident-to-resident altercations when he wandered into other residents' rooms. The DON stated R1 was not intentionally aggressive towards other residents but R1 was involved in three or four physical altercations with other residents due to his wandering. The DON stated that R1 was referred to receive psych services and is being seen by a consultant once every quarter as an intervention. During an observation on 2/26/2024 at 3:15 pm, R1 was not in his room and an attempt to locate him was unsuccessful. Approximately five to six minutes later, CNA FFF located R1 in R20's room. During an interview at this time, R20 stated R1 was in his room messing with his table. R20 stated his attempts to make R1 leave were unsuccessful. R20 stated on numerous occasions staff had to help remove R1 from his room. R20 further stated that no one likes to be around R1 and that he was afraid that R1 was going to continue to be physically abusive towards other residents. R20 stated he was afraid R1 would eventually get hurt by other residents. A review of the progress notes documented by LPN TT dated 2/26/2024 revealed that R1 was wandering through hallway and LPN TT observed an altercation between R1 and R30. LPN TT documented that R30 yelled at R1 and pushed R1; R1 retaliated and hit R30 in the face; R1 was immediately separated by staff, assessed for injury, no noted injury; and the family and physician were notified. During an interview on 2/27/2024 at 9:34 am, the administrator stated she was aware of R1's aggression when she came on board at the facility in September 2023. She stated R1's aggressive behavior was discussed in meetings with the Medical Director on several different occasions. She confirmed that the facility was unable to assign a staff member to the resident for one-to-one supervision. During an interview on 2/27/2024 at 1:23 pm, CNA DDD revealed R1 had dementia and was a wanderer. They further stated the DON instructed staff to continue redirecting R1 when he gets into other residents' rooms. They confirmed that there was never an assigned staff to manage R1's behavior. CNA DDD stated that they always hear female residents in the unit yelling at R1 to leave their rooms. During an interview on 2/27/2024 at 1:30 pm LPN TT revealed on 2/26/2024 at approximately 7:30 pm, they noticed R30 was irritable and then R30 pushed R1, causing R1 to stumble back. They stated that R1 then swung and hit R30 on the face. LPN TT stated the incident happened at the nurse's station which was located a few feet from R30's room. R30 stated he was fed up with R1 messing with his possessions. TT instructed staff to continue redirecting R1. TT stated redirection was the only intervention staff had been successfully implemented by the facility. TT stated most of the residents in the locked unit were unbale to verbalize their concerns and it was normal for the residents to retaliate when confronted. TT stated there were sixty-four residents in the locked unit. During an interview on 2/27/2024 at 1:40 pm, CNA EEE revealed that R1 did not like to stay in his room and walked continuously around the unit. CNA EEE stated that R1 gets aggressive and violent when other residents confront him and that she would hate to see R1 get hurt by other residents. CNA EEE confirmed that R1 is not always supervised and that it was impossible for the staff to continuously watch all the residents. During an interview on 2/27/2024 at 4:33 pm, the Physician Assistant (PA) QQ revealed she was aware R1 had behaviors and was physically aggressive towards other residents. She stated R1 wanders into other residents' rooms and has trouble sleeping so they made some medication adjustments and non-pharmacological interventions such staff redirecting R1 to his room. PA QQ stated she advised staff to leave R1 alone when R1 gets agitated and to attempt to reapproach later. During an interview on 2/27/2024 at 4:33 pm, Nurse Practitioner (NP) RR revealed that she had worked with R1 and visits with him monthly. NP RR stated R1 was ambulatory, walked freely around the secured memory unit and went into other resident rooms. NP RR stated they were aware that R1 has had resident-to-resident altercations and confirmed that R1 required closer surveillance. They stated that the most plausible way for that to happen is to increase staff on the unit. During an interview on 2/27/2024 at 6:49 pm, R1's representative revealed R1 used to walk continuously on his previous job. She stated that R1 enjoyed exercise and was unable to sit down for long periods, but over the last two years, R1 has been unable to hold a conversation and his confusion has progressed. She stated that she visited R1 on 2/24/2024 and staff took approximately five minutes to locate R1. She said that when the staff found R1, he was in another resident's bathroom. She stated that she was unaware of an action plan staff implemented to stop R1 from roaming and wandering in other resident rooms. The facility implemented the following actions to remove the IJ: 1. On 2/26/2024, R1 was assessed by the Psych Physician Assistant per physician order. On 2/27/2024, a skin assessment was conducted on R1 with no skin alterations noted. On 2/28/2024, the Corporate Operations Consultant, the Administrator and the Social Services Director met to discuss placement options for the R1. On 2/28/2024 at 9:00 pm, the R1 was transferred to a Psychiatric Facility per the physician order. The facility Social Worker will assist the Psychiatric facility with finding placement for R1. On 2/29/2024, an immediate discharge notice was issued to R1 and R1's legal representative. 2. On 2/29/2024 the Behavioral Health Physician's Assistant, the facility's Psychiatric provider, the Administrator, the Director of Nursing Services, and Corporate Operations Consultant had a telephone conference to discuss alternate placement for current of future residents that may present to be a danger to self or others. 3. On 2/29/2024, an Ad Hoc QAPI meeting was held with the Medical Director, Corporate Operations Consultant, Administrator, Director of Nursing, Social Services Director, MDS staff, and Nurse Managers to review the IJ Removal Plan, altercations involving R1 and alternate placement of R1. The Abuse Policy and the Behavior Management Policy were reviewed, and no changes were made. 4. On 2/29/2024 and 3/1/2024, the Staff Development Coordinator educated the following facility staff on the Abuse Policy, the Behavior Management Policy, and Resident to Resident Altercation Policy: three of four Registered Nurses; 21 of 22 Licensed Practical Nurses; 17 of 17 Medication Technician; the Activity Director, three of three Activity Assistants; 33 of 33 Certified Nursing Assistants; the Administrator; the Human Resources Director; the Admissions Director; the Marketing Director; four of four receptionists; the Business Office Manager; the Business Office Assistant, two of two Medical Records Coordinators; the Dietary Manager; 13 of 13 Dietary Assistants; the Housekeeping/ Laundry Director; the Maintenance Director; the Maintenance Assistant; the Laundry Supervisor; 11 of 11 Environmental Employees; the Therapy Director; three of three therapy assistants; the Social Services Director; two of two Social Services Assistants; the MDS Director; and two of two MDS Coordinators. In-services will be conducted on an ongoing basis by the Staff Development Coordinator and nurse managers. Agency staff will be educated on the facility policies prior to working in the facility. Those employees identified to be on LOA or FMLA will be in-serviced upon return, prior to their shift. All new employees will be in-serviced during the facility orientation. 5. On 3/1/2024, a Skin Assessment Audit was conducted by the nurse management team for 63 of 63 residents on the secured memory unit. There were no new areas of concern identified. 6. The corrective actions were completed on 3/1/2024 and facility alleges that immediate jeopardy is removed on 3/2/2024. All corrective actions were completed on 3/1/2024. The facility alleges that the IJ is removed on 3/2/2024. 1. Review of notes taken revealed three facility physicians and the Medical Director and Corporate Operations Consultant, DON and the Administrator met and discussed placement options for R1. A review of the physician's order dated 2/29/2024 revealed that R1 was transferred to a Psychiatric Facility. 2. During an interview on 3/6/2024 at 6:45 pm the Medical Director (MD) revealed he attended a QAPI meeting on 2/29/2024 and they discussed placement for R1 and other residents with behaviors in the future. 3. During an interview on 3/5/2024 at 1:13 pm, the Corporate Nurse NN confirmed that they educated MDS staff regarding abuse, behaviors were discussed regarding who staff should notify and making sure the residents were safe and notifying the proper authorities' doctors and families. During an interview on 3/7/2024 at 10:25 am Corporate Operations Director (COD) HH revealed the Administrator, Medical Director DON, SSD, MDS Director were educated regarding the immediate jeopardy concerns. HHH stated QAPI staff will be tracking trends, and she will be reviewing abuse logs monthly. HHH stated, Nurse Consultant, will be monitoring incidents and accidents. HH stated, R1 will not be returning to the facility. R1 was given an immediate discharge notice, and the facility is assisting R1 in finding alternative placement. 4.On 3/5/2024 at 2:15 pm, RN KKK Infection Preventionist and educator revealed she educated staff and in serviced all nursing and non-nursing staff on Resident-to-Resident altercations, behaviors, care plans and abuse and neglect reporting on 2/29/2024. RN, KKK, stated the in-service will be ongoing, which will include new hires. Record review showed a total of fifty-six staff were interviewed from 3/5/2024 through 3/6/2024, which included Nursing staff, Dietary staff, housekeeping staff, laundry staff, Maintenance staff, Reception staff and Management staff. Signatures and interviews verified staff were in serviced on 2/29/2024 by RN KKK. On 3/5/2024 the following clinical staff were interviewed: LPN KKK at 2:15 pm; LPN RRR at 7:04 pm; CNA HHH at 1:30 pm; CNA III at 1:38 pm; CNA JJJ at 1:49 pm.; CNA EEE at 1:56 pm; CNA AAA at 2:03 pm; CNA SSS at 7:15 pm. On 3/6/2024 the following clinical staff were interviewed: HK OOO at 2:38 pm; Laundry Aide PPP at 3:03 pm; HK Director QQQ at 3:04 pm; Dietary [NAME] LLL at 3:20 pm; Dietary [NAME] UUU at 2:32 pm; Business Office WWW at 2:05 pm; PTA XXX at 2:19 pm; COTA YYY at 2:23 pm; Human Resources ZZZ at 2:26 pm; Activity Aide AAAA at 2:35 pm; and CMT DDDD at 3:28 pm. 5. Record review revealed skin observations audit was conducted on 3/1/2024, of the sixty-three residents assessed one resident refused to be assessed and two residents were actively being seen by a wound care nurse. During an interview on 3/6/2024 at 1:14 pm, The administrator revealed she attended a personalized additional computerized education. In addition, the NC-NN in-serviced the Medical Director (MD), DON, SSD, Staff Development Coordinator (SDC) regarding QAPI review and ongoing quality assurance performance and improvement, which included wandering residents and residents with aggressive behaviors. For residents with repetitive aggressive behaviors, one staff will be instructed to supervise the resident until the behavior improves other services such as psych services will be provided. She stated Care plans should be updated immediately as soon as an incident arises, and an IDT will make a follow up, assessment All staff were educated regarding abuse and behavioral monitoring. New staff will be educated during orientation and the Inservice will be ongoing. During an interview on 3/7/2024 at 10:55 am LPN, TTT revealed on 3/1/2024 she conducted skin assessments on the locked unit on sixty-three residents. TTT was assisted by LPN, XX regarding skin assessments. TTT stated the weekly skin assessments audit will be on going for all the residents. 6. It was verified that the corrective actions were completed by 3/1/2024 and the immediate jeopardy was removed on 3/2/2024.

Based on record review, interviews, and review of the Administrator's Job Description, Administration failed to provide protective oversight of the facility environment including adequate supervision for wandering residents and failed to protect residents on the secured memory unit from an abuse free environment. This failure had the likelihood of affecting all residents residing on the secured memory unit. In addition, the facility failed to ensure that the call light communication system was functioning to alert staff that residents required assistance on one of four floors (Fourth Floor) in the facility. On 2/28/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy (IJ) on 2/28/2024 at 3:05 pm. The noncompliance related to the IJ was identified to have existed on 9/30/2023. An Acceptable Removal Plan was received on 3/4/2024. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 3/2/2024. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff conformance with the facility's policies and procedures governing abuse in the facility. Findings included: Review of the Administrator Job Description signed and dated 9/18/2024 by the Administrator, documented the summary of the position is to lead and direct facility functions in accordance with the resident's needs, government regulations, and company policies to maintain care for the residents. Essential job functions include: Plan, develop, organize, implement, evaluate, and direct the facility's programs and activities in accordance with guidelines issued by the governing board. Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the facility. Makes routine inspections of the facility to assure that established policies and procedures are being implemented and followed. Assist the Quality Assurance and Assessment Committees in developing and implementing appropriate plans of action to correct identified quality deficiencies. Conducts regular rounds to monitor residents' needs are being met. Ensure that all facility personnel, residents, visitors Maintains a working knowledge and ensures compliance with all governmental regulation Ensures that residents rights to fair and equitable treatment, self-determination, individuality, privacy, property, and civil rights, including rights to wage complaints, are well established, and always maintained. Review resident complaints and grievances and make written reports of action taken. Discuss such actions with resident family as appropriate. 1. R1 with a history of wandering, repeatedly engaged in resident-to-resident physical altercations starting on 9/30/2023 with, R16, R17, R18, R19, R22 and R30. In addition, the facility failed to monitor R1 when R1 continuously wandered into R12's room over a three-month time frame and on 1/25/2024, R12 pushed R1 out of her room and R1 fell and sustained a fracture of the left elbow. During an interview on 2/27/2024 at 9:34 am, the administrator stated she was aware of R1's aggression when she came on board at the facility in September 2023. She stated R1's aggressive behavior was discussed in meetings with the Medical Director on several different occasions. She confirmed that the facility was unable to assign a staff member to the resident for one-to-one supervision. Staff interview on 2/27/2024 at 1:40 pm, CNA, EEE revealed, R1 did not like to stay in his room, and R1 walked continuously around the unit. R1, gets aggressive and violent when other residents confront him. EEE further stated she would hate to see R1 get hurt by other residents. CNA EEE concluded it was impossible for staff to continuously watch all the residents. During an interview on 2/27/2024 at 4:33 pm, Nurse Practitioner (NP) RR revealed that she had worked with R1 and visits with him monthly. NP RR stated R1 was ambulatory, walked freely around the secured memory unit and went into other resident rooms. NP RR stated they were aware that R1 has had resident-to-resident altercations and confirmed that R1 required closer surveillance. They stated that the most plausible way for that to happen is to increase staff on the unit. Cross refer to F600 2. An observation and interview on 2/22/2024 at 10:30 am, the Fourth-Floor call light system at the nurse's station was blank and there was no sound or signal alerting that residents needed assistance. Licensed Practical Nurse (LPN) UU was observed behind the nursing station and confirmed that the fourth-floor nursing call system was not functioning and stated the sound was not audible and the monitor did not blink or show residents who required assistance. He stated he was not sure how long the system had not been working. Observations on 2/22/2024 at 10:40 am on the 400 Hall revealed the following rooms were tested by pushing the red button. However, the light above the door did not light up and no sound was heard.: 415 bed A and B; 416 bed A and B; 417 bed A and B; 420 bed A and B and 424 bed A and B. An interview on 2/22/2024 at 10:50 am LPN WW stated the nursing call system had not been operational for three weeks and that the maintenance Director had been made aware, and that the staff put in requests for repair in the electronic maintenance care log. An interview on 2/22/2024 at 10:55 am, the Maintenance Director stated he was not sure why the call light monitoring system was not functioning. He stated that he was aware staff documented in the maintenance care system when equipment needed to be repaired. A review of a letter signed and dated by the facility administrator on 10/22/2023 revealed that the facility call light system was malfunctioning at that time. An interview on 2/22/2024 at 12:06 pm, the administrator revealed the monitoring system was a concern when she got hired and added it was not audible. She was unaware the monitors had stopped working again. Cross refer to F919 The facility implemented the following actions to remove the IJ: 1. On 2/29/2024 at 10:00 am, an Ad Hoc Abuse Performance Improvement Meeting was held with the Administrator, Director of Social Services, the DON, Corporate Operations Consultant, and the Corporate Nurse Consultant to identify the root cause of resident-to-resident altercations with a subsequent plan of action. The Abuse Prevention Policy, Resident to Resident Policy, and the Behavioral Management Policy were reviewed no changes made. 2. On 3/1/2024 the Administrator's job description was reviewed with the Administrator by the Corporate Operations Consultant. No revisions were made. 3. On 2/29/2024, the Corporate Operations Consultant in-serviced the Administrator, DON, and Social Services Director (SSD) on how to properly conduct an abuse investigation, how to track and to determine trends, root cause analysis and communication among departments on abuse reporting. The facility QAPI policy was reviewed specifically regarding how to determine root cause analysis. 4. On 2/29/2024, the Corporate Operations Consultant audited, completed, and signed the facility Abuse Log from September 2023 through current for any further areas of concern. Name of Audit- Abuse Log Audit. Trends noted to be primarily on third floor and in the evenings involving R1. Residents and the time of altercations were discussed with the Administrator and Director of Social Services. Interventions were put into place on the Abuse Performance Improvement Plan. 5. On 2/29/2024 the Corporate Nurse Consultant and DON audited the resident-to-resident altercations from September 2023 through current. The audit is named Resident to Resident Documentation Audit. It was identified that care plans were not initiated on all resident-to-resident altercations. Care plans were implemented on 3/1/2024. The DON and Administrator will discuss all abuse allegations in the morning meeting to ensure all departments respond appropriately. Documentation will be monitored through the Abuse Performance Improvement Plan and reported during QAPI by the Director of Nursing and Administrator. 6. On 2/29/2024, the Administrator was educated through the company online training modules on Implementation of QAPI Programs in Nursing Facilities through a one hour approved course. The Administrator successfully completed a post class test and received a certification. On 2/29/2024, the Corporate Operations Consultant conducted educated the Administrator on how to conduct a QAPI meeting and how to identify and complete a Root Cause Analysis. All corrective actions were completed on 3/1/2024. The facility alleges that the IJ was removed on 3/2/2024. 1. A review of Abuse/Resident to Resident Altercations staff education on 2/9/2024 attended by four Registered Nurses (RN) twenty-two Licensed Practical Nurses (LPN), seventeen medical technicians (CMT), four Certified Nurses Assistants (CNA), twelve administration staff, seventeen environmental/maintenance staff, nine Therapy staff, two staff from Social Services and the MDS coordinator. During an interview on 3/5/2024 at 11:51 am, the DON revealed that in services were held regarding abuse, wandering and resident to resident altercations. She verified that all abuse should be reported within two hours to the state. QAPI meetings are addressed monthly, and clinical meetings are held every morning, when interventions are discussed during the QAPI, in service starts the same day if possible. 2. A review of the job description titled, Administrator last revised 3/1/2024, revealed the administrator was hired on 9/18/2024. Review of the administrator's job description included directing day to day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be always provided to all residents. Additionally, duties included Administrative Functions, Committee Functions, Personal Functions, Staff Development, Safety and Sanitation, Equipment and Supply Functions, Budget and Planning Functions, Residents Rights and Working Conditions. 3. The QAPI policy was reviewed and showed the composition of the performance Improvement Committee including, the Administrator, DON, Medical Director, Nurse Practitioner, Resident Assessment Instrument Coordinator. The policy documented QAPI program had the responsibility for designing and implementing corrective action plans as needed to resolve identified resident aspects of care/service problems. During an interview on 3/5/2024 at 12:46 pm, Nurse Consultant (NC) NN, revealed the facility abuse policy was not updated, she stated it was reviewed. On 2/29/2024, she educated the Administrator, DON, and SSD regarding monitoring residents behaviors including verbally aggressive behavior and physically aggressive behavior. The consultant stated, the QAPI policy was reviewed, she talked to the MDS- Coordinator, MMM regarding comprehensive care plans. She identified the care plan was not updated on other occasions. Discussed staff the care plan should be updated as soon as an incident or behavior is identified. Documentation revealed staff received the in-service on 2/29/2024. 4. Documentation and interviews of facility staff (nurses, CNA's, Housekeeping and the Laundry department) and The Abuse Log Audit. During an interview on 3/5/2024 at 11:56 am, Assistant Director of Nursing (ADON) revealed the following, all staff were in serviced, regarding behavioral management, specifically the way staff are to manage residents with behaviors, skin assessments, QAPI was reviewed. Staff were informed to immediately assess residents for injuries and report to the abuse coordinator immediately whenever a resident-to-resident altercation occurs. Staff discussed alternative placement for residents involved in repetitive resident to resident altercations. There were no changes made to the Abuse Policy. ADON stated all abuse must be reported to the abuse coordinator immediately and to the state within two hours. 5. The QAPI meeting was held for the following Tags F600, F656 and F835, and signatures were documented regarding completion of the in service. A total of fifty-six staff were interviewed from 3/5/2024 through 3/6/2024, which included Nursing staff, Dietary staff, housekeeping staff, laundry staff, Maintenance staff, Reception staff and Management staff. Signatures and interviews verified staff were in serviced on 2/29/2024 by RN-KKK. 6. Reviewed the audit tools dated 2/29/2024 verified that 100% of audits had been completed. A sample was reviewed for R1, R11, R12, R16, R19, R20, and R22. The documentation reviewed for Care Plans, MDS, and Pocket Guides was accurate.

Based on observations, interviews, and record review, the facility failed to ensure the accuracy of the comprehensive assessment addressed the wandering behaviors for one of 30 sampled residents (R) (R1). R1's wandering led to physical altercations with multiple residents, including a physical altercation on 1/25/2024 when R1 wandered into R12's room and R12 pushed R1, causing R1 to sustain a fracture of the left elbow. On 2/28/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy (IJ) on 2/28/2024 at 3:05 pm. The noncompliance related to the IJ was identified to have existed on 9/30/2023. An Acceptable Removal Plan was received on 3/4/2024. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 3/2/2024. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing abuse in the facility. Findings included: A review of the clinical record for R1 revealed that the resident was admitted to the facility on [DATE] with diagnosis including but not limited to adjustment disorder with depressed mood, psychotic disorder with delusions due to known physiological diagnosis, and dementia with agitation. A review of the quarterly MDS assessment dated [DATE] revealed R1 presented with a BIMS score of three, indicating that the resident had severe cognitive impairment, R1 was independent in mobility. The assessment documented that R1 did not exhibit any wandering behaviors. A review of the clinical record and other facility documents revealed the following incidents of resident-to-resident altercations: A review of the progress notes documented by Licensed Practical Nurse (LPN) KKKK dated 9/30/2023 revealed that R17 was involved in a resident-to-resident altercation. It was documented that R17 was slapped by R1, a male resident; R17 was removed from immediate danger; and LPN KKKK observed redness to right of R17's face. A review of the progress notes documented by LPN FFFF dated 9/30/2023 revealed R1 slapped R17. When R18 attempted to intervene, R1 hit R18 and R19. Staff intervened. A review of the written statement of Certified Nursing Assistant (CNA) LLLL dated 9/30/2023 revealed that she observed R1 being physically aggressive towards other residents. She stated that R1 picked up a chair and an unknown resident grabbed the chair from R1, R1 fought R18 outside the breakroom, and that R1 was the aggressor. A review of the written statement of CNA MMMM dated 9/30/2023 revealed that she heard residents shouting in the dining room. She stated that some residents were stating that R1 grabbed R17's hair and slapped her. CNA MMMM stated that she was unable to calm R1 and R1 continued fighting, striking R18 before he was subdued and placed in his room. A review of the facility investigation summary written by the Director of Nursing (DON) dated 9/30/2023 revealed that R17 was seated in the common area in her wheelchair; R1 walked up to R17 and slapped R17 across her face unprovoked; and R18 and R19 attempted to intervene and R1 struck R18 and R19. The DON documented R1 directed his aggression towards staff when staff intervened and was not redirectable. Police were notified and R1 was hospitalized for three days. A review of the written statement of LPN GGGG dated 10/23/2023 revealed that R1 wandered into R12's room, and an argument occurred; and R1 was scratched by R12 on his hands. LPN GGGG documented that she cleansed R1 with nontoxic cleansing solution and notified the Unit Manager. A review of the progress notes documented by LPN IIII dated 11/13/2023 revealed he notified the police department following a verbal altercation between R1 and R16. LPN IIII documented he heard R16 yelling at R1 to get out of R16's room. A review of the facility incident report dated 11/19/2023 revealed that LPN YY documented R1 was exhibiting aggressive behavior; R22 came to get a snack at the nurses' station; and R1 slapped R22, stating that R22 got too close. A review of the progress notes documented by LPN IIII dated 12/13/2023 revealed R1 wandered into R12's room and attempted to pull R12 out of bed by her wrists. Staff immediately intervened and assisted R1 out of the room. A review of the progress notes documented by LPN JJJJ dated 1/25/2024 revealed R1 wandered into R12 room and R12 pushed R1. R1 fell and sustained a fracture of the left elbow. During an observation on 2/20/2024 at 2:30 pm showed R1 walked along the hallway of the third floor with his head facing down. R1 continued pacing along the hallway in the locked unit. During an interview 2/26/2024, at 1:44 pm the DON stated R1 was not cognitively intact and that R1 wanders into resident rooms. The DON stated that the staff constantly had to redirect R1 and that R1 had been involved in resident-to-resident altercations when he wandered into other residents' rooms. During an observation on 2/26/2024 at 3:15 pm, R1 was not in his room and an attempt to locate him was unsuccessful. Approximately five to six minutes later, CNA FFF located R1 in R20's room. During an interview at this time, R20 stated R1 was in his room messing with his table. R20 stated his attempts to make R1 leave were unsuccessful. R20 stated on numerous occasions staff had to help remove R1 from his room. R20 further stated that no one likes to be around R1 and that he was afraid that R1 was going to continue to be physically abusive towards other residents. R20 stated he was afraid R1 would eventually get hurt by other residents. During an interview on 2/27/2024 at 1:23 pm, CNA DDD revealed R1 had dementia and was a wanderer and that the DON instructed staff to continue redirecting R1 when he gets into other residents' rooms. CNA DDD stated that they always heard female residents in the unit yelling at R1 to leave their rooms. During an interview on 2/27/2024 at 1:40 pm, CNA EEE revealed that R1 did not like to stay in his room. CNA EEE stated R1 walked continuously around the unit. During an interview on 2/27/2024 at 4:33 pm, the Physician Assistant (PA) QQ revealed she was aware R1 had behaviors and was physically aggressive towards other residents. She stated R1 wanders into other residents' rooms and has trouble sleeping so they made some medication adjustments and non-pharmacological interventions such staff redirecting R1 to his room. During an interview on 2/27/2024 at 4:33 pm, Nurse Practitioner (NP) RR revealed that she had worked with R1 and visits with him monthly. NP RR stated R1 was ambulatory, walked freely around the secured memory unit and went into other resident rooms. The facility implemented the following actions to remove the IJ: 1. On 2/28/2024, R1's MDS and care plan was updated to reflect the behavior of wandering. 2. On 2/29/2024, an Ad Hoc QAPI meeting was held with the Medical Director, Corporate Operations Consultant, Administrator, Director of Nursing, Social Services Director, MDS staff, and Nurse Managers to review the IJ Removal Plan. The MDS/Care Plan policy was reviewed with no changes. 3. On 2/29/2024, the Corporate Nurse Consultant conducted an in-service with the three of three MDS department staff and one of two Social Services department staff on the MDS/Care plan Policy and how to develop a comprehensive care plan. 4. On 2/29/2024, a Wandering MDS and Care Plan Audit was completed on the secure unit. A total of 35 of 63 residents were identified as wanderers and care plans were updated to reflect the behavior of wandering. 5. On 2/29/2024, a behavior management meeting was held with the MDS Director, two MDS Coordinators, and the Social Services Director. They were provided with a copy of all residents involved in resident-to-resident altercations from September 2023 through current and care plans were reviewed for those that wander. Care plans were updated as necessary to reflect individualized interventions. 6. The corrective actions were completed on 3/1/2024 and facility alleges that immediate jeopardy is removed on 3/2/2024. All corrective actions were completed on 3/1/2024. The facility alleges that the IJ is removed on 3/2/2024. 1. A review of the MDS assessment and care plans showed, the MDS and care plans were updated for Residents with behaviors and for wandering residents. Staff were educated on 2/29/2024 and interventions were put in place. The following interviews verified; facility interventions were in place: During an interview on 3/6/2024 at 1:57 pm, the SSD revealed she completed an in-service on 2/29/2024, which was conducted by the staff development coordinator. The topics discussed included care plans. SSD expected the MDS coordinator to update care plans in a timely manner. SSD stated, care plans should be updated to include wandering behaviors. The interdisciplinary team (IDT) was responsible for care plan updates. SSD was part of the IDT. SSD stated Abuse and Care plan In-service's will be ongoing. 2. A review of the sign in sheet revealed that the QAPI Meeting was held on 2/29/2024 with the Medical Director, Corporate Operations Consultant, Administrator, Director of Nursing, Social Services Director, MDS staff, and Nurse Managers to review the IJ Removal Plan. The MDS/Care Plan policy was reviewed with no changes. During an interview on 3/5/2024 at 12:46 pm, NC NN revealed on 2/29/2024, she educated the Administrator, DON, and SSD regarding monitoring residents behaviors including verbally aggressive behavior and physically aggressive behavior. NC NN stated that the QAPI policy was reviewed, she talked to the MDS- Coordinator regarding comprehensive care plans. She identified the care plan was not updated on other occasions. Discussed staff the care plan should be updated as soon as an incident or behavior is identified. Documentation revealed staff were educated. 3. A review of the policy education to staff, QAPI minutes and Resident to Resident documentation audit was conducted and was completed as outlined in the plan. During an interview on 3/5/2024 at 11:56 am, ADON revealed all staff received the education. During an interview on 3/5/2024 at 12:46 pm, Nurse Consultant NN stated the QAPI policy was reviewed, she talked to the MDS- Director MM regarding comprehensive care plans on 2/29/2024. During an interview on 3/5/2024, at 1:13 pm, MDS coordinator MMM, confirmed that education was received related to MDS and Care Plans. During an interview on 3/6/2024 at 1:14 pm, the administrator revealed she attended a personalized additional computerized education. During an interview on 03/07/2024 at 1:25 pm, with the MDS Coordinator EEEE, confirmed that education was received related to MDS and Care Plans. During an interview on 03/07/2024 at 1:45 am MDS director/ RN, MM. NN educated all MDS staff on 2/29/2024 in her office. 4. During an interview on 3/5/2024, at 1:13 pm, MDS coordinator MMM, revealed care plans are updated quarterly, annually, whenever there was a significant change and whenever an incident happened. She was part of a facility wide in service. Review of the wandering Care Plan Audit revealed that it was completed on the secure unit. A total of 35 of 63 residents were identified as wanderers and care plans were updated to reflect the behavior of wandering. 5. A review of the sign in sheet revealed that on 2/29/2024, a behavior management meeting was held with the MDS Director, two MDS Coordinators, and the Social Services Director. 6. It was verified that the corrective actions were completed by 3/1/2024 and the immediate jeopardy was removed on 3/2/2024.

