Every finding on record at Magnolia Ridge

Based on interviews, medical record review, and review of a facility policy titled, Genesis Physician Services, the facility's Medical Director (MD) failed to ensure the appropriateness and quality of Resident Identifier (RI) #9's medical care. On 04/07/2025 a change of condition was noted in RI #9's medical record related to bleeding from a surgical incision. The CRNP (Certified Registered Nurse Practitioner) was notified, and orders were obtained to hold RI #9's Apixaban (Eliquis) 5 milligrams (mgs), ordered twice daily, for three days. RI #9's Eliquis was held on 04/07/2025 at 8 PM until 04/10/2025 at 8PM.On 04/09/2025 the MD (Medical Director) made an acute care visit for RI #9. The MD's note indicated that he was not aware of ongoing concerns regarding bleeding from RI #9's surgical incision and RI #9's current lab results. The lab results documented on the MD's note dated 04/09/2025 were not the most current results. The MD reported RI #9's Eliquis should have continued to be held, but he expected the specialist, RI #9's Orthopedic Surgeon, to discontinue the medication.RI #9's Eliquis was resumed at 8 PM on 04/10/2025.The Orthopedic surgeon said he would have not resumed the Eliquis on 04/10/2025, but he left those decisions to the facility's Medical Director.On 04/16/2025 a repeat hemoglobin was drawn and resulted on 04/17/2025 with value of 4.9 g/dL. RI #9 was transferred to the hospital on [DATE].It was determined the facility's noncompliance with one or more requirements of participation has cause, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.70 Administration is Free from Unnecessary Drugs.On 05/31/2025 at 7:08 PM, the interim Administrator and Market Clinical Advisor were provided a copy of the IJ template and notified of the findings of immediate jeopardy and substandard quality of care in the area of Administration at F841- Responsibilities of the Medical Director.The IJ began on 04/07/2025 and continued until 06/04/2025 when the survey team verified onsite that corrective actions had been implemented. On 06/05/2025 the immediate jeopardy was removed. F580 was lowered to the lower severity of no actual harm with a potential for more that minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revised their corrective actions as necessary to achieve substantial compliance.This deficient practice had the potential to affect all residents who resided at the facility.Findings Include:Cross Reference F580 and F757.Review of a facility policy titled, Genesis Physician Services, with a revision date of 07/26/2023 revealed the following:POSITION TITLE: Medical Director .POSITION SUMMARY: The Medical Director partners with the Regional Medical Director to promote the delivery of clinical services in a manner that fulfills the Genesis Physician Services (GPS) mission of achieving the highest levels of clinical quality, efficiency, and outcomes .RESPONSIBILITIES: .Coordination of Medical Care - Direct and coordinate facility-wide medical care. Resolve issues related to continuity of care and transfer of medical information between the facility and other care settings. Review individual resident cases as requested or indicated .ESTABLISHES STRATEGIC FOCUS AND EFFICIENCY AT THE CENTERreadmission Avoidance - Co-lead the Center's strategy to minimize avoidance readmission with the DON (Director of Nursing), through readmission review and center-based clinical meeting, as well as collaboration with hospital and home health agencies . DIRECTS PATIENT CAREDirect the medical care of Center residents who are assigned to the Medical Director as the Attending Physician .RI #9 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Unspecified Atrial Fibrillation and Displaced Intertrochanteric Fracture of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing. RI #9's face sheet identified the MD as RI #9's Primary/Attending physician.A Progress Note dated 04/01/2025 indicated RI #9's Orthopedic follow-up appointment was pending.Progress Notes for RI #9 dated 04/07/2025, revealed a SBAR (Situation Background Assessment Recommendation) Summary for Providers that documented:Situation: The Change in Condition/s reported on this CIC [Change in Condition] are/were: Bleeding (other than GI [gastrointestinal]) . Nursing observation, evaluation, and recommendations are: Bleeding at incision site left hip . The note indicated that the Primary Care Provider was notified and ordered RI #9's Eliquis 5 mg (milligram) to be held for three days, a hemoglobin and hematocrit to be obtained on 04/08/2025, and apply three drops of Afrin to 4x4 gauze and apply left hip.A Lab Results Report for RI #9 revealed the lab was collected on 04/08/2025 and was reported on 04/09/2025 at 10:41 AM. The results indicated RI #9 had a hemoglobin of 7.7 which was low. The normal range for a hemoglobin level was 12.0 - 16.0. RI #9's hematocrit level was 25.9 which was also low. The normal range for a hematocrit level was 36.0 - 48.0. On 04/09/2025 MD made rounds and documented in RI #9's record: Nursing staff voices no new concerns . no joint deformity, swelling, redness . Skin warm and dry . CPT Codes: Total time spent 30 minutes reviewing labs, medications . examining patient . Labs reviewed 7/10/2024 Hemoglobin (HGB) 12.3 and Hematocrit (HCT) 39.5 and 1/6/2025 indicated H&H 11/38.A Progress Note for RI #9 with an effective date of 04/09/2025 at 11:00 AM electronically signed by LPN #26 documented that the MD and CRNP #75 visited RI #9. The note indicated a follow-up X-Ray of his/her left hip was ordered and no other orders were indicated. The note also indicated that RI #9 had a follow-up appointment with the orthopedic doctor on 04/10/2025. A Progress Note for RI #9 with an effective date of 04/09/2025 at 11:00 AM electronically signed by the Medical Director (MD) documented: . Continue current POC [Plan of Care] . Nursing staff voices no new concerns. The patient and all other medical conditions are stable at this time . Medications: . Apixaban Oral Tablet 5 MG Give 1 tablet by mouth two times a day for anticoagulants . Physical Exam: . Heart Rate: 106 bpm [beats per minute] . The patient is well developed and in no acute distress . Labs . 7/10/2024 HGB [Hemoglobin] 12.3 and HCT [Hematocrit] 39.5 and 1/6/2025 indicated H&H 11/38.A review of RI #9's April 2025 Medication Administration Record (MAR) revealed RI #9's Eliquis was held on 04/07/2025 at 8:00 PM; on 04/08/2025 at 8:00 AM and 8:00 PM; on 04/09/2025 at 8:00 AM and 8:00 PM; on 04/10/2025 at 8:00 AM and resumed on 04/10/2025 at 8:00 PM. A Progress Note for RI #9 with an effective date of 04/16/2025 at 11:48 AM electronically signed by the Medical Director (MD) documented: . Continue current POC [Plan of Care] . Nursing staff voices no new concerns. The patient and all other medical conditions are stable at this time . Medications: . Apixaban Oral Tablet 5 MG Give 1 tablet by mouth two times a day for anticoagulants . Physical Exam: . Heart Rate: 62 bpm . The patient is well developed and in no acute distress . Labs . 7/10/2024 HGB [Hemoglobin] 12.3 and HCT [Hematocrit] 39.5 and 1/6/2025 indicated H&H 11/38.Progress Notes for RI #9 dated 04/16/2025 at 11:48 documented another Summary for Providers that documented a change in condition was reported to CRNP #75 by LPN #26. The note indicated that RI #9 had poor appetite, confusion, lethargy. CRNP #75 gave order to hold Eliquis for three (3) days, obtain a Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) labs on 04/17/2025.Another Lab Results Report for RI #9 dated 04/17/2025 documented RI #9 had a hemoglobin of 4.9 g/dL and a hematocrit level of 16.6%.On 05/30/2025 at 5:00 PM, a telephone interview was conducted with RI #9's Ortho MD. The Ortho MD said he was not aware RI #9 had a Hemoglobin level of 7.7 when he/she came to his office on 04/10/2025. The Ortho MD said from a doctor's perspective he would not have resumed RI #9's Eliquis when the Hemoglobin was 7.7, but the decision was left up to RI #9's primary MD.On 05/28/2025 at 7:25 PM an interview was conducted with the Medical Director (MD). The MD was asked, what was his role at the facility. The MD said he was the Medical Director, Physician Provider, and he supervised the medical team. The MD said three CRNPs worked under his license at the facility. The MD was asked what was the CRNPs role at the facility. The MD said, medical care and they discuss issues that need to be sorted out with him. The MD was asked if he was notified about RI #9's incision bleeding several days post-operatively. The MD said he did not know much about the bleeding until after RI #9 had been transferred back to the hospital. The MD said if there were concerns with wound care, incisions, or bleeding that he would ask the wound management treatment nurse. The MD was asked when was he notified of RI #9 having any concerns like excessive bleeding from surgical incision from 03/28/2025 through 04/17/2025. The MD said no one told him about that. The MD was asked, was he notified about RI #9's hemoglobin level of 4.9 on 04/17/2025. The MD said no, he did not think so. The MD added that the facility's staff would call the CRNP. The MD was asked, would he want to be called about a resident's hemoglobin level of 4.9. The MD said, they can call me about anybody in the building. The MD was asked should he be notified and he said yes, he wanted to be notified about anything. During a follow-up interview on 05/30/2025 at 5:10 pm with MD, he stated again that he was not made aware of RI #9's hemoglobin levels but should have been made aware immediately. On 05/31/2025 at 2:41 pm a final follow-up interview was conducted with the MD. The MD was asked, when he made rounds with the residents, how did he know that he was reviewing their most recent labs. The MD said, the labs were in the chart, but usually the CRNP made visits when he was not there because they were here daily, so they saw the labs first, and if it was something that he should know or they cannot address themselves, they would let him know and they discussed it. The MD said the facility was responsible for notifying him if there were any labs for review. The MD said he could look in the chart to review them, but the staff also rounded with him and they would tell him about any new problems or concerns with the residents. The MD was asked, when the CRNP wrote orders for RI #9's Eliquis to be held for three days, for Afrin drops, and to repeat labs when his/her hip wound was bleeding, should the Eliquis have been restarted without the results of the follow-up labs. The MD said a decision was made to recheck the labs when his/her hemoglobin was 7.7 because that was not critical. The MD said it was necessary to look at the big picture, but later when it was critical at 4.9, RI #9 was sent out. The MD said before that RI #9 was seen by the Orthopedic Surgeon who was a specialist and was expected to know when the resident went to see him in his office what medications the resident was on, if he should review labs or anything to do with the resident while they were in his office. The MD said he was not trying to throw the Orthopedic Surgeon under the bus, but this was a nursing home and not a hospital, and they sent the resident to him about a problem since he was the surgeon, so he should be expected to assess the resident and do what he needed to for his/her condition while in his care. On 05/30/2025 at 5:00 PM, a telephone interview was conducted with RI #9's Orthopedic Surgeon. The Orthopedic Surgeon said he was not aware RI #9 had a Hemoglobin level of 7.7 when RI #9 came to his office on 04/10/2025 and he would have liked to have been notified. The Orthopedic Surgeon was asked would he have resumed RI #9's Eliquis at 5 mg twice daily when RI #9's hemoglobin was 7.7 the day prior. The Orthopedic Surgeon said he did not manage that, but as a doctor's perspective he would have wanted to know, and he would not have resumed the Eliquis. The Orthopedic Surgeon said that decision was left to the Medical Director or primary physician.2) A review of RI #9's hospital medical record revealed a Progress Note-Generic signed on 05/01/2025 by a hospital physician. The note included: . Medications . DAPTOmycin . 600 mg [milligram] . daily .piperacillin-tazobactam 4.5 g [grams] . q8hr [every eight hours] .Assessment/Plan: .Wound growing Pseudomonas-carbapenem resistant and VRE [Vancomycin Resistant Enterococcus] - Cont [continue] Zosyn and Daptomycin - need long term IV antibiotics - Place PICC . ID [infection disease] has give [sic] DC [discharge] antibiotic regimen - CM [Case Management] is aware - PICC ordered - pt [patient should be ready for DC in am if antibiotics arranged .RI #9's Discharge Summary created by a hospital physician on 05/02/2025 documented: . Hospital Course: . Wound growing Pseudomonas-carbapenem resistant and VRE - Cont [continue] Zosyn and Daptomycin - need long term antibiotics - PICC is in place - DC [discharge] with daptomycin and Zosyn through June 2 .On 05/27/2025 at 9:10 AM an interview was conducted with the admission Director (AD) who reviewed RI #9 hospital records from his/her admission to the facility on [DATE]. The AD was asked, looking at the hospital records what can she tell the surveyor about what RI #9 needed for his/her re-admission to the facility. The AD said there was a medications list, that RI #9 had a Peripherally Inserted Central Catheter (PICC), and RI #9 needed intravenous Daptomycin and Zosyn through 06/02/2025.The facility's Order Summary Report for RI #9 documented an order for Zosyn 4.5 gram every 8 hours with start date of 05/05/2025.A review of RI #9's May 2025 MAR revealed neither of the antibiotics were administered until 05/05/2025, three days later after RI #9 was readmitted to the facility.During an interview on 05/25/2025 with LPN #27/Unit Supervisor stated when RI #9 was admitted to facility on 05/02/2025 there was an order to administer Zosyn but no instructions on how to administer it. LPN #27 stated she called the hospital on [DATE] to obtain orders but was unable to get anyone. She stated she did not notify the physician. LPN #27 stated RN #25 contacted RI #9's Orthopedic Surgeon on 05/04/2025 and documented to start the Zosyn on 05/05/2025.During an interview on 05/28/2025 at 7:25 PM with the MD he stated when a resident was admitted from the hospital with a PICC line and the discharge summary included administration of IV antibiotics, but the discharge orders did not include the IV antibiotics, he would expect the facility to notify the doctor that ordered the medication and notify him as Medical Director as well. The MD was asked, who should provide the orders. The MD said the department that the resident came from, and then call the physician group or his group. The MD was asked about his involvement with behavior management and he send they tended to call psychiatric services because they were the specialist.********************************************************The facility submitted an acceptable plan to remove the immediacy of the identified deficient practice that included:*******************************************Assessments1. RI #9 was discharged from the facility on 5/19/25. Audits1. On 5/31/25, the facility conducted an audit of 118 residents from 04/01/04 to 06/01/25 to identify residents receiving anticoagulant therapy with laboratory orders to verify physician notification. Of 118 residents, 13 residents were identified receiving anticoagulant medications with 1 resident identified with laboratory orders. Based on review, the Physician and/or Certified Registered Nurse Practitioner was notified of the abnormal laboratory values. 