Based on record review, interviews, policy review, and review of the Centers for Disease Control and Prevention (CDC) COVID-19 guidance, the facility administration failed to provide oversight and monitoring of the Infection Control Program by not implementing the Center for Medicare and Medicaid Services (CMS) and CDC recommended practices to prevent the spread of COVID-19 to residents. Specifically, the facility failed to promptly and correctly initiate COVID-19 outbreak testing, failed to properly cohort COVID-19 positive and negative residents, and failed to perform COVID-19 testing of staff based on the level of community transmission. On 8/4/2022, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator was informed of the Immediate Jeopardy (IJ) on 8/4/2022 at 5:24 p.m. The noncompliance related to the IJ was identified to have existed on 7/25//2022. A removal plan (Credible Allegation of Compliance) was received on 8/6/22. The survey team conducted observations, reviewed training records, and interviews with staff and residents to verify elements of the facility's removal plan were implemented. The immediacy of the Immediate Jeopardy was removed on 8/6/22. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures. In-service materials and records were reviewed. Observations and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's policies and procedures. Findings included: Review of the CDC guidance titled Contact Tracing for COVID 19, https://www.cdc.gov/coronavirus/2019-ncov/php/contact-tracing/contact-tracing-plan/overview.html and dated 2/10/2022, revealed, Investigation and contact tracing are fundamental activities that involve working with a patient (symptomatic and asymptomatic) who has been diagnosed with an infectious disease to identify and provide support to people (contacts) who may have been infected through exposure to the patient. This process prevents further transmission of disease by separating people who have (or may have) an infectious disease from people who do not. It is a core disease control measure that has been employed by public health agency personnel for decades. Case investigation and contact tracing are most effective when part of a multifaceted response to an outbreak. Review of the policy titled Facility Testing Requirements for Staff and Residents, revised 9/24/2021, revealed Outbreak Trigger Testing - Test all staff and residents in response to an outbreak (defined [as] any single new infection in staff or any nursing home onset infection in a resident). Continue to test all staff and residents that tested negative every three days to seven days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. Standard of Practice, step 1. The facility may choose to conduct outbreak testing, through either a contact tracing or broad-based testing approach. For a newly identified COVID-19 positive staff or resident in a facility that could not identify close contacts, should test all staff (vaccinated and unvaccinated) facility-wide or at a group level if staff were assigned to a specific location where the new case occurred and test all residents (vaccinated and unvaccinated) facility-wide or at a group level. Routine testing for unvaccinated staff will be conducted based on the community COVID-19 transmission level rates. The Routine Testing Intervals indicated for counties with substantial or high community transmission rates, unvaccinated staff were to be tested twice a week. The facility failed to provide effective oversight and monitoring of their infection control and prevention program. 1. Administration failed to ensure monitoring systems were provided with feedback for data collection related to Infection Control, including COVID-19 outbreak testing, and failed to identify issues with outbreak and routine testing for staff and outbreak testing for residents. A total of 40 residents tested positive for COVID-19 from 7/25/2022 through 8/7/2022. Cross Refer to F867 2. Administration failed to ensure COVID positive residents were not cohorted with COVID negative residents and failed to place newly admitted residents in isolation/persons under investigation. Cross Refer to F880 3. Administration failed to ensure routine and outbreak testing for COVID-19 for staff was conducted in a manner consistent with current standards of practice based on the level of community transmission. The facility's county community transmission rate for COVID-19 was RED (high community transmission) prior to the outbreak. The facility did not perform employee testing twice weekly for those not up to date with vaccines. The facility had 15 unvaccinated employees who tested on ce weekly on Wednesdays. Cross Refer to F886 On 7/25/2022, the first day of the COVID-19 outbreak, the facility completed COVID-19 testing on the third-floor residents, and 14 residents tested positive for COVID-19. No residents were placed in Persons Under Investigation (PUI) status for exposure. No residents on the second and fourth floor units were tested . No staff were tested . No contact tracing was completed. On 7/26/2022, the residents on the second floor were tested , and two additional residents who were new admissions tested positive for COVID-19. No residents were placed in PUI status for exposure. No residents on the fourth floor were tested . No staff were tested . No contact tracing was completed. On 7/27/2022, the unvaccinated staff were tested for COVID-19. No other staff members were tested . According to the CDC guidance, unvaccinated staff should be tested twice a week when the county transmission rate was high and all staff should be tested during a COVID-19 outbreak in the facility, regardless of vaccination status. On 7/29/2022, the 14 residents on the third floor were re-tested , and four of the residents tested positive for COVID-19. No residents were placed in PUI status for exposure. No staff or other residents were tested . On 8/1/2022, the residents on the second floor were re-tested , and an additional eleven residents tested positive for COVID-19. Residents on the third floor were re-tested , and one additional resident tested positive for COVID-19. No residents were placed in PUI for exposure. No residents on the fourth floor were tested , and no staff were tested . On 8/2/2022, the residents on the fourth-floor unit were tested , and one resident tested positive for COVID-19. No staff were tested , and no residents were placed in PUI status. Interview on 8/3/2022 at 12:26 p.m. with the Director of Nursing (DON), revealed the reason she did not test all residents and staff on 7/25/2022 was because the facility practiced panic control. The DON stated there were no residents exhibiting signs and symptoms of COVID-19 on the second and fourth floor units and that the facility only tested unvaccinated staff. The DON indicated there were 15 unvaccinated staff at that time. She stated the facility had still not tested all staff and residents on 7/26/2022 when additional residents tested positive because the facility again practiced panic control. The DON and the ADON confirmed that the facility tested residents based on signs and symptoms and stated there were no residents with signs and symptoms during that time. The DON stated the fourth-floor unit was tested on [DATE] for the first time because there was a resident who had signs and symptoms of COVID-19. She stated the resident who had signs and symptoms tested negative for COVID-19; however, another resident who was not exhibiting signs and symptoms tested positive for COVID-19. Interview on 8/4/2022 at 8:50 a.m., the DON stated she misunderstood the surveyor's questions in the previous interview and that the facility had performed contact tracing during the COVID-19 outbreak. She stated she made a floor grid and reviewed to determine if there were any common factors with the residents who had tested positive. The DON stated she determined if there were any visitors who had visited those residents and which staff had worked with those residents. She concluded that after the first positive resident case, she would assign designated staff to work on those units. She stated she could not pinpoint any common factors related to the first COVID-19 positive residents. The DON indicated there were no visitors for the first positive residents and that none of the staff who had taken care of those residents had tested positive. When asked how she determined this, since the facility only tested unvaccinated staff, the DON was unable to explain how she arrived at the determination. She stated, I would not be able to determine that; we are not testing all of the staff. The DON confirmed the facility had not effectively implemented and completed contact tracing during the COVID-19 outbreak. She stated she had not documented the contact tracing she performed. The DON stated the only COVID-positive employee to date was an activity aide who had worked the fourth-floor unit for the past two weeks. She indicated out of 140 total staff members, 15 were unvaccinated. Interview on 8/7/2022 at 10:25 a.m., the Regional Director revealed the facility had a Quality Assurance Performance Improvement (QAPI) meeting on 7/28/2022 and had discussed the residents who tested positive on 7/25/2022 and 7/26/2022. Monitoring for signs and symptoms was discussed, but the QAPI members had not discussed outbreak testing, cohorting, or contact tracing. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Root cause completed with (DON) Director of Nursing. From the root cause analysis, systems were identified that required an immediate action plan to correct deficient practices. The root cause analysis findings that the facility failed to ensure effective testing procedures covid-19, appropriate cohorting (which means who would be appropriate to have in the same room), and completion of contact tracing staff sign in sheets were reported to the Ad Hoc Quality Improvement Performance Improvement Committee. This committee reviewed and approved the (IJ) Immediate Jeopardy removal plan on August 6, 2022. Members of the Ad Hoc QAPI committee consisted of Medical Director and LNHA [Licensed Nursing Home Administrator] via phone, DON, Regional Director, and Department Heads. 2. A Quality improvement tool was developed and initiated which will be monitored weekly by DON or designee to ensure effective testing procedures covid-19, appropriate cohorting, and completion of contact tracing staff sign in sheets. An audit was completed on August 5, 2022, on 20 COVID-19 positive residents. Initial audit results where contact tracing employee signature forms were needed on the rooms of those 20 covid-19 positive residents and have been reported to the QAPI AD HOC committee and corrective measure taken to ensure compliance of COVID19 testing and proper cohorting and isolation precautions have been taken. Daily audits will be conducted on newly admitted residents, or those returning from extended leaves of absences. Future audit will be completed weekly x's [times] eight weeks and then monthly x's three months. DON will report findings in QAPI x's three months or until a period of compliance is achieved. 3. On 8/5/2022 45 staff tested for COVID-19. 44 of staff test results negative. One staff test resulted positive. Staff members who have not completed COVID-19 testing will be unable to work until COVID19 testing has been completed. 4. On 8/5/2022 167 in-house residents were tested for COVID-19. 147 test results negative. 20 test results positive. [Room numbers of COVID-19 positive residents]. 5. On 8/5/2022 all new admissions tested . 1 tested with negative test results for COVID-19. Any new admissions/readmissions will be tested for COVID-19 going forward. 6. On 8/5/2022 (20) Residents tested positive have been cohorted with other residents that tested positive and placed in transmission-based precautions. The following rooms have COVID positive residents in transmission-based precaution isolation. [Room numbers of COVID-positive residents]. 7. On 8/5/2022 (30) residents that tested negative and were in close contact or assigned to the same room as a resident who tested positive will be cohorted with other residents who also tested negative and were in close contact or assigned to the same room as a resident who tested positive and placed on transmission-based precautions as PUIs. (30) of residents meet CDC criteria for possible exposure risk and are categorized as a PUI. The following rooms are identified as persons under investigation for COVID19 due to their possible exposure risk. [Room numbers of residents under PUI status]. 8. On 8/5/2022 all new admissions who are unvaccinated placed with other new admissions who are unvaccinated and placed on transmission-based precautions as PUIs. One new admission was tested and assigned to appropriate rooms based on test results. Any unvaccinated new admissions going forward will be placed in PUI with other unvaccinated new admissions, following CDC guidelines. 9. On 8/5/2022 all rooms with any resident that tested positive or were in close contact or assigned to the same room as a resident who tested positive will have a staff contact tracing sign in log attached to their door. [Room numbers]. 10. On 8/5/2022 DON, Infection preventionist and Administrator educated on COVID-19 testing policy, Cohorting practices, PUI practices, and contact tracing by Regional Director. 11. On 8/5/2022 124 [staff] will be educated on COVID-19 testing policy, cohorting practices, PUI practices, and contact tracing by DON or her designee who is trained by the DON. Any staff member who has not completed education and COVID-19 testing will be unable to work until it has been completed. 68 out of 124 employees [completed]. 12. Facility COVID-19 testing policy, Facility Respiratory Protection Program, CDC recommendations for transmission-based practices to prevent the spread of COVID19 including cohorting guidelines, persons under investigation related to possible exposure to COVID-19, Contact Tracing procedures were reviewed by the Medical Director, Administrator, Director of Nursing and Regional Director of Clinical Operations during an Ad Hoc QAPI meeting on 8/5/2022. The Infection Control and Prevention policy was reviewed on 8/5/2022 and no changes were made. 13. 55 employees participated in N-95 fit (re)testing with the medical clearance forms on 8/5/2022. The DON has been trained to perform the fit tests. Anyone who cannot physically complete the fit testing will have documentation that they cannot medically complete the testing. 14. All corrections were completed on August 5, 2022. 15. The immediacy of the IJ was removed on August 6, 2022. Survey Agency validated removal of the Immediate Jeopardy as follows: The IJ was removed on 8/6/2022 after the survey team performed onsite verification that the Removal Plan had been implemented. COVID-19 positive residents were verified to have been moved to the second floor and were not placed with COVID-19 negative residents. Implementation of the removal plan was verified through observations, staff interviews, and record reviews. Observations and record reviews verified that the staff and residents were tested as per the removal plan, residents were cohorted according to their positive or negative COVID-19 test results, and residents who were exposed to COVID-positive residents were placed in PUI status. Contact tracing sheets were observed on resident room doors. Interviews with staff verified education and training was provided related to COVID-19 testing, cohorting, and contact tracing.

Based on observations, record review, staff interviews, and policy review, the facility failed to maintain an effective infection control program to prevent the spread of COVID-19 on three of three nursing units (second floor, third floor, and fourth floor). Specifically, the following failures were identified: 1.The facility failed to ensure one resident (R) (R#233) of 11 residents admitted in the last 30 days was promptly tested for COVID-19 and quarantined, which resulted in failure to separate COVID-positive and COVID-negative residents to the extent possible. 2. The facility failed to ensure testing of residents and staff for COVID-19 was promptly initiated when a COVID-19 outbreak was identified in the facility. 3. The facility failed to ensure staff were fit tested for N95 masks in accordance with Occupational Safety and Health Administration (OSHA) standards and adhered to requirements for the use of personal protective equipment (PPE) during a COVID-19 outbreak in the facility. 4. The facility failed to ensure screening for signs and symptoms and/or exposure to COVID-19 was consistently completed for staff upon entering the facility. On 8/4/2022, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator was informed of the Immediate Jeopardy (IJ) on 8/4/2022 at 5:24 p.m. The noncompliance related to the IJ was identified to have existed on 7/25//2022. A removal plan (Credible Allegation of Compliance) was received on 8/6/22. The survey team conducted observations, reviewed training records, and interviews with staff and residents to verify elements of the facility's removal plan were implemented. The immediacy of the Immediate Jeopardy was removed on 8/6/22. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures. In-service materials and records were reviewed. Observations and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's policies and procedures. Findings included: Review of the facility's policy titled, Pandemic Event Emergency Procedure Coronavirus (COVID-19) Respiratory Disease Infection, revised 3/20/2020, revealed Strategies to prevent the spread of the COVID-19 virus in general are the same strategies to detect and prevent the spread of other respiratory viruses. The facility will make attempts to protect the health and safety of our employees, residents, and visitors by attempting to prevent the spread of this emerging disease. The facility will adhere to recommendations from the Centers for Disease Control and Prevention. 1. Review of the policy titled, Facility Testing Requirements for Staff and Residents, revised 9/24/2021, revealed Residents will be tested upon admission for COVID-19. Review of the facility's policy titled, Cohorting Residents Guidance, dated 8/2/2020, revealed, Cohorting - The practice of isolating multiple individuals with similar symptoms and conditions together. The policy included a grid, which indicated residents with the same COVID-19 status should be cohorted. The examples included housing two residents with unknown COVID-19 status and no symptoms together or housing two residents with unknown COVID-19 status with symptoms together. For a COVID-positive resident, the options were to place the resident in a private room or COVID unit or to cohort them with another COVID-positive resident. Review R#233's clinical record revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's immunization history revealed no evidence the resident had been vaccinated against COVID-19. Review of the Resident COVID Line Testing revealed R#233's COVID-19 status was unknown until testing on 7/26/2022 when R#233 tested positive for COVID-19. A concurrent review of the Resident COVID Line Testing and the Detailed Census Report revealed, R#233 had changed rooms three times between 7/21/2022 and 7/26/2022. Further review of the Detailed Census Report dated 8/6/2022 revealed R#233 was admitted to a room on the second floor. On 7/23/2022 and 7/26/2022, the resident was moved to other rooms on the second floor. Review of the Resident COVID Line Testing dated 8/1/2022 revealed four residents (R#14, R#4, R#232 and R#60) who had been roommates of R#233 between 7/21/2022 and 7/26/2022 had tested positive for COVID-19. Interview on 8/4/2022 at 2:26 p.m., the Director of Nursing (DON) confirmed if a resident tested positive for COVID-19 and the roommate tested negative, the facility would leave them in the same room. During continued interview, the DON indicated the facility had been at 180 capacity and, if a resident tested positive, then the roommate was likely positive. The DON stated, We did not move anyone, just in case we had false positives, and to decrease transmission. Interview on 8/7/2022 at 9:35 a.m., the DON indicated her expectation was that new admissions would be tested on admission and room placement would be based on COVID-19 status. She stated Persons Under Investigation (PUI) would be in quarantine for 14 days. 2. Review of the policy titled, Facility Testing Requirements for Staff and Residents, revised 9/24/2021, revealed, a table titled, Testing Summary which indicated Newly identified COVID-19 positive staff or resident in a facility that is unable to identify close contacts - Test all staff vaccinated and unvaccinated, facility wide or at a group level if staff are assigned to a specific location where the new case occurred. The policy also indicated, Outbreak Trigger Testing - Test all staff and residents in response to an outbreak (defined [as] any single new infection in staff or any nursing home onset infection in a resident). Continue to test all staff and residents that tested negative every three days to seven days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. Interview on 8/1/2022 at 9:59 a.m., the Administrator stated the facility had some COVID-19 positive residents in the building. Review of a Resident COVID Line Testing document, dated 7/25/2022 for the third floor of the facility, revealed 14 residents (R#150, R#76, R#116, R#134, R#54, R#140, R#22, R#135, R#33, R#130, R#93, R#104, R#156, and R#63) tested positive for COVID-19. Review of a Resident COVID Line Testing document dated 7/26/2022 for the second floor of the facility revealed two residents (R#233 and R#275) tested positive for COVID-19. Review of a Resident COVID Line Testing document dated 7/29/2022 for the third floor revealed one resident (R#20) tested positive for COVID-19. Review of a Resident COVID Line Testing document dated 8/1/2022 revealed 11 additional residents on the second floor (R#103, R#165, R#23, R#2, R#137, R#172, R#43, R#14, R#4, R#232 and R#60) tested positive for COVID-19. Review of a Resident COVID Line Testing document revealed testing for the fourth floor of the facility was not completed until 8/2/2022, eight days after the COVID-19 outbreak started. The document for the fourth floor revealed one resident (R#90) tested positive. Interview on 8/3/2022 at 11:04 a.m., the DON and the Assistant DON (ADON) stated they were sharing the Infection Preventionist (IP) role because the Staff Development Coordinator was new. The DON indicated outbreak testing had started on 7/25/2022, when two residents (R#93 and R#320) on the third floor had signs and symptoms of COVID-19. The DON indicated all residents on the third floor were tested and 14 tested positive. The DON indicated unvaccinated staff were tested every Wednesday; however, the DON revealed not all staff had been tested . The DON indicated the facility determined staff testing needs by presence of signs and symptoms and reported none of the staff had symptoms. The DON indicated the second-floor residents were tested on [DATE], and two residents tested positive. The fourth-floor residents were tested on [DATE], and one resident tested positive. The DON indicated the delay in testing the residents on the fourth floor was due to none of the residents on the fourth floor having displayed signs or symptoms of COVID-19. The DON indicated the third-floor residents were retested on [DATE], and four of the 14 residents remained positive. The DON indicated from 7/25/2022 to 8/3/2022, one staff member had tested positive. The ADON added that unvaccinated staff were tested on ce weekly (Wednesday) prior to the outbreak; this did not include existing residents, just unvaccinated employees, and any new admissions. The ADON indicated new admissions were tested on admission and all residents had orders to be tested as needed. Interview on 8/3/2022 at 11:16 a.m., the ADON confirmed the facility only tested unvaccinated staff routinely. Other employees were only tested if they had signs and symptoms. 3. Review of the Centers for Disease Control and Prevention (CDC) guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, revised 2/2/2022, revealed, Source control options for HCP [healthcare personnel] include: A NIOSH [National Institute for Occupational Safety and Health]-approved N95 or equivalent or higher-level respirator OR a respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering facepiece respirators. (Note: These should not be used instead of a NIOSH-approved respirator when respiratory protection is indicated) OR a well-fitting facemask. Further review of the CDC guidance revealed, Source Control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting. Additionally, the guidance indicated, Implement universal use of PPE for healthcare personnel. Review of Occupational Safety and Health Administration (OSHA) Health Standard 1910.134, titled, Respiratory Protection, revealed the following: - 1910.134(c)(1) - In any workplace where respirators are necessary to protect the health of the employee or whenever respirators are required by the employer, the employer shall establish and implement a written respiratory protection program with worksite-specific procedures. The program shall be updated as necessary to reflect those changes in workplace conditions that affect respirator use. The employer shall include in the program the following provisions of this section, as applicable: Procedures for selecting respirators in the workplace; Medical evaluations of employees required to use respirators; Fit testing procedures for tight-fitting respirators; Training of employees in the proper use of respirators, including putting on and removing them, any limitations on their use, and their maintenance. - 1910.134(f) - Fit testing. This paragraph requires that, before an employee may be required to use any respirator with negative or positive pressure tight-fitting facepiece, the employee must be fit tested with the same make, model, style, and size of respirator that will be used. - 1910.134(f)(2) - The employer shall ensure that an employee using a tight-fitting facepiece respirator is fit tested prior to initial use of the respirator, whenever a different respirator facepiece (size, style, model or make) is used, and at least annually thereafter. Observation and interview on 8/3/2022 at 9:22 a.m., Licensed Practical Nurse (LPN) Manager AA, who was wearing an N95 mask, indicated staff had to wear an N95 mask in the hallway and full PPE in rooms that had stop signs on the door, which indicated the residents in those rooms were on isolation precautions. LPN Manager AA indicated this started on Monday, 8/1/2022, because a new admission from the hospital had tested positive. The LPN Manager indicated N95 masks were individually packaged and were obtained at the front desk. LPN Manager AA indicated she had not been fit tested for the mask she was wearing. Interview on 8/3/2022 at 11:04 a.m., the DON indicated N95 masks were required on all floors. When asked about the N95 fit testing for staff, the DON indicated the masks came in a standard size and further stated that no one had complained the masks did not fit. Observation and interview on 8/3/2022 at 1:50 p.m., LPN CCC was passing medications to residents on the third floor of the facility without wearing a face mask. She stated she had taken her mask off and forgot to put it back on. Interview on 8/7/2022 at 9:35 a.m., the DON indicated her expectation was for all staff to wear PPE appropriately. The DON indicated N95 masks, goggles, gown, and gloves were to be worn on the unit in COVID-positive residents' rooms. The DON indicated face coverings should always be worn in the building, either a 3-ply mask when downstairs (the non-resident-occupied floor of the facility), or an N95 when in patient care areas. 4. Review of a facility policy titled, Pandemic Event Emergency Procedure Coronavirus (COVID-19) Respiratory Disease Infection, dated as revised 3/20/2020, revealed, Residents, employees, contract employees and visitors should be evaluated daily for symptoms. Employees should self-report symptoms and exposure. Symptoms of Respiratory Infections including COVID-19 are: -Fever -Cough -Shortness of Breath. The policy also indicated, All Employees - Screen all Employees by obtaining temperatures and assessing for coughing, and sore throat symptoms, chest discomfort or shortness of breath. If temperature is greater than 100 degrees Fahrenheit, and/or employee reports respiratory type symptoms the employee will not be allowed to start work duty and will need to follow up with their healthcare provider immediately. Review of the policy titled, Facility Testing Requirements for Staff and Residents, revised 9/24/2021, revealed, Facility staff and individuals entering facility will be screened upon entering the facility for signs and symptoms of COVID-19, vaccination status and potential exposure risk. Observation on 8/2/2022 at 8:00 a.m. revealed signage posted at the facility entrance directing everyone to be screened upon entering the building. Review of the facility's Employee and Essential Worker COVID-19 Screening Log revealed the staff COVID-19 screenings included taking the employee's temperature, as well as determining the following: - Whether the employee had any of the following symptoms: loss of smell or taste, nausea, diarrhea, vomiting, fever, cough, shortness of breath, sore throat. - Whether, in the past 14 days, the employee had traveled internationally. - Whether, in the past 14 days, the employee had any contact with any person with known COVID-19 infection or was under evaluation for exposure to COVID-19, or a person with respiratory illness. - Whether, in the past 14 days, the employee had worked in or entered a facility with suspected or confirmed COVID-19 infection (and if so, whether the employee wore appropriate PPE). Interview on 8/5/2022 at 9:40 a.m., Certified Nursing Assistant (CNA) PP stated the screening process was for each person to check their temperature and answer the screening questions. CNA PP indicated there was a screening form for visitors and a different form for staff. Per CNA PP, she had forgotten to screen and started work before screening but later remembered and went back to complete the screening. Interview on 8/5/2022 at 10:40 a.m., CNA EE stated the screening process included a temperature check and signing the book located at the main entrance to the facility. Interview on 8/5/2022 at 10:55 a.m., Licensed Practical Nurse (LPN) FF stated the screening process included a temperature check and answering questions every time she came to work. LPN FF stated the front entrance was the only entrance to enter the facility. On 8/4/2022, the surveyor reviewed and compared the facility's screening log and time report. The number of staff who had clocked in for work was compared to the number of staff who had completed their COVID-19 screenings. The results were as follows: - On 7/20/2022, 68 staff clocked in for work and only 49 staff completed the COVID-19 screening. - On 7/21/2022, 71 staff clocked in for work and only 32 staff completed the COVID-19 screening. - On 7/23/2022, 35 staff clocked in for work, and only 29 staff completed the COVID-19 screening. - On 7/25/2022, 62 staff clocked in for work, and only 29 completed the COVID-19 screening. - On 7/26/2022, 71 staff clocked in for work, and only 37 completed the COVID-19 screening. - On 7/31/2022, 36 staff clocked in for work, and only 16 completed the COVID-19 screening. Interview on 8/4/2022 at 10:38 a.m., Human Resources (HR) Staff BBB compared the above lists to a daily number of staff on payroll and reported the same results as calculated by the surveyor. Interview on 8/7/2022 at 8:12 a.m., the DON stated she expected staff to continue screening for COVID-19 when entering the building and not just walk through. The DON indicated the Staff Development Coordinator would be responsible for auditing the screening forms. Interview on 8/7/2022 at 10:16 a.m., Receptionist DDD stated when staff and visitors entered the facility, they were to stop at the front desk for screening. She stated there had been occasions when staff sneaked into the facility through a rear entrance. The Administrator was not available for interview. Removal Plan: 1. Root cause completed with (DON) Director of Nursing. From the root cause analysis, systems were identified that required an immediate action plan to correct deficient practices. The root cause analysis findings were reported to the Ad Hoc Quality Improvement Performance Improvement Committee. This committee reviewed and approved the (IJ) Immediate Jeopardy removal plan on August 6, 2022. Members of the Ad Hoc QAPI [Quality Assurance Performance Improvement] committee consisted of Medical Director and LNHA [Licensed Nursing Home Administrator] via phone, DON, Regional Director, and Department Heads. 2. A Quality improvement tool was developed and initiated which will be monitored weekly by DON or designee to ensure proper N95 [sic] are used, proper PPE are used by staff and residents, and anyone who enters the facility will complete covid-19 screening. Initial audit results were not all employees have been fit tested , some residents and staff not wearing masks to cover nose and mouth, and not all visitors/staff had screened properly. These deficient practices have been reported to the QAPI AD HOC committee and corrective measure taken to ensure compliance has been taken. Future audits will be completed weekly X 8 weeks and then monthly X3 months. DON will report findings in QAPI X 3 months or until a period of compliance is achieved. 3. 55 employees participated in N-95 fit (re)testing with the medical clearance forms on 8/5/2022. The DON has been trained to perform the fit tests. Anyone who cannot physically complete the fit testing will have documentation that they cannot medically complete the testing. 4. On 8/5/2022 The DON or her designee will educate 124 staff on proper N95 use, proper PPE use by staff and residents. Anyone who enters the facility will complete covid-19 screening. The DON will audit screening process daily by comparing the screening logs to the schedules to verify compliance of the deficient practice. Any staff member who has not completed education and COVID-19 testing will be unable to work until it has been completed. 68 employees out of 124. 5. On 8/5/2022 all residents were supplied with a mask for use and explained that the mask was necessary while out of room. Additional face masks available on each nursing unit for clinical and non-clinical staff to distribute to residents. 6. On 8/5/2022 regional director educated DON, Infection preventionist and Administrator on proper N95 use, proper PPE use by staff and residents, and anyone who enters the facility will complete covid-19 screening. 7. Facility respiratory protection program, PPE utilization and visitor and staff screening procedures per CDC recommended guidelines were reviewed by the Medical Director, Administrator, Director of Nursing and Regional Director of Clinical Operations during an Ad Hoc QAPI meeting on 8/5/2022. The Infection Control and Prevention policy was reviewed on 8/5/2022 and no changes were made. 8. All corrections were completed on August 5, 2022. 9. The immediacy of the IJ was removed on August 6, 2022. Onsite Verification: The IJ was removed on 8/6/2022 after the survey team performed onsite verification that the Removal Plan had been implemented. COVID-19 positive residents were verified to have been moved to the second floor and were not placed with COVID-19 negative residents. Review of sign-in sheets and testing records revealed staff education was ongoing and N95 fit testing was completed. Interviews were conducted with random staff, who correctly verbalized the requirements regarding the need to always wear N95 masks in resident areas, as well as gown, gloves, and face shield/goggles to be worn in the rooms of COVID-positive residents or persons under investigation for COVID-19. The screening process was observed on 8/7/2022, and an audit was completed to verify COVID-19 screening was completed for all staff on duty. The DON's audits were reviewed and verified to have been completed. The DON's education by the Regional Director was verified to have been completed. On 8/7/2022, staff from both shifts were interviewed to confirm education and corrective measures including: - Knowledge of the COVID-19 screening process. - When each interviewed staff member was last tested for COVID-19. - Whether each interviewed staff member had been fit tested for an N95 mask. - Knowledge of the proper PPE for entering the rooms of COVID-positive residents or persons under investigation for COVID-19.

Based on record review, interviews, and policy review, the facility failed to conduct routine and outbreak testing for COVID-19 for all staff and residents in accordance with Centers for Disease Control and Prevention (CDC) and the Centers for Medicare and Medicaid Services (CMS) requirements, which potentially caused delays in identifying, treating, and isolating COVID-19 positive residents and staff on 3 of 3 resident-occupied floors of the facility (second floor, third floor, and fourth floor). Specifically, the facility failed to quarantine and test one of 11 newly admitted residents (R) R#233; failed to conduct outbreak testing/contract tracing for employees and residents upon identifying a COVID-19 outbreak in the facility; and failed to ensure unvaccinated or staff not up to date with COVID-19 vaccines were routinely tested twice weekly per CDC guidance when the community transmission level was high in the county where the facility was located. On 8/4/2022, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator was informed of the Immediate Jeopardy (IJ) on 8/4/2022 at 5:24 p.m. The noncompliance related to the IJ was identified to have existed on 7/25//2022. A removal plan (Credible Allegation of Compliance) was received on 8/6/22. The survey team conducted observations, reviewed training records, and interviews with staff and residents to verify elements of the facility's removal plan were implemented. The immediacy of the Immediate Jeopardy was removed on 8/6/22. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures. In-service materials and records were reviewed. Observations and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's policies and procedures. Findings included: Review of a CMS Quality/Survey and (&) Oversight (QSO) Group memorandum, Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements, QSO-20-38-NH, revised 3/10/22, indicated, Routine Testing of Staff, Routine testing of staff, who are not up-to-date, should be based on the extent of the virus in the community. Staff, who are up-to date, do not have to be routinely tested . Facilities should use their community transmission level as the trigger for staff testing frequency. Table 2: Routine Testing Intervals by County COVID-19 Level of Community Transmission Level of COVID-19 Community Transmission/Minimum Testing Frequency of Staff who are not up to date+ Low (blue) = Not recommended Moderate (yellow) = Once a week Substantial (orange) = Twice a week High (red) = Twice a week + Staff who are up to date do not need to be routinely tested . Review of the CDC guidance titled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 [severe acute respiratory syndrome coronavirus 2] Spread in Nursing Homes, dated 2/2/2022, revealed, In nursing homes, newly admitted residents should be tested immediately. Review of a facility policy titled, Facility Testing Requirements for Staff and Residents, revised 9/24/2021, revealed Residents will be tested upon admission for COVID-19. 1.Review of R#233's clinical record revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Detailed Census Report, revealed R#233 was initially admitted to a room on the second floor. On 7/23/2022, the resident was moved to another room on the second floor. Review of the Resident COVID Line Testing, dated 7/26/2022, revealed R#233 tested positive for COVID-19. The Detailed Census Report indicated the resident was moved to a third room on the second floor on this date. The resident remained in this room at the time of the survey. Review of the Resident COVID Line Testing, dated 8/1/2022, revealed a total of four residents (R#14, R#4, R#232 and R#60) who had been R#233's roommates between 7/21/2022 and 7/26/2022 had tested positive for COVID-19. Interview on 8/3/2022 at 11:04 a.m., the Director of Nursing (DON) and the Assistant DON (ADON) stated they were sharing the Infection Preventionist (IP) role. The DON indicated residents on the second floor were tested on [DATE], and two residents tested positive. The ADON indicated new admissions were to be tested for COVID-19 upon admission and all residents had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Review of a Resident COVID Line Testing, dated 7/25/2022, revealed 14 residents on the third floor tested positive for COVID-19. There was no evidence outbreak testing was immediately initiated for residents on other floors or for facility staff. No contact tracing efforts were documented. Review of a Resident COVID Line Testing, dated 7/26/2022, revealed two residents on the second floor tested positive for COVID-19. Review of a Resident Covid Line Testing, dated 7/29/2022, revealed four residents on the third floor tested positive for COVID-19. There was no evidence facility staff and residents residing on the fourth floor had been tested as a result of the ongoing COVID-19 outbreak in the facility. Review of a Resident COVID Line Testing, dated 8/1/2022, revealed the same four residents on the third floor tested positive for COVID-19. Review of a Resident COVID Line Testing, dated 8/1/2022, revealed a total of 11 residents on the second floor tested positive for COVID-19. There was still no evidence facility staff and residents residing on the fourth floor had been tested as a result of the ongoing COVID-19 outbreak in the facility. Review of a Resident COVID Line Testing, dated 8/2/2022, revealed one resident on the fourth floor tested positive for COVID-19. There was no evidence outbreak testing had been initiated for facility staff. Interview on 8/3/2022 at 11:04 a.m., with the DON and the ADON revealed outbreak testing had started on 7/25/2022, when two residents on the third floor had signs and symptoms of COVID-19. The DON indicated all residents on the third floor were tested , and 14 were positive. The DON stated no staff members had been tested . She confirmed that the facility did not test all employees during an outbreak. She stated the facility tested staff based on COVID symptoms, and none of the staff had exhibited symptoms. The DON indicated residents on the second floor were tested on [DATE] and there were two COVID-positive residents. During further interview, the DON stated the residents on the fourth floor were tested on [DATE] and there was one COVID-positive resident. She indicated the facility had not tested the fourth-floor residents prior to 8/2/2022 because there had been no residents on that floor exhibiting signs or symptoms of COVID-19. The DON indicated the third floor had been retested on [DATE], and four of the 14 residents remained positive. The DON indicated from 7/25/2022 to 8/3/2022, one staff (who was tested as part of the weekly testing of unvaccinated staff) had tested positive. Interview on 8/3/2022 at 11:16 a.m., the ADON confirmed unvaccinated staff were tested for COVID-19 routinely, but other employees were only tested if they had signs and symptoms of COVID-19. Interview on 8/4/2022 at 8:50 a.m., the DON stated she did perform contact tracing during the current COVID-19 outbreak. She stated she made a floor grid and looked to see if there were any common factors with the positive rooms. She stated she determined if there were any visitors who visited the positive residents and she looked to determine if the staff who worked with the positive residents had worked with any other residents in the facility. She stated she decided after the first two positive residents were identified to assign designated staff to work on the units and not work on any of the other units during the outbreak. She stated she could not pinpoint any common factors related to the first two positive residents. She stated there were no visitors for the first two positive residents. She also indicated none of the staff who had taken care of the two COVID-positive residents were COVID-positive. When asked how she determined this, since the facility only tested unvaccinated staff or staff who were symptomatic, the DON could not explain and stated, You are right. I would not be able to determine that; we are not testing all staff. The DON confirmed the facility had not effectively implemented and completed contact tracing during the COVID-19 outbreak. She stated she had not documented the contact tracing she had performed. The DON stated the only COVID-positive employee identified to date was an activity aide who had worked on the fourth-floor unit for the past two weeks. Interview on 8/7/2022 at 9:35 a.m., the DON indicated she expected contact tracing to be conducted and for staff and residents to be tested per CDC guidance. The Administrator was not available for interview. 3. Review of the CDC guidance titled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 [severe acute respiratory syndrome coronavirus 2] Spread in Nursing Homes, dated 2/2/2022, revealed in nursing homes, HCP [healthcare personnel] who are not up to date with all recommended COVID-19 vaccine doses should continue expanded screening testing based on the level of community transmission. The guidance indicated in nursing homes located in counties with substantial to high community transmission, HCP should have a [CONDITION(S)] test twice a week. Review of the Centers for Disease Control and Prevention (CDC) Covid Data Tracker for 8/3/2022 revealed the county where the facility was located had a high COVID-19 community transmission level. On 8/3/2022 at 11:04 a.m., the DON and the ADON were interviewed as the Infection Preventionists (IP). The DON indicated unvaccinated staff were being tested on ce per week, every Wednesday. Interview on 8/7/2022 at 9:35 a.m., the DON indicated the facility would follow CDC guidance and expected unvaccinated staff to be tested twice weekly. Removal Plan: 1. Root cause completed with (DON) Director of Nursing. From the root cause analysis, systems were identified that required an immediate action plan to correct deficient practices. The root cause analysis findings were reported to the Ad Hoc Quality Improvement Performance Improvement Committee. This committee reviewed and approved the (IJ) Immediate Jeopardy removal plan on August 6, 2022. Members of the Ad Hoc QAPI [Quality Assurance Performance Improvement] committee consisted of Medical Director and LNHA [Licensed Nursing Home Administrator] via phone, DON, Regional Director, and Department Heads. 2. A Quality improvement tool was developed and initiated which will be monitored weekly by DON or designee to ensure effective testing procedures COVID-19, appropriate cohorting, and completion of contact tracing staff sign in sheets. An audit was completed on August 5, 2022, on 20 COVID-19 positive residents. Initial audit results where contact tracing employee signature forms were needed on the rooms of those 20 COVID-19 positive residents and have been reported to the QAPI AD HOC committee and corrective measure taken to ensure compliance of COVID19 testing and proper cohorting and isolation precautions have been taken. Daily audits will be conducted on newly admitted residents, or those returning from extended leaves of absences. Future audit will be completed weekly X [times] 8 weeks and then monthly X 3 months. DON will report findings in QAPI X 3 months or until a period of compliance is achieved. 3. On 8/5/2022 45 staff tested for COVID-19. 44 of staff test results negative. 1 staff test results positive. Staff members who have not completed COVID-19 testing will be unable to work until COVID19 testing has been completed. 4. On 8/5/2022 167 in-house residents were be tested for COVID-19. 147 test results negative. 20 test results positive. 5. On 8/5/2022 all new admissions tested . 1 tested with negative test results for COVID-19. Any new admissions/readmissions will be tested for COVID-19 going forward. 6. On 8/5/2022 (20) Residents tested positive have been cohorted with other residents that tested positive and placed in transmission-based precautions. The following rooms have COVID positive residents in transmission-based precaution isolation. [Room numbers listed]. 7. On 8/5/2022 (30) residents that tested negative and were in close contact or assigned to the same room as a resident who tested positive will be cohorted with other residents who also tested negative and were in close contact or assigned to the same room as a resident who tested positive and placed on transmission-based precautions as PUIs [Persons Under Investigation]. (30) of residents meet CDC criteria for possible exposure risk and are categorized as a PUI. The following rooms are identified as persons under investigation for COVID19 due to their possible exposure risk. [Room numbers listed]. 8. On 8/5/2022 all new admissions who are unvaccinated placed with other new admissions who are unvaccinated and placed on transmission-based precautions as PUIs. (1) new admissions were tested and assigned to appropriate rooms based on test results. Any unvaccinated new admissions going forward will be placed in PUI with other unvaccinated new admissions, following CDC guidelines. 9. On 8/5/2022 all rooms with any resident that tested positive or were in close contact or assigned to the same room as a resident who tested positive will have a staff contact tracing sign in log attached to their door. [Room numbers listed]. 10. All residents who have tested positive were notified by the Unit Managers and/or Social Services on the day they tested positive. 11. On 8/5/2022 DON or her designee (who has been educated by the DON) will educate 124 staff members on COVID-19 testing policy, cohorting practices, PUI practices, and contact tracing. Any staff member who has not completed education and COVID-19 testing will be unable to work until it has been completed. 68 employees out of 124. 12. Contact tracing signage were [sic] placed on the doors of all residents testing positive and all PUI. [Room numbers listed]. 13. On 8/5/2022 regional director educated the DON, Infection preventionist and Administrator on COVID-19 testing policy, Cohorting practices, PUI practices, and contact tracing. 14. Facility COVID-19 testing policy, Facility Respiratory Protection Program, CDC recommendations for transmission-based practices to prevent the spread of COVID-19 including cohorting guidelines, persons under investigation related to possible exposure to COVID-19, Contact Tracing procedures were reviewed with the Medical Director, Administrator, Director of Nursing and Regional Director of Clinical Operations during an Ad Hoc QAPI meeting on 8/5/2022. The Infection Control and Prevention policy was reviewed on 8/5/2022 and no changes were made. 15. All corrections were completed on August 5, 2022. 16. The immediacy of the IJ was removed on August 6, 2022. Survey Agency validated removal of the Immediate Jeopardy as follows: The IJ was removed on 8/6/2022 after the survey team performed onsite verification that the Removal Plan had been implemented. COVID-19 positive residents had been moved to the second floor and were not placed with negative residents. Sign-in sheets for staff were observed to have been placed outside resident room doors as per the removal plan. Implementation of the removal plan was verified through observations, staff interviews, and record reviews. Staff and resident COVID-19 testing was verified through record review and interview. Inservice sign-in sheets were reviewed to verify staff education was provided per the removal plan. The DON audits were reviewed. Review of education records verified the DON's education by the Regional Director was completed. Staff members from both shifts were interviewed regarding when they were last tested for COVID-19 and whether they were aware of the purpose of the sign-in sheets posted on the residents' room doors.

Based on observations, interviews, record review, and policy review, the facility failed to implement the care plan for one resident (R) (R#25) of 24 sampled residents. Specifically, the facility failed to implement the care plan to provide supervision during mealtime for R#25, who was at risk for aspiration (entrance of food, drink, saliva, or vomit into the lungs). R#25 was left unsupervised with his/her meal and was found by the surveyor in respiratory distress. On 9/20/2022, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator was informed of the Immediate Jeopardy (IJ) on 9/20/2022 at 6:49 p.m. The noncompliance related to the IJ was identified to have existed on 8/1/2022. A removal plan (Credible Allegation of Compliance) was received on 9/23/22. The survey team conducted observations, reviewed training records, and interviews with staff and residents to verify elements of the facility's removal plan were implemented. The immediacy of the Immediate Jeopardy was removed on 9/24/22. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures. In-service materials and records were reviewed. Observations and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's policies and procedures. Findings included: Review of the policy titled, Care Plan Policy, reviewed November 18, 2021, revealed each resident will have a plan of care to identify problems, needs, and strengths that will identify how the facility staff will provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Standard of Practice number 7. Areas of concern or potential concern and residents [sic] strengths will be addressed with measurable goals and specific person-centered approaches to promote attainment or maintenance of the goal(s). Review of the clinical record revealed R#25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. Per the MDS, the resident was totally dependent for eating and did not have signs/symptoms of a possible swallowing disorder. Review of the care plan reviewed 5/23/2022, revealed resident has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R#25 was on aspiration precautions and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/21/2021, a Certified Nursing Assistant (CNA) noted the resident in bed choking while sitting at a 90-degree angle. On 11/26/2021, another choking episode was noted. The care planned interventions/tasks included: - 2/13/2020: Aspiration precautions: assistance with all meals with resident sitting upright. - 7/23/2021: up in wheelchair sitting upright during all meals as needed. - 7/23/2021: must be supervised during all meals ensuring small bits, slow pacing. - 11/16/2021: ST [speech therapy] referral completed. Review of a CNA assignment sheet, dated 8/1/2022, revealed R#25's room/bed number was included on a list of residents who needed to be fed by staff. Review of R#25's Visual/Bedside Kardex Report (a guide used by CNAs to determine the care a resident required) revealed the resident required the following: - Aspiration precautions which included assistance with all meals and that the resident needed to sit upright for all meals (dated 2/13/2020). - Have the resident sit upright in a wheelchair during all meals (dated 7/23/2021). - Supervise the resident during all meals/snacks ensuring the resident takes small bites and eats at a slow pace (undated). - Aspiration precautions (undated). - Assist the resident with all meals as needed (undated). - Clinical staff to monitor communal dining or supervised in room as resident can tolerate (undated). - A regular diet, pureed texture, nectar thick liquids consistency (undated). - Monitor the residents' ability to tolerate diet and notify the Medical Doctor (MD) of any problems (undated). On 8/1/2022 at 1:10 p.m. surveyor observed staff delivering meal trays to residents who ate in their rooms. On 8/1/2022 at 2:54 p.m. surveyor observed R#25 in his room with a meal tray in front of him, with about 50% of the meal consumed. There were no staff members in the room feeding or supervising the resident. R#25 was slumped over to the left side and had thick [MEDICATION(S)] running out of the side of his mouth. He appeared to be in respiratory distress, using accessory muscles to breathe, and had an audible gurgle in his chest/throat. The surveyor immediately alerted Licensed Practical Nurse (LPN) LL, who entered the room and started to suction the resident. R#25 was deeply coughing and trying to breathe. LPN LL checked the resident's oxygen saturation, which was noted to be 61% (normal range is greater than 90%). LPN LL obtained an oxygen canister and started R#25 on oxygen. R#25 was moaning and trying to catch his breath. After the oxygen was applied, the oxygen saturation increased to only 82%. LPN LL waved for another LPN, Nurse Manager RR, to assist. Nurse Manager RR asked LPN LL if he wanted to send R#25 to the emergency room (ER), since the resident's oxygen saturation would not increase to greater than 82%. Nurse Manager RR left the room and made a phone call to the physician. Nurse Manager RR came back to the room and stated the physician ordered the resident be sent to the ER. Interview on 8/1/2022 at 3:33 p.m. with CNA NN, stated he was watching R#25 eat until the roommate finished his meal, and he left the room and went to pick up trays on the hall. CNA NN stated R#25 would not let him take his meal tray. CNA NN stated R#25 must have eaten part of the meal after he left the room. CNA NN stated he usually left R#25's tray in front of him, and R#25 was usually fine. Interview on 8/1/2022 at 3:41 p.m., LPN LL stated R#25 was usually fed by staff but was not being fed today, according to CNA NN. LPN LL stated the resident required full assistance with feeding and that R#25 should not have been left with the tray in front of him. Interview on 8/2/2022 at 12:04 p.m. with Nurse Practitioner (NP) TT stated R#25 generally fed himself but needed someone nearby during meals. She stated staff should not leave R#25's tray in front of him and leave the room during mealtime. She stated someone needed to be checking on the resident during the meal. Interview on 8/2/2022 at 12:47 p.m., Speech Therapist (ST) SS stated staff needed to remind R#25 to slow down when eating and staff needed to be in the vicinity where R#25 was eating in case the resident was in distress. Interview on 8/2/2022 at 3:44 p.m., the Director of Nursing (DON) stated R#25 could not be left alone while eating for an extended period. She stated if staff left the resident and picked up trays on the hall, that was an extended period, and R#25 should not have been left without supervision. Interview on 8/3/2022 at 12:33 p.m. with CNA WW, stated if the care plan indicated R#25 must be supervised during all meals, ensuring small bites and slow pacing, the resident should be continuously monitored. She stated that would require someone to always be present with resident during meals. She confirmed R#25 was at risk for choking and should not be left alone. Interview on 8/3/2022 at 3:14 p.m. with the Medical Director, stated if the care plan indicated the resident should be supervised during meals, there should be someone in the room with the resident while the resident was eating. Interview on 9/24/2022 at 10:07 a.m., CNA DDD stated she was required to look at the Kardex or care plan to obtain information on residents' care. She stated supervision meant to stay with the resident and not leave the room until the resident was finished eating. Interview on 9/24/2022 at 10:45 a.m., LPN VV stated CNAs went to the Kardex to know how to care for a resident. He stated staff should never leave a tray in front of a resident who was at risk for aspiration. During a follow-up interview on 9/23/2022 at 12:43 p.m., the DON revealed staff should read the Kardex, which would match the care plan, to determine how to take care of residents. She stated following the plan of care ensured safety for the residents. Interview on 9/23/2022 at 9:39 a.m. with the Regional Director of Clinical Operations stated CNA staff were to look at the Kardex to determine what care to provide to residents on aspiration precautions to keep them safe during meals, snacks, and hydration. Removal Plan: 1. 9/21/22 - Resident #25 continues to reside in the facility, Legacy Nursing and Rehabilitation Center. 8/1/22 - Resident #25 was showing signs of respiratory distress when the surveyor entered the room. A plate of pureed food was left in front of the resident at lunch. The licensed practical nurse suctioned Resident #25 and oxygen was applied. Resident #25 was sent to the emergency room and admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. 9/21/22 - a root cause analysis was completed and presented to the Ad Hoc QAPI [Quality Assurance Performance Improvement] Committee (Administrator, Chief Clinical Operations (CCO), Medical Director and Regional Director of Clinical Operations. From the root cause analysis, systems were identified that required an immediate action plan to correct deficient practices including the need to follow residents' care plan and provide supervision during mealtimes for residents at risk for aspiration. 3. 9/21/22 - an Ad Hoc QAPI meeting was held with the QAPI Committee (Administrator, Chief Clinical Operations, Medical Director, and Regional Director of Clinical Operations) to discuss incident involving Resident #25. 4. 9/21/22 - the policies for Care Plan, Incident Report - Documentation, Investigation and Reporting and Respiratory - Aspiration Precautions were reviewed by the Chief Clinical Operations, Medical Director, Regional Director of Clinical Operations, with no revisions made. 5. 9/20/22 - the MDS Director, completed a Care Plan/Kardex Audit of care plans and Kardex for all 10 of the 10 residents identified at risk for aspiration. No deficient practices noted in individualized care plans or interventions. 6. 9/21/22 - Regional Director Clinical Operations in-serviced the IDT, which consists of Chief Clinical Operations (CCO), MDS Director, and Staff Development Coordinator (SDC) on instructions for care plans (resident centered related to importance of following individualized care plans/ interventions for residents identified at risk for aspiration). 7. 9/22/22 and 9/23/22 - the Chief Clinical Operations (CCO)and Staff Development Coordinator (SDC) in-serviced 58 of 68 clinical staff on instruction for care plans (resident centered related to importance of following individualized care plans/interventions for residents identified at risk for aspiration: RN: 4 of 5 LPN: 21 of 25 CMA: 4 of 4 C.N.A: 29 of 34 Total: 85% 8. 9/22/22 and 9/23/22 - the CCO and SDC in-serviced 58 of 68 clinical staff how to access Care Plan/Kardex to identify interventions for residents at risk for aspiration. RN: 4 of 5 LPN: 21 of 25 CMA: 4 of 4 C.N.A: 29 of 34 Total: 85% Those not in-serviced will not be placed in the schedule and/or will not be allowed to return to work until in-services are completed. 9. Newly admitted residents or residents newly identified with swallowing disorders or choking episodes will be referred to therapy services for screening. Therapy will communicate any changes in plan of care with Chief Clinical Officer, CCO or Assistant Chief Clinical Officer, ACCO and Unit Managers who will in-service clinical staff of residents at risk of aspiration including care plan and interventions. All corrective actions were completed on 9/23/22. The facility alleges that the IJ is removed on 9/24/22. Onsite Verification: The IJ was removed on 9/24/2022 after the survey team performed onsite verification that the Removal Plan had been implemented. Interviews were conducted with staff to ensure they demonstrated knowledge of the facility's policies and procedures. Observations revealed staff were providing the care planned level of supervision to residents during mealtime. Care plans and the Kardex were reviewed to ensure accuracy. The Ad Hoc QAPI meeting minutes were reviewed, and attendance sheets were verified. The Minimum Data Set (MDS) Director's care plan/Kardex audit was reviewed. Sign-in sheets were reviewed for the in-service provided on care plans by the Regional Director of Clinical Operations. The Chief Clinical Operation's audit for ensuring supervision of residents at risk of aspiration was also reviewed. In-service sign-in sheets were reviewed to verify staff education was provided per the removal plan including the importance of following the care plan and how to access care plan. Sign-in sheets were verified, and schedules were reviewed to ensure untrained staff were not working prior to being educated. New admissions were reviewed to ensure newly admitted residents with swallowing disorders were referred to therapy.