2. On 6/01/25, Nurse Managers and/or designee conducted an audit of 118 residents to identify residents with surgical incisions. 3 of 118 residents identified with a surgical incision. On 06/01/25, an assessment was completed with no abnormalities. In-services1. On 06/01/25, the Regional Medical Director educated the Medical Director on his/her role in facilitating and coordinating medical care to ensure the appropriateness and quality of medical care. Education consisted of monitoring residents' post-surgery, evaluating surgical incisions, assessing appropriateness of medications, duration, and adequate monitoring. Additional education included monitoring and following up on abnormal lab values and collaborating with other medical providers as needed. Additionally, the Medical Director was educated to review the discharge summary from the hospital records of newly admitted or re-admitted residents to ascertain pertinent medical information to ensure the appropriateness and quality of care. 2. On 06/01/25 to 06/04/2025, the Director of AlignMed Partners and/or Regional Medical Director educated 2 of 2 Certified Registered Nurse Practitioners and 1 of 1 Optum Certified Registered Nurse Practitioners on his/her role in facilitating and coordinating medical care to ensure the appropriateness of medical care. Education included specific emphasis on monitoring residents' post-surgery, evaluating surgical incisions, assessing appropriateness of medications, duration, and adequate monitoring. Additional education included monitoring and following up on abnormal lab values and collaborating with other medical providers as needed.3. On 6/3/25 to 06/04/2025, the Regional Medical Director and/or Director of AlignMed Partners educated the Medical Director and 2 of 2 Certified Registered Nurse Practitioners, and 1 of 1 Optum Nurse Practitioner regarding reviewing the discharge summary, discharge orders, and admission orders of new or re-admitted patients within 72 hours of admission. The Physician will conduct a physical exam when completing the patient's visit on site, review post-surgical follow-up appointment notes, and assess surgical incisions as indicated by the surgical orders. Simultaneously, the Physician will assess the appropriateness of medications, durations, adequate monitoring, most recent lab values, and coordinate with other medical care practitioners and physicians.4. On 6/3/25 to 06/04/2025, the Market Clinical Advisor educated the Director of Nursing Services, Unit/Nurse Managers, Certified Registered Nurse Practitioners and/or designee on maintaining a list of residents with a significant change in condition to validate physician notification/consultation. The list of significant changes will be maintained in a binder in the DON office. The list of residents will be updated by the Unit/Nurse Managers and/or Certified Registered Nurse Practitioners and provided to the Physician weekly. Unit/Nurse Managers and/or Certified Registered Nurse Practitioners will document on the list that the Medical Director was notified/consulted weekly. Additionally, education consisted of maintaining a list of new admissions to validate the Physician has reviewed the discharge summary within 72 hours. The discharge summary will be sent electronically or by paper. The list will be documented and reviewed by the Administrator for completeness and the Medical Director will sign off weekly. The Regional Medical Director educated the Medical Director on this process on 6/3/25 to present. 5. On 6/3/25 to 06/04/2025, the Director of Nursing educated the Unit/Nurse Managers, Medical Assistant and/or designee on providing the Medical Director with the most current lab values for review. The Unit/Nurse Managers, Medical Assistant and/or designee will provide the Medical Director with the current lab values on a weekly basis. The labs are automatically integrated into the electronic Point of Care system. ***************************************************After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team verified onsite that the immediate corrective actions had been implemented the Immediate Jeopardy was removed on 06/05/2025. The scope/severity level of F841 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on interviews, record review, and the Administrator's and Director of Nursing's Job Description the administration failed to provide oversight and guidance to the facility's staff to ensure policies and procedures were developed and implemented to ensure: staff knew what behaviors and abuse should be reported and communicated; residents with Mental Illness were determined to be appropriate for the facility and received the appropriate treatment and medications as ordered; staff communicated resident's needs pre-admission to ensure medications were administered as expected following a transition of care from hospital to the facility; and management staff identified medications that had not been administered. It was determined the facility's noncompliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.70 Administration. On 05/13/2025 at 3:30 PM the Administrator (ADM) and Director of Nursing (DON) were provided a copy of the IJ template and notified of the finding of immediate jeopardy in the area of Administration and at F835- Administration. On 05/19/2025, after the facility submitted the removal plan for the above non-compliance and while the removal plan was being validated, it was determined that staff had witnessed and were aware of Resident Identifier (RI) #9's behaviors of using derogatory language and roommate incompatibility. RI #9's behaviors were not communicated and addressed until RI #9 verbally abused his/her roommate on 05/17/2025 and 05/18/2025. Further, while validating the removal plan for F760 it was determined that on 05/14/2025 the DON and Registered Nurse (RN) #25 documented missed doses of Resident Identifier (RI) #9's intravenous antibiotics scheduled to be administered between 05/06/2025 and 05/13/2025 as administered. It was determined the facility's continued noncompliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.70 Administration. On 05/28/2025 at 9:37 PM, the interim Administrator, the interim DON, and the Market Clinical Advisor were provided a copy of an updated IJ template and notified of the additional findings of immediate jeopardy in the area of Freedom from Abuse Neglect, and Exploitation at F600- Free from Abuse and Neglect. The IJ began on 04/01/2025 and continued until 05/24/2025 when the survey team verified onsite that corrective actions had been implemented. On 05/25/2025 the immediate jeopardy was removed. F835 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy to allow the facility time to monitor and/or revised their corrective actions as necessary to achieve substantial compliance. The deficient practice had the potential to affect all residents who resided at the facility. Findings Include: Cross-reference F600, F645, F609, F610, F740, F658, F760, F835, and F867. The Administrator's job description documented the Administrator's responsibilities as follows: REPORTED TO: Market President and/or Regional Administrator . POSITION SUMMARY: Create an environment where staff members are highly engaged and focused on providing the highest level of clinical care . to residents . Responsible for assuring that the center operates in full compliance with Federal and State regulations while Doing the Right Things, which will result in high levels of performance . The Administrator is responsible for planning and is accountable for all activities and departments of the Center subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents. The Administrator administers, directs, and coordinates all activities of the Center to assure that the highest degree of quality of care is consistently provided to residents. ESSENTIAL FUNCTIONS Business Excellence 1. Assures that the QAPI Process is understood and utilized by all members of the Center Leadership Team to continually improve all aspects of Center performance . 2. Oversees and assures an efficient Refer to Admit Process which maximizes Center occupancy. Staff Excellence . 3. Works in close collaboration with the Director of Nursing and department heads to assure professional development and career goals are met. Clinic Excellence 1. Is highly visible throughout the Center on all shifts and days of the week to develop positive relationships with residents, patients, family members and staff to assure that the needs of all are being met. 2. Works in close collaboration with the Director of Nursing, Medical Director . to assure high quality clinical outcomes, appropriate level of hospital readmissions, acceptable survey results and the best possible 5 Star rating. 3. Assures that staffing levels in all departments are appropriate to meet the needs of all patients and residents. 4. Confers with consultants to various departments concerning problem areas and utilizes the Q.A.P.I. Process to improve performance. 5. Creates an environment that is focused on patient and staff safety. Customer Excellence 1. Create a culture of Service Excellence which focuses on the patient experience and is responsive to patients/families concerns and grievances. Compliance . 2. Complies with and promotes adherence to applicable legal requirements, standards, policies and procedures including but not limited to those within the Compliance and Ethics Program, Standard/Code of Conduct, Federal False Claims Act and HIPAA. 3. As the center Compliance Liaison, provides leadership and support for the Compliance and Ethics Program within management area. 4. Attempts to resolve any compliance issues brought to his/her attention and report all significant compliance issues to the Compliance Officer, and assist in their resolution in any way necessary. 6. Ensures that staff participates in orientation and training programs including but not limited to all required compliance courses and relevant policies and procedures, and that such training is properly documented. Participates in compliance and other required training programs. 7. Provides open lines of communication regarding compliance issues within management area and access to the Integrity Line, and ensures that retaliation against staff who report suspected incidences of non-compliance does not occur. Promptly reports concerns and suspected incidences of non-compliance to supervisor, Compliance Liaison or to the Compliance Officer. 8. Participates in education, monitoring and auditing activities and investigations, and implementing quality assurance and performance improvement processes, as required. The Director of Nursing job description included: POSITION TITLE: Clinical POD Leader- DON (PDON) . DEPARTMENT: NURSING ADMINISTRATION . POSITION SUMMARY: . is responsible for overseeing clinical aspects for the assigned POD, in addition to the responsibilities outlined for the Director of Nursing . The Director of Nursing leads the Center clinical team . This position has overall accountability for providing leadership, direction, and administration of day-to-day operations associated with direct patient care activities, nursing practice, and clinical education and development . RESPONSIBILITIES/ACCOUNTABILITIES: . 7. Develops, collaborates with and supervises the Nurse Practice Educator to assure her/his effective, ongoing development of nurse practice and engagement through education, training, and frontline coaching; . CLINICAL EXCELLENCE: 1. Maintains a working knowledge if current clinical practice and the regulatory requirements . 2. Determines the workforce/staffing model for the Nursing department necessary to meet the nursing needs of the patients; 3. Oversees the implementation and evaluation of the staffing model to assure high-quality . care; 4. Implements, evaluates, and develops an effective nursing practice model to meet the needs of diverse patient populations; . 6. Ensure there are safe, coordinated and thorough admission and discharge planning processes in place; 7. Organizes and leads effective clinical meetings, rounds, shift to shift communication and huddles to assumes effective patient/resident outcomes. CUSTOMER EXCELLENCE: . 4. Ensures that patient's attending physician and family or responsible party are promptly notified of any significant change in the patient's health condition; . 6. Actively develops relationships and strategies for collaboration with hospitals/health systems . to promote value based care delivery. BUSINESS EXCELLENCE 1. Contributes to creating an environment that has a reputation for high ethical standards; 2. Implements the QAPI [Quality Assurance and Performance Improvement] process to assure quality, safety, and efficient clinical outcomes; . 6. Provides oversight and approves nursing department schedules . 1.3.1 Determines the staffing needs of the Nursing Department necessary to meet the nursing needs of the patients; . On 05/12/2025 at 6:46 PM an interview was conducted with the DON (FDON #2). FDON #2 reported she had worked at the facility since July of 2024 and her job duties included providing oversight to the nursing department, staffing, and day-to-day operations. FDON #2 said she provided oversight to licensed and non-licensed (nursing) staff. FDON #2 was asked how she provided oversight. FDON #2 said, daily the facility had charge nurses and administrative staff the helped with that responsibility. FDON #2 said the nurse managers reviewed residents Electronic Medication Administration Records (EMARs) for missed doses Monday through Fridays. FDON #2 said she did not know two of RI #119's monthly injections of Invega was not administered in January or February of 2024 until the current survey team identified the missed doses. FDON #2 said she did not know when she became aware of RI #119's behaviors. FDON #2 said all behaviors should be documented by staff. On 05/27/2025 at 4:00 PM during a follow-up interview with FDON #2, regarding behavior management, FDON #2 said all behaviors should be documented and if staff were not documenting residents' behaviors it would be hard to develop the correct interventions which would result in ineffective behavior management. FDON #2 was asked, how did that provide a safe, homelike environment for residents. FDON #2 said if that was the case it would be difficult. FDON #2 said she was responsible to ensure the documentation and monitoring occurred and to ensure the correct medication was administered. On 05/12/2025 at 7:47 PM an interview was conducted with the Administrator (ADM #1). The Administrator said she did not know when she first became aware of RI #119's behaviors. The ADM was asked if she was aware of RI #119's behaviors before the incident on 03/18/2025. The ADM said she was not going to be able to answer that on this big of a home. The ADM said staff were trained to document in the nursing notes and the Cardex. The ADM said all behaviors should be documented. The ADM was asked, what was her responsibility to ensure residents who had behaviors were managed, tracked, supervised, and monitored for appropriate interventions and improvement in behaviors. The ADM said her responsibility was to ensure the staff were trained and doing the stuff that they were required to do. The ADM said she provided oversight to everyone, and it was a collaborative effort to ensure residents who had behaviors were managed, tracked, supervised, and monitored for appropriate interventions and improvement in behaviors. The ADM said the oversight was provided by having clinical meetings, stand-up meetings, behavior management, behavior monitoring weekly, and care plans. The ADM said behavior monitor should continue and interventions on the care plan should be changed based on the need on the individual when a resident continued to have behaviors affecting others over several months. The ADM was asked who reviewed residents' records for missed doses of medications. The ADM said she was not clinical and could not answer. The ADM said she did not know RI #119 had missed doses of his/her antipsychotic medication. The ADM said she was not sure if RI #119's Invega was discussed in the morning clinical meeting because she could not be a voice for other staff and she could only be a voice for herself. The ADM was asked, what were her responsibilities to residents at the facility. The ADM said to make sure they were cared for properly and they were safe and out of harm's way. On 05/27/2025 at 4:00 PM during a follow-up interview with FDON #2, she said the admission Liaison (AL) was responsible for assessing residents at the hospital and communicating with the hospital before residents were admitted to the facility. FDON #2 said the AL communicated with the admission Director (AD) regarding resident needs including intravenous (IV) antibiotic. FDON #2 said she did not recall being aware before RI #9 was admitted that RI #9 needed IV antibiotics. FDON #2 was asked, who reviewed to ensure treatment and medications were administered and documented per facility policy and standards of practice. FDON #2 said Unit Managers reviewed the MARs and the Treatment Administration Records (TARs) and they had another check during the clinical meeting for all MARs and TARs. Regarding the facility's process to ensure sufficient staffing to administer RI #9's IV antibiotics, FDON #2 said a Registered Nurse was in the building to administer the 8 AM, 12 PM, and 4 PM doses. FDON #2 said RN #25 would administer the 12 AM dose. FDON #2 said there was nothing written, just verbal. FDON #2 was asked, what education was provided regarding IV antibiotics. FDON #2 said no training was documented. FDON #2 said there was no specific training provided regarding IV flushes, PICC assessment, care, or dressing changes. On 05/23/2025 at 12:11 PM during a follow-up interview with FDON #2 was asked why RI #9's Zosyn was documented as administered on 05/14/2025 that were days past due their scheduled time for administration. FDON #2 said, because that was when she identified the doses had not been documented as administered. FDON #2 said the Unit manager be looking at residents' EMARs on a daily basis. FDON #2 said RI #9's Zosyn doses that were past due and not documented as administered should have been included on the facility's initial removal plan for F760 and she was not sure why they were not. FDON #2 was asked, what evidence did they have that RI #9's Zosyn was administered considering that 42 doses of the medication were administered and only 33 doses had been used from the residents' medication supply. FDON #2 said she did not have anything other than the EMAR. FDON #2 was asked, how was RI #9's EMAR accurate. FDON #2 said RI #9's EMAR might not be accurate. On 05/23/2025 at 3:29 PM during a follow-up interview with FDON #2 she was asked about her involvement in the audit of mediations for removal plan for F760. FDON #2 said she would look at the EMAR and validate the omission or not. FDON #2 was asked, what prompted her to review these medications on 05/14/2025 when RI #9's Zosyn was documented on the EMAR. FDON #2 said she was just doing a regular check with the EMARS. FDON #2 said she understood the purpose of the audit was to validate that medications were administered and to look for omissions. FDON #2 said RN #62 and the Market Clinical Advisor provided her the instructions for performing the audit for the removal plan for Medication Administration. FDON #2 said she made the decision to document omissions on 05/14/2025 as administered rather than investigate to ensure the medication had been administered as ordered. FDON #2 said she had not investigated to determine whether RI #9's IV antibiotics were administered as ordered. FDON #2 was asked what knowledge she had of other nurses documenting missed doses of RI #9's Zosyn as administered on 05/14/2025 during the audit. FDON #2 said that she just suggested that the nurses check their EMARs. On 05/24/2025, a notification of change in Administrator and Director of Nursing was provided to the surveyor team onsite. ****************************************** The facility submitted an acceptable plan to remove the immediacy of the identified deficient practice that included: ******************************************* The Market Operations Advisor educated the Administrator on OPS300 Abuse Prohibition Policy on 5/13/25 to ensure the Administrator understands her role in operationalizing and overseeing policies within the Center, specifically the Abuse Prohibition Policy. Effective 5/24/25, a notification of change in Administrator and Director of Nursing was provided to the surveyor on site. Effective 5/24/25, a notification of change in Administrator and Director of Nursing was provided to the surveyor on site. In-services 1. On 5/13/25, the Market Operations Advisor educated the Nursing Home Administrator on: NSG206 Behaviors: Management of Symptoms and the role of the Administrator to ensure the staff are aware of what behaviors and abuse should be reported and communicated to the Abuse Prevention Coordinator. The education emphasized patients exhibiting behavioral symptoms will be individually evaluated by the Interdisciplinary team to determine the behavior. Additionally, the interdisciplinary team will identify underlying medical, physical, functional, psychosocial, emotional, psychiatric, or environmental causes that contribute to the patient's behavior and develop a person-centered plan of care. The Administrator was educated on the following responsibilities: a. Participating in and providing input to the facility staff to ensure the behavior management program is executed, and staff know what behaviors should be reported promptly to determine if the behavior rises to a potential abuse occurrence. The Administrator will be responsible for reporting and investigating all allegations of abuse to APDH in a timely manner as needed. i. The Administrator will be responsible for ensuring that the Behavior Management Program will be carried out to include daily review of Behavior Monitoring Report, a weekly behavior meeting to include a review of behaviors, care planning and education as needed to ensure Behavior Monitoring is occurring and interventions are implemented as needed. The Administrator will provide oversight and guidance to the facility staff to ensure a behavior management program was developed and implemented, staff know what behaviors and abuse should be reported and communicated ii. The Administrator will document the daily reviews, actions and recommendations on the Morning Meeting Sheet. The weekly audit includes a sign -in sheet for the weekly behavior meeting. 2. The Market Operations Advisor educated the Administrator on the Administrator's job description and to include, but not limited to, ensuring the Administrator administers, directs, and coordinates all activities of the center. To attain and maintain the highest practicable physical, mental and psychosocial well-being of the residents as part of the facility governing body on 5/13/25. The Administrator educated on the following responsibilities: a. Tracking and trending the following areas in the monthly QAPI meetings and assisting with the development of performance plans in the areas: significant medication errors, behavior management trends, allegations of abuse, and pre-admission screening. The reviews will be documented on the monthly QAPI form and maintained in the Administrator's office. 3. The Market Operations Advisor educated the Administrator on OPS300 Abuse Prohibition Policy on 5/13/25 to ensure the Administrator understands her role in operationalizing and overseeing policies within the Center, specifically the Abuse Prohibition Policy. The Administrator plays a vital role in ensuring staff are properly trained on what behaviors and abuse should be reported and communicated. The Administrator educated on the following responsibilities: a. Leading in the investigation process and following up with outstanding activities needed for a thorough investigation. The Investigation checklist will be used which includes but not limited to the following: initial report, resident/ staff interviews signed and dated, Resident care plans pertaining to the investigation, Record of training after incident, Nurses notes, Social and Psych notes if applicable, documentation of resident's behaviors, resident's outcome and corrective actions taken by the facility. A copy of the investigation checklist will be placed in all abuse allegation files. b. Ensuring that each reportable event is taken to the QAPI committee monthly for thorough review of completion, deliberation on investigation findings, and development of appropriate actions to take regarding elimination of future recurrence. c. Hosting an ADHOC QAPI to identify root cause analysis for each reportable and implement proper interventions. The ADHOC QAPI will take place within one week if a reportable event occurs. 4. On 5/13/25, the Market Operations Advisor educated the Administrator on SS105- Pre-admission Screening for Mental Disorder and/or Intellectual Disability on oversight and guidance to ensure that all patients are screened for Mental Disorders and/or Intellectual Disability prior to admission. In addition, individuals identified with Mental Disorder or Intellectual Disability are evaluated and receive care and services in the most integrated setting appropriate to their needs. The Administrator was educated on the responsibility of the following: a. Reviewing the audits completed by the Social Service Director and/or Admissions' Director to validate all residents are screened prior to admission and evaluations needed upon admission are promptly submitted for a Determination. The review will be completed after each admission to the Center. The results will be documented on a PASSAR monitoring tool. 5. On 5/15/25, the Administrator was educated by the Market Clinical Advisor and Market Clinical Lead on communicating to the governing body any concerns identified with regarding Abuse Prohibition and Behavior Monitoring. The Administrator will promptly report any allegations of abuse to the governing body for oversight and assistance. Additionally, the Administrator will track performance improvement plans in the monthly QAPI and report findings to the governing body. 6. On 5/24/25, the Market Clinical Advisor educated the new Administrator on everything the previous Administrator was educated on with a focus on the Administrator's role in the Behavior Management process to include review of behavior rounds, trends, input into causative factors and corrective actions monthly in QAPI. Education conducted on validating admissions have a pre-admission screen and evaluations are acted upon promptly. Additionally, education was conducted on reviewing the medication administration audit tools to add input and provide guidance and oversight through the QAPI process. Quality Assurance 1. The Nursing Home Administrator /designee was educated on 05/13/25 by the Market President to report findings monthly to the Quality Assurance Performance Improvement Committee for any additional follow up and/or in servicing until the issue is resolved and randomly thereafter as determined by the QAPI committee. ******************************************* After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team verified onsite that the immediate corrective actions had been implemented the Immediate Jeopardy was removed on 05/25/2025. The scope/severity level of F835 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on interviews, record reviews, and the job description for Center Sr. Executive Director the Governing Body failed to provide oversight to ensure residents were free from abuse, neglect, and significant medications errors. Further the Governing Body failed to ensure the facility staff responsible for administering medications and parenteral fluids via PICC were trained on the standards of practice. The Governing Body further failed to ensure facility staff were trained on proper resident care for residents with a PICC. It was determined the facility's noncompliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.70 Administration. On 05/28/2025 at 9:37 PM, the interim Administrator (ADM), the interim Director of Nursing (DON), and the Market Clinical Advisor were provided a copy of the IJ template and notified of the findings of immediate jeopardy in the area of Administration and at F837-Governing Body.The IJ began 05/02/2025 and continued until 05/29/2025. On 05/30/2025 the immediate jeopardy was removed. F837 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revised their corrective actions as necessary to achieve substantial compliance. This deficient practice had the potential to affect all residents who resided at the facility. Findings Include:Cross-Reference F600, F609, F610, F740, F658, F694, F835, F867.A review of the job description for Center Sr. Executive Director, documented, . REPORTS TO: Regional [NAME] President and/or Regional Executive Director.POSITION SUMMARY: Create an environment where staff members are highly engaged and are focused on providing the highest level of clinical care and compassion to patients, residents and families. Responsible for assuring that the center operates in full compliance with Federal and State regulations while Doing the Right Things, which will result in high levels of performance in each of the (company name) Strategic Focus Areas. ESSENTIAL FUNCTIONSBusiness Excellence 1.Assures that the QAPI Process is understood and utilized by all members of the Center Leadership Team to continually improve all aspects of Center performance as measured by the Center Performance Scorecard. Clinic Excellence . 4.Confers with consultants to various departments concerning problem areas and utilizes the Q.A.P.I. Process to improve performance.A review of the job description for Market Clinical Advisor documented, . REPORTS TO: Market ops Advisor and Market Leader . RESPONSIBILITIES/ACCOUNTABILITIES: . Leadership: .Provide clinical leadership in resident-centered initiatives that focus on enhancing resident's lives, periodically participating in activities to provide actionable feedback .Work collaboratively with the team to fully implement QAPI to maximize current and future clinical performance .Collaborate with the interdisciplinary team at the market and facility level to instill accountability in all departmental components tied to resident wellness. Clinical Market Management:Provide open lines of communication regarding compliance issues, operating with a deep commitment to preventing, identifying, and addressing such issues .Ensure education, training, and experience are effectively deployed to best serve our patients .******************************************The facility submitted an acceptable plan to remove the immediacy of the identified deficient practice that included:******************************************Effective 5/24/25, a notification of change in Administrator and Director of Nursing was provided to the surveyor onsite. 