Based on observations, record review, interviews, and policy review, the facility failed to provide adequate supervision to prevent potential accidents for three residents (R) (R#25, R#167, and R#325) of five sampled residents reviewed for accident hazards. Specifically, the facility failed to: 1. Provide supervision during mealtime for R#25 of three sampled residents at risk for aspiration (entrance of food, drink, saliva, or vomit into the lungs). On 8/1/22, R#25 was left unsupervised with his meal and was found by the surveyor in respiratory distress. The resident was sent to the emergency room (ER) and subsequently admitted with a diagnosis of subsegmental atelectasis (collapse of a small area of the lung) or aspiration. 2. Provide physician ordered thickened liquids for R#167 of three sampled residents at risk for aspiration. 3. Thoroughly investigate a fall from a mechanical lift to determine the cause and facilitate development of effective interventions to prevent potential recurrence for R#325 of two sampled residents reviewed for mechanical lift transfers. On 9/20/2022, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator was informed of the Immediate Jeopardy (IJ) on 9/20/2022 at 6:49 p.m. The noncompliance related to the IJ was identified to have existed on 8/1/2022. A removal plan (Credible Allegation of Compliance) was received on 9/23/22. The survey team conducted observations, reviewed training records, and interviews with staff and residents to verify elements of the facility's removal plan were implemented. The immediacy of the Immediate Jeopardy was removed on 9/24/22. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures. In-service materials and records were reviewed. Observations and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's policies and procedures. Findings included: 1. Review of the policy titled, Respiratory - Aspiration Precautions, revised January 2019, revealed the policy statement is to implement and educate patient/caregiver on precautions that prevent aspiration. Considerations 1. Precautions should be taken with all patients who are unable to protect their airway to prevent the involuntary inhalation of foreign substances, such as gastric contents, oropharyngeal secretions, food, or fluids, in the tracheobronchial passages. Procedure 7. Monitor patient when eating/drinking: a. Instruct family or caregiver to do the same. b. Observe adequacy of swallowing. Review of the clinical record revealed R#25 was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)] without behavioral disturbance and [CONDITION(S)] ([CONDITION(S)]). Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. Per the MDS, the resident was totally dependent for eating and did not have signs/symptoms of a possible swallowing disorder. Review of the care plan reviewed 5/23/2022, revealed resident was on aspiration precautions and had a diagnosis of dysphagia (difficulty swallowing). The care plan indicated on 2/13/2020, the resident was observed choking. On 7/21/2021, a Certified Nursing Assistant (CNA) noted the resident in bed choking while sitting at a 90-degree angle. On 11/26/2021, another choking episode was noted. The care planned interventions/tasks included: - 2/13/2020: Aspiration precautions: assistance with all meals with resident sitting upright. - 7/23/2021: up in wheelchair sitting upright during all meals as needed. - 7/23/2021: must be supervised during all meals ensuring small bits, slow pacing. - 11/16/2021: ST [speech therapy] referral completed. Review of a Physician Progress Note, dated 11/19/2021, revealed staff were to assist R#25 with feeding and monitor for aspiration or choking. Review of a Physician Progress Note, dated 12/10/2021, revealed staff were to assist R#25 with meals due to the resident's history of difficulty swallowing. Review of an Order Summary Report revealed R#25 had a physician's order dated 05/07/2020 for a regular, pureed/dysphagia diet with liquids thickened to nectar consistency. Review of a CNA assignment sheet, dated 8/1/2022, revealed R#25's room/bed number was included on a list of residents who needed to be fed by staff. On 8/1/2022 at 2:54 p.m. the surveyor observed R#25 in his room with a meal tray in front of him, with about 50% of the meal consumed. No staff were in the room feeding or supervising the resident. R#25 was slumped over to the left side and had thick [MEDICATION(S)] running out of the side of his mouth. R#25 appeared to be in respiratory distress, using accessory muscles to breathe, and had an audible gurgle in his chest/throat. R#25 was deeply coughing and trying to breathe. The surveyor immediately alerted Licensed Practical Nurse (LPN) LL, who entered the room and started to suction the resident. LPN LL checked resident's oxygen saturation, which was noted to be 61% (normal range is greater than 90%). LPN LL obtained an oxygen canister and started R#25 on oxygen. R#25 was moaning and trying to catch his breath. After the oxygen was applied, the oxygen saturation increased to only 82%. LPN LL waved for another LPN, Nurse Manager RR, to assist. Nurse Manager RR asked LPN LL if he wanted to send R#25 to the emergency room (ER), since the resident's oxygen saturation would not increase to greater than 82%. Nurse Manager RR left the room and made a phone call to the physician. Nurse Manager RR came back to the room and stated the physician ordered the resident be sent to the ER. Review of a hospital Radiology Result dated 8/1/2022 at 5:00 p.m. revealed the resident's chest x-ray findings included opacities (white spots on the x-ray) that represented atelectasis or aspiration. Review of a hospital Progress Note dated 8/3/2022, revealed the resident presented to the hospital after an acute aspiration event with acute hypoxemic (low oxygen levels in the blood) and hypercapnic (high carbon [MEDICATION(S)] levels in the blood) respiratory failure requiring bilevel positive airway pressure ([CONDITION(S)]) support on presentation. The resident was now weaned to room air, the oxygen saturation level was 92% at rest, and the respiratory failure had resolved. The resident was started on [MEDICATION(S)] (a glucocorticoid medication used to decrease inflammation) and [MEDICATION(S)] (an antibiotic) for possible community-acquired pneumonia versus aspiration pneumonia. A review of the hospital Discharge Summary revealed R#25 was transferred back to the facility on [DATE] with orders to continue [MEDICATION(S)] and [MEDICATION(S)]. Interview on 8/1/2022 at 3:33 p.m. with CNA NN, stated he was not sure what happened to R#25. He stated R#25 was fine when he set up the meal tray for the resident. CNA NN stated he usually just kept an eye on R#25 while he provided feeding assistance to the resident's roommate. CNA NN stated he was watching R#25 eat until the roommate finished his meal. He stated R#25 would not let him take his meal tray, so he left and went to pick up trays on the hall. CNA NN stated R#25 must have eaten part of the meal after he left the room. CNA NN stated he usually left R#25's tray in front of him, and R#25 was fine. Interview on 8/1/2022 at 3:41 p.m. with LPN LL, stated R#25 was fine earlier that morning and must have had problems while eating. LPN LL stated R#25 was usually fed by staff but was not being fed today, according to CNA NN. LPN LL stated the resident required full assistance with feeding. LPN LL stated R#25 should not have been left with the tray in front of him. LPN LL indicated he provided CNA NN with an assignment sheet that morning, which indicated who required assistance with feeding, and that the assignment sheet specified that R#25 was to be assisted with feeding. Interview on 8/2/2022 at 12:04 p.m., Nurse Practitioner (NP) TT stated R#25 generally fed himself but needed someone nearby during meals. She stated staff should not leave R#25's tray in front of him and leave the room during mealtimes. She stated someone needed to be checking on him during the meal. Interview on 8/2/2022 at 12:47 p.m., Speech Therapist (ST) SS stated R#25 wanted to eat, but every time the resident was evaluated, he had a poor prognosis. She stated R#25 was at high risk for aspiration. She stated the last time she worked with R#25 she recommended a feeding tube be placed. She stated R#25, and his family declined the tube placement. During further interview, she stated someone should be in the room with R#25 while he ate due to the high risk for aspiration. She stated staff needed to remind R#25 to slow down. She stated someone would need to be in the vicinity where R#25 was eating in case the resident was in distress. Interview on 8/2/2022 at 3:44 p.m. with the Director of Nursing (DON), stated R#25 could not be left alone while eating. She stated if staff left the resident and picked up trays on the hall, that was an extended period, and R#25 should not have been left without supervision. Interview on 8/3/2022 at 12:33 p.m. with CNA WW, stated if the care plan indicated R#25 must be supervised during all meals, ensuring small bites and slow pacing, the resident should be continuously monitored. She stated that would require someone to always be present during meals. She stated R#25 was to be sitting upright at a 90-degree angle. She stated R#25 could feed himself but needed to be continuously monitored and reminded to drink and take small bites. She stated R#25 was prone to choking and should not be left alone during meals. Interview on 8/3/2022 at 12:41 p.m. with CNA UU, stated if the care plan indicated R#25 must be supervised during all meals, ensuring small bites and slow pacing, the resident should be continuously monitored. He stated R#25 should not have a meal tray left in front of him. During further interview, he stated R#25 would reach and get food off the tray. He stated R#25 had a history of taking very large bites and choking. Interview on 8/3/2022 at 9:35 a.m. with the DON stated there were no documented staff in-services that covered aspiration precautions during the past year. Interview on 8/3/2022 at 9:47 a.m. with the Administrator, stated he looked back over the past year and found no staff in-service trainings on aspiration precautions. Interview on 8/3/2022 on 3:14 p.m. with the Medical Director, stated if the care plan indicated the resident should be supervised, there should be someone in the room with the resident while the resident was eating. Removal Plan: 1. 9/21/22 - Resident #25 continues to reside in the facility, Legacy Nursing and Rehabilitation Center. 8/1/22 - Resident #25 was showing signs of respiratory distress when the surveyor entered the room. A plate of pureed food was left in front of the resident at lunch. The licensed practical nurse suctioned Resident #25 and oxygen was applied. Resident #25 was sent to the emergency room and admitted with a diagnosis of aspiration. Resident #25 returned to the facility 8/4/22. 2. 9/21/22 - a root cause analysis was completed and presented to the Ad Hoc QAPI [Quality Assurance Performance Improvement] Committee. (Administrator, Chief Clinical Operations (CCO), Medical Director and Regional Director of Clinical Operations). From the root cause analysis, systems were identified that required an immediate action plan to correct deficient practices including the need to follow residents' care plan and provide supervision during mealtimes for residents at risk for aspiration. 3. 9/21/22 - an Ad Hoc QAPI meeting was held with the QAPI Committee, Administrator, Chief Clinical Operations (CCO), Medical Director, and Regional Director of Clinical Operations, to discuss incident involving Resident #25. 4. 9/21/22 - the policies for Care Plan and Respiratory - Aspiration Precautions were reviewed by the Administrator, Chief Clinical Operations, Medical Director, and Regional Director of Clinical Operations, with no revisions made. 5. 9/20/22 - the MDS Director, completed a Care Plan/Kardex Audit of care plans and Kardex for all 10 of 10 residents identified at risk for aspiration. No deficient practices were noted in individualized care plans or interventions. 6. 9/21/22 - The Chief Clinical Operations, CCO, began completing a daily written Resident at Risk for Aspiration Monitoring Audit (Monday through Sunday) for the 10 residents with risk for aspiration and/or Nursing Supervisor designee to perform Quality Improvement Monitoring of residents at risk for aspiration. 7. 9/21/22 - Regional Director Clinical Operations in-serviced the IDT [Interdisciplinary Team], which consists of Chief Clinical Operations (CCO) MDS Director, and Staff Development Coordinator (SDC) on instructions for care plans (resident centered related to importance of following individualized care plans/ interventions for residents identified at risk for aspiration). 8. 9/22/22 and 9/23/22 - The CCO and SDC in-serviced 58 of 68 clinical staff regarding aspiration precautions and providing supervision during meals for residents who have a history of swallowing disorders and choking episodes and are at risk for aspiration. RN (Registered Nurse): 4 of 5 LPN (Licensed Practical Nurse): 21 of 25 CMA (Certified Medication Aide): 4 of 4 CNA (Certified Nursing Assistant): 29/34 Total: 85% 9. Those not in-serviced will not be placed in the schedule and/or will not be allowed to return to work until in-services are completed. 10. Newly admitted residents or residents newly identified with swallowing disorders or choking episodes will be referred to therapy services for screening. Therapy will communicate any changes in plan of care with Chief Clinical Officer, CCO or Assistant Chief Clinical Officer, ACCO and Unit Managers, who will in-service clinical staff of residents at risk of aspiration including care plan and interventions. All corrective actions were completed on 9/23/22. The facility alleges that the IJ is removed on 9/24/22. Onsite Verification: The IJ was removed on 9/24/2022 after the survey team performed onsite verification that the Removal Plan had been implemented. Observations revealed staff were providing supervision during mealtime for all residents at risk for aspiration, according to their care plans. Care plans and Kardex were reviewed to ensure accuracy. The facility's root cause analysis was reviewed. The Ad Hoc QAPI meeting minutes were reviewed, and attendance sheets were verified. The Minimum Data Set (MDS) Director's care plan/Kardex audit was reviewed. Sign-in sheets were reviewed for the in-service provided on care plans by the Regional Director of Clinical Operations. The Chief Clinical Operation's audit for ensuring supervision of residents at risk of aspiration was also reviewed. In-service sign-in sheets were reviewed to verify staff education was provided per the removal plan, including the importance of following the care plan and how to access the care plan. Sign-in sheets were verified, and schedules were reviewed to ensure untrained staff were not working prior to being educated. New admissions were verified to ensure newly admitted residents with swallowing disorders were referred to therapy. 2. Review of the Transfer/Discharge Report revealed R#167 had diagnoses that included acute kidney failure, dependence on supplemental oxygen, and dysphagia oral phase. Review of the quarterly MDS, dated [DATE], revealed R#167 had a BIMS score of two, indicating severely impaired cognition. The MDS indicated the resident was totally dependent with eating and received a mechanically altered diet. Review of a care plan revised 4/29/2021, revealed resident was at risk for nutritional/hydration problems related to being on a therapeutic diet. The care plan indicated that the resident pocketed food (held food in his mouth without swallowing). A planned interventions was to provide the diet as ordered. Review of the Rehab Services Referral (Nursing Communication) form, dated 7/7/2021, revealed the resident was referred for a swallowing study related to the resident pocketing food. Speech Therapy (ST) was to evaluate the resident and treat as indicated. Review of an Order Summary Report revealed R#167 had a physician's order dated 2/7/2022 for a pureed/dysphagia diet, mechanical soft with pureed meats, and liquids thickened to nectar consistency. Review of the Healthcare Services Dietary assessment dated [DATE], revealed R#167 had orders for a mechanical soft diet, with no added salt, low concentrated sweets, and pureed meat. The assessment indicated the resident was edentulous (without teeth), causing difficulty with chewing. On 8/3/2022 at 12:15 p.m., R#167 was observed lying in bed with the head of the bed elevated. An empty glass with a straw was on the over-bed table, which was positioned across the bed in front of the resident. Observation on 8/3/2022 at 12:45 p.m., revealed R#167 had been served a pureed diet and a glass of lemonade with ice that was not thickened to nectar consistency. The resident was observed to take a drink of the lemonade. Interview on 8/3/2022 at 12:55 p.m., Licensed Practical Nurse (LPN) Unit Manager (UM) DD was asked to observe the resident's liquids for consistency. LPN UM DD observed the lemonade and confirmed it was not thickened. LPN UM DD then went to the computer, reviewed the resident's diet order, and reported the resident was to have nectar thickened liquids. Interview on 8/3/2022 at 1:00 p.m., LPN UM DD confirmed R#167 had received the wrong liquids. She stated the resident was supposed to receive thickened liquids. LPN UM DD reported the dietary department put the thickened liquids on the food trays prior to delivering them to the units to give to the residents. LPN UM DD with the surveyor reviewed the meal card that was on R#167's lunch tray. The card indicated the resident was to receive a pureed diet, no added salt, and low concentrated sugar. The beverage section of the card indicated, NA [not applicable]. The meal card did not address the order for thickened liquids. Interview on 8/3/2022 at 1:14 p.m., LPN UM DD stated Speech Therapy was assessing R#167 to determine whether the resident aspirated the non-thickened liquids. Interview on 8/3/2022 at 1:18 p.m., Speech Therapist (ST) SS verified the current diet order and stated R#167 was to receive nectar-consistency thickened liquids and pureed food. ST SS stated a chest x-ray would be obtained to rule out aspiration. Review of the Rehabilitation Screening Form, dated 8/3/2022 by ST SS, revealed a nurse had reported possible aspiration for R#167. The report indicated R#167 was on a nectar liquid/pureed diet and had no signs or symptoms of aspiration. Review of an Order Summary Report revealed a physician's order was obtained on 8/3/2022 for a chest x-ray to rule out aspiration. An additional order dated 8/3/2022 indicated the resident was to be monitored for signs and symptoms of aspiration pneumonia every 12 hours. Review of an Order Summary Report revealed a physician's order was obtained on 8/3/2022 for a chest x-ray to rule out aspiration. An additional order dated 8/3/2022 indicated the resident was to be monitored for signs and symptoms of aspiration pneumonia every 12 hours. Observation and interview on 8/3/2022 at 2:42 p.m. with Director of Social Work (DSW) JJ was passing drinks to residents during the lunch meal. DSW JJ was passing only regular consistency liquids and reported going by the dietary card to determine who could have regular liquids. DSW JJ denied having passed the regular lemonade to R#167. Interview on 8/6/2022 at 2:19 p.m., Dietary Manager (DM) XX confirmed the resident had an order for thickened liquids, but it was not on the resident's dietary card. DM XX reported the process for changes to diets was that a pink slip would be completed and given to the dietary department, and the card would be updated in the computer. DM XX denied having received a pink slip changing to thickened liquids for R#167. DM XX reported the meal card was updated to reflect thickened liquids, and the thickened liquids would be coming from the dietary department on meal trays. Interview on 8/7/2022 at 8:12 a.m. with the DON, stated the resident should have received the nectar-thick liquids and that the facility would be returning to weekly audits of dietary orders. The DON indicated the unit manager and nurse managers were working the carts and the floor due to being short of nurses, and therefore, processes had been lacking. During further interview, she stated their goal was to get back to auditing. The Administrator was not available for interview. 3. Review of a Transfer/Discharge Report revealed R#325 had diagnoses that included chronic respiratory failure, muscle weakness, [CONDITION(S)], left sided [CONDITION(S)], and peripheral vascular disease (PVD). Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed R#325 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. The MDS indicated R#325 was totally dependent for bed mobility and transfer. According to the MDS, the resident had experienced one fall with no injury since admission, reentry, or prior assessment. Review of the Progress Note, dated 12/28/2021 at 11:08 p.m. revealed R#325 had a fall from the mechanical lift, after which the resident complained of pain to the left leg. Pain medication was administered, and an x-ray was ordered immediately (STAT). Review of the related incident report dated 12/28/2021 at 11:00 p.m. revealed R#325 fell from the mechanical lift. The resident reported suffering a hard fall and was having leg pain. The immediate actions taken included notification of the Director of Nursing and Medical Doctor, administration of pain medication, and obtaining an order for an x-ray. Further review of the incident report revealed the following: - The location of the incident was the resident's room. The report indicated there were no witnesses to the fall but also indicated the resident, fell from Hoyer [mechanical] lift while being transferred. - A note dated 12/29/2021 on the report revealed, Resident was lowered to the floor by the assigned CN [Charge Nurse] and CNA [Certified Nursing Assistant] from the Hoyer lift. The BLE [bilateral lower extremities] x-ray revealed no abnormalities. - A handwritten statement with the incident report revealed the staff member was transferring the resident from a Geri chair to bed. When the lift was moved from the hallway to the bed, the staff member was having to hold onto the sling under the resident's bottom, and the lift began to tilt and fall over. The staff member managed to guide [resident's] feet first onto the floor, having hold of the top of the sling. I put my foot under [her] bottom, I eased [her] back down as it was in an upright position and made sure [she] would not hit [her] head, made sure [she] was able to keep [her] head up before I let go to go & [and] get pillows. Review of an x-ray report, dated 12/29/2021 at 2:15 a.m., indicated the x-ray was completed due to pain in the resident's right and left thighs. The results indicated no fracture or dislocation was seen, and the hip joint was grossly intact. Review of a Transfer/Discharge Report revealed that on 12/30/2021, R#325 was transferred to the hospital for further evaluation post-fall. Interview on 8/4/2022 at 12:16 p.m. with Licensed Practical Nurse (LPN) Manager AA indicated she recalled the resident and the incident but had no training documents related to the incident. Interview on 8/4/2022 at 12:58 p.m. with the Social Worker (SW) reported incidents were discussed in morning meetings, and nursing investigated the falls. Interview on 8/4/2022 at 1:21 p.m. with the DON stated the CNA involved in the incident gave a statement which indicated the mechanical lift tipped over during the transfer. The DON revealed she did not have a documented investigation of the incident and had not determined the root cause of the mechanical lift tipping. The DON reported it had not been determined how many staff were present during the transfer, or if the mechanical lift had been used properly. The DON reported there had not been any additional training for staff using the mechanical lift since the incident. During a follow-up interview on 8/7/2022 at 8:12 a.m. with the DON, stated she felt it was an isolated incident. The DON reported she expected a thorough investigation be completed and that the findings should be documented. The Administrator was not available for interview.