1.On 5/29/25, the Senior Market President educated the Market Clinical Advisor, Market Clinical Lead, Administrator, and Director of Nursing on ensuring the facility QA committee review allegations of abuse allegations within one week after occurrence to identify causative factors, ensure a thorough investigation has been completed, and verify the development and implementation of corrective actions. Education was provided not to admit and/or re-admit IV hydration or IV medication via PICC. The governing body will review the facility's reported allegations to ensure a thorough investigation has been conducted after the facility's five-day investigation. If a thorough investigation has not been completed, the governing body will provide additional guidance and appropriate corrective actions will be implemented. 2. The Administrator hosted an AD HOC QAPI on 5/29/25 to review allegations of abuse to include causative factors and/or root cause, barriers to comprehension of education, identification of abuse, reporting, investigation, and proactive strategies/corrective actions to prevent abuse and abuse allegations. Any identified concerns will be addressed with prompt education and QAPI evaluation for the development and implementation of new interventions to ensure residents are free from abuse. Participants included the Administrator, Director of Nursing, Nurse Managers, Director of Memory Support, MDS Nurse, a Licensed Nurse, and a Certified Nursing Assistant3. Effective 5/25/25, the facility will not accept patients receiving IV therapy. The Administrator updated the Facility Assessment on 5/29/25. 4. On 5/29/25, the Market Clinical Advisor educated the Director of Admissions and Director of Marketing on the admission process related to IV therapy and antibiotics to include the facility will not admit patients with orders for IV hydration or IV medications.*******************************************************After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team verified onsite that the immediate corrective actions had been implemented the Immediate Jeopardy was removed on 05/31/2025. The scope/severity level of F725 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on interviews and record reviews the facility failed to ensure Resident Identifier (RI) #119, RI #76, and RI #9 were free of a significant medication errors. Specifically, the facility failed to ensure: 1) RI #119's monthly paliperidone (Invega) injection was administered on 01/24/2025 and 02/24/2025. RI #119 had a history of cursing and yelling in the facility and on 03/18/2025 RI #119 threatened to kill people in the facility. RI #119 was sent to the hospital for evaluation. On 04/01/2025 RI #119 hit RI #53 in the face twice with a closed fist. 2) Further the facility failed to ensure RI #76's morning medications including Imdur (Isosorbide Dinitrate), Lacosamide, Keppra, Amlodipine, and Losartan were administered on 05/06/2025 when RI #76 requested that Licensed Practice Nurse (LPN) #42 administer the medications after he/she ate breakfast. The LPN did not administer the medications. On 05/07/2025 RI #76's blood pressure was 200/97. It was determined the facility's noncompliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.45 Pharmacy Services. On 05/13/2025 at 3:30 PM, the Administrator and Director of Nursing (DON) were provided a copy of the IJ template and notified of the findings of immediate jeopardy in the area of Pharmacy Services at F760- Residents are free of Significant Med Errors. After the facility submitted the removal plan for the above non-compliance that indicated the DON conducted an audit of residents Medications Administration Records and no significant medication errors were identified, the survey team began to validate the removal plan and identified: 3) The facility failed to ensure RI #9 was free from significant medication errors when facility staff failed to administer RI #9's intravenous antibiotic Piperacillin-Tazobactam (Zosyn) as ordered. RI #9's Electronic Medication Record documented that facility staff administered 42 doses of Zosyn to RI #9. Of the 42 times, five doses were documented as administered days later on 05/14/2025 by Registered Nurse (RN) #25 who was not clocked in at the time the doses were due, two doses were documented as administered days later on 05/14/2025 by the Former Director of Nursing (FDON #2), and three doses were documented as administered by Licensed Practical Nurse (LPN) #101 who was not qualified to administer the antibiotic and reported she did not administer the medication. RI #9's scheduled dose of Zosyn 05/17/2025 at 12 AM was not administered. A total of ten of 42 doses of RI #9's scheduled Zosyn were either documented days later or documented by staff who reported it was documented in error. RI #9's pharmacy records indicated 56 doses were delivered. On 05/20/2025, 23 of the 56 delivered doses of RI #9's Zosyn were observed unused in the medication room. On 05/28/2025 at 9:37 PM, the interim Administrator (ADM), the interim DON, and the Market Clinical Advisor were provided a copy of an updated IJ template and notified of the additional findings of immediate jeopardy in the area of Pharmacy Services at F760- Residents are free of Significant Med Errors. The IJ began on 04/01/2025 and continued until 05/30/2025. On 05/31/2025 the immediate jeopardy was removed. F760 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revised their corrective actions as necessary to achieve substantial compliance. These deficient practices affected RI# 119, RI #76, and RI #9, three of three residents sampled for medication administration. Findings Include: Cross-reference F600, F658, F694, F740. Review of a facility policy titled, Medication Administration General Guideline, dated 01/25, revealed the following: POLICY . PROCEDURES . 7.1 General Guidelines . Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber. 4. Medications are to be administered at the time they are prepared. 14. Medications are administered within 60 minutes of the scheduled time . Medications should not be given at mealtimes . unless specifically ordered with meal. Documentation: 1. The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications. 2. If a regularly scheduled medication is withheld, refused, or given at other than the scheduled time . the nurse shall be documented in either the Electronic Medication Administration Record or the paper MAR that the dose was withheld, refused, or given at other than the scheduled time, and enter an explanatory note . 4. The administration of the resident's medication is documented by one of the following processes: Documentation of the medication administration in the Electronic Health Record . 1) Cross-Reference F600 and F740. RI #119 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnoses to include: Schizophrenia Bipolar, Insomnia, and Severe Dementia with Agitation. RI #119's MDS assessment with an ARD of 01/02/2025 documented RI #119 had a Brief Interview for Mental Status (BIMS) score of 14 of 15 which indicated that he/she had intact cognition. RI #119's hospital Extended Care Facility Transfer Note dated 12/27/2024 included RI #119's Discharge Orders. The Discharge Orders included an order for . Paliperidone (Invega Sustenna 117 mg [milligram] /0.75 mL [milliliter] intramuscular suspension, extended release) . Every 1 Month . Next dose due 01/24/25 . RI #119 physician orders included an order dated 01/26/2025 for Invega Sustenna injection once per month for Schizoaffective Disorder. The order indicated that RI #119 was to receive the medication injection intramuscularly and it was to start on 01/24/2025. RI #119's Electronic Medication Administration Record (EMAR) for the month of January 2025 indicated RI #119 had an order for monthly Invega injection that was to start on 01/24/2025. The EMAR revealed that Invega was not administered to RI #119 in January 2025. On 05/12/2025 at 12:17 PM an interview was conducted with RN #4, Unit Supervisor. RN #4 reviewed her documentation and said on 01/24/2025 RI #119's Invega was not available, and she re-ordered it from the pharmacy and entered a note that it needed to be administered on 01/25/2025. RN #4 was asked; how would staff have known to administer RI #119's Invega on 01/25/2025. RN #4 said she would have verbally communicated it with them, but did not recall who. RN #4 said she should have written a one-time dose for the Invega to be administered on 01/25/2025, notified the CRNP or Medical Director, and documented the notification. RN #4 was asked about RI #119's behaviors, and she said part of RI #119's personality was to yell and curse daily or every other day. RN #4 could not recall exactly what RI #119 would say, but said RI #119 would say shit, damn, bitch in the hallway and anyone, including residents, in the hallway could hear RI #119. RN #4 said when RI #119's Invega was not administered as ordered it would result in RI #119 having increased behaviors. RN #4 was asked, when she said RI #119's personality was yelling out and cursing, could that have been because he/she did not get his/her Invega and should those behaviors have been documented daily. RN #4 said, yes, the yelling and cursing could have been attributed to RI #119's Invega not being administered and staff should have been documenting RI #119's behaviors on a daily basis. RI #119's EMAR for the month of February 2025 indicated RI #119 refused monthly Invega injection on 02/24/2024. The refusal was documented by the Assistant Director of Nursing (ADON) #3. On 05/10/2025 at 5:54 PM an interview was conducted with ADON #3. The ADON said the doctor, or the Certified Registered Nurse Practioner (CRNP) should have been notified when RI #119 refused his/her monthly injection of medication prescribed for Schizophrenia. RI #119's nursing notes did not include documentation that the doctor or CRNP was notified that RI #119 refused his/her monthly injection of Invega. On 05/10/2025 at 3:30 PM an interview was conducted with CRNP #53. The CRNP said RI #119 was admitted with orders for Invega. The CRNP said RI #119's Invega was ordered for Schizophrenia and was to be given once a month. When asked, how long would someone need to be prescribed Invega, the CRNP said continuously, and she would not discontinue that medication. On 05/12/2025 at 11:31 AM a phone interview was conducted with the Pharmacy Director. The Pharmacy Director said the facility ordered and received RI #119's Invega on 01/24/2025. The Pharmacy Director said the facility did not order another dose until April 2025. The Pharmacy Director said the nurses had to call in all orders with the pharmacy because it was not on an automatic cycle because the Governing Body wanted the nurses to be responsible for the medications. The Pharmacy Director said Invega was a second-generation antipsychotic, and it was for mood stabilization. The Pharmacy Director said if Invega was not administered as prescribed to a resident who was prescribed Invega for Schizophrenia, the resident could have a full break and could start hearing voices. The Pharmacy Director continued to say the resident would not be stable at all. On 05/12/2025 at 4:36 PM an interview was conducted with the facility's Medical Director (MD). The MD said he was not made aware that RI #119 had missed doses of Invega. The MD was asked, what was the concern with RI #119 not receiving his/her ordered Invega for two months. The MD said RI #119 might have symptoms of behavior. The MD said he should be notified any when the medication is not administered as ordered. The MD said when a resident refused a medication that was prescribed to be administered once per month, he would expect the nurse to administer the medication the following day. On 05/13/2025 at 7:45 PM an interview was conducted with the Administrator (ADM) #1. The ADM said she did not know RI #119 had not received his/her Invega in January or February before the survey team informed her. 2) RI #76 was admitted on [DATE] and readmitted on [DATE] and had diagnoses that included Ileus, Epilepsy without Status Epilepticus, Hypertension, Bradycardia, Depression, and Other Specified Noninfective Gastroenteritis and Colitis. RI #76's physician's order included orders for Amlodipine 10 mg daily for hypertension, Hydralazine 100 mg three time per day for hypertension, Isosorbide Dinitrate 40 mg three times a day for heart, Lacosamide 150 mg daily for seizures, Keppra 500 mg twice daily for seizures, Losartan 100 mg daily for hypertension, 2 tablets of Bisacodyl 5 mg daily for constipation, Doxazosin Mesylate 1 mg daily for hypertension, and Aspirin 81 mg daily for anti-inflammatory. On 05/06/2025 at 9:18 AM an observation was made of LPN #42 preparing to administer medications to RI #76 to include: Amlodipine 10 mg, Hydralazine 100 mg, Isosorbide Dinitrate 40 mg, Lacosamide 150 mg, Keppra 500 mg, Losartan 100 mg, 2 tablets of Bisacodyl 5 mg daily, Doxazosin Mesylate 1 mg, and Aspirin 81 mg. On 05/06/2025 at 9:30 AM RI #76 told LPN #42 that he/she wanted his/her medications after eating breakfast. LPN #42 did not administer the medications. RI #76 EMAR indicated that LPN #42 did not administer the medications on 05/06/2025 after breakfast as requested by RI #76. Further review of RI #76's EMAR revealed that on 05/07/2025, RI #76's blood pressure was 200/97 mmHG (millimiters of mercury). On 05/07/2025 at 8:45 AM an interview was conducted with LPN #42 who said RI #76 refused his/her medications while he/she was eating. LPN #42 said RI #76 told her that he/she did not want his/her medications when she brought them, and she did not offer again. LPN #42 was asked, why did she not return to administer the medications. LPN #42 said because RI #76 refused them. On 05/08/2025 at 1:55 PM a follow-up interview was conducted on the phone with LPN #42. LPN #42 said she did not notify the doctor, the family, or the Director of Nursing, but she should have. LPN #42 said the doctor needed to be notified so he knew the resident did not take their medications. LPN #42 said residents had the right to take their medications after they eat. On 05/07/2025 at 5:35 PM an interview was conducted with RI #76. RI #76 said he/she got sick when he/she took his/her medications before eating. RI #76 said he/she did not refuse to take his/her medications on 05/06/2025. RI #76 said he/she wanted to take the medications because he/she knew his/her blood pressure would get high like it did that morning when he/she did not take the medications. RI #76 said the nurse never returned to his/her room on 05/06/2025 to offer the medications after he/she ate. On 05/12/2025 at 7:47 PM an interview was conducted with the Administrator (ADM) #1. The ADM was asked, during morning medication pass a resident requested the nurse administer their medications after breakfast, what should the nurse have done. The ADM said the nurse should give the medication after the resident ate. The ADM said the facility had been providing in-services to staff on medication administration since the last survey. On 05/08/2025 at 9:26 AM an interview was conducted with CRNP #87 who said he expected medications to be administered as ordered. CRNP #87 said on 05/06/2025 around 1:00 PM, RI #76 said he/she had not received his/her medications, and he went to the LPN #42 and told her that RI #76 needed his/her medications. The CRNP said LPN #42 said RI #76 refused the medications. CRNP #87 said since RI #76 was ready for his/her medications, the nurse should have administered the medications at that time because they were daily medications. CRNP #87 said the nurse should have notified him earlier that morning when the medications were refused. The CRNP was asked, what would be the risk of facility staff not administered RI #76 the following medications as ordered: Amlodipine 10 mg; Aspirin 81 mg; Doxazosin Mesylate 1 mg; Hydralazine 100 mg; Isosorbide Dinitrate 40 mg; Lacosamide 150 mg; Keppra 500 mg; Losartan 100 mg; and Biscodyl 10 mg. CRNP #87 said RI #76's blood pressure could increase and he/she could have a stroke or a heart attack. CRNP #87 said without his/her seizure medication his/her therapeutic levels could decrease and he/she could be at risk for seizure. CRNP #87 said, RI #76 had a problem with Colitis and they had to keep his/her bowels calmed down to help keep RI #76 from having another hospitalization. CRNP #87 said the facility notified another CRNP when RI #76's blood pressure was 200/97 on 05/07/2025. 