Based on observation, record review, review of facility policies titled Abuse Prevention Policy, Resident-to-Resident Altercations, and Behavioral Assessment, Intervention, and Monitoring, and interviews, the facility failed to provide adequate supervision for two identified vulnerable residents (R) (R#1 and R#6) from a sample of 20 residents, to protect from actual sexual abuse. This failure resulted in R#6 being raped by R#17 and R#1 was exposed to sexually inappropriate behavior by R#16. The facility failed to follow up with psychiatric services for R#16 and failed to put interventions in place to prevent other residents from potential sexually inappropriate behaviors. In addition, the facility failed to assess other residents who were at risk for sexual abuse. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) for F600 and F609 on [DATE] at 2:50 p.m. The noncompliance related to the IJ was identified to have existed on [DATE]. The IJ is outlined as follows: 1. R#17, age 56, was admitted to the facility on [DATE], with a history of [CONDITION(S)] and Human Immunodeficiency Virus (HIV). The resident was found by the Certified Nursing Assistant (CNA) in the room of R#6, a cognitively impaired resident, on [DATE] at 3:45 a.m., the same night he was admitted . R#17 was observed on top of R#6 having sexual intercourse. R#6 was noted to have blood in her brief which was taken as evidence by the police. R#6 was transported to the hospital, bloodwork, and a Sexual Assault Nurse Examiner (SANE) kit was collected. Per the facility, R#6 tested negative for HIV. R#17 was interviewed by the police and admitted that he had sexual intercourse with the resident, and that it had been a long time since he had sex. R#17 was arrested and removed from the facility. R#6 was transferred to another nursing home where she expired on [DATE] of [CONDITION(S)]. The facility failed to assess the other residents who were also at risk for sexual abuse. 2. On [DATE], R#16 was found in the room of R#1, a cognitively impaired resident, with his hand in her brief. R#1 was sent to the hospital for evaluation and a SANE kit was collected. The police were called and during interview, R#1 told police that she asked R#16 to check if she was wearing a diaper. R#16, who was also cognitively impaired, was moved to another unit at the end of the hall. No other interventions were implemented, and R#1 remains in the facility. The facility failed to notify the State Survey Agency (SSA) within the two-hour timeframe of these two incidents. The IJ was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12 (a)(a)(1), Freedom from Abuse, Neglect, and Exploitation (F600, Scope/Severity: J); and 42 CFR 483.12(b)(1)(4) Reporting of Allege Violations (F609, Scope/Severity: J). Additionally, Substandard Quality of Care was identified at 42 CFR 483.12(a)(1) Abuse and Neglect, F600 Scope/Severity: J; and F609 Scope/Severity: J. At the time of the exit on [DATE], the IJ remained ongoing. Findings include: Review of the policy titled Abuse Prevention Policy with a review date of [DATE] revealed that residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Continued review revealed that abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Sexual abuse includes but is not limited to sexual harassment, sexual coercion, or sexual assault. Further review revealed that it is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatments shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse, neglect, or mistreatment. Review of the policy titled Resident-to-Resident Altercations revised [DATE] revealed that the facility will take reasonable precautions including providing adequate supervision when the risk of resident-to-resident altercation is identified. Continued review revealed that the facility should identify the factors that increase the risks associated with individual residents, including those that could trigger an altercation. Interventions could include supervision and other actions that could address potential or actual negative interactions, can include: providing safe supervised areas for unrestricted movement; eliminating or reducing underlying causes of distressed behavior, such as boredom and pain; evaluating staffing levels to ensure adequate supervision; and ongoing staff training and supervision, including how to approach who may be agitated, combative, verbally or physically aggressive, or anxious, and how and when to obtain assistance in managing a resident with behavior symptoms. All direct care staff need to know which residents are at risk for behavior(s) and what interventions are needed to prevent an occurrence. Resident Kardex and care plan should include interventions and goals for managing the potential risk for resident-to-resident altercations. 1. Review of the clinical record for R#6 revealed she was admitted to the facility on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R#6 also had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R#6 resided on the second floor. Review of the BIMS (Brief Interview of Mental Status) Evaluation with effective date of [DATE] revealed that R#6 scored a one. BIMS scores between 0 and 7 indicate severe cognitive impact, scores between 8 and 12 indicate moderate cognitive impairment, and scores between 13 and 15 indicate little to no cognitive impairment. Review of the Social Services assessment dated [DATE] revealed that R#6 was alert and oriented to self and family with memory loss noted. Review of the Nurses' Note dated [DATE] revealed that at 4:15 a.m., the CNA in charge of assignments told the nurse that a male resident was found on top of R#6. The resident reported she was lying in her bed when male resident (R#17) entered her room and laid on top of her. Continued review revealed that the CNA separated the two residents, a thorough physical assessment was done on R#6, without any visible signs of injuries, and R#6 denied any pain. Further review revealed that the male resident (R#17) admitted to going into her room and getting on top of her. The family, DON, and Physician were notified of the incident, along with the Administrator. The facility contacted the police, and R#6 was sent out to the emergency room (ER) for evaluation and treatment. Review of the E-Interact Transfer Form dated [DATE] revealed that there was a sexual encounter with another resident (R#17), which R#6 was sent to the hospitalER on [DATE] at 7:25 a.m. Review of the Hospital Note dated [DATE] revealed that R#6 was brought in for alleged sexual abuse. Continued review revealed that R#6 was refusing any medications, she was alert and orientated to self only, and having visual hallucinations, stating that she sees a man outside trying to kill them and he had a gun, with actively pointing in the direction of the visual hallucination. Also, per review revealed that nursing home staff said that R#6 was alert and orientated x1 and was at baseline. Further review revealed that the night of [DATE] at 4:00 a.m., nursing home staff walked into R#6's room and found another resident (R#17) sexually assaulting R#6 with witnessed penetration and blood on bedsheets. The assailant (R#17) is HIV positive and has a history of syphilis which remains seropositive (positive result in blood test) despite treatment. Family member agreed to an exam for sexual assault victims along with agreeing for R#6 to receive all medical prophylactic treatment due to R#17's medical history. Laboratory testing was completed, including an HIV test, which came back negative, but recommended future testing; however, newly detected [CONDITION(S)] C was found, and family member unaware of any prior history. Review of the written statement by CNA LL on [DATE] revealed that around 3:45 a.m., she made rounds and all residents were in their beds. However, at 4:15 a.m., she went back into R#17's room to check on him, after having to redirect him several times prior, and found him missing. Continued review revealed that she went for assistance in locating the resident. Staff found R#17 in R#6's room. Further review revealed that when staff opened R#6's door, they noticed that R#17 was on top of R#6. She ran immediately and got the nurse. Review of a written statement by CNA MM on [DATE] revealed that she was in another room giving care when CNA LL asked for assistance in locating R#17 around 4:15 a.m. Continued review revealed that all night R#17 had to be redirected about staying in his room. She stated that R#17 was wearing a gown without a diaper, and he was observed on top of R#6. CNA MM questioned R#6 about penetration and R#6 said he (R#17) went as far as he could go and said that she (R#6) was [AGE] years old and had never been raped before. Review of a written statement by Registered Nurse (RN) TT on [DATE] revealed that she was the charge nurse that night on the 11:00 p.m. to 7:00 a.m. shift. Continued review revealed that around 4:15 a.m., CNA LL had informed her that R#17 had gone into R#6's room and laid on top of her without a diaper on. When questioned, R#17 admitted to going into R#6's room to have sex with her. However, when R#6 was interviewed, she could not recall much. The police were contacted, and R#17 was escorted out of the facility in handcuffs, while R#6 was taken to the hospital for further evaluation. Review of the Nurses' Note dated [DATE] revealed that R#17 was questioned by the police and admitted going into R#6's room and getting on top of her, stating he had not done it for a long time and that is why. Continued review revealed that R#17 was detained by the officer and escorted out of the facility. Review of the Police Department Incident Report dated [DATE] at 9:35 a.m., revealed that the event took place on [DATE] between 4:45 a.m. and 6:00 a.m., when the police were contacted by the facility and requested the investigative assistance for an alleged sexual assault. Continued review revealed that R#17 was just placed at the facility on [DATE]. However, R#6 had been a resident for some time. The two witnesses which are part of the CNA nursing staff, advised that R#17 was missing from his room around 3:45 a.m., where CNA LL began walking the floor looking for R#17. CNA LL stated that she observed the door to the room of R#6 closed, and reports that the door normally is left partially open in case R#6 needs assistance. CNA LL stated that she opened R#6's door and found R#17 physically on top of R#6, engaging in what she believed to be sexual intercourse based on his humping movements. Both R#17 and R#6 were wearing hospital gowns and R#6 had on a diaper. CNA LL left the room and went to get assistance from staff. CNA MM accompanied CNA LL back to R#6's room at which time they observed R#17 in the same position and CNA MM told R#17 to remove himself. CNA MM stated that she observed R#6's diaper moved to the side. When CNA MM asked R#6 if R#17 penetrated her, R#6 stated that he got all of what he could in her and stated that she had never been raped before. The primary officer arrived on the scene and questioned R#17, at which time R#17 admitted to having sex with R#6 because it has been a long time since I had sex. R#6 was placed under arrest and was transported to police headquarters, where R#17 was interviewed by a detective from the Special Victims Unit (SVU). However, R#17 told the officer no thanks. R#17 was charged accordingly and transported to jail. R#6 was attempted to be interviewed, which R#6 appeared disoriented and later was informed R#6 was blind. R#6 was transported to hospital to be treated and a sexual assault kit administered. The crime scene was processed along with collecting R#6's gown, bedding, and diaper, which nursing staff observed blood stains in R#6's diaper. Review of the Police Arrest Report dated [DATE] revealed that on [DATE] between 6:00 a.m. and 7:07 a.m., R#17 was arrested on a general felony arrest (when the police take a person into custody, on suspicion that they have committed a crime) with a charge of rape. During phone interview with CNA LL on [DATE] at 4:42 p.m. she revealed that R#17 was wandering up and down the halls, behind the nursing station and in an out of resident rooms throughout the night and that evening and she had to redirect him. She stated that R#17 had on a hospital gown and could not recall if he was wearing a diaper. She stated that she had this feeling about him, which required her to check on him frequently that evening, including around 3:45 a.m., when she made her rounds and R#17 was in his room. However, after returning from downstairs getting ice, she went to check on R#17 and he was not there. She enlisted another CNA's assistance, CNA MM, in locating R#17. When they opened R#6's bedroom door, she found R#17 on top of R#6 making movements as if he was having sex with her. She screamed and ran to get the nurse while CNA MM stayed at the doorway. She said that it could not have been more than 20 minutes between the time that she went to get ice to when she found R#17 on top of R#6. When she returned with the nurse, the two residents were separated. The police were notified and came to the facility along with the crime scene people, which collected R#6's sheets, diaper and gown. She and CNA MM cleaned up R#6 prior to her going out to the hospital, which included changing her brief, that was dry but had spots of blood inside and one side undone (unsure of the side that was undone). They also changed her linen and placed a fresh gown on R#6. CNA LL could not recall if there were any spots of blood on the linen. She said that at first the resident was refusing care, but when the two CNAs obtained the help from the treatment nurse, R#6 began to cooperate. She confirmed that R#6 was alert and stated that R#6 said that the man got up in her as far as he could. During phone interview with Police Lieutenant NN from the SVU on [DATE] at 5:14 p.m., she revealed that she was unsure of the timeframe for the rape kit to return. The other evidence will be processed at the same time as the rape kit. Police Lieutenant NN confirmed that the alleged perpetrator (R#17) was currently in jail. During phone interview with family of R#17 on [DATE] at 8:40 p.m. she revealed she had been trying to get help for the resident for years. She stated that R#17 had been off his medication for over one year and was having behaviors. During phone interview with CNA MM on [DATE] at 9:19 p.m. she revealed she currently works as a night shift CNA and had for the past four years. Continued interview revealed that she was working with another CNA that night, CNA LL. She said that she was in another resident's room working with that resident when CNA LL came to get her and asked for her assistance in locating R#17. R#17 had been having wandering behavior throughout the night, such as walking towards the nursing station and he had to be redirected back into his room. She stated that when they entered R#6's room, R#17 was observed lying flat on R#6, hunching R#6. R#17 had only his gown on with no diaper. At first, she screamed and stated to R#17 that he was going to jail for this behavior, when R#17 turned his head and calmly got off R#6 and returned to his room. The police were contacted and came to the facility along with the crime scene investigators. She assisted other staff in getting R#6 ready for transport to the hospital, when R#6 said that he went as far as he could go, and R#6 said that she had never been raped before. She confirmed that R#6's brief had some red little stuff inside, which was packed with R#6's gown and linen by the crime scene staff. During an interview with the DON on [DATE] at 10:47 a.m., she revealed that R#17 was a new admission to the unit when it was reported to her that R#17 had been wandering since admission up and down the hallways, but denies any wandering into other resident rooms. However, she stated that the facility did not know of any inappropriate sexual behavior prior to admission. During interview with the DON and Administrator on [DATE] at 3:54 p.m., the DON said that the third floor is the memory care/behavioral unit where most of the dementia and Alzheimer's residents will be located. This is due to having to ensure that these residents receive special attention with line-of-sight observation. If the rooms are full on the third floor then the residents can be placed on the other floors (second and fourth) with alternatives put into place such as line of sight observation, and increased communication with direct care staff. The DON also said that staff can redirect any wandering behavior by using Velcro stop signs that can be placed at a resident's door. Review of the clinical record for R#17 revealed that he was admitted to the facility on [DATE], the day before the sexual assault occurred involving R#6. Review of the clinical record revealed R#17 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R#6 resided on the second floor. Review of the hospital paperwork revealed that R#17 had been on psychiatric medications in the past but currently had not been taking for over a month. Review of the Hospital Discharge Summary dated [DATE] revealed that R#17 was brought into the ER by police after a call from his family related to behavioral disturbances. Continued review revealed that per family member, R#17 had been living at another nursing home for one year where he escaped from and was found roaming the streets, and tormenting family members. R#17 has a history of breaking items at home and at a nearby church. He had not been taking his medications for over a month and was having positive A/V/H (Auditory and Visual Hallucinations) while seeing gentiles but was unclear of what they are telling him. Review revealed that R#17 was admitted to the hospital for further treatment. R#17 demonstrated improvement in behavior after re-start of medications. Review of the Clinical Admission Evaluation dated [DATE] revealed that resident was admitted on a stretcher after he was living at another facility. Even though the resident was observed to be wandering since admission, continued review revealed that R#17 was assessed as mildly impaired for cognition, follows commands with mood being pleasant without any wandering behavior at night. Review of the facility's investigation revealed no evidence that other vulnerable residents were assessed for signs of sexual abuse. 2. Review of the clinical record revealed that R#1 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician's Orders for R#1, dated [DATE], revealed, Psychiatry and Psychology to evaluate and treat as needed. Review of a Quarterly MDS, dated [DATE], coded R#1 with a BIMS of 2, indicating severe cognitive impairment. The resident was coded as not having any behaviors or moods. The MDS coded R#1 as needing extensive assistance with bed mobility and dressing and also was totally dependent on staff for hygiene, toilet use, locomotion off unit and transfers. Review of the Facility Incident Report Form, dated [DATE], documented, that the CNA reported to the charge nurse that upon entering R#1's room she noted R#16 in the room. Upon approaching the bed, she noticed R#16's hand under R#1's gown. When asked what he was doing he removed his hand. R#16 was removed from the room and assessment was done for R#1. The assessment revealed no injuries. Steps taken by the facility to prevent further incidents: R#1 was transferred out to the emergency room for further evaluation and treatment. The police were called with no action taken. Investigative findings to follow. On [DATE], R#16 was spoken to regarding the incident with the female peer. R#16 denied any wrongdoing by avoiding questions being asked and not making eye contact. R#16 has been referred to behavioral health for follow up on next visit. Social Services will continue to monitor and intervene as needed. R#16 adjusting with room change and roommate. On [DATE], after readmission R#1 was interviewed by writer who does not recall incident of abuse with peer and appears to be adjusting with no adverse reactions on readmission. Family is aware. Social Worker will continue to monitor and intervene as needed. Review of the police report, dated [DATE], documented, a call was placed from (the facility) in reference to a male and female in dispute. (The hospital) was called to the scene and transported R#1 to (the hospital). R#1 was asked what took place and they advised nothing. R#1 stated she called R#16 to her room to check and see if she had a diaper on because she didn't believe the staff put one on her. R#1 advised that R#16 pulled the covers back and that's when the nurse walked in and called the police. R#1 said R#16 did not do anything to her. Writer advised the nurse of what R#1 stated. Nothing further. Review of documentation from the Hospital Emergency Department for R#1, dated [DATE], revealed that R#1 was brought to the ER for an allegation of Sexual Assault of Adult, Initial Encounter, and Nauseous. Lab tests were completed including HIV-,d+[DATE] AB Screen, Metabolic profile, Imaging tests CAT Scan of Abdomen and pelvis with IV contrast only, x-ray abdomen KUB (kidney, urinary and bladder), and XR chest x-ray 1 view. Review of the (name) Behavioral psychology reviews for R#1 revealed the resident was seen in April and May of 2021. The report dated [DATE] (prior to the incident) documented R#1 was assessed for depressed mood. The staff reported the resident had attention seeking behaviors. The report dated [DATE] documented the resident's mood was mildly depressed with associated symptom of feeling down. Per staff, [DATE]: On readmission resident was interviewed by writer who does not recall incident of abuse with peer and appears to be adjusting with no adverse reactions upon readmission. Family is aware. Social worker will intervene as needed. Discontinue [MEDICATION(S)] and start [MEDICATION(S)]. Review of the clinical record revealed R#16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician's Orders revealed an order, dated [DATE], Consult Psychiatrist to evaluate and treat as needed. Review of the Annual MDS Assessment, dated [DATE], for R#16 documented a BIMS score of 6, indicating severe cognitive impairment. The resident was coded as needing supervision of one for bed mobility and transfer, limited assistance with walking in room, on unit and in corridor. The resident used a wheelchair and didn't walk off the unit. The resident was coded as not having any behaviors or moods for the time frame and behavioral symptoms did not trigger for further review utilizing the Care Area Assessment (CAA) summary process. Review of R#16's care plan, initiated [DATE], and revised on [DATE], listed under Focus, R#16 has a history of demonstrated physical behaviors related to anger, history of observed throwing bowl of dessert, resident has difficulty in expressing and/or finding words to say during conversing and seems to upset him. R#16's care plan was updated on [DATE] to include the problem deficit of the resident having a history of touching other residents sexually. The care planned problem deficit was reviewed on [DATE] with documentation stating there had been no behaviors noted. Interventions included to obtain a psychiatric/psychogeriatric consult, as indicated. Continued review of the care plan revealed another focus area, which was checked as resolved, listed Problematic manner in which resident has a history of acts characterized by inappropriate sexual behavior (masturbation) related to need for affection. The goal listed was that the resident will carry out sexual behavior with self only in privacy of own room. Interventions listed were to avoid type of conversation that could encourage or initiate inappropriate behavior, determine cause and previous sexual history and document it, display an accepting, nonjudgmental manner to encourage resident to discuss concerns about sexuality, explain and explore with resident effects of his behavior on other residents and staff, and move to another floor. After specifying the resident was moved to another floor the care plan focus area was indicated to be resolved. The care plan did not include interventions to address the resident's history of sexually inappropriate behaviors. Review of (name) Behavioral psychology reviews for R#16 revealed the resident was seen by the Physician's Assistant in February and March of 2021. The [DATE] Behavioral Report documented the resident was seen as a result of the staff thought the resident's confusion was getting worse. A review of the [DATE] report revealed documentation: Patient is forgetful and confused related to dementia. Mood is pleasant today. Patient is seen again today due to worsened confusion since last visit. Improving symptoms now. The [DATE] report documented, Mood has been improving. Staff does not report worsening depressed mood. There were no other reports for 2021. Review of R#16's medical record revealed that the resident was not seen by Psychological services following the incident. Review of R#16's Documentation Survey Report for [DATE], revealed R#16's behaviors were being monitored and documented. Review of documentation for [DATE] revealed R#16 had no documented behaviors for that date. All three shifts documented no evidence of behavior. However, review of a Facility Incident Report Form revealed on [DATE] staff discovered R#16 touching R#1 in a sexually inappropriate manner. Further review of the documentation revealed for the month of [DATE], there were 27 out of 31 days where nursing staff did not consistently document behaviors for all three shifts. For the month of [DATE], there were 27 out of 30 days that were left blank for all three shifts and no behaviors were documented for R#16. For the month of [DATE], there were 21 out of 23 days where R#16's behaviors were not consistently documented. An observation of R#16 on [DATE] at 11:30 a.m. revealed the resident used a wheelchair to propel himself throughout the unit. R#16 had some difficulty using their right arm but was still able to maneuver throughout the unit. The resident's room was located near the end of the hall away from the nursing station. During an interview with the fourth floor Unit Manager on [DATE] at 10:50 a.m., she confirmed that R#16 currently resides on the fourth floor. She stated the resident has not had any behaviors since he has been on the unit, which was [DATE]. When asked how behaviors are monitored, the LPN stated they document in the progress notes and behavior monitoring is listed on the CNA Kardex. She stated they will also list behaviors on the communication form they use for report at the end of shift. However, review of R#16 Visual/Bedside Kardex Report revealed behaviors were not listed as a concern to be monitored on the Kardex as of [DATE]. During an interview with the Administrator on [DATE] at 11:56 a.m., he stated that he did not think R#16 had been seen by behavioral health after the incident. He stated the psychologist went out on maternity leave the day after the evaluation was ordered. During an interview with R#16, with the Activity Director present, on [DATE] at 10:50 a.m., the resident stated he didn't remember R#1 and didn't remember having any female friends on the second floor. He stated he didn't know of any incident between himself and another resident. An observation of R#1 on [DATE] at 11:00 a.m., revealed the resident used a Geri-chair when out of her room. The resident stated that she was comfortable and didn't know who R#16 was. She stated she didn't have any male friends on the unit. During an interview with CNA WW on [DATE] at 11:25 a.m., she stated she found R#16 in R#1 room on [DATE] with his hand in R#1 brief. CNA WW said R#1 reported she had asked R#16 to change her tampon. When R#16 was removed from the room he said, My bad, my bad, I'm sorry, I'm sorry. She stated that R#16 told the police he did something very bad. The police said R#1 gave him permission. CNA WW stated R#16 could be a little inappropriate with the staff when they were changing him. He would sometimes try to grab at staff who were trying to change him or start to masturbate. During an interview with LPN VV on [DATE] at 11:35 p.m., she confirmed that she was the Unit Manager on the second floor when the incident occurred. She stated R#16 normally stayed in the dining room and normally did not go into other resident's rooms. She stated that R#16 has had to be redirected around the staff, but not residents. LPN VV stated no one had reported anything to her about R#16 before or since the incident. During an interview with the DON and Administrator on [DATE] at 3:54 p.m., the Administrator stated it was a very broad category to keep the residents safe. He said they educate, have private rooms, and try to match up residents with appropriate roommates. The Administrator stated the third floor is for dementia care and is a locked unit where behaviors are closely monitored. The second and fourth floor are general floors. He stated for the third-floor dementia care, they keep residents in the line-of -sight and have increased communication with the unit manager and direct care staff to determine behavior management. He stated that R#16 had been at the facility since 2017 and the staff know him. He stated there must have been some trigger between the two residents that triggered R#16 to do what he did. The Administrator also explained they had a weekly Behavioral Meeting in which Social Services, Unit Managers, MDS and Care Plan, and Psychotherapist attend. He confirmed that the first Behavioral Meeting where R#16's behaviors had been discussed was on [DATE], two months after the resident had exhibited sexually inappropriate behaviors. The only intervention in place was to move R#16 to a different floor. During an interview with the DON on [DATE] at 9:27 a.m., she stated R#16's behavior did not trigger for the CNA Visual/Bedside Kardex Report because the behavior was a one-time thing. She confirmed that nothing else was done, other than move the R#16 to another floor, to closely monitor him and prevent additional behaviors. She confirmed that R#16's care planned intervention of obtaining a psychiatric/psychogeriatric consult, as indicated had not been implemented. Review of the facility policy, Behavioral Assessment, Intervention, and Monitoring, undated, documented, New onset or changes in behavior will be documented regardless of the degree of risk to the resident or others. To conclude, R#16 sexually abused R#1 on [DATE]. R#16 was moved to the fourth floor with the same vulnerable population as on the second floor where the assault occurred. R#16 continued to reside among vulnerable residents with no mechanism, including lack of behavior monitoring, in place to prevent further incidents of sexual abuse of vulnerable residents.

Based on interview, record review, and review of facility policy titled Abuse Prevention Policy, the facility failed to ensure that alleged sexual abuse was reported to the State Survey Agency (SSA) within a two-hour timeframe for two identified vulnerable residents (R) (R#1 and R#6) of 20 sampled residents. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) for F600 and F609 on [DATE] at 2:50 p.m. The noncompliance related to the IJ was identified to have existed on [DATE]. The IJ is outlined as follows: 1. R#17, age 56, was admitted to the facility on [DATE], with a history of [CONDITION(S)] and Human Immunodeficiency Virus (HIV). The resident was found by the Certified Nursing Assistant (CNA) in the room of R#6, a cognitively impaired resident, on [DATE] at 3:45 a.m., the same night he was admitted . R#17 was observed on top of R#6 having sexual intercourse. R#6 was noted to have blood in her brief which was taken as evidence by the police. R#6 was transported to the hospital, bloodwork, and a Sexual Assault Nurse Examiner (SANE) kit was collected. Per the facility, R#6 tested negative for HIV. R#17 was interviewed by the police and admitted that he had sexual intercourse with the resident, and that it had been a long time since he had sex. R#17 was arrested and removed from the facility. R#6 was transferred to another nursing home where she expired on [DATE] of [CONDITION(S)]. The facility failed to assess the other residents who were also at risk for sexual abuse. 2. On [DATE], R#16 was found in the room of R#1, a cognitively impaired resident, with his hand in her brief. R#1 was sent to the hospital for evaluation and a SANE kit was collected. The police were called and during interview, R#1 told police that she asked R#16 to check if she was wearing a diaper. R#16, who was also cognitively impaired, was moved to another unit at the end of the hall. No other interventions were implemented, and R#1 remains in the facility. The facility failed to notify the SSA within the two-hour timeframe of these two incidents. The IJ was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12 (a)(a)(1), Freedom from Abuse, Neglect, and Exploitation (F600, Scope/Severity: J); and 42 CFR 483.12(b)(1)(4) Reporting of Alleged Violations (F609, Scope/Severity: J). Additionally, Substandard Quality of Care was identified at 42 CFR 483.12(a)(1) Abuse and Neglect, F600 Scope/Severity: J; and F609 Scope/Severity: J. At the time of the exit on [DATE], the IJ remained ongoing. Findings include: Review of the policy titled Abuse Prevention Policy with a review date of [DATE] revealed that all alleged violation involving abuse, neglect, exploitation or mistreatment . are reported immediately, but no later than two hours after the allegation is made if the events that cause the allegation involve abuse or result in seriously bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the SSA) and adult protective services where state law provides for jurisdiction in long term care facilities in accordance with state law. Continued review revealed that the results of all investigations will be reported to the facility Administrator and the SSA within five working days of incident, and if the alleged violation is verified, appropriate corrective action must be taken. 1. Review of the clinical record for R#6 revealed that she was admitted to the facility on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R#6 also had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed R#17 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nurses' Note dated [DATE] revealed that at 4:15 a.m., the CNA in charge of assignments told the nurse that a male resident (R#17) was found on top of R#6. R#6 admitted she was lying in her bed when R#17 entered her room and laid on top of her. Continued review revealed that the CNA separated the two residents and a thorough physical assessment was done on R#6 without any visible signs of injuries. Further review revealed that R#17 admitted to going into R#6's room and getting on top of R#6. R#6 was sent out to the hospital for an evaluation. R#17 was arrested by the police. Review of a written statement by Registered Nurse (RN) TT on [DATE] revealed that she was the charge nurse that night on the 11:00 p.m. to 7:00 a.m. shift. Around 4:15 a.m., CNA LL informed her that R#17 had gone into R#6's room and laid on top of her without a diaper on. When questioned, R#17 admitted to going into R#6's room to have sex with her. The police were contacted, and R#17 was escorted out of the facility in handcuffs, while R#6 was taken to the hospital for further evaluation. Review of the report to the SSA dated [DATE], revealed that the type of incident reported to the SSA was a resident-to-resident encounter. Continued review revealed that R#17 was observed in R#6's room on top of her with his pants down. Further review revealed that R#17 was removed and placed back into his room with the police being called. Review of the email confirmation that the facility received back from the SSA on [DATE] at 11:11 a.m. revealed the initial report was sent via computer. During an interview on [DATE] at 10:47 a.m., the DON revealed that R#17 was a new admission to the unit when it was reported to her that R#17 had been wandering since admission up and down the hallways. Continued interview revealed that on [DATE] at 4:00 a.m. facility staff found R#17 in R#6's room on top of R#6. The DON confirmed that the initial report was sent to the SSA on [DATE] at 11:11 a.m. with an email confirmation sent back with a due date for follow up report as of [DATE]. The DON said that she was unaware of the two-hour reporting requirement for abuse. During a follow up interview with the DON on [DATE] at 2:38 p.m., she revealed that at the time of the alleged incident, the facility felt it was a resident-to-resident encounter, but she was unable to explain the meaning of a resident-to-resident. 2. Review of the clinical record for R#1 revealed that she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record for R#16 revealed that he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Facility Incident Report Form, dated [DATE], documented, that the CNA reported to the charge nurse that upon entering R#1's room she noted R#16 in the room. Upon approaching the bed, she noticed R#16's hand under R#1's gown. When asked what he was doing he removed his hand. R#16 was removed from the room and assessment was done for R#1. The assessment revealed no injuries. Steps taken by the facility to prevent further incidents: R#1 was transferred out to the emergency room for further evaluation and treatment. The police were called with no action taken. The report to the SSA was dated [DATE] without a time. Review of facility documentation revealed the facility failed to report the allegation of sexual abuse by R#16 toward R#1 within a two-hour timeframe. A review of the facility's email confirmation, on [DATE] at 6:04 p.m., revealed the initial report was sent via computer to the SSA. During an interview with the Social Services Director on [DATE] at 1:30 p.m., she stated the actual incident between R#1 and R#16 occurred mid-morning on [DATE]. However, the facility failed to document the exact time of the alleged sexual abuse. During an interview with the Administrator on [DATE] at 1:21 p.m., he revealed that all allegations of abuse or anything with bodily injury is reported to the SSA within a two-hour timeframe. Continued interview revealed that he confirmed that the initial report for R#6 and R#1 were not submitted to the SSA within this two-hour timeframe. Cross refer to F600.