3) Cross-Reference F600, F658, and F694. The facility's Timeline of Events for RI #9 indicated that RI #9 was transferred to the hospital on [DATE] for critical lab values. RI #9 returned on 05/02/2025 with a PICC line. A review of RI #9's hospital medical record revealed a Progress Note-Generic signed on 05/01/2025 by a hospital physician. The note included: . Medications . DAPTOmycin . 600 mg [milligram] . daily . piperacillin-tazobactam 4.5 g [grams] . q8hr [every eight hours] . Assessment/Plan: . Wound growing Pseudomonas-carbapenem resistant and VRE [Vancomycin Resistant Enterococcus] - Cont [continue] Zosyn and Daptomycin - need long term IV antibiotics - Place PICC . ID [infection disease] has give [sic] DC [discharge] antibiotic regimen - CM [Case Management] is aware - PICC ordered - pt [patient should be ready for DC in am if antibiotics arranged . RI #9's Discharge Summary created by a hospital physician on 05/02/2025 documented: . Hospital Course: . Wound growing Pseudomonas-carbapenem resistant and VRE - Cont [continue] Zosyn and Daptomycin - need long term antibiotics - PICC is in place - DC [discharge] with daptomycin and Zosyn through June 2 . The facility's Order Summary Report for RI #9 documented an order for Zosyn 4.5 gram every 8 hours with start date of 05/05/2025. RI #9 RX History Report documented 56 doses of Zosyn 4.5 g was delivered from the pharmacy to the facility for RI #9. On 05/20/2025 at 4:50 PM an interview was conducted with the Pharmacist who reported 56 doses of Zosyn were delivered to the facility for RI #9. The Pharmacist said the facility did not stock Zosyn 4.5 g. On 05/20/2025 at 1:00 PM an observation was made with LPN #28 of RI #9's remaining doses of Zosyn. 23 doses of RI #9's Zosyn 4.5 g was observed in the medication room. RI #9's EMAR indicated 42 doses of Zosyn were documented as administered to RI #9. On 05/27/2025 at 4:00 PM during a phone interview with the FDON #2, she said she was not aware RI #9 had not received his/her IV antibiotics as ordered until the survey team discussed the 12 AM doses. The FDON said she did not know how it was possible that 42 doses of Zosyn were documented as administered when the pharmacy delivered 56 doses of Zosyn for RI #9, and 23 doses were observed in the medication room. On 05/23/2025 at 12:11 PM during a follow-up interview with the FDON #2, she said the Unit manager should be looking at residents' EMARs on a daily basis. On 05/30/2025 at 12:53 PM an interview was conducted with the Orthopedic Surgeon (OS) who provided care to RI #9. The OS reported that RI #9 had a hip surgery and then RI #9 had an infection and procedure to wash it out and culture. The OS said the facility failing to administer at least 10 doses of RI #9's Zosyn was a concern and that 10 was a lot of missed doses. On 05/28/2025 at 7:25 PM an interview was conducted with the facility's Medical Director (MD). The MD said depending on the resident's kidney function, he considered two missed doses of Zosyn to be significant when ordered every 8 hours. The MD said depending on the resident's kidney function, he considered two missed doses of Daptomycin to be significant when ordered every 24 hours. The MD said he was not notified RI #9 had missed doses of either medication until RI #9 was transferred to the hospital on [DATE]. The MD said he was told RI #9 returned to the facility on a 05/02/2025, a Friday evening and did not have a full prescription. The MD said it was not started until 05/05/2025, so RI #9 missed about two days dosage. The MD said RI #9 missing at least 17 of 50 doses of Zosyn was significant. RI #9's hospital progress note dated 05/22/2025 documented that RI #9 was being treated for . Sepsis with shock Chronic left hip postoperative infection . ******************************************** The facility submitted a plan to remove the immediacy of the identified deficient practice that included: ********************************************* Assessment 1. On 05/12/2025 the DON reviewed RI #119's Medication Administration Record that RI #119 received Invega as prescribed by the Physician on 03/24/2025 and 04/24/2025 by review of the Medication Administration Record. 2. On 5/13/25, RI #119 was assessed by the Certified Registered Nurse Practitioner and no new orders were completed 3. On 5/13/25, a Pharmacy Consultant completed a Drug Regimen Review on RI #119. 4. The Director of Nursing and/or designee reviewed RI #119's plan of care and revisions were made as needed. 5. On 5/7/25, the Physician assessed RI #76, and a new order was received to monitor blood pressure every shift for 72 hours. 6. The Certified Registered Nurse Practitioner assessed RI #76 on 5/8/25 and medication times were changed to accommodate medication preferences. 7. The Medical Provider was notified of the omission in medications on 5/8/25, an attempt was made to contact the Responsible Party of RI #76 on 5/8/25 and 5/9/25; with no response due to no longer in-service. 8. RI #9 was discharged from the facility on 5/19/25. 9. Effective 5/25/25, the facility will not administer IV hydration or IV medication. The Administrator updated the Facility Assessment on 5/29/25 Audits 1. On 5/14/25, a Medication Administration audit was conducted by ACSPRO and results sent to the DON and/or designee for review/follow-up. Based on the results of the audit, a medication error report was generated if an omission was identified. The Nurse Managers notified the Physician and Responsible Party and interviewed the residents related to medication preference. No significant medication errors were found. 2. The DON and/or designee conducted an audit of other residents receiving monthly injections on 5/14/25, no other residents were scheduled for a monthly injection. 3. On 5/23/25, the Market Clinical Advisor conducted an audit of residents receiving intravenous antibiotic medications, no other residents were identified as receiving intravenous medications. 4. On 5/27/24, 93 of 93 residents were interviewed related to medication administration, at that time all residents stated they were receiving their medications. 5. On 5/27/25 thru 5/29/25, 123 residents Medication Administration Records were reviewed from 5/1/25 to current for omissions, late meds, and medications not documented at the time of receiving by the DON and Nurse Managers. A total of 32 residents were affected and identified with significant medication errors. RI #9 who was identified with a significant medication error was discharged on 5/19/25. The Medical Director and Nurse Practitioners were notified of the medication errors on 5/28/25 and 5/29/25. An assessment was conducted by Unit Manager/RNs and the Certified Registered Nurse Practitioner on 5/30/25 and no adverse outcomes were identified. In-services 1. On 5/8/25, the Market Clinical Lead educated the DON on auditing medication refusal reports and the medication administration record report during the daily clinical meeting to validate appropriate actions have been taken if a medication is omitted or refused. 2. Education was initiated on 5/07/2025 with the Licensed Nurses and Certified Medication Assistant by the Nurse Practice Educator and/or designee regarding Significant Medication Errors; what to do when a medication is not available, who to notify, refusal of medications and what to do, completing a medication error report if applicable, escalation process for missing medications, and Checking RX Dispensary. Facility staff received the education by 5/9/25. The facility has a total of 44 active Licensed Nurses and/or Certified Medication Assistants. 43 have received the education by 5/9/25. Active employees, employees on leave of absence (FMLA), and PRN staff who have not received the education aforementioned will be educated prior to returning to their assigned shift by the NPE. New employees will receive the education during their on-boarding process prior to starting the assigned shift on the floor. 3. The Director of Nursing and/or designee, conducted 1:1 education with the Licensed Practical Nurse who failed to administer the medications to RI #76. The Registered Nurse who failed to administer the medication to RI #119 on January 24, 2025 is no longer employed at the Center. The Registered Nurse who documented refusal of medication for RI #119 on 2/24/25 is now PRN; the Market Clinical Advisor educated the RN via phone on 5/19/25. 4. Education provided to the DON regarding reviewing the Medication Administration Records during AM Clinical meetings to validate medications were administered per the Physician orders. 5. On 5/24/25, the Market Clinical Advisor and Market Clinical Lead educated 19 of 22 full-time licensed nurses on the medication administration policy related to administering medications in accordance to the physician orders, documenting medications at the time of administration, late entry process, and medication errors. Education included types of medication errors to include omissions, wrong dose, incorrect duration, wrong time, incorrect dose, incorrect route of administration, and wrong patient. Education completed on acceptable professional standards and practices related to documentation of medications to include accurate and complete medication records. In addition, the education included not documenting medication services not performed, not documenting medication services before they are performed, and timely medication documentation. Education included performing nursing care within the scope of practice and in accordance with nursing standards of care. The facility has 12 PRN licensed nurses; 3 of 12 PRN licensed nurses received the education on 5/24/25. The facility attempted to contact the 9 PRN licensed nurses via phone; the DON will monitor the schedule and provide 1:1 in-services before their next scheduled shift. Active licensed nurses, licensed nurses on leave of absence (FMLA), and PRN nurses who have not received the education aforementioned will be educated prior to returning to their assigned shift by the NPE or designee. New employees will receive the education during their on-boarding process prior to starting their assigned shift on the floor. 6. On 5/24/25, the Market Clinical Advisor and/or Market Clinical Lead educated 6 of 6 full-time RNs on the medication administration policy related to administering intravenous medications in accordance to the physician orders, documenting medications at the time of administration, and medication errors. Education included types of medication errors to include omissions, wrong dose, incorrect duration, wrong time, incorrect dose, incorrect route of administration, and wrong patient. Education completed on acceptable professional standards and practices related to documentation of medications to include accurate and complete medication records. In addition, the education included not documenting medication services not performed, not documenting medication services before they are performed, and timely medication documentation. Education included performing nursing care within the scope of practice and in accordance with nursing standards of care. The facility has 4 RNs who work on a PRN basis, the facility was able to reach 1 of 4 via phone; attempts were made to contact the remaining 3 RNs that did not receive the education via phone. The Director of Nursing will monitor the schedule and provide the 1:1 in-services to the PRN RNs before their next scheduled shift begins. 7. On 5/30/25, the DON educated the ADON, and three Nurses/Unit Managers on rounding on the halls to ensure medications are administered as ordered; rounds to include random audits on each shift and weekends to proactively monitor medication administration. The monitoring will be documented on a Medication Administration audit tool. Quality Assurance 1. On 5/08/25, the Administrator hosted an AD HOC Quality Assurance Performance Improvement (QAPI) meeting to review the significant medication errors, medication refusals/preferences, medication administration, and notifying the Physician and/or Provider of significant medications errors. The QAPI personnel who participated included the following disciplines: Market Clinical Advisor, Clinical Lead, Administrator, Director of Nursing, and Nurse Managers 2. On 5/13/25, the Administrator hosted an AD HOC Quality Assurance Performance Improvement (QAPI) meeting to review the process to ensure medications are administered as prescribed and the Physician and/or Provider has been notified of significant medications errors. The QAPI personnel who participated included the following disciplines: Market President, Market Clinical Advisor, Clinical Lead, Administrator, Director of Nursing, Social Services, Activities Director, and Nurse Managers 3. On 5/30/25, the QAPI committee reviewed medication errors to identify medication error patterns, the significant medication errors occurred on 2 of 3 units and during day shift. The identified concerns were addressed by education with licensed nurses, monitoring of medication administration records, and rounds to provide verbal cueing/reminders on medication administration ******************************************** After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team verified onsite that the immediate corrective actions had been implemented the Immediate Jeopardy was removed on 05/31/2025. The scope/severity level of F760 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on interviews, resident record review, and review of a facility policy titled Pre-admission Screening for Mental Disorder and or Intellectual Disability Patients, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) screening process was completed for Resident Identifier (RI) #119 for a Level I or Level II determination to be made about the level of services RI #119 required for Mental Disorder or Mental Illness (MI) before admission to the facility. RI #19 was admitted to the facility on [DATE] and had a diagnosis of Schizoaffective Disorder which is a Mental Illness.On 03/18/2025 RI #119 threatened to kill people in the facility. On 04/01/2025 RI #119 hit another resident, RI #53, in the face twice with a fist. A Level I determination was not made for RI #119 until 05/08/2025 during the survey.It was determined the facility's noncompliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.20 Resident Assessments.On 05/13/2025 at 3:30 PM, the Administrator, Director or Nursing (DON), Regulatory Compliance Advisor, Clinical Lead and the Market Clinical Advisor were provided a copy of the IJ template and notified of the findings of immediate jeopardy in the area of Resident Assessments at F645- PASRR Screening for MD & ID.The IJ began on 04/01/2025 and continued until 05/13/2025. On 05/14/2025 the immediate jeopardy was removed. F600 was lowered to the lower severity of no actual harm with a potential for more that minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revised their corrective actions as necessary to achieve substantial compliance.This deficient practice affected RI #119 one of 18 sampled residents.Findings include:Cross-Reference F600, F740, and F835.A facility policy titled Pre-admission Screening for Mental Disorder (and/or) Intellectual Disability Patients, with a revision date of 02/16/2024, documented: POLICYCenter Social Worker or designated stall will assure that all patients with Mental Disorders (MD) and/or Intellectual Disability (ID) receive appropriate pre-admission screenings according to federal and/or state regulations.PURPOSETo ensure that all individuals are screened for a MD and/or ID prior to admission.To ensure that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs.PRACTICE STANDARDS1. Social Services will coordinate and/or inform the appropriate agency to conductevaluation and obtain results if:1.1 It is learned after admission that Pre-admission Screening and Resident Review (PASRR) was not completed or is incorrect, or 1.2 There is a significant change in status that results in new evidence of possible mental disorder, intellectual disability or a related condition.RI #119 was initially admitted to the facility on [DATE] and readmitted on [DATE] and had diagnoses to include: Schizophrenia; Schizoaffective Disorder, Bipolar Type; Insomnia due to Mental Disorder; and Severe Vascular Dementia with Agitation. RI #119's Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 01/02/2025 documented a Brief Interview for Mental Status (BIMS) score of 14 of 15 which indicated intact cognition.RI #119's medical record was reviewed and revealed the following PASRR records: RI #119 was admitted from the hospital with a PASRR form titled State of Alabama Department of Mental Health PASRR Level I Screening & Results for Mental Illness (MI)/ Intellectual Disability (ID)/ Related Condition (RC) dated 12/26/2024 which documented . NOT AN OBRA PASRR LEVEL I DETERMINATION **MAY REQUIRE A LEVEL II** . Number 2a. on the form documented RI #119 had Schizoaffective Disorder; number 4. on the form documented RI #119 had Dementia; number 5. on the form documented RI #119's current behavior or recent history within one year indicated RI #119 was a danger to self or others; number 5a. on the form documented . Patient was in non-violent restraints for interfering with care devices from 12/09/2024 until 12/15/2024. The Level I screening results included: Based on the information provided during the screening process, the individual MAY require a Level II. A VALAD LEVEL 1 DETERMINIATION WILL BE FAXED. The facility received a form for RI #119 titled PASRR Level II Service Determination from Bock Associates, signed by the Registered Nurse (RN) representative, dated 01/15/2025 that documented: . This evaluation was CANCELLED due to: . Rationale and Sign-OffCancel this level. We are waiting on medical records to review. The level will need to be resubmitted when the current medical records are available.On 05/07/2025 at 6:17 PM the Social Service Director (SSD) was asked about RI #119's PASRR screenings not indicating a Level I or Level II determination was made. The SSD said, RI #119 triggered a Level II screening that was canceled after she had not submitted the requested additional medical records timely. The SSD said, she spoke with the Bock Associates RN and she advised the facility to resubmit the Level I. The SSD was asked when she planned to resubmit the Level I. The SSD said, as soon as possible.On 05/10/2025 at 4:17 PM in a follow up interview with the SSD, she was asked about the additional information not being sent as requested in the PASRR record dated 01/15/2025. The SSD said, she tried to send an email to the Bock Associates RN but it was not received. When asked what happened next, the SSD said, nothing happened, they had canceled the previous Level. When asked who was responsible for resubmission of the Level, the SSD said, she was.A Level I screening was completed for RI #119 on 05/08/2025 during the survey with a determination of NO NEED FOR A LEVEL II EVALUATION due to a primary diagnosis of Dementia.The facility submitted an acceptable plan to remove the immediacy of the identified deficient practice that included:*******************************************Assessment: 1. On 12/26/2024, UAB Hospital completed the Level I Screening on RI #119, prior to admission to Magnolia Ridge center and determined RI #119 met the criteria to admit to a LTC facility. The Level I screening on 12/26/24, indicated that it was not a level 1 determination and a Level II may be required, but RI #119 could be admitted for 120 days if she had PT/OT orders from a physician for therapy 5x per week. Audits1. The Market Clinical Reimbursement Manager audited short stay residents currently in the facility for less than 100 days. 1 of 5 residents identified to have a PSARR Level II Determination due on 5/30/25. The Social Service Director has notified the state mental health authority of the need for the Level II. In-services1. On 5/13/25, the Administrator educated the Social Service Director, Social Service Assistant, and Admissions Director on reviewing pre-admission paperwork to ensure residents are evaluated for a serious mental disorder and/or intellectual disorder and are not admitted with a diagnosis of Mental disorder unless the State mental health authority has determined the residents are appropriate for nursing home placement. The Admissions Director, Social Service Director and/or designee will promptly notify the state mental health authority upon admission or after a significant change in mental condition of residents admitted with a mental illness or intellectual disability for further review and determination. The education outlined the following responsibilities:a. The Social Service Director, Admissions Director, and/or designee will review Level 1 upon admission, update Level I when needed and sign the document. b. The Social Service Director, Admissions Director and/or designee will submit to the state mental health authority and will be responsible for following up. 2. On 5/13/25, the Administrator educated the Social Services Director on monitoring residents upon admission without a Level I or II determination to ensure the assessment is completed and submitted when the resident no longer meets criteria for a convalescent care admission. Quality Assurance 1. On 5/13/25, the Administrator hosted an AD HOC Quality Assurance Performance Improvement (QAPI) meeting to review PASRR policy and OBRA PASRR guidelines. The corrective actions and recommendations from the QAPI committee consisted of conducting a 100% audit of PASRR; educating the Social Service Director, Social Service Assistant and admission Director on the pre-admission screening process, and engaging the state mental health authority as needed for evaluation and determination to ensure residents are appropriately placed in the nursing facility. The QAPI personnel who participated included the following disciplines: Administrator, Admissions Director, Social Services Director and Social Services Assistant. ******************************************After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team verified onsite that the immediate corrective actions had been implemented the Immediate Jeopardy was removed on 05/14/2025. The scope/severity level of F645 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on interviews, resident record review, and review of a facility policy titled, Medication Administration General Guidelines, and review of ALABAMA BOARD OF NURSING ADMINISTRATIVE CODE CHAPTER 610-X-6 STANDARDS OF NURSING PRACTICE the facility failed to ensure licensed staff implemented physician orders and followed standards of practice when they documented administration of Resident Identifier (RI) #9's intravenous (IV) medications. Specifically, on 05/14/2025 the facility submitted a plan to remove the immediacy of jeopardy that included . On 5/14/25, the DON [Director of Nursing (Former DON #2)] and/or designee reviewed Medication Administration Records for the last 60 days and no additional concerns were identified. Upon review of documentation in RI #9's medical record it was identified that of the 42 times the facility's staff documented that Zosyn was administered to RI #9, five doses were documented as administered days later on 05/14/2025 by a Registered Nurse (RN) #25 who was not clocked in at the time the doses were due, two doses were documented as administered days later on 05/14/2025 by the Former DON (FDON) #2, and three doses were documented as administered by a Licensed Practical Nurse (LPN) #101 who was not qualified to administer the antibiotic and reported she did not administer the medication. It was determined the facility's noncompliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.21 Comprehensive Resident Center Care Plan. On 05/28/2025 at 9:37 PM, the interim Administrator (ADM), interim Director or Nursing (DON), and the Market Clinical Advisor were provided a copy of the IJ template and notified of the findings of immediate jeopardy in the area of Comprehensive Resident Center Care Plan at F658- Services provided Meet Professional Standards. The IJ began on 05/05/2025 and continued until 05/30/2025. On 05/31/2025 the immediate jeopardy was removed. F658 was lowered to the lower severity of no actual harm with a potential for more that minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revised their corrective actions as necessary to achieve substantial compliance. This deficient practice affected RI #119 one of 18 sampled residents. Findings Include: Cross-Reference F600, F760, F835, F694, and F837. The ALABAMA BOARD OF NURSING ADMINISTRATIVE CODE CHAPTER 610-X-6 STANDARDS OF NURSING PRACTICE included: . 610-x-6-.06 Standard for Documentation (1) The standards for documentation of nursing care provided to patients by licensed nurses are based on principles of documentation, regardless of the documentation format. (2) Documentation of nursing care shall be: . (d) Timely. 1. Charted at the time or after the care, to include medications. Charting prior to care being provided, including medications, violates principles of documentation. 2. Documentation of patient care that is not in the sequence of the time the care was provided shall be recorded as a late entry, including a date and time the late entry was made, as well as the date and time the care was provided. Review of a facility policy titled, Medication Administration General Guideline, dated 01/25, revealed the following: POLICY . PROCEDURES . 7.1 General Guidelines . Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber. 4. Medications are to be administered at the time they are prepared. 14. Medications are administered within 60 minutes of the scheduled time . Medications should not be given at mealtimes . unless specifically ordered with meal. Documentation: 1. The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications. 2. If a regularly scheduled medication is withheld, refused, or given at other than the scheduled time . the nurse shall be documented in either the Electronic Medication Administration Record or the paper MAR that the dose was withheld, refused, or given at other than the scheduled time, and enter an explanatory note . 4. The administration of the resident's medication is documented by one of the following processes: Documentation of the medication administration in the Electronic Health Record . RI #9 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnoses that included Vascular Dementia and Cerebral Infarction due to Thrombosis of Middle Cerebral Artery. The facility's Order Summary Report for RI #9 documented a discontinued order for Daptomycin 600 milligram (mg) IV at 25 milliliter (mL) per hour (hr) daily was entered on 05/04/2025 with a start date of 05/05/2025. A second order was entered on 05/09/2025 with a start date of 05/09/2025 for Daptomycin 600 mg IV daily at 60 mL/hr. The facility's Order Summary Report for RI #9 documented an order for Zosyn 4.5 gram every eight hours was entered on 05/04/2025 with start date of 05/05/2025. On 05/24/2025 at 6:16 PM an interview was conducted with Medication Administration Certified (MAC) Assistant #102. MAC #102 said the standard of practice for administering and documenting medication as administered in the EMAR was to look at the medication card to ensure the right medication, right patient, right time, right route and then document whether the medication was administered or not. On 05/25/2025 at 4:45 PM an interview was conducted with LPN #74 who said the standard of practice to administer medications was to review the EMAR and verify correct route, resident, time, and dose. LPN #74 said once the medication was administered the medication was documented as administered. RI #9's EMAR documented that LPN #101 documented that she administered RI #9's 4 PM dose of IV Zosyn on 05/05/2025, 05/06/2025, and 05/07/2025. The EMAR documentation indicated the Zosyn was administered intravenously, and location was to RI #9's abdomen, left upper quadrant. The report also revealed that LPN #101 documented that she administered RI #9's 05/12/2025 dose of IV Daptomycin. The documentation indicated the Daptomycin was administered by LPN #101 intravenously to RI #9's left upper quadrant of his/her abdomen. The report revealed that LPN #101 administered tuberculin injection intradermally to RI #9's left upper quadrant of abdomen on 05/15/2025. On 05/25/2025 at 3:42 PM an interview was conducted with LPN #101 who said she did not administer IV medications. LPN #101 was asked about her documentation that she administered Zosyn to RI #9 and LPN #101 said it was an error and that she did not administer the medication. LPN #101 did not recall who administered those doses. LPN #101 said the facility policy directed staff to make an addendum or follow-up note if a medication was documented by mistake. LPN #101 said she did not make an addendum or follow-up note for those errors because it was not brought to her attention until the week before, and she was told that if it needed to be addressed she would know. During a follow-up interview with LPN #101 on 05/28/2025 at 10:20 AM, LPN #101 said she did not administer the Tuberculin injection to RI #9 in his/her abdomen and that it was a charting error. LPN #101 was asked, what was the risk of documenting that a medication was administered when it was not administered. LPN #101 said it could be perceived that the medication was administered, but she did not give the IV antibiotics. A review of RI #9's EMAR revealed the documentation on the EMAR for administered medications did not include the date or time the medications were administered. A review of the electronic health record's Medication Admin Audit Report revealed documentation for each dose that include date and time dose was scheduled, date and time staff documented the dose as administered, date and time the dose was administered, and the staff who documented each dose as administered. A review of the facility report titled Medication Admin Audit Report for RI #9 revealed that on 05/14/2025 at 3:43 PM the FDON #2 documented that she administered RI #9's 05/08/2025 4:00 PM scheduled dose of Zosyn timely on 05/08/2025. The report revealed that on 05/14/2025 at 3:44 PM the FDON #2 documented