Based on observation, record review, facility policy review, resident and staff interviews, the facility failed to follow care plan interventions related to the supervision of four (4) residents who smoked (R#2, R#15, R#6, R#9), and for one (1) resident (R#2) that required a safety apron while smoking, who was observed to drop a cigarette on his lap while smoking unsupervised from twenty (20) sampled residents who smoke. An extended partial survey was conducted on 3/17/16 through 3/23/16 the sample was expanded to include eleven (11) residents who smoke in the facility. The total sample increased to thirty-one (31) residents. The facility's failure to ensure safe smoking under supervision in accordance with the care plan, increased the likelihood of harm, serious harm, impairment or death to all residents who frequently sign out of the facility Leave of Absence (LOA) on a short pass to smoke. On January 13, 2016, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause serious injury, harm, impairment or death to residents. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on January 13, 2016 at 1:09 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed on December 8, 2015, the date that R#2 who was assessed by the facility to require staff supervision while smoking cigarettes, as well as the need for a smoke apron when smoking, was observed to drop a lit cigarette on himself while smoking unsupervised outside of the facility. After Supervisory Review by the SSA of the investigative findings from the partial extended surveys completed on January 13, 2016 and March 23, 2016 it was determined that the immediacy of the deficient practice no longer existed. However, the facility was not informed that Immediate Jeopardy was identified to exist until January 13, 2016. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on January 11, 2016. Therefore, the facility remained out of compliance at a lower scope and severity of D while the facility develops and implements the Plan of Correction, and the facility Quality Assurance monitors the effectiveness of the system changes. The Immediate Jeopardy is outlined as follows: 1. R#2 who was assessed by the facility to require staff supervision while smoking cigarettes, as well as the need for a smoke apron when smoking. On 12/8/16 at 4:30 p.m. R#2 was observed to drop a lit cigarette on himself while smoking unsupervised outside of the facility. Ashes were observed on the resident's pants. R#2 stood up from his wheelchair and slapped at the cigarette that fell into his lap. The cigarette was observed on the ground still burning. Review of the care plan revealed that the resident is at risk for injury related to smoking and has a history of non-compliance regarding the smoking policy. R#2 was known to smoke in his room and the bathroom and has impaired cognitive skills related to his altered thought process. R#2 has a history of paranoid [MEDICAL CONDITION] and delusions with a BIMS score of fourteen (14) which revealed that he was cognitively intact. However, he was assessed by staff as an unsafe smoker and required constant supervision while smoking. 2. Continued investigation revealed additional residents that signed out LOA during the day to go outside the facility to smoke. R#15 was not his own Responsible Party (RP), his BIMS score was zero (0) indicating severe cognitive impairment, and his name was listed as a Resident Not Safe for Independent LOA. R#15 was assessed by the facility to require staff supervision while smoking cigarettes however, he was permitted to sign out LOA during the day to go outside the facility to smoke. Review of the resident LOA sign out sheet revealed the resident signed out on 1/4/16 (no time noted), 1/4/16 at 3:52; 1/7/16 at 9:40, and 6:08 (a.m., or p.m. is not designated). Interview with Receptionist ZZ revealed that R#15 is one of the residents that sign themselves out of facility so they can go outside to smoke. Continued interview revealed that a list is kept at the front desk identifying residents that are safe, or not safe to sign themselves out of the facility. ZZ further revealed that she does not know how residents are determined to be safe to sign themselves out of the building. R#15 has a problem with depth perception and is not able to sign his name, but signs an X and staff will write his name on the resident sign out sheet. 3. During a resident interview on 1/12/16 at 2:20 p.m. R#6 revealed that he signs out of the facility daily to go out and smoke. R#6 stated the staff tell the residents not to smoke in front of the building so he has gone down the road to smoke. The staff have come down the road and told him he has to go on down the road further and around the corner to smoke or else put the cigarette out and come back inside the facility. Continued interview revealed he goes to the store and buys cigarettes and/or cigarette lighter when he needs to. He gives the cigarettes and cigarette lighter to the staff, but admitted he sneaks some of the cigarettes and saves them for later when he signs himself out to go smoke. Review of the resident LOA sign out sheet revealed the resident signed out on 1/5/16 at 11:40, 2:04, 4:50, 6:00; 1/7/16 at 7:45, 2:45; 1/8/16 at 10:10, 4:20; 1/9/16 at 11:02, 2:58; 1/10/16 at 11:55, 7:33 (a.m., or p.m. is not designated). R#6 was assessed by the facility to require staff one on one assistance while smoking cigarettes however, he was permitted to sign out LOA during the day to go outside the facility to smoke. 4. During interview on 1/12/16 at 2:40 p.m. R#9 revealed that when he signs out to smoke the staff tell him don't smoke around the facility. As long as you don't smoke around the building they are okay with it. R#9 further revealed that he signs himself out to smoke one (1) or two (2) times a day. He further revealed that the Administrator doesn't tell them where to smoke, just says don't hang around the building. Review of the resident LOA sign out sheet revealed the resident signed out on 1/4/16 at 11:00, 12:25, 4:00, 5:26; 1/5/16 at 7:25, 11:00, 12:20, 12:40, 3:30, 5:40; 1/7/16 at 7:45, 8:45, 12:40, 5:30; 1/8/16 at 5:30, 5:45, 7:22, 10:50; 1/10/16 at 11:00, 12:20, 4:45, 7:46 (a.m., or p.m. is not designated). Findings include: Cross Refer F323 A Smoker's List provided by the facility documented a total of forty-six (46) residents who were identified to smoke cigarettes. The approved smoke times were Monday through Sunday as follows: 7:00 a.m. - 7:30 a.m. monitored by Restorative; 9:00 a.m. - 9:30 a.m. monitored by Activities; 10:30 a.m. - 11:00 a.m. monitored by Restorative; 1:30 - 2:00 p.m. monitored by Activities; 4:30 p.m. - 5:00 p.m. monitored by 4th floor staff; 7:00 - 7:30 p.m. monitored by 3rd floor staff; 8:30 p.m. - 9:00 p.m. monitored by 2nd floor staff. 1. Observation on 12/08/15 at 4:30 p.m. revealed Resident #2 sitting in a wheelchair outside on the sidewalk between the facility and the main highway. The resident was observed bringing a lit cigarette up to his mouth for inhale. After inhaling the cigarette smoke R#2 removed the cigarette from his mouth then accidentally dropped the lit cigarette onto his lap. The resident stood up from the seat of the wheelchair and began slapping at the cigarette on his lap. The resident was not wearing a safety apron. Ashes were observed on the resident's pants. The cigarette was on the ground next to the sidewalk and remained burning. There was no facility staff observed outside to assist the resident. The Director of Nursing (DON) was informed of the incident by Surveyor. The DON went for Licensed Practical Nurse (LPN) GG and they escorted R#2 into the facility. Record review for Resident #2 revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) summary Score of fourteen (14) indicating the resident is cognitively intact. Section J- Health Conditions does not identify if the resident uses tobacco or not. Review of the Comprehensive Care Plan dated 4/11/15 revealed R#2 is at risk for injury related to smoking and a has history of smoking in his room/bathroom. It further revealed the Resident exhibits non-compliance regarding the smoking policy. Interventions included, but not limited to, residents identified as needing smoking apron will be provided with this each smoke time, all smoking will be supervised by staff, resident ' s will be assessed on admission, quarterly and as needed to identify safety issues and smoking will be carried out according to facility schedule. Schedule will be provided and explained to residents. Review of the Responsible Smoking Evaluation for R#2 dated 07/07/15 revealed the resident was not able to communicate that he understands smoking materials are for the use only in designated smoking area. Therefore, R#2 was determined to be an unsafe smoker. Not Responsible. Interview on 1/11/16 at 5:55 p.m. with the Administrator while reviewing the LOA sign out sheets revealed that residents don't have to tell us (Administrator/staff) where they are going when they sign out. When a resident signs out they take full responsibility for where they go and what they do. Further interview with the Administrator revealed I have the staff to walk around the campus every day to be sure there are not any stragglers, or homeless people around the facility. The staff check and make sure none of the residents are blocking the center across the street, and they make sure the residents are not in the way of visitors coming into our facility. 2. Record review for R#15 revealed a Quarterly MDS assessment dated [DATE] which documented in Section C-Cognitive Patterns that the resident had a BIMS summary score of zero (0), indicating severe cognitive impairment. Section J- Health Conditions did not identify if the resident uses tobacco or not. Review of the Comprehensive Care Plan for R#15 dated 8/20/15 revealed that the resident is at risk for injury related to smoking. The resident is a safe smoker but needs supervision. An update of the smoking care plan on 11/17/15 revealed that R#15 had violated the smoking policy. The interventions included but not limited to, all smoking will be supervised by staff, resident will be assessed on admission, quarterly and as needed to identify safety issues and smoking will be carried out according to facility scheduled. The care plan also identified the resident has impaired cognitive skills as evidenced by poor and unsafe decision making. The resident exhibits periods of non-compliancy with regards to smoking. Review of the Progress Notes dated 10/5/15 at 4:14 p.m. revealed nursing staff (NS) reported resident violating Legacy's smoking policy. NS will provide detail information per specific violation. Policy has been reiterated to resident. Social Service (SS) will continue to monitor changes. Further review of Progress notes revealed the resident was outside in front of the building smoking this morning and all during the day even when asked not to by staff. 11/1/15 at 10:17 a.m. documented R#15 has been advised of the smoking policy. R#15 continues to be outside of the facility in the garden area smoking. Refuses to give weekend supervisor cigarettes and lighter. R#15 has been advised of the smoking policy Review of the Smoking Assessment for R#15 dated 11/09/15 revealed that the resident required Supervision during smoking. Review of the resident Leave of Absence (LOA) sign out sheet revealed his name listed on the following dates: 1/4/16 (no time out or time of return noted), 1/4/16 out at 3:52 p.m. return at 4:10 p.m.; 1/7/16 out at 9:40 return 10:00 (a.m. or p.m. not specified), 1/7/16 out at 6:08 p.m. return at 6:11 p.m. Interview on 1/11/16 at 5:00 p.m. with Receptionist ZZ revealed R#15 is one of the residents that sign themselves out of the facility so they can go outside to smoke. ZZ further confirmed the resident LOA sign out sheet showing that R#15 signed out of the facility on 1/4/16 at 3:52 p.m., 1/4/16 (no time noted), 1/7/16 at 9:40 a.m. and on 1/7/16 at 6:11 p.m. 3. Record review for R#6 revealed a Quarterly MDS assessment dated [DATE] which revealed the resident had a Brief Interview for Mental Status (BIMS) summary score of fifteen (15) indicating the resident is cognitively intact. Section J- Heath Conditions did not identify if the resident uses tobacco or not. Review of the Comprehensive Care Plan for R#6 dated 12/9/15 identified the resident is at risk for injury related to smoking. Resident chooses not to wear smoking apron when smoking. Interventions included, but not limited to, resident will be assessed on admission, quarterly and as needed to identify safety issues, smoking will be carried out according to facility schedule, schedule will be provided and explained to resident, smoking will be supervised by staff: his rights will be respected related to use of smoking apron. Review of the Smoking Assessment for R#6 dated 12/9/15 revealed the resident required Supervision during smoking. Review of an updated Smoking assessment dated [DATE] revealed that the resident now required one on one (1:1) assistance. Review of the resident Leave of Absence (LOA) sign out sheet revealed that R#6 signed out of the facility on the following dates: 1/5/16 at 11:40, 2:04, 4:50, 6:00; 1/7/16 at 7:45, 2:45; 1/8/16 at 10:10, 4:20; 1/9/16 at 11:02, 2:58; 1/10/16 at 11:55, 7:33. (a.m. or p.m. is not designated) Interview on 01/12/16 at 2:20 p.m. with R#6 revealed that he signs out of the facility daily to go out and smoke. R#6 stated the staff tell the residents not to smoke in front of the building so he has gone down the road to smoke. The staff have come down the road and told him he has to go on down the road further and around the corner to smoke, or else put the cigarette out and come back inside the facility. R#6 stated he goes to the store and buys cigarettes and/or cigarette lighter when he needs to. He gives the cigarettes and/or cigarette lighter to the staff but admitted he sneaks some of the cigarettes and saves them for later when he signs himself out to go smoke. 4. Record review for R#9 revealed a Quarterly MDS assessment dated [DATE] which revealed that the resident had a Brief Interview for Mental Status (BIMS) summary score of fifteen (15) indicating the resident is cognitively intact. Section J- Heath Conditions did not identify if the resident uses tobacco or not. Review of the Comprehensive Care Plan for R#9 dated 2/10/12 identified the resident is at risk for injury related to smoking, safe smoker, Supervision when smoking. Care plan updated to reflect on 10/13/15 R#9 noted violating the smoking policy. Interventions included, but not limited to, all smoking will be supervised by staff on the patio, resident will be assessed on admission, quarterly and as needed to identify safety issues, smoking will be carried out according to facility schedule, provided and explained to resident. Review of the Smoking Assessment for R#9 dated 12/08/15 revealed the resident required Supervision during smoking. Review of the resident Leave of Absence (LOA) sign out sheet revealed the resident signed out of the facility on the following dates: 1/4/16 at 12:25, 5:26, 4:00, 11:00; 1/5/16 at 7:25, 11:00, 12:20, 12:40, 3:30 5:40; 1/7/16 at 7:45, 8:45, 12:40, 5:30; 1/8/16 at 5:30, 7:22, 10:50, 5:45; 1/10/16 at 12:20, 4:45, 11:00, 7:46 (a.m. or p.m. is not designated) Interview on 1/12/16 at 2:40 p.m. with R#9 he stated when I sign out to smoke the staff say don't smoke around the facility. As long as you don't smoke around the building they are okay with it. R#9 said he signs himself out to smoke one to two times a day. R#9 further stated the Administrator don't tell us where to smoke just says don't hang around the building. Review of the facility's Smoking Policy last revised March 2015 and documented in part; Safety Restrictions: All residents shall not be permitted to smoke without the direct supervision of a staff member, and direct supervision must be provided throughout the entire smoking period. Direct Supervision of Residents: The facility shall provide a reasonable means of providing direct supervision to those residents wishing to smoke. Staff Members shall be the persons to assist in providing this service to the residents. The care plan must be reviewed to ascertain if any specific safety devices, like a non-flammable apron, must be used during the smoking period. While the facility will attempt to accommodate those residents who desire to smoke, the facility's primary obligation is to the safety of the facility as a whole. The State Survey Agency validated the corrective action taken by the facility as follows: In-service materials, smoking assessments audits, care plans, and Leave of Absence (LOA) sign out sheets were reviewed to ensure compliance. Interviews and observations were conducted with staff and residents to ensure they were knowledgeable with the changes in the Smoking and LOA policies. There was no further evidence of residents signing out LOA to smoke, and no observations of unsupervised, or unsafe smoking by residents. The facility's Smoking Policy for Residents was revised January 2016: Procedures: 1. Prior to, or upon admission, residents shall be informed in writing, that smoking is permitted in the designated area only - patio, and that smoking articles of any kind are to be stored in the nurses' station (or area designated by the facility) and not permitted to be stored in resident living and sleeping quarters. 2. All residents will be evaluated by licensed nursing staff regarding smoking preferences upon admission, quarterly, and with significant change in resident mental or physical condition. All resident s who smoke will be further evaluated for risk factors, responsibility, and will be oriented to smoking areas and procedures. Residents who smoke will have a plan of care related to this activity. 4. Only facility approved ashtrays shall be used in designated smoking areas. Direct Supervision of Residents: 1. Any resident regardless of classification shall not have their smoking privileges altered solely because of the restrictions placed on their smoking habits. 2. The facility shall provide a reasonable means of providing this service to residents wishing to smoke. 3. Staff members shall be the persons to assist in providing this service to residents. 4. The care plan must be reviewed to ascertain if any specific safety devices, like a non-flammable apron, must be used during the smoking period. The revised Smoking Policy addressed all areas including: Procedures, Safety Restrictions; Smoking Articles, Purchasing/Storage of Smoking Articles, and Direct Supervision of Residents. Review of materials provided by the Administrator revealed that the facility has conducted education for all staff related to the Smoking Policy. Smoking assessments and care plans were reviewed and updated as needed and smoking attendants were educated on functional capabilities for each resident. In addition, the Administrator facilitated a Smokers meeting on January 11, 2016, for all residents and responsible parties to review the smoking policy and enforcement measures which will be taken for non-compliance. The Administrator further revealed that through staff interviews and observations the facility has not had any reports of injury related to smoking while under personnel supervision or when a resident has been out of the facility on LOA. On 12/10/15, the facility conducted a Smoking Assessment Audit of every resident that smoked cigarettes. Review of the Audit revealed that at that time there were forty-four (44) residents residing in the facility that smoked. Each resident care plan was updated, the type of intervention required was listed (ex: supervision, 1:1, apron). The assessment date and whether the resident was identified as a safe or non-safe smoker. On 12/9/15, the facility conducted staff in-service training regarding the facility's Smoking Assessments and requirements for completion. Smoking assessments will be completed within 24 hours of admission, quarterly, with significant changes, and annually. The material was presented orally with opportunity for questions and answers at the end of the in-service. A total of ninety-seven (97) licensed and unlicensed staff were in attendance. On 12/10/15, the facility conducted staff in-service training regarding Confirmation of Responsible Party/Person (RP) designation upon admission. If a resident is admitted to the facility without RP designation or confirmation of such; the received personnel must call the location from which the party was received and speak to whomever responsible to confirm and/or obtain the existence of and contact information for the RP. A total of fifty-seven (57) licensed and unlicensed staff were in attendance. On 12/11/15 and 12/12/15, the facility conducted staff in-service training regarding Smoking Policy/Assessments. A total of eighty-nine (89) licensed and unlicensed staff were in attendance. On 12/9/15, the facility conducted staff in-service training regarding the Leave of Absence (LOA) Process. A total of seventy-one (71) licensed and unlicensed staff members were in attendance. The material presented included that residents may leave the facility from time to time for various reasons. Many times it is medically related, and other times it is socially focused. It must be noted that the process of leave of absence could place the facility at risk for events occurring while the resident is away from the facility; depending on the steps the facility takes before the resident leaves. There must be a process to assure: There is a signed release for leave by the resident and/or responsible party. Arrangements for medications to be administered while the resident is absent from the facility are in place. This must include instructions, packaging and a medication count. This should be noted in the nursing notes that address LOA. Certainly a resident who is their own responsible party can be independent with deciding if and when they would like to take a leave of absence. It is important for their safety that they let the facility know when they are taking a leave of absence. In addition, the capability to take a leave of absence must be approved by their primary physician. If a resident wishes to leave the facility against medical advice (AMA) then an AMA from must be signed by the resident. If they have a responsible party, notification must occur prior to release. At times a resident who is independent may want to leave the facility to seek unsafe activity. When this is recognized the staff must notify the physician immediately and involve the appropriate agencies that can assist the resident to not be a harm to themselves. When knowledge of such is present, it is expected that the administrator is also notified and the appropriate action taken. The LOA/AMA Policy was updated on 3/26/16 to reveal that residents who are their own responsible party can be independent in deciding of and when to take a LOA. Observations made of the 1:30 p.m. resident smoking breaks on the patio on 3/17/16, 3/18/16, and 3/21/16 revealed that the smoking assessment/care plan binder was present at each smoke break and was used to indicate the guidelines for safe smoking of each resident. There were no concerns observed with residents' safety or supervision. Interview on 3/18/16 at 1:50 p.m. with the Administrator after reviewing actions put in place revealed that every smoker in the facility has been assessed and their care plans updated. She further revealed that the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) completed visual observations of every smoker observing for physical dexterity, and safety awareness. Residents were questioned regarding their smoking preferences, but safety was given a priority. Interview on 3/23/16 at 2:00 p.m. with the Administrator revealed that the facility has slowly transitioned the more independent residents to less restrictive environments. The Administrator confirmed that residents repeatedly not abiding by the smoking policy are issued a discharge. Continued interview revealed that the facility used a general care plan that stated supervision while smoking, but it has been updated since December 2015 to be more specific for each resident in regards to whether or not the resident needs an apron etc. The Administrator revealed the care plans have been revised to say supervision while on the smoking patio. Continued interview revealed that Interview on 3/23/16 at 2:20 p.m. with the Administrator revealed that the LOA sign out sheet had been modified in January to include more information as to resident's responsible party and phone number. The Administrator further revealed that the information on the top section of the LOA form had not changed and resident's that sign out LOA have been educated that once they sign out of the facility, the facility is not responsible for them once they leave the campus. When asked what steps the facility has taken to ensure that the smoking residents are safe, she revealed that the smoking residents have attended a smoking meeting to discuss that the facilities expectations are for safe smoking practices. She revealed that the issues of smoking is also discussed at each resident council meeting, staff perform daily room checks looking for smoking paraphernalia in resident's rooms. Continued interview revealed that facility has also been trialing additional smoke break times to discourage resident's from signing out LOA to smoke. The facility has been trialing on the weekends having the smoking patio open and available from 9:00 a.m. to 9:00 p.m. When asked what happens when staff make smoking paraphernalia rounds and a resident is found multiple times with smoking items. The Administrator revealed they would educate the resident on the importance for safety for them as well as all of the other residents and that smoking items need to be locked away. She revealed that if a resident has been found multiple times with smoking items and education is not working then the facility will begin the process of finding the resident a less restricted place to reside such as an assisted living facility.