that she administered RI #9's 05/09/2025 4:00 PM dose of Zosyn timely on 05/09/2025. The facility report titled Medication Admin Audit Report for RI #9 revealed that on 05/14/2024 at 3:49 PM RN #25 documented that she administered RI #9's 05/06/2025 12:00 AM dose of Zosyn as administered. The documentation indicated RI #9's 05/06/2025 12:00 AM dose was administered on 05/05/2025 at 12:49 AM. A review of RN #25's timecard revealed that RN #25 was not clocked in on 05/05/2025 after 1:43 AM or 05/06/2025. The facility report titled Medication Admin Audit Report for RI #9 revealed that on 05/14/2024 at 3:48 PM RN #25 documented that she administered RI #9's 05/07/2025 at 12:00 AM dose of Zosyn. The documentation indicated RI #9's 05/07/2025 12:00 AM dose was administered on 05/06/2025 at 12:48 AM. A review of RN #25's timecard revealed that RN #25 was not clocked in on 05/06/2025 05/07/2025 until 7:04 PM. The facility report titled Medication Admin Audit Report for RI #9 documented that on 05/14/2025 at 3:50 PM RN #25 documented that she administered RI #9's 05/09/2025 at 12:00 AM dose of Zosyn. The documentation indicated the 05/09/2025 12:00 AM dose of Zosyn was administered on 05/08/2025 12:49 AM. Further review of RN #25's timecard revealed that RN #25 was not clocked in on 05/08/2025 or 05/09/2025. The facility report titled Medication Admin Audit Report for RI #9 documented that on 05/14/2025 at 3:51 PM RN #25 documented that she administered RI #9's 05/10/2025 at 12:00 AM dose of Zosyn. The documentation indicated that it was administered on 05/09/2025 at 12:50 AM. Further review of RN #25's timecard revealed that RN #25 was not clocked in on 05/10/2025 until 7:28 AM. The facility report titled Medication Admin Audit Report for RI #9 documented that on 05/14/2025 at 3:47 PM RN #25 documented that she administered RI #9's 05/13/2025 at 12 AM dose of Zosyn. The documentation indicated that it was administered on 05/13/2025 at 3:46 PM. Further review of RN #25's timecard revealed that RN #25 was not clocked in on 05/13/2025 until 11:12 PM. On 05/22/2025 at 5:40 PM an interview was conducted with RN #25 who said she did not work the night shift that began on 05/12/2025 and ended on 05/13/2025. RN #25 was asked; did she administer RI #9's IV Zosyn on 05/13/2025. RN #25 said no, and that RN #61 administered the Zosyn. RN #25 said medication should be documented in the resident's EMAR immediately after administration of the medication. RN #25 was asked, what was the concern with documenting medication administration late, like five days. RN #25 said that it would have been falsified. On 05/25/2025 at 2:50 PM an interview was conducted with RN #25 who said the FDON #2 called her to the facility on [DATE], but she did not recall why. RN #25 said FDON #2 thought she had missed documenting RI #9's Zosyn at 12:00 AM on 05/14/2025, but it was 05/13/2025. RN #25 said FDON #2 told her to sign the medication as administered. On 05/27/2025 at 4:00 PM during a phone interview with the FDON #2, she said that she was not aware RI #9 had not received his/her IV antibiotics as ordered until the survey team discussed the 12:00 AM doses. The FDON said she did not know how it was possible that 42 doses of Zosyn was documented as administered when the pharmacy delivered 56 doses of Zosyn for RI #9, and 23 doses were observed in the medication room. RI #9's hospital progress note dated 05/22/2025 documented that RI #9 was being treated for . Sepsis with shock Chronic left hip postoperative infection . ********************************************************* The facility submitted a plan to remove the immediacy of the identified deficient practice that included: ********************************************************* Assessments 1. RI #9 was discharged from the facility on 5/19/25. 2. The new Director of Nursing Services placed RN #25 on administrative leave on 5/28/25. 3. On 5/24/25, the Market Clinical Advisor placed DON #2 on administrative leave and on 5/29/25, DON #2 was informed of employment separation. 4. The Director of Nursing completed 1:1 education with LPN #101 on 5/29/25 on medication administration documentation, standards of nursing practice, and accuracy of medical records. 5. Effective 5/25/25, the facility will not administer IV hydration and/or IV medication. The Administrator updated the Facility Assessment on 5/29/25. Audits 1. On 5/23/25, the Market Clinical Advisor conducted an audit of residents receiving intravenous antibiotic medications, no other residents were identified as receiving intravenous medications. In-services 1. The Director of Nursing educated LPN #101 on 5/29/25 on medication administration documentation, standards of nursing practice, and accuracy of medical records. 2. On 5/24/25, the Market Clinical Advisor and Market Clinical Lead educated 19 of 22 full-time licensed nurses on the medication administration policy related to administering medications in accordance to the physician orders, documenting medications at the time of administration, late entry process, and medication errors. Education included types of medication errors to include omissions, wrong dose, incorrect duration, wrong time, incorrect dose, incorrect route of administration, and wrong patient. Education completed on acceptable professional standards and practices related to documentation of medications to include accurate and complete medication records. In addition, the education included not documenting medication services not performed, not documenting medication services before they are performed, and timely medication documentation. Education included performing nursing care within the scope of practice and in accordance with nursing standards of care. The facility has 12 PRN licensed nurses; 3 of 12 PRN licensed nurses received the education on 5/24/25. The facility attempted to contact the 9 PRN licensed nurses via phone; the DON will monitor the schedule and provide 1:1 in-services before their next scheduled shift. Active licensed nurses, licensed nurses on leave of absence (FMLA), and PRN nurses who have not received the education aforementioned will be educated prior to returning to their assigned shift by the NPE or designee. 3. On 5/24/25, the Market Clinical Advisor and/or Market Clinical Lead educated 6 of 6 full-time RNs on the medication administration policy related to administering intravenous medications in accordance to the physician orders, documenting medications at the time of administration, and medication errors. Education included types of medication errors to include omissions, wrong dose, incorrect duration, wrong time, incorrect dose, incorrect route of administration, and wrong patient. Education completed on acceptable professional standards and practices related to documentation of medications to include accurate and complete medication records. In addition, the education included not documenting medication services not performed, not documenting medication services before they are performed, and timely medication documentation. Education included performing nursing care within the scope of practice and in accordance with nursing standards of care. The facility has 4 RNs who work on a PRN basis, the facility was able to reach 1 of 4 via phone; attempts were made to contact the remaining 3 RNs that did not receive the education via phone. The Director of Nursing will monitor the schedule and provide the 1:1 in-services to the PRN RNs before their next scheduled shift begins. 4. On 5/29/25, the Market Clinical Advisor educated the Director of Admissions and Director of Marketing on the admission process related to IV therapy and antibiotics to include the facility will not admit, readmit, and/or treat patients with orders for IV hydration or IV medications. 5. On 5/29/25 and 5/30/25, the Administrator educated the Physician, Certified Registered Nurse Practitioners, Pharmacy, and Lumina that the facility will not admit and/or readmit and/or treat patients with IV hydration or IV medication. 6. On 5/30/25, the Administrator communicated to 31 licensed nurses that the facility will not admit and/or readmit patients with orders for IV hydration or IV medications. 7. The DON and/or designee educated the Nurse Managers by 5/30/25 on reviewing the medication administration records to ensure staff are following the standards of practice for medication administration. The DON educated the Nurse Managers to conduct medication administration audits Mon-Friday. The monitoring will be documented on a Medication Administration monitoring tool. **************************************************** After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team verified onsite that the immediate corrective actions had been implemented the Immediate Jeopardy was removed on 05/31/2025. The scope/severity level of F658 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on interviews, record review, and review of facility policies titled, Vascular Access Devises and Infusion Therapy Procedures- Maintaining Patency of Peripheral and Central Vascular Access Devices and Administration of IV Fluids and Medication - SETTING UP A PRIMARY INFUSION (HYDRATION OR MEDICATION, and the ALABAMA BOARD OF NURSING ADMINISTRATIVE CODE CHAPTER 610-X-6 STANDARDS OF NURSING PRACTICE the facility failed to ensure Resident Identifier (RI) #9's intravenous antibiotics (IV) were administered in accordance with professional standards of practice. 1) The facility failed to ensure a process was implemented to ensure RI #9's IV antibiotics were ordered and administered upon RI #9's re-admission on [DATE]. Seven doses of Piperacillin-Tazobactam (Zosyn) were not administered on 05/03/2025, 05/04/2025, and 05/05/2025. Two doses of Daptomycin were not administered on 05/03/2025 and 05/04/2025. 2) The facility further failed to ensure facility staff followed their policy for administering and documenting IV medication. On 05/05/2025, 05/06/2025, and 05/07/2025 Licensed Practical Nurse (LPN) #101 documented that she administered RI #9's doses of Zosyn scheduled for 4:00 PM. LPN #101 also documented that she administered RI #9's IV Daptomycin on 05/12/2025. Also, the facility's staff documented RI #9's Zosyn as administered days after the documented dose was scheduled to be administered. Specifically, on 05/14/2025 Registered Nurse (RN) #25 documented that she administered RI #9's 12:00 AM dose of Zosyn scheduled on 05/06/2025, 05/07/2025, 05/09/2025, 05/10/2025, and 05/13/2025. RN #25 was not clocked in and working at the time the 12:00 AM Zosyn was scheduled to be administered on 05/06/2025, 05/07/2025, 05/09/2025, 05/10/2025, and 05/13/2025. On 05/14/2025 the Director of Nursing (Former DON) #2 documented RI #9's 4:00 PM dose of Zosyn scheduled for 05/08/2025 and 05/09/2025. 3) The facility further failed to ensure sufficient Registered Nurses were scheduled to administer RI #9's intravenous antibiotic, at 12:00 AM on 05/07/2025, 05/09/2025, 05/13/2025, or 05/17/2025. RI #9's 12:00 AM dose of Zosyn was not administered on 05/17/2025. RI #9 should have received a total of 50 doses of Zosyn from 05/03/2025 until his/her discharge on [DATE]. Seven doses of Zosyn were not ordered timely and not administered and one dose was not documented as administered. A total 42 doses were documented as administered, but ten of the 42 doses were either documented as administered by unqualified staff, documented late by RN #25 who was not clocked in when the doses she documented late were scheduled to be administered, or documented five to six days later by the FDON #2. 4) The facility further failed to ensure all licensed facility staff who administered IV medications were provided education on the facility's policy and procedures for IV care and medication administration. The facility further failed to ensure RI #9's peripherally inserted central catheter (PICC) was flushed in accordance with standards of care. It was determined the facility's noncompliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.25 Quality of Care at F694- Parenteral/IV Fluids. On 05/28/2025 at 9:37 PM, the interim Administrator, the interim DON, and the Market Clinical Advisor were provided a copy of the IJ template and notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Quality of Care at F694- Parenteral/IV Fluids. The IJ began on 05/02/2025 and continued until 05/30/2025 when the survey team verified onsite that corrective actions had been implemented. On 05/31/2025 the immediate jeopardy was removed. F694 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revised their corrective actions as necessary to achieve substantial compliance. Findings Include: Cross-Reference F600, F658, F694, F760, F835, and F837. The ALABAMA BOARD OF NURSING ADMINISTRATIVE CODE CHAPTER 610-X-6 STANDARDS OF NURSING PRACTICE included: . 610-x-6-.14 Intravenous (IV) Therapy By Licensed Practical Nurses. (6) Tasks that shall not be performed by a licensed practical nurse include: . (b) Administration of: . 7. IV medications via push or bolus through a central line including a peripherally inserted central catheter (PICC). The facility policy titled Administration of IV Fluids and Medication - SETTING UP A PRIMARY INFUSION (HYDRATION OR MEDICATION dated 10/24 documented: . Purpose To correctly and asceptically [sic] set up the primary IV bag and administration set. Policy The professional nurse with documented IV education, as designated by the facility, and as allowed by state regulation may set up a primary infusion. Procedure . 12. begin infusion. 16. Document according to facility procedure. The facility policy titled Vascular Access Devises and Infusion Therapy Procedures- Maintaining Patency of Peripheral and Central Vascular Access Devices dated 10/24 documented: . Purpose To maintain that patency of all peripheral and central vascular access devices (VADs). Policy . Vascular access devices are flushed after each infusion to clear the infused medication from the catheter lumen. 1. A prescriber's order is needed for all IV flushes. Procedure 1. Obtain prescriber order for appropriate flush solutions. 12. Document the flush in the resident's medication record. 1) RI #9 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnoses that included Vascular Dementia and Cerebral Infarction due to Thrombosis of Middle Cerebral Artery. A review of RI #9's hospital medical record revealed a Progress Note-Generic signed on 05/01/2025 by a hospital physician. The note included: . Medications . DAPTOmycin . 600 mg [milligram] . daily . piperacillin-tazobactam 4.5 g [grams] . q8hr [every eight hours] . Assessment/Plan: . Wound growing Pseudomonas-carbapenem resistant and VRE [Vancomycin Resistant Enterococcus] - Cont [continue] Zosyn and Daptomycin - need long term IV antibiotics - Place PICC . ID [infection disease] has give [sic] DC [discharge] antibiotic regimen - CM [Case Management] is aware - PICC ordered - pt [patient should be ready for DC in am if antibiotics arranged . RI #9's Discharge Summary created by a hospital physician on 05/02/2025 documented: . Hospital Course: . Wound growing Pseudomonas-carbapenem resistant and VRE - Cont [continue] Zosyn and Daptomycin - need long term antibiotics - PICC is in place - DC [discharge] with daptomycin and Zosyn through June 2 . On 05/27/2025 an interview was conducted with the facility's admission Liaison (AL). The AL said when RI #9 was re-admitted on [DATE], she knew RI #9 was returning back on antibiotics and said she thought it was two different types of antibiotics. The AL reported that while RI #9 was still in the hospital, she told the Admissions Director (AD) to let the Former Director of Nursing (FDON) #2 know that RI #9 was returning with IV antibiotics. On 05/27/2025 at 9:10 AM an interview was conducted with the facility's admission Director (AD). The AD said she did not recall the AL communicating with her about RI #9's medications before RI #9 was re-admitted on [DATE], but said before RI #9 was re-admitted the facility had received progress notes that indicated that RI #9 needed IV antibiotics. The AD reviewed RI #9's hospital records from 05/02/2025 and said RI #9 had a PICC line and needed IV Daptomycin and Zosyn through 06/02/2025. The AD said RI #9 was admitted on [DATE] at 6:18 PM and the IV antibiotics were to start on 05/03/2025 at 12:00 AM. The AD said the hospital did not send paper copies of the prescription for Daptomycin or Zosyn, because there was no need for paper prescription since it was not controlled substances. On 05/27/2025 at 4:00 PM a phone interview was conducted with the FDON #2. FDON #2 said she did not know that RI #9 needed IV antibiotics via PICC until after RI #9 returned to the facility. On 05/27/2025 at 10:47 AM an interview was conducted with LPN Supervisor (LPN-S) #27 who said she did not know what had been communicated when RI #9 was readmitted on [DATE]. LPN-S #27 said when RI #9 was admitted on [DATE] she had the discharge summary but no orders. LPN-S #27 said she reported to RN #25 and FDON #2 that RI #9 did not have orders for antibiotics. LPN-S #27 said the Medical Director should have been contacted when they identified that RI #9 did not have orders for IV antibiotics. The facility's Order Summary Report for RI #9 documented a discontinued order for Daptomycin 600 milligram (mg) IV at 25 milliliter (mL) per hour (hr) daily was entered on 05/04/2025 with a start date of 05/05/2025. A second order was entered on 05/09/2025 with a start date of 05/09/2025 for Daptomycin 600 mg IV daily at 60 mL/hr. The facility's Order Summary Report for RI #9 documented an order for Zosyn 4.5 gram every eight hours was entered on 05/04/2025 with start date of 05/05/2025. RI #9's EMAR documented the first dose of Zosyn was administered on 05/05/2025 at 8:00 AM and the first dose of Daptomycin was administered on 05/05/2025 at 12:00 PM. The EMAR documented that RI #9 did not receive a dose of Zosyn 05/03/2025 or 05/04/2025. The EMAR documented that RI #9 received his/her first dose of Zosyn at the facility on 05/05/2025 at 8:00 AM. The EMAR documented that RI #9 did not receive a dose of Daptomycin on 05/03/2025 or 05/04/2025. 2) Cross-reference F658 A review of RN #25's timecard revealed that she was not clocked in on several shifts in which she had documented medications as administered. The facility report titled Medication Admin Audit Report for RI #9 revealed that on 05/14/2025 RN #25 documented that she administered RI #9's doses of Zosyn scheduled to be administered at 12:00 AM on 05/06/2025, 05/07/2025, 05/09/2025, 05/10/2025, and 05/13/2025. A review of RN #25's timecard revealed that she was not working within two hours of 12:00 AM on 05/06/2025, 05/07/2025, 05/09/2025, 05/10/2025, or 05/13/2025. On 05/25/2025 at 2:50 PM an interview was conducted with RN #25 who said she should be clocked in for the duration of the medication administration when administering IV antibiotics. RN #25 said when the medication was due, she would check the resident's EMAR and then administer the medication. The facility report titled Medication Admin Audit Report for RI #9 revealed that on 05/14/2025 FDON #2 documented that she administered RI #9's doses of Zosyn scheduled to be administered on 05/08/2025 at 4:00 PM and 05/09/2025 at 4:00 PM. 3) On 05/28/2025 at 12:49 PM during a follow-up interview with the facility's Staffing Coordinator (SC), she reported that there was no RN scheduled to be at the facility during the 12:00 AM shift on 05/07/2025, 05/09/2025, 05/13/2025, or 05/17/2025. The SC said according to the schedule there was not an RN in the facility at 12:00 AM on those dates. On 05/27/2025 at 4:00 PM during a phone interview with the FDON #2, she said the RNs had a set schedule that was verbally discussed. The FDON said RN #25 worked weekends 7:00 AM to 7:00 PM and the rest worked dayshift during the week. The FDON was asked what was the process to ensure an RN was scheduled to administer RI #9's IV antibiotics. The FDON said, at 8:00 AM, 12:00 PM, and 400 PM RNs were scheduled to be in the building and RN #25 would administer the 12:00 AM doses. The FDON said it was communicated verbally and she did not have anything in writing. RI #9's EMAR documented his/her dose of Zosyn scheduled for 05/17/2025 at 12:00 AM was not administered. During an interview with RN #25 on 05/22/2025 at 5:40 PM, RN #25 said she did not administer RI #9's IV Zosyn on 05/17/2025 at 12:00 AM. 4) On 05/27/2025 at 4:00 PM during an interview with FDON #2, she was asked, what education was provided regarding IV antibiotics. The FDON said no training was documented. The DON said there was no specific training provided regarding IV flushes, PICC assessment, care, or dressing changes. RI #9's Care Plan Report included a care plan initiated on 05/05/2025 for (RI #9) receives IV therapy via PICC line due to wound infection, 5/10/25 PICC site change to rt (right) arm . The care plan included an intervention to flush the PICC line as ordered. RI #9's physician orders included an order dated 05/02/2025 to flush unused lumen with 10 milliliters (mL) of normal saline (NS) daily every seven days. RI #9's Electronic Medication Administration Record (EMAR) documented that RI #9's unused lumen was flushed on 05/10/2025 and 05/17/2025 by RN #25. No IV flushes were documented as administered on RI #9's EMAR from 05/02/2025 through 05/09/2025. RI #9's physician orders included an order with start date of 05/08/2025 for RN to use only red lumen for medication and flush 10 mL NS after each medication administration. RN to flush purple lumen after each medication administration per red lumen only do not give medication via purple lumen every day and evening shift. RI #9's EMAR documented that LPN #101 documented that she flushed RI #9's PICC on 05/08/2025 at 3:00 PM. The flush was documented as administered twice on 05/09/2025 and once on 05/10/2025 by an RN. The order discontinued on 05/10/2025 at 2:59 PM. RI #9's Nursing Notes included a note dated 05/09/2025 at 11:15 AM electronically signed by the Nurse Educator, RN #18. The note documented . left PICC line, unable to flush purple port, Red port flushes sluggishly. (PICC Line Insertion Company) notified and will arrive on 5/10/25 to check it. RI #9's physician orders included an order dated 05/10/2025 for assessment or replacement of PICC. A nursing note dated 05/10/2025 at 2:51 PM signed by LPN #27, Unit Manager documented PICC site changed and tolerated procedure well. RI #9's physician orders included an order dated 05/10/2025 for RN to flush both ports with 10 mL of NS after each medication administration. RI #9's EMAR documented the order for RN to flush both ports with 10 mL of NS after each medication administration every day and evening shift, start 05/10/2025 at 4:00 PM. The flush was not documented as administered on 05/12/2025 and 05/13/2025 during the evening shift. RI #9's hospital progress note dated 05/22/2025 documented that RI #9 was being treated for . Sepsis with shock Chronic left hip postoperative infection . ****************************************************************** On 06/01/2025 the facility submitted the following Plan of Correction: ****************************************************************** Assessments 1. RI #9 was discharged from the facility on 5/19/25. 2. Effective 5/25/25, the facility will not administer IV hydration or IV medications. The Administrator updated the Facility Assessment on 5/29/25. Audits 1. On 5/23/25, the Market Clinical Advisor conducted an audit of residents receiving intravenous antibiotic medications, no other residents were identified as receiving intravenous medications. In-services 1. The Director of Nursing educated LPN #101 on 5/29/25 on medication administration documentation, standards of nursing practice, and accuracy of medical records. 2. On 5/24/25, the Market Clinical Advisor and Market Clinical Lead educated 19 of 22 full-time licensed nurses on the medication administration policy related to administering medications in accordance to the physician orders, documenting medications at the time of administration, late entry process, and medication errors. Education included types of medication errors to include omissions, wrong dose, incorrect duration, wrong time, incorrect dose, incorrect route of administration, and wrong patient. Education completed on acceptable professional standards and practices related to documentation of medications to include accurate and complete medication records. In addition, the education included not documenting medication services not performed, not documenting medication services before they are performed, and timely medication documentation. Education included performing nursing care within the scope of practice and in accordance with nursing standards of care. The facility has 12 PRN licensed nurses; 3 of 12 PRN licensed nurses received the education on 5/24/25. The facility attempted to contact the 9 PRN licensed nurses via phone; the DON will monitor the schedule and provide 1:1 in-services before their next scheduled shift. Active licensed nurses, licensed nurses on leave of absence (FMLA), and PRN nurses who have not received the education aforementioned will be educated prior to returning to their assigned shift by the NPE or designee. 3. On 5/24/25, the Market Clinical Advisor and/or Market Clinical Lead educated 6 of 6 full-time RNs on the medication administration policy related to administering intravenous medications in accordance to the physician orders, documenting medications at the time of administration, and medication errors. Education included types of medication errors to include omissions, wrong dose, incorrect duration, wrong time, incorrect dose, incorrect route of administration, and wrong patient. Education completed on acceptable professional standards and practices related to documentation of medications to include accurate and complete medication records. In addition, the education included not documenting medication services not performed, not documenting medication services before they are performed, and timely medication documentation. Education included performing nursing care within the scope of practice and in accordance with nursing standards of care. The facility has 4 RNs who work on a PRN basis, the facility was able to reach 1 of 4 via phone; attempts were made to contact the remaining 3 RNs that did not receive the education via phone. The Director of Nursing will monitor the schedule and provide the 1:1 in-services to the PRN RNs before their next scheduled shift begins. 4. On 5/29/25, the Market Clinical Advisor educated the Director of Admissions and Director of Marketing on the admission process related to IV therapy and antibiotics to include the facility will not admit, re-admit, or treat patients with orders for IV hydration or IV medications. 5. On 5/29/25 to present, the Administrator educated 1 Medical Director, 2 Certified Registered Nurse Practitioners, 4 Nurse Practitioners, 1 Pharmacy, and 1 (after hour group) that the facility will not admit, readmit, or treat patients with IV hydration or IV medication. 6. On 5/30/25, the Administrator communicated to 31 licensed nurses that the facility will not admit, readmit, or treat patients with orders for IV hydration or IV medications via regroup messaging. ********************************************************************* After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team verified onsite that the immediate corrective actions had been implemented the Immediate Jeopardy was removed on 05/31/2025. The scope/severity level of F694 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on observations, interviews, and record reviews, the facility failed to ensure a Registered Nurse (RN) was consistently scheduled to administer Resident Identifier (RI) #9's 12:00 AM dose of intravenous (IV) antibiotic, Piperacillin-Tazobactam (Zosyn). Six doses of RI #9's Zosyn scheduled to be administered at 12: AM were either not documented as administered or documented days later by RN #25 who was not clocked in at the time the documented doses were scheduled. It was determined the facility's noncompliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.35 Nursing Services at F725- Sufficient Nursing Staff. On 05/28/2025 at 9:37 PM, the interim Administrator, the interim DON, and the Market Clinical Advisor were provided a copy of the IJ template and notified of the finding of immediate jeopardy in the area of Nursing Services at F725- Sufficient Nursing Staff. The IJ began on 05/05/2025 and continued until 05/30/2025. On 05/31/2025 the immediate jeopardy was removed. F725 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revised their corrective actions as necessary to achieve substantial compliance. This deficient practice affected RI #9 one of one resident for IV therapy. Findings Include: Cross-Reference F600, F658, F694, F760, F835, and F837. On 05/20/2025 at 1:00 PM an observation was made with Licensed Practical Nurse (LPN) #28 of RI #9's remaining doses of Zosyn. 23 doses of RI #9's Zosyn 4.5 grams (g) was observed in the medication room. RI #9 RX History Report documented that 56 doses of Zosyn 4.5 g were delivered to the facility for RI #9. On 05/20/2025 at 4:50 PM an interview was conducted with the Pharmacist who reported 56 doses of Zosyn were delivered to the facility for RI #9. The Pharmacist said the facility did not stock Zosyn 4.5 g. RI #9's Electronic Medication Administration Record (EMAR) indicated 42 doses of Zosyn were administered. The EMAR documented that RI #9's Zosyn scheduled for 12:00 AM on 05/17/2025 was not administered. A review of RI #9's EMAR for the month of May 2025 revealed that RN #25 documented RI #9's 12:00 AM dose of Zosyn as administered from 05/06/2025 through 05/19/2025 except 05/17/2025 which was blank. The EMAR did not document the time the medication was administered or when RN #25 documented the doses as administered. A review of RN #25's timecard revealed that she was not clocked in on several shifts in which she had documented medications as administered. On 05/27/2025 at 4:00 PM during a phone interview with the FDON #2, she said including two MDS RNs, the facility had six full-time RNs in May of 2025. The FDON said the RNs had a set schedule that was verbally discussed. The FDON said RN #25 worked weekends 7 AM to 7 PM and the rest worked dayshift during the week. The FDON was asked what was the process to ensure an RN was scheduled to administer RI #9's IV antibiotics. The FDON said at 8:00 AM, 12:00 PM, and 4 PM RNs were scheduled to be in the building and RN #25 would administer the 12:00 AM doses. The FDON said it was communicated verbally and she did not have anything in writing. On 05/28/2025 at 12:49 PM during a follow-up interview with the facility's Staffing Coordinator (SC), she reported that there was no RN scheduled to be at the facility during the 12:00 AM shift on 05/07/2025, 05/09/2025, 05/13/2025, or 05/17/2025. The SC said according to the schedule there was not a RN in the facility at 12:00 AM on those dates. RI #9's hospital progress note dated 05/22/2025 documented that RI #9 was being treated for . Sepsis with shock