Based on observation, record review, Responsible Smoking Evaluation, Smoking Assessment review, facility Smoking Policy for Residents review, Leave of Absence (LOA) or Against Medical Advice (AMA) Policy review, staff written statement review, resident and staff interviews the facility failed to ensure adequate supervision to prevent potential smoking related accidents for four (4) residents (R#2, R#15, R#6, R#9) and did not provide a safety apron for one (1) resident (R#2) of the twenty (20) sampled residents who smoke. Additionally, the facility failed to ensure that two (2) residents (R#2, R#15) that were not identified as Safe for Independent Leave of Absence (LOA), did not sign out and temporarily leave the facility. An extended partial survey was conducted on 3/17/16 through 3/23/16 the sample was expanded to include eleven (11) residents who smoke in the facility. The total sample increased to thirty-one (31) residents. The facility's failure to ensure safe smoking under supervision, increased the likelihood of harm, serious harm, impairment or death to all residents who smoked cigarettes and sign out of the facility LOA to smoke, and for two (2) residents who were not safe for Independent LOA who were permitted to sign out LOA. An Abbreviated Survey investigating (GA 251) was conducted December 7, 2015, through December 10, 2015. After Supervisory review by the State Survey Agency (SSA) it was determined based on observation of a resident smoking unsupervised, that the investigation was not completed. A survey to complete the investigation was conducted January 11, 2016 through January 13, 2016. After further Supervisory review by the Center for Medicare and Medicaid Services (CMS) Regional Office (RO) the survey was re-opened by the SSA for further investigation and a Partial/Extended Survey was conducted March 17, 2016 through March 23, 2016.It was determined that the facility was not in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations (C.F.R.) Part 483, Subpart B - Requirements for Long Term Care Facilities. Immediate Jeopardy was identified to exist. The facility census was one-hundred-seventy-six (176) residents. On January 13, 2016, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause serious injury, harm, impairment or death to residents. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on January 13, 2016 at 1:09 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed on December 8, 2015, the date that R#2 who was assessed by the facility to require staff supervision while smoking cigarettes, as well as the need for a smoke apron when smoking, was observed to drop a lit cigarette on himself while smoking unsupervised outside of the facility. After Supervisory Review by the SSA of the investigative findings from the partial extended surveys completed on January 13, 2016 and March 23, 2016 it was determined that the immediacy of the deficient practice no longer existed. However, the facility was not informed that Immediate Jeopardy was identified to exist until January 13, 2016. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on January 11, 2016. Therefore, the facility remained out of compliance at a lower scope and severity of D while the facility develops and implements the Plan of Correction, and the facility Quality Assurance monitors the effectiveness of the system changes. The Immediate Jeopardy is outlined as follows: 1. R#2 who was assessed by the facility to require staff supervision while smoking cigarettes, as well as the need for a smoke apron when smoking. On 12/8/15 at 4:30 p.m. R#2 was observed to drop a lit cigarette on himself while smoking unsupervised outside of the facility. Ashes were observed on the resident's pants. R#2 stood up from his wheelchair and slapped at the cigarette that fell into his lap. The cigarette was observed on the ground still burning. Review of the care plan revealed that the resident is at risk for injury related to smoking and has a history of non-compliance regarding the smoking policy. R#2 was known to smoke in his room and the bathroom and has impaired cognitive skills related to his altered thought process. R#2 has a history of paranoid schizophrenia and delusions with a BIMS score of fourteen (14) which revealed that he was cognitively intact. However, he was assessed by staff as an unsafe smoker and required constant supervision while smoking. 2. Continued investigation revealed additional residents that signed out LOA during the day to go outside the facility to smoke. R#15 was not his own Responsible Party (RP), his BIMS score was zero (0) indicating severe cognitive impairment, and his name was listed as a Resident Not Safe for Independent LOA. R#15 was assessed by the facility to require staff supervision while smoking cigarettes however, he was permitted to sign out LOA during the day to go outside the facility to smoke. Review of the resident LOA sign out sheet revealed the resident signed out on 1/4/16 (no time noted), 1/4/16 at 3:52; 1/7/16 at 9:40, and 6:08 (a.m., or p.m. is not designated). Interview with Receptionist ZZ revealed that R#15 is one of the residents that sign themselves out of facility so they can go outside to smoke. Continued interview revealed that a list is kept at the front desk identifying residents that are safe, or not safe to sign themselves out of the facility. ZZ further revealed that she does not know how residents are determined to be safe to sign themselves out of the building. R#15 has a problem with depth perception and is not able to sign his name, but signs an X and staff will write his name on the resident sign out sheet. 3. During a resident interview on 1/12/16 at 2:20 p.m. R#6 revealed that he signs out of the facility daily to go out and smoke. R#6 stated the staff tell the residents not to smoke in front of the building so he has gone down the road to smoke. The staff have come down the road and told him he has to go on down the road further and around the corner to smoke or else put the cigarette out and come back inside the facility. Continued interview revealed he goes to the store and buys cigarettes and/or cigarette lighter when he needs to. He gives the cigarettes and cigarette lighter to the staff, but admitted he sneaks some of the cigarettes and saves them for later when he signs himself out to go smoke. Review of the resident LOA sign out sheet revealed the resident signed out on 1/5/16 at 11:40, 2:04, 4:50, 6:00; 1/7/16 at 7:45, 2:45; 1/8/16 at 10:10, 4:20; 1/9/16 at 11:02, 2:58; 1/10/16 at 11:55, 7:33 (a.m., or p.m. is not designated). R#6 was assessed by the facility to require staff one on one assistance while smoking cigarettes however, he was permitted to sign out LOA during the day to go outside the facility to smoke. 4. During interview on 1/12/16 at 2:40 p.m. R#9 revealed that when he signs out to smoke the staff tell him don't smoke around the facility. As long as you don't smoke around the building they are okay with it. R#9 further revealed that he signs himself out to smoke one (1) or two (2) times a day. He further revealed that the Administrator doesn't tell them where to smoke, just says don't hang around the building. Review of the resident LOA sign out sheet revealed the resident signed out on 1/4/16 at 11:00, 12:25, 4:00, 5:26; 1/5/16 at 7:25, 11:00, 12:20, 12:40, 3:30, 5:40; 1/7/16 at 7:45, 8:45, 12:40, 5:30; 1/8/16 at 5:30, 5:45, 7:22, 10:50; 1/10/16 at 11:00, 12:20, 4:45, 7:46 (a.m., or p.m. is not designated). It was determined that the noncompliance with one or more requirements caused, serious injury, is likely to cause harm, impairment, or death to residents, related to the failure to protect residents from leaving the facility to smoke unsupervised for their own safety. The immediate jeopardy was related to the facility's noncompliance with program requirements at CFR 483.25(h) (2) F323-S/S: J - Failure to provide adequate supervision and assistive devices to prevent accidents related to smoking. 483.20 (k)(3)(ii) F282-S/S: J - Failure to provide care in accordance with each residents' written plan of care related to supervised smoking sessions and providing safety assistive devices. 483.75 F490-S/S: J - Administration failure to ensure resident safety by monitoring residents who required supervision during smoking from signing out LOA multiple times for short periods to smoke. 483.75 (o) (l) F520-S/S: J - Failed to ensure that the QAA developed and implemented an effective plan of action to address residents who had access to smoking materials and signed out LOA to smoke as they desired. In addition Substandard Quality of Care (SQC) was identified with requirements at F323-S/S: J - Failure to provide supervision. Findings include: A Smoker's List provided by the facility documented a total of forty-six (46) residents who were identified to smoke cigarettes. The approved smoke times were listed as Monday through Sunday as follows: 7:00 a.m. - 7:30 a.m. monitored by Restorative; 9:00 a.m. - 9:30 a.m. monitored by Activities; 10:30 a.m. - 11:00 a.m. monitored by Restorative; 1:30 - 2:00 p.m. monitored by Activities; 4:30 p.m. - 5:00 p.m. monitored by 4th floor staff; 7:00 - 7:30 p.m. monitored by 3rd floor staff; 8:30 p.m. - 9:00 p.m. monitored by 2nd floor staff. 1. Record review for R#2 revealed the resident was admitted to the facility with the following Diagnosis: [REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) summary Score of fourteen (14) indicating the resident is cognitively intact. Section J- Health Conditions does not identify if the resident uses tobacco or not. Review of the Comprehensive Care Plan dated 4/11/15 revealed that R#2 has impaired cognitive skills with altered thought processing, exhibits delusional, disorganized thinking, rambling and incoherent speech, he is unable to stay on topic, but is primarily oriented. Interventions included to conduct regular safety checks and re-orient resident to surroundings as needed. Further review revealed the resident is at risk for injury related to smoking and has a history of smoking in his room/bathroom. It was noted that the resident exhibits non-compliancy regarding the smoking policy. Interventions included needed smoking apron will be provided with each smoke time, all smoking will be supervised by staff, resident ' s will be assessed on admission, quarterly and as needed to identify safety issues and smoking will be carried out according to facility schedule. Review of the Responsible Smoking Evaluation for R#2 dated 07/07/15 revealed that the resident is not able to communicate that he understands smoking materials are for the use only in designated smoking area. Therefore, R#2 was determined to be an unsafe smoker. Not Responsible Review of the Nurse's Note dated 11/1/15 at 10:17 a.m. revealed that R#2 has been advised of the smoking policy and continues to be outside of the facility in the garden area smoking. R#2 refuses to give the weekend supervisor his cigarettes and lighter. Observation on 12/08/15 at 4:30 p.m. revealed R#2 sitting in a wheelchair on the sidewalk between the facility and the main highway. R#2 was observed bringing a lit cigarette up to his mouth for inhale. After inhaling the cigarette smoke R#2 removed the cigarette from his mouth then accidentally dropped the lit cigarette onto his lap. The resident stood up from the seat of the wheelchair and began slapping at the cigarette on his lap. The resident was not wearing a safety apron. Ashes were observed on the resident's pants. The cigarette was on the ground next to the sidewalk and remained burning. There was no facility staff present to assist the resident. The Director of Nursing (DON) was informed of the incident by Surveyor, that the resident was not being supervised. The DON and Licensed Practical Nurse (LPN) GG went outside and escorted R#2 into the facility for evaluation. Interview on 12/08/15 at 4:50 p.m. with the Director of Nursing (DON) revealed that R#2 was assessed by LPN GG for any injuries. The DON further revealed that R#2 was not burned or injured by the event. The DON stated that the resident had signed out to smoke, which is always done. Interview on 12/08/15 at 4:53 p.m. with LPN GG revealed a head to toe assessment of R#2 was conducted and there were no burns or injuries anywhere. Review of the Nurse's Notes (Wound Care Note) dated 12/8/15 revealed that staff received a report that R#2 was noted with cigarette on his clothing. Resident confirmed that he was smoking. No visible holes were observed in the resident's clothing. He denied pain or discomfort to the skin. Resident agreed to an assessment of his skin to check for injuries. Resident's skin was intact and free from injury. Noted that treatment team would repeat assessment tomorrow to rule out delayed injury. The Unit Manager and Responsible Party (RP) were made aware and the smoking assessment for R#2 was updated. Interview on 12/09/15 at 2:35 p.m. with Receptionist FF revealed that their job responsibilities included to monitor the front door and make sure residents and family members sign in and out of the facility. FF stated some of the residents go out regularly, they write where they are going, the time they are leaving and upon return to the facility they sign in the time of return. Some of the regulars sign out to go outside to smoke but they are not allowed to smoke in front of the facility they go on down the road to smoke. Interview conducted on 12/09/15 at 3:17 p.m. with R#2 revealed that the resident was not able to answer the following simple questions: What is your name? R#2 replied I have a lot of names. What is your first name? R#2 replied have you seen my building code? Can you sign yourself out of the building? R#2 replied I don't know if they allow me to sign out of the building. Do you smoke? R#2 replied, I am the governors adopted son. I am allowed to go. Review of the Independent Leave of Absence (LOA) list revealed that R#2 is identified on the Safe for Independent LOA list for Front of building only. The list was updated on 12/11/15 to reflect that R#2 was crossed off the list as Safe for Independent LOA and added to the list of Residents Not Safe for Independent LOA. Interview on 12/09/15 at 3:41 p.m. with the DON revealed that according to the facility sign out policy resident's need to have a Brief Interview for Mental Status (BIMS) score of ten (10) or higher and are physically capable of being mobile. The DON further revealed that if the receptionist is not sure about a resident, then the receptionist will call and ask the charge nurse. Continued interview revealed that there is an Elopement List at the front desk that identifies residents who are, and are not safe to sign themselves out of the facility on a short pass. Continued interview revealed the DON, the Unit Manager, and the Administrator meet to determine if a resident is able to sign themselves out. The DON revealed that currently there is a lot of verbal communication. The receptionist asks and we say if a resident is okay or not okay. The DON further stated that when a resident is a smoker then a smoking assessment will be done on admission, quarterly, and as needed. If a resident is seen with any smoking paraphernalia then it is confiscated. The staff conducts room sweeps to check for smoking paraphernalia usually on the 11:00 p.m. - 7:00 a.m. shift. The DON revealed that the resident's cigarettes and lighters are kept in three tackle boxes located at the front desk. 2. Record review for Resident #15 revealed he was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the facility face sheet revealed the resident was not his own Responsible Party. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed that a Brief Interview for Mental Status (BIMS) should be conducted, however, the resident was unable to complete the interview. The Staff Assessment for Mental Status indicated the resident had both short and long term memory problems. Section G- Functional Status documented the resident had functional limitations in range of motion of both upper and lower extremities. Section J- Health Conditions documented the resident currently uses tobacco. Further review of the Quarterly MDS assessment dated [DATE] revealed the resident had a BIMS summary score of zero (0), indicating severe cognitive impairment. Section J- Health Conditions did not identify if the resident uses tobacco. Review of the Comprehensive Care Plan for R#15 dated 8/20/15 revealed that the resident is at risk for injury related to smoking. It was noted that the resident is a safe smoker, but needs supervision. The care plan was updated on 11/17/15 indicating that the resident had violated the smoking policy. The interventions included that all smoking will be supervised by staff, resident will be assessed on admission, quarterly and as needed to identify safety issues and that smoking will be carried out according to facility schedule. The schedule will be provided and explained to the residents. Further review of the care plan revealed that R#15 has impaired cognitive skills with poor and unsafe decision making, and exhibits cognitive deficits. Continued review of the behavior disturbances care plan revealed that he was socially inappropriate due to communication barriers and expresses himself with cursing and verbal aggressiveness. The resident also exhibits periods of non-compliance with regards to smoking. The care plan identified further concerns: at risk for injury secondary to [DIAGNOSES REDACTED]. Review of the Smoking assessment dated [DATE] revealed the resident was a safe smoker, but required supervision. Review of the Progress Notes dated 10/5/15 at 4:14 p.m. revealed nursing staff (NS) reported resident violating Legacy's smoking policy. NS will provide detail information per specific violation. Policy has been reiterated to resident. Social Service (SS) will continue to monitor changes. Further review of Progress notes revealed that the resident was outside in front of the building smoking this morning and all during the day even when asked not to by staff. 11/1/15 at 10:17 a.m. revealed that R#15 has been advised of the smoking policy. R#15 continues to be outside of the facility in the garden area smoking. Refuses to give weekend supervisor cigarettes and lighter. Review of the resident Leave of Absence (LOA) sign out sheet revealed that R#15 was signed out of the facility on 1/4/16 (no time noted), 1/4/16 at 3:52 p.m. return 4:10 p.m., 1/7/16 at 9:40 a.m., and 6:08 p.m. return 6:11 p.m. Further review of the list of Residents Safe for Independent LOA revealed that R#15 was listed as a resident Not Safe for Independent Leave. Transcribed next to his name was a notation that he can go out when in motorized wheelchair (this statement was crossed out and dated 12/14/15). Interview on 01/11/16 at 5:00 p.m. with Receptionist ZZ revealed that R#15 has a problem with depth perception and is not able to sign his name but signs an X and staff will write his name on the resident sign out sheets. ZZ further confirmed that R#15 did sign out of the facility on 1/4/16 at 3:52 p.m., 1/4/16 (no time noted), 1/7/16 at 9:40 a.m. and on 1/7/16 at 6:08 p.m. Continued interview revealed that they do have some residents that smoke that sign themselves out of the facility to go outside to smoke. ZZ further revealed the names of twelve (12) residents including R#15 who sign themselves out to smoke. Interview on 01/11/16, at 5:55 p.m. with the Administrator and review of the Resident LOA sign out sheets revealed that the residents don't have to tell us where they are going when they sign out. When a resident signs out they take full responsibility. The Administrator stated in order for a resident to sign themselves out of the facility we would assess their physical limitations to make sure the resident doesn't have any restrictions and we assess the resident's cognition. Continued interview revealed that the facility does not have a policy on what an acceptable BIMs score would be, but the expectation is that resident's BIMs score would be ten (10) or greater. The Administrator stated, she instructs a staff member to walk around the campus to be sure there's not any stragglers, or homeless people around the facility. The staff checks to makes sure none of the residents are blocking the Center across the street and that the residents are not in the way of visitors. Continued interview revealed that when the staff walk the facility's campus, it's just a general check, not a specific check. There is no specific checklist for staff when canvassing the facility but that if they did have one, then checking for resident's smoking would be on it. During a telephone interview on 01/12/16 at 3:48 p.m. with the Responsible Party (RP) for R#15 revealed they had never been asked by the facility staff if R#15 could sign himself out of the facility. The RP further revealed that they had never given permission allowing R#15 to sign himself out of the facility. The RP stated they were not aware that the resident was signing himself out of the facility to smoke. R#15 was not observed outside the facility during the 1/11/16 through 1/13/16 survey. Interview with the Administrator on 3/23/16 at 2:00 p.m. revealed that she has observed R#15 outside, but never smoking. She further revealed that she was aware that R#15 was unable to be assessed for BIMS and had held meetings with his brother. Continued interview revealed that R#15 has a communication barrier. She revealed that the Ombudsman informed her that there is a device that she is trying to obtain for the resident. The Administrator confirmed that R#15 has not signed himself out since the complaint survey. 3. Record review for R#6 revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) summary score of fifteen (15) indicating the resident is cognitively intact. Review of the Comprehensive Care Plan for R#6 dated 12/9/15 revealed the resident is at risk for injury related to smoking. R#6 chooses not to wear a smoking apron when smoking. Interventions included that resident will be assessed on admission, quarterly and as needed to identify safety issues, smoking will be carried out according to facility schedule, schedule will be provided and explained to resident, smoking will be supervised by staff, his rights will be respected related to use of smoking apron. Review of the Smoking Assessment for R#6 dated 12/9/15 revealed the resident required Supervision during smoking. Review of an updated Smoking assessment dated [DATE] revealed that the resident now required one on one (1:1) assistance. During an interview on 1/11/16 at 5:00 p.m. with Receptionist ZZ revealed that they do have some residents that smoke that sign themselves out of the facility to go outside to smoke. ZZ further revealed the names of twelve (12) residents including R#6 who sign themselves out to smoke. Review of the Independent LOA list revealed that R#6 was identified as a resident who is Safe for Independent LOA. Review of the resident Leave of Absence (LOA) sign out sheet revealed that R#6 signed out of the facility on the following dates: 1/5/16 at 11:40, 2:04, 4:50, 6:00; 1/7/16 at 7:45, 2:45; 1/8/16 at 10:10, 4:20; 1/9/16 at 11:02, 2:58; 1/10/16 at 11:55, 7:33. (a.m. or p.m. is not designated) Interview on 01/12/16 at 2:20 p.m. with R#6 revealed that he signs out of the facility daily to go out and smoke. R#6 stated the staff tell the residents not to smoke in front of the building so he has gone down the road to smoke. The staff have come down the road and told him he has to go on down the road further and around the corner to smoke, or else put the cigarette out and come back inside the facility. R#6 stated he goes to the store and buys cigarettes and/or cigarette lighter when he needs to. He gives the cigarettes and/or cigarette lighter to the staff but admitted he sneaks some of the cigarettes and saves them for later when he signs himself out to go smoke. Interview on 3/17/16 with Licensed Practical Nurse (LPN) MM revealed that all of the smoking residents had to attend a meeting a while back to discuss the smoking policy. She revealed that at the meeting the residents were told that if they purchase any cigarettes or lighters they needed to give them to staff and have them locked up in the smoking box. Continued interview revealed that the residents were notified that there would be random room checks performed, to check for smoking paraphernalia. MM further revealed if smoking paraphernalia was found they would tell the resident that their items will be confiscated and placed in the locked smoking box. Review of the room sweep documentation for smoking paraphernalia from 12/11/15 through 3/11/16 revealed that daily room checks for smoking supplies are conducted and documented per policy. Review of the Grievance/Concerns Log revealed no grievances made by residents regarding smoking policy changes, or residents being permitted to sign out and/or smoke in front of the building. 4. Record review for R#9 revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS summary score of fifteen (15) indicating the resident is cognitively intact. Review of the Comprehensive Care Plan for R#9 initiated on 2/10/12 revealed the resident is at risk for injury related to smoking, safe smoker. Supervision when smoking. The care plan was updated 10/13/15 R#9 was noted to violate the smoking policy. Interventions included that all smoking will be supervised by staff on the patio, the resident will be assessed on admission, quarterly and as needed to identify safety issues, smoking will be carried out according to facility schedule, provided and explained to resident. Review of the Smoking Assessment for R#9 dated 12/08/15 revealed the resident required Supervision during smoking. During an interview on 1/11/16 at 5:00 p.m. with Receptionist ZZ revealed that they do have some residents that smoke that sign themselves out of the facility to go outside to smoke. ZZ further revealed the names of twelve (12) residents including R#9 who sign themselves out to smoke. Review of the Independent LOA list revealed that R#9 was not identified on either list as Safe for Independent LOA, or the Not Safe for Independent LOA list. However, review of the resident Leave of Absence (LOA) sign out sheet revealed the resident signed out of the facility on the following dates: 1/4/16 at 12:25, 5:26, 4:00, 11:00; 1/5/16 at 7:25, 11:00, 12:20, 12:40, 3:30 5:40; 1/7/16 at 7:45, 8:45, 12:40, 5:30; 1/8/16 at 5:30, 7:22, 10:50, 5:45; 1/10/16 at 12:20, 4:45, 11:00, 7:46 (a.m. or p.m. is not designated) Interview on 1/12/16 at 2:40 p.m. with R#9 he stated when I sign out to smoke the staff say don't smoke around the facility. As long as you don't smoke around the building they are okay with it. R#9 said he signs himself out to smoke one to two times a day. R#9 further stated the Administrator don't tell us where to smoke just says don't hang around the building. Interview on 01/12/16 at 3:25 p.m. with Certified Nursing Assistant (CNA) XX revealed if a resident is going out of the facility to smoke I tell them to either come back inside the facility, or go to the gas station or wherever their destination is. XX further revealed that some residents tell her they are going out of the facility to smoke. Some residents go to the store and buy cigarettes or cigarette lighters but they turn them into the staff. Interview on 01/12/16 at 3:37 p.m. with CNA WW revealed that the DON has told the staff that the residents are not allowed to smoke in front of the building. WW further stated the staff have always told residents that sign out of the facility to smoke, they are not to smoke in front of the building however, WW has seen residents smoking outside of the facility. Interview on 01/13/16 at 12:43 p.m. with the Medical Director revealed if residents are their own Responsible Party (RP) and are not cognitively impaired, then they have the right to sign themselves out anytime they desire. If a resident signs out and they are not their own RP and the facility is allowing them to do that, then that would not be proper. The MD further stated if a resident had a BIMS summary score of zero (0) it would be difficult to see how they would be able to sign themselves out, should not be unsupervised and the RP should be notified. If the facility is allowing a resident that is cognitively impaired with a BIMS summary score of zero (0) that would be troubling. If a resident is cognitively impaired but is their own RP, they can sign themselves out, they can do whatever, and it's their right. The MD stated the criteria he would expect a resident to meet in order to sign himself out of the facility would be: the resident would not be cognitively impaired having a BIMS summary score of ten (10) to fifteen (15) and they would be their own RP. Review of the facility's Smoking Policy revealed the following: Safety Restrictions: 1. The Attending Physician, Director of Nurses, and the Care Plan Team shall have the authority to make determination as to which residents are responsible (cognitively able to make safe decisions for self and others) or non-responsible (not cognitively able to make safe decisions for self and others), prior to or upon Admission, and to what restrictions, if any, will need to be placed on the resident's smoking privileges. The Smoking Evaluation, which is completed upon admission, quarterly, and with a Significant Change in resident's mental or physical condition, will assist with determination of responsibility. 2. Any restrictions placed on smoking privileges shall be noted on the care plan so that all personnel may be alert to smoking restrictions. 4. All residents shall not be permitted to smoke without the direct supervision of a staff member, and direct supervision must be provided throughout the entire smoking period. Direct Supervision of Residents: 2, The facility shall provide a reasonable means of providing direct supervision to those residents wishing to smoke. 3. Staff Members shall be the persons to assist in providing this service to the residents. 4. The care plan must be reviewed to ascertain if any specific safety devices, like a non-flammable apron, must be used during the smoking period. While the facility will attempt to accommodate those residents who desire to smoke, the facility's primary obligation is to the safety of the facility as a whole. Review of the Leave of Absence (LOA) or Against Medical Advice (AMA) Policy revealed that it is the standard of practice of this facility that effort will be made to strongly discourage any resident to leave out against medical advice. Practice Guidelines: #1 There is a signed release for leave, releasing the facility of liability for accompanied or unaccompanied leaves. #2 Arrangements for medications to be administered while the resident is absent from the facility are in

Based on observation, record review, and staff interview, the facility failed to be administered in a manner to ensure the Leave of Absence (LOA) and the Smoking Policy was fully implemented and, failed to monitor the implementation and effectiveness of interventions to keep residents safe from smoke related accidents, and failed to ensure there was supervision to protect the residents who smoked on the entire campus, failed to notify the Responsible Party of one (1) resident (R#15) that had severe cognitive impairment, when the resident repeatedly signed in and out of the facility, and for one (1) resident (R#2) who was assessed to need a smoking apron, however was observed smoking unsupervised without a smoking apron. The sample size was thirty-one (31) residents. It was also determined that the provider's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on January 13, 2016 at 1:09 p.m. The immediate jeopardy was related to the facility's noncompliance with program requirements at CFR 483.25 (h) Free of Accident Hazards/Supervision Devices (F323 with a S/S of J); CFR 483.20 (k)(3)(ii) Services by Qualified Persons/Per Care Plan (F282 with a S/S of J); CFR 483.75 Effective Administration/Resident Well-Being (F490 with a S/S of J) and (CFR 483.75 (o)(1) QAA Committee-Members/Meet Quarterly/Plans (F520 with a S/S of J). In addition, Substandard Quality of Care (SQC) was identified with the requirements at CFR 483.25 (h) Free of Accident Hazards/Supervision Devices (F323 with a S/S of J) Findings include: 1. R#2 who was assessed by the facility to require staff supervision while smoking cigarettes, as well as the need for a smoke apron when smoking. On 12/8/16 at 4:30 p.m. R#2 was observed to drop a lit cigarette on himself while smoking unsupervised outside of the facility. Ashes were observed on the resident's pants. R#2 stood up from his wheelchair and slapped at the cigarette that fell into his lap. The cigarette was observed on the ground still burning. Review of the care plan revealed that the resident is at risk for injury related to smoking and has a history of non-compliance regarding the smoking policy. R#2 was known to smoke in his room and the bathroom and has impaired cognitive skills related to his altered thought process. R#2 has a history of paranoid [MEDICAL CONDITION] and delusions with a BIMS score of fourteen (14) which revealed that he was cognitively intact. However, he was assessed by staff as an unsafe smoker and required constant supervision while smoking. 2. Continued investigation revealed additional residents that signed out LOA during the day to go outside the facility to smoke. R#15 was not his own Responsible Party (RP), his BIMS score was zero (0) indicating severe cognitive impairment, and his name was listed as a Resident Not Safe for Independent LOA. R#15 was assessed by the facility to require staff supervision while smoking cigarettes however, he was permitted to sign out LOA during the day to go outside the facility to smoke. Review of the resident LOA sign out sheet revealed the resident signed out on 1/4/16 (no time noted), 1/4/16 at 3:52; 1/7/16 at 9:40, and 6:08 (a.m., or p.m. is not designated). Interview with Receptionist ZZ revealed that R#15 is one of the residents that sign themselves out of facility so they can go outside to smoke. Continued interview revealed that a list is kept at the front desk identifying residents that are safe, or not safe to sign themselves out of the facility. ZZ further revealed that she does not know how residents are determined to be safe to sign themselves out of the building. R#15 has a problem with depth perception and is not able to sign his name, but signs an X and staff will write his name on the resident sign out sheet. 3. During a resident interview on 1/12/16 at 2:20 p.m. R#6 revealed that he signs out of the facility daily to go out and smoke. R#6 stated the staff tell the residents not to smoke in front of the building so he has gone down the road to smoke. The staff have come down the road and told him he has to go on down the road further and around the corner to smoke or else put the cigarette out and come back inside the facility. Continued interview revealed he goes to the store and buys cigarettes and/or cigarette lighter when he needs to. He gives the cigarettes and cigarette lighter to the staff, but admitted he sneaks some of the cigarettes and saves them for later when he signs himself out to go smoke. Review of the resident LOA sign out sheet revealed the resident signed out on 1/5/16 at 11:40, 2:04, 4:50, 6:00; 1/7/16 at 7:45, 2:45; 1/8/16 at 10:10, 4:20; 1/9/16 at 11:02, 2:58; 1/10/16 at 11:55, 7:33 (a.m., or p.m. is not designated). R#6 was assessed by the facility to require staff one on one assistance while smoking cigarettes however, he was permitted to sign out LOA during the day to go outside the facility to smoke. 4. During interview on 1/12/16 at 2:40 p.m. R#9 revealed that when he signs out to smoke the staff tell him don't smoke around the facility. As long as you don't smoke around the building they are okay with it. R#9 further revealed that he signs himself out to smoke one (1) or two (2) times a day. He further revealed that the Administrator doesn't tell them where to smoke, just says don't hang around the building. Review of the resident LOA sign out sheet revealed the resident signed out on 1/4/16 at 11:00, 12:25, 4:00, 5:26; 1/5/16 at 7:25, 11:00, 12:20, 12:40, 3:30, 5:40; 1/7/16 at 7:45, 8:45, 12:40, 5:30; 1/8/16 at 5:30, 5:45, 7:22, 10:50; 1/10/16 at 11:00, 12:20, 4:45, 7:46 (a.m., or p.m. is not designated). Review of the Leave of Absence (LOA) or AMA Policy Standards: It is the standard of practice of this facility that effort will be made to strongly discourage any resident to leave out against medical advice. Practice Guidelines: #1There is a signed release for leave, releasing the facility of liability for accompanied or unaccompanied leaves. #2 Arrangements for medications to be administered while the resident is absent from the facility are in place. This must include instructions, packaging and a medication count. #3 Criteria that designates residents, by level of care, who requires escorts or who must be accompanied. #4 A resident who is their own responsible party can be independent with deciding if and when they would like to take a leave of absence. It is important for their safety to let the facility know where they would like to take their leave of absence. If the resident wishes to leave the facility against medical advice (AMA) then a form must be signed by the resident. Review of the Leave of Absence list dated 1/4/16 and 1/7/16 revealed most entries signed by residents leaving the facility on LOA were incomplete with missing information noted. Each entry required a Date, Time out, Resident or Legal Representative Signature, Responsible party phone number, Destination, Date of return, Time of return, and Comments/Staff initials. Most entries contained the date, time and signature, but was inconsistent with adding the RP number, the destination, date and time of return. Further review revealed that most resident entries for leave of absence were for short periods of time consisting anywhere from ten (10) to fifteen (15) minute intervals or more multiple times during the day. Interview on 3/23/16 at 2:20 p.m. with the Administrator revealed that the LOA sign out sheet had been modified in January to include more information as to resident's responsible party and phone number. Continued interview revealed that she was not aware that R#15 had signed himself LOA and had a BIMS score of zero (0). She revealed that R#15 is in his right mind he just is not able to communicate and answer the questions correctly when the BIMS score test is being completed. The Administrator revealed that R#15 has not signed out LOA by himself since the citations were presented in January. Review of Progress Notes for resident #15 dated 1/25/16 revealed that the Social Worker contacted the Ombudsman per resident request. R#15 has been deemed unsafe to leave the facility without an escort which he is not receptive to, awaiting ombudsman intervention. Review of the facility's Smoking Policy revealed the following: Safety Restrictions: The Attending Physician, Director of Nurses, and the Care Plan Team shall have the authority to make determination as to which residents are responsible (cognitively able to make safe decisions for self and others) or non-responsible (not cognitively able to make safe decisions for self and others), prior to or upon Admission, and to what restrictions, if any, will need to be placed on the resident's smoking privileges. The Smoking Evaluation, which is completed upon admission, quarterly, and with a Significant Change in resident's mental or physical condition, will assist with determination of responsibility. Any restrictions placed on smoking privileges shall be noted on the care plan so that all personnel may be alert to smoking restrictions. All residents shall not be permitted to smoke without the direct supervision of a staff member, and direct supervision must be provided throughout the entire smoking period. Direct Supervision of Residents: The facility shall provide a reasonable means of providing direct supervision to those residents wishing to smoke. Staff Members shall be the persons to assist in providing this service to the residents. The care plan must be reviewed to ascertain if any specific safety devices, like a non-flammable apron, must be used during the smoking period. While the facility will attempt to accommodate those residents who desire to smoke, the facility's primary obligation is to the safety of the facility as a whole. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on January 11, 2016, and the facility remained out of compliance at a lower scope and severity of D while the facility develops and implements the Plan of Correction; and the facility Quality Assurance monitors the effectiveness of the system changes. The State Survey Agency validated the corrective action taken by the facility as follows: In-service materials, smoking assessments audits, care plans, and Leave of Absence (LOA) sign out sheets were reviewed to ensure compliance. Interviews and observations were conducted with staff and residents to ensure they were knowledgeable with the changes in the Smoking and LOA policies. There was no further evidence of residents signing out LOA to smoke, and no observations of unsupervised, or unsafe smoking by residents. The facility's Smoking Policy for Residents was revised January 2016: Procedures: 1. Prior to, or upon admission, residents shall be informed in writing, that smoking is permitted in the designated area only - patio, and that smoking articles of any kind are to be stored in the nurses' station (or area designated by the facility) and not permitted to be stored in resident living and sleeping quarters. 2. All residents will be evaluated by licensed nursing staff regarding smoking preferences upon admission, quarterly, and with significant change in resident mental or physical condition. All resident s who smoke will be further evaluated for risk factors, responsibility, and will be oriented to smoking areas and procedures. Residents who smoke will have a plan of care related to this activity. 4. Only facility approved ashtrays shall be used in designated smoking areas. Direct Supervision of Residents: 1. Any resident regardless of classification shall not have their smoking privileges altered solely because of the restrictions placed on their smoking habits. 2. The facility shall provide a reasonable means of providing this service to residents wishing to smoke. 3. Staff members shall be the persons to assist in providing this service to residents. 4. The care plan must be reviewed to ascertain if any specific safety devices, like a non-flammable apron, must be used during the smoking period. The revised Smoking Policy addressed all areas including: Procedures, Safety Restrictions; Smoking Articles, Purchasing/Storage of Smoking Articles, and Direct Supervision of Residents. Review of materials provided by the Administrator she revealed that the facility has conducted education for all staff related to the Smoking Policy. Smoking assessments and care plans were reviewed and updated as needed and smoking attendants were educated on functional capabilities for each resident. In addition, the Administrator facilitated a Smokers meeting on January 11, 2016, for all residents and responsible parties to review the smoking policy and enforcement measures which will be taken for non-compliance. The Administrator further revealed that through staff interviews and observations the facility has not had any reports of injury related to smoking while under personnel supervision or when a resident has been out of the facility on LOA. On 12/10/15, the facility conducted a Smoking Assessment Audit of every resident that smoked cigarettes. Review of the Audit revealed that at that time there were forty-four (44) residents residing in the facility that smoked. Each resident care plan was updated, the type of intervention required was listed (ex: supervision, 1:1, apron). The assessment date and whether the resident was identified as a safe or non-safe smoker. On 12/9/15, the facility conducted staff in-service training regarding the facility's Smoking Assessments and requirements for completion. Smoking assessments will be completed within 24 hours of admission, quarterly, with significant changes, and annually. The material was presented orally with opportunity for questions and answers at the end of the in-service. A total of ninety-seven (97) licensed and unlicensed staff were in attendance. On 12/10/15, the facility conducted staff in-service training regarding Confirmation of Responsible Party/Person (RP) designation upon admission. If a resident is admitted to the facility without RP designation or confirmation of such; the received personnel must call the location from which the party was received and speak to whomever responsible to confirm and/or obtain the existence of and contact information for the RP. A total of fifty-seven (57) licensed and unlicensed staff were in attendance. On 12/11/15 and 12/12/15, the facility conducted staff in-service training regarding Smoking Policy/Assessments. A total of eighty-nine (89) licensed and unlicensed staff were in attendance. On 12/9/15, the facility conducted staff in-service training regarding the Leave of Absence (LOA) Process. A total of seventy-one (71) licensed and unlicensed staff members were in attendance. The material presented included that residents may leave the facility from time to time for various reasons. Many times it is medically related, and other times it is socially focused. It must be noted that the process of leave of absence could place the facility at risk for events occurring while the resident is away from the facility; depending on the steps the facility takes before the resident leaves. There must be a process to assure: There is a signed release for leave by the resident and/or responsible party. Arrangements for medications to be administered while the resident is absent from the facility are in place. This must include instructions, packaging and a medication count. This should be noted in the nursing notes that address LOA. Certainly a resident who is their own responsible party can be independent with deciding if and when they would like to take a leave of absence. It is important for their safety that they let the facility know when they are taking a leave of absence. In addition, the capability to take a leave of absence must be approved by their primary physician. If a resident wishes to leave the facility against medical advice (AMA) then an AMA from must be signed by the resident. If they have a responsible party, notification must occur prior to release. At times a resident who is independent may want to leave the facility to seek unsafe activity. When this is recognized the staff must notify the physician immediately and involve the appropriate agencies that can assist the resident to not be a harm to themselves. When knowledge of such is present, it is expected that the administrator is also notified and the appropriate action taken. The LOA/AMA Policy was updated on 3/26/16 to reveal that residents who are their own responsible party can be independent in deciding of and when to take a LOA. Observations made of the 1:30 p.m. resident smoking breaks on the patio on 3/17/16, 3/18/16, and 3/21/16 revealed that the smoking assessment/care plan binder was present at each smoke break and was used to indicate the guidelines for safe smoking of each resident. There were no concerns observed with residents' safety or supervision. Interview on 3/18/16 at 1:50 p.m. with the Administrator after reviewing actions put in place revealed that every smoker in the facility has been assessed and their care plans updated. She further revealed that the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) completed visual observations of every smoker observing for physical dexterity, and safety awareness. Residents were questioned regarding their smoking preferences, but safety was given a priority. Interview on 3/23/16 at 2:00 p.m. with the Administrator revealed that the facility has slowly transitioned the more independent residents to less restrictive environments. The Administrator confirmed that residents repeatedly not abiding by the smoking policy are issued a discharge. Continued interview revealed that the facility used a general care plan that stated supervision while smoking, but it has been updated since December 2015 to be more specific for each resident in regards to whether or not the resident needs an apron etc. The Administrator revealed the care plans have been revised to say supervision while on the smoking patio. Continued interview revealed that Interview on 3/23/16 at 2:20 p.m. with the Administrator revealed that the LOA sign out sheet had been modified in January to include more information as to resident's responsible party and phone number. The Administrator further revealed that the information on the top section of the LOA form had not changed and resident's that sign out LOA have been educated that once they sign out of the facility, the facility is not responsible for them once they leave the campus. When asked what steps the facility has taken to ensure that the smoking residents are safe, she revealed that the smoking residents have attended a smoking meeting to discuss that the facilities expectations are for safe smoking practices. She revealed that the issues of smoking is also discussed at each resident council meeting, staff perform daily room checks looking for smoking paraphernalia in resident's rooms. Continued interview revealed that facility has also been trialing additional smoke break times to discourage resident's from signing out LOA to smoke. The facility has been trialing on the weekends having the smoking patio open and available from 9:00 a.m. to 9:00 p.m. When asked what happens when staff make smoking paraphernalia rounds and a resident is found multiple times with smoking items. The Administrator revealed they would educate the resident on the importance for safety for them as well as all of the other residents and that smoking items need to be locked away. She revealed that if a resident has been found multiple times with smoking items and education is not working then the facility will begin the process of finding the resident a less restricted place to reside such as an assisted living facility.

Based on record review and staff interview, the facility failed to maintain a Quality Assessment and Assurance (QAA) committee that identified, developed, and failed to identify that their established policies for Leave of Absence (LOA) and Smoking were not being fully operationalized, and therefore failed to implement effective corrective actions to address the problems. The facility census was one hundred seventy-six (176) and the sample size was thirty-one (31) residents. The Administrator and Director of Nursing (DON) was notified that Immediate Jeopardy (IJ) existed. The IJ was determined to exist as of 12/8/16 in CFR 483.25 Quality of Care (F 323 S/S: J; CFR 483.20 Resident Assessment (F 282 S/S: J), CFR 483.75 Administration (F 490 S/S: J), and CFR 483.75(o)(1) QAA (F520 S/S:J), the date that R#2 who was assessed by the facility to require staff supervision while smoking cigarettes, as well as the need for a smoke apron when smoking, was observed to drop a lit cigarette on himself while smoking unsupervised outside of the facility. Ashes were observed on the resident's pants. R#2 stood up from his wheelchair and slapped at the cigarette that fell into his lap. The cigarette was observed on the ground still burning. Review of the care plan revealed that the resident is at risk for injury related to smoking and has a history of non-compliance regarding the smoking policy. R#2 was known to smoke in his room and the bathroom and has impaired cognitive skills related to his altered thought process. R#2 has a history of paranoid [MEDICAL CONDITION] and delusions with a Brief Interview for Mental Status (BIMS) score of fourteen (14) which revealed that he was cognitively intact. However, he was assessed by staff as an unsafe smoker and required constant supervision while smoking. It was determined that the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents. Findings include: Review of the (QA) Committee sign in sheets revealed meetings held on 2/10/15, 5/15/15, 8/20/15, 11/3/15 and 2/8/16 with each meeting an audit tool Smoking revealed a monitor of smoking in the designated area, however the Smoking audit tool does not address residents smoking on the campus. Review of the Resident Council Meetings related to Smoking, revealed the following: On 3/1/15 Resident Council Meeting: LNHA reiterated smoking policy: NO keeping of smoking materials, No selling of Cigarettes. Activity is available to do store runs. On 9/10/15 Resident Council Meeting: Residents reminded of zero tolerance smoking policy. 12.41-1A reiterated that residents are not allowed to smoke in the building, in front of the building and loiter the public walkway. Residents reminded that they were allowed to smoke on the smoking patio. LNHA informed Residents reminded that Legacy has a new smoking policy that will take effect immediately. Residents were provided a smoke break schedule and Wellington's new smoking policy. Residents informed they will not be provided their smoking paraphernalia while out on LOA. Residents also informed that their smoking utensils (lighters, cigarettes, etc.) will be labeled, placed in a lock box and placed at each nursing station. Residents are to confer with their respective unit nurses for their belongings. On 11/13/15 Resident Council Meeting: Residents reminded of cigarette policy and non-compliancy. Residents informed of Wellington's current smoking paraphernalia policy and asked to give paraphernalia to Staff to retain in smoking box. On 12/15/15 Resident Council Meeting: Residents reminded of cigarette policy and non-compliancy. Residents informed of Wellington's current smoking paraphernalia policy and asked to give paraphernalia to Staff to retain in smoking box. On 1/19/16 Resident Council Meeting: Residents voiced concern that the CNA being removed the floors to facilitate smoke breaks is taking away from their care primarily on the 3-11 shift, as the smoke breaks on occasion extend beyond the Spin time frame. DON addressed the concern and will revamp the smoke break allocation. The DON re-emphasized the smoke policy and clarified for residents that all smoking is to be supervised residents reminded of cigarette policy and non-compliancy. Residents informed of Wellington's current smoking paraphernalia policy and asked to place paraphernalia in designated areas. On 2/9/16 Resident Council Meeting: Frustration voiced by a resident to being questioned if he had cigarettes on his person, The President stated that the policy denotes that no resident is to have cigarettes on them and as such the staff are to ascertain if that is being adhered to. A resident put forward the proposal to restrict smoke breaks to only those residents who actually had cigarettes, however, that would be a discriminatory practice and would not be allowed no selling of cigarettes by residents, or asking other residents to buy cigarettes from the store. Staff not available in a timely manner to facilitate smoke break The Smoke breaks have been restructured. Staff have been hired to cover the weekend {Saturday/Sunday} from 9AM-9PM, Monday through Friday the smoke break will begin at 6:30AM, schedule attached. The Activity department will make store runs twice daily to facilitate those who need items from the store. Announcements will be made throughout the day as reminders NO RESIDENT IS TO KEEP SMOKING MATERIAL ON THEIR PERSON, all smoking material is to be maintained by staff Review of the facility's Smoking Policy revealed the following: Safety Restrictions: The Attending Physician, Director of Nurses, and the Care Plan Team shall have the authority to make determination as to which residents are responsible (cognitively able to make safe decisions for self and others) or non-responsible (not cognitively able to make safe decisions for self and others), prior to or upon Admission, and to what restrictions, if any, will need to be placed on the resident's smoking privileges. The Smoking Evaluation, which is completed upon admission, quarterly, and with a Significant Change in resident's mental or physical condition, will assist with determination of responsibility. Any restrictions placed on smoking privileges shall be noted on the care plan so that all personnel may be alert to smoking restrictions. All residents shall not be permitted to smoke without the direct supervision of a staff member, and direct supervision must be provided throughout the entire smoking period. Direct Supervision of Residents: The facility shall provide a reasonable means of providing direct supervision to those residents wishing to smoke. Staff Members shall be the persons to assist in providing this service to the residents. The care plan must be reviewed to ascertain if any specific safety devices, like a non-flammable apron, must be used during the smoking period. While the facility will attempt to accommodate those residents who desire to smoke, the facility's primary obligation is to the safety of the facility as a whole. Interview on 12/07/15 at 10:43 a.m. with the Administrator revealed residents are allowed to sign themselves out of the facility. If a resident has a low Brief Interview for Mental Status (BIMS) score then they are not allowed to sign out. The facility does not have a policy on what an acceptable BIMS score would be, but the expectation is that a resident's BIMS summary score would be ten (10) or greater. The Administrator further revealed that we are aware of concerns of resident's signing themselves out and purchasing drugs and alcohol. Continued interview revealed they have residents that have returned to the facility intoxicated. Interview on 12/09/15 at 2:35 p.m. with Receptionist FF revealed that her job responsibilities include to monitor the front door and make sure residents and family members sign in/out of the facility. FF stated some of the residents go out regularly, they write where they are going, the time they are leaving and upon return to the facility they sign in the time of return. Some of the regulars sign out to go outside to smoke but they are not allowed to smoke in front of the facility they go on down the road to smoke. Interview on 12/09/15 at 3:41 p.m. with the DON revealed that according to the facility sign out policy resident's needs to have a Brief Interview for Mental Status (BIMS) score of ten (10) or higher and are physically capable of being mobile. If the receptionist is not sure about a resident then she will call and ask the charge nurse. There is an elopement list at the front desk that list resident who are and who are not safe to sign themselves out of the facility on short pass. The DON, the Unit Manager, and the Administrator meet to determine if a resident is able to sign themselves out. Currently there is a lot of verbal communication. The receptionist asks and we say okay or not okay. The DON further stated that when a resident is a smoker then a smoking assessment will be done on admission, quarterly, and as needed. If a resident is seen with any smoking paraphernalia then it is confiscated. The staff conducts sweeps to check for smoking paraphernalia usually on the 11 - 7 shift. The resident's cigarettes and lighters are kept in three tackle boxes at the front desk. Interview on 01/11/16, at 5:55 p.m. with the Administrator and review of the Resident sign out sheets revealed the Administrator stated that the residents don't have to tell us (Administrator/staff) where they are going when they sign out. When a resident signs out they take full responsibility for where they go and what they do. Further interview with the Administrator revealed I have the staff to walk around the campus every day to be sure there are not any stragglers, or homeless people around the facility. The staff check and make sure none of the residents are blocking the center across the street, and they make sure the residents are not in the way of visitors coming into our facility. When the staff walk the facility campus, it's a general check, not a specific check. I don ' t have a specific check off list that the staff can go by when they are canvassing the facility but, if I did have a checklist, for the staff, then checking for resident ' s smoking around the campus. Interview on 01/12/16 at 2:20 p.m. with R#6 revealed he signs out of the facility daily to go out and smoke. R6 stated the Receptionist, Activity Director and DON knows that he signs out of the facility to smoke. R6 stated the staff tell the residents not to smoke in front of the building so he has to go down the road to smoke. The staff have come down the road and told him he has to go on down the road further and around the corner to smoke or else put the cigarette out and come back inside the facility. R6 stated he goes to the store and buys cigarettes and/or cigarette lighter when he needs to. He gives the cigarettes and/or cigarette lighter to the staff but admitted he sneaks some of the cigarettes and saves them for later when he signs himself out to go smoke. Interview on 01/12/16 at 2:40 p.m. with R#9 stated when I sign out to smoke the staff say don't smoke around the facility. As long as you don t smoke around the building they are okay with it. R9 said he signs himself out to smoke one to two times a day. R9 further stated the Administrator don't tell us where to smoke just says don't hang around the building. Interview on 01/12/16 at 2:48 p.m. with R#12 revealed she signs herself out of the facility two times a day to go to the store to play the lottery. R12 stated I don't usually smoke when I sign myself out but sometimes I will smoke, at the store, if I see someone from the neighborhood. I can buy cigarettes and cigarette lighters but I turn them in to the staff when I get back to the facility. Interview on 01/12/16 at 3:37 p.m. with CNA WW revealed that the DON has told the staff that the residents are not allowed to smoke in front of the building. WW further stated the staff have always told residents that sign out of the facility to smoke, they are not to smoke in front of the building however, WW has seen residents smoking outside of the facility. Interview on 01/13/16 at 12:43 p.m. with the Medical Director revealed if a resident had a BIMS summary score of zero (0) it would be difficult to see how that resident would be able to sign themselves out. The Medical Director further revealed that the resident should not be unsupervised and the RP should be notified. Continued interview revealed that if the facility is allowing a resident that is cognitively impaired with a BIMS summary score of zero (0) that would be troubling. He stated the criteria he would expect a resident to meet in order to sign themselves out of the facility was that the resident would not be cognitively impaired having a BIMS summary score of ten (10) to fifteen (15) and that they would be their own RP. The State Survey Agency validated the corrective action taken by the facility as follows: In-service materials, smoking assessments audits, care plans, and Leave of Absence (LOA) sign out sheets were reviewed to ensure compliance. Interviews and observations were conducted with staff and residents to ensure they were knowledgeable with the changes in the Smoking and LOA policies. There was no further evidence of residents signing out LOA to smoke, and no observations of unsupervised, or unsafe smoking by residents. The facility's Smoking Policy for Residents was revised January 2016: Procedures: 1. Prior to, or upon admission, residents shall be informed in writing, that smoking is permitted in the designated area only - patio, and that smoking articles of any kind are to be stored in the nurses' station (or area designated by the facility) and not permitted to be stored in resident living and sleeping quarters. 2. All residents will be evaluated by licensed nursing staff regarding smoking preferences upon admission, quarterly, and with significant change in resident mental or physical condition. All resident s who smoke will be further evaluated for risk factors, responsibility, and will be oriented to smoking areas and procedures. Residents who smoke will have a plan of care related to this activity. 4. Only facility approved ashtrays shall be used in designated smoking areas. Direct Supervision of Residents: 1. Any resident regardless of classification shall not have their smoking privileges altered solely because of the restrictions placed on their smoking habits. 2. The facility shall provide a reasonable means of providing this service to residents wishing to smoke. 3. Staff members shall be the persons to assist in providing this service to residents. 4. The care plan must be reviewed to ascertain if any specific safety devices, like a non-flammable apron, must be used during the smoking period. The revised Smoking Policy addressed all areas including: Procedures, Safety Restrictions; Smoking Articles, Purchasing/Storage of Smoking Articles, and Direct Supervision of Residents. Review of materials provided by the Administrator she revealed that the facility has conducted education for all staff related to the Smoking Policy. Smoking assessments and care plans were reviewed and updated as needed and smoking attendants were educated on functional capabilities for each resident. In addition, the Administrator facilitated a Smokers meeting on January 11, 2016, for all residents and responsible parties to review the smoking policy and enforcement measures which will be taken for non-compliance. The Administrator further revealed that through staff interviews and observations the facility has not had any reports of injury related to smoking while under personnel supervision or when a resident has been out of the facility on LOA. On 12/10/15, the facility conducted a Smoking Assessment Audit of every resident that smoked cigarettes. Review of the Audit revealed that at that time there were forty-four (44) residents residing in the facility that smoked. Each resident care plan was updated, the type of intervention required was listed (ex: supervision, 1:1, apron). The assessment date and whether the resident was identified as a safe or non-safe smoker. On 12/9/15, the facility conducted staff in-service training regarding the facility's Smoking Assessments and requirements for completion. Smoking assessments will be completed within 24 hours of admission, quarterly, with significant changes, and annually. The material was presented orally with opportunity for questions and answers at the end of the in-service. A total of ninety-seven (97) licensed and unlicensed staff were in attendance. On 12/10/15, the facility conducted staff in-service training regarding Confirmation of Responsible Party/Person (RP) designation upon admission. If a resident is admitted to the facility without RP designation or confirmation of such; the received personnel must call the location from which the party was received and speak to whomever responsible to confirm and/or obtain the existence of and contact information for the RP. A total of fifty-seven (57) licensed and unlicensed staff were in attendance. On 12/11/15 and 12/12/15, the facility conducted staff in-service training regarding Smoking Policy/Assessments. A total of eighty-nine (89) licensed and unlicensed staff were in attendance. On 12/9/15, the facility conducted staff in-service training regarding the Leave of Absence (LOA) Process. A total of seventy-one (71) licensed and unlicensed staff members were in attendance. The material presented included that residents may leave the facility from time to time for various reasons. Many times it is medically related, and other times it is socially focused. It must be noted that the process of leave of absence could place the facility at risk for events occurring while the resident is away from the facility; depending on the steps the facility takes before the resident leaves. There must be a process to assure: There is a signed release for leave by the resident and/or responsible party. Arrangements for medications to be administered while the resident is absent from the facility are in place. This must include instructions, packaging and a medication count. This should be noted in the nursing notes that address LOA. Certainly a resident who is their own responsible party can be independent with deciding if and when they would like to take a leave of absence. It is important for their safety that they let the facility know when they are taking a leave of absence. In addition, the capability to take a leave of absence must be approved by their primary physician. If a resident wishes to leave the facility against medical advice (AMA) then an AMA from must be signed by the resident. If they have a responsible party, notification must occur prior to release. At times a resident who is independent may want to leave the facility to seek unsafe activity. When this is recognized the staff must notify the physician immediately and involve the appropriate agencies that can assist the resident to not be a harm to themselves. When knowledge of such is present, it is expected that the administrator is also notified and the appropriate action taken. The LOA/AMA Policy was updated on 3/26/16 to reveal that residents who are their own responsible party can be independent in deciding of and when to take a LOA. Observations made of the 1:30 p.m. resident smoking breaks on the patio on 3/17/16, 3/18/16, and 3/21/16 revealed that the smoking assessment/care plan binder was present at each smoke break and was used to indicate the guidelines for safe smoking of each resident. There were no concerns observed with residents' safety or supervision. Interview on 3/18/16 at 1:50 p.m. with the Administrator after reviewing actions put in place revealed that every smoker in the facility has been assessed and their care plans updated. She further revealed that the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) completed visual observations of every smoker observing for physical dexterity, and safety awareness. Residents were questioned regarding their smoking preferences, but safety was given a priority. Interview on 3/23/16 at 2:00 p.m. with the Administrator revealed that the facility has slowly transitioned the more independent residents to less restrictive environments. The Administrator confirmed that residents repeatedly not abiding by the smoking policy are issued a discharge. Continued interview revealed that the facility used a general care plan that stated supervision while smoking, but it has been updated since December 2015 to be more specific for each resident in regards to whether or not the resident needs an apron etc. The Administrator revealed the care plans have been revised to say supervision while on the smoking patio. Continued interview revealed that Interview on 3/23/16 at 2:20 p.m. with the Administrator revealed that the LOA sign out sheet had been modified in January to include more information as to resident's responsible party and phone number. The Administrator further revealed that the information on the top section of the LOA form had not changed and resident's that sign out LOA have been educated that once they sign out of the facility, the facility is not responsible for them once they leave the campus. When asked what steps the facility has taken to ensure that the smoking residents are safe, she revealed that the smoking residents have attended a smoking meeting to discuss that the facilities expectations are for safe smoking practices. She revealed that the issues of smoking is also discussed at each resident council meeting, staff perform daily room checks looking for smoking paraphernalia in resident's rooms. Continued interview revealed that facility has also been trialing additional smoke break times to discourage resident's from signing out LOA to smoke. The facility has been trialing on the weekends having the smoking patio open and available from 9:00 a.m. to 9:00 p.m. When asked what happens when staff make smoking paraphernalia rounds and a resident is found multiple times with smoking items. The Administrator revealed they would educate the resident on the importance for safety for them as well as all of the other residents and that smoking items need to be locked away. She revealed that if a resident has been found multiple times with smoking items and education is not working then the facility will begin the process of finding the resident a less restricted place to reside such as an assisted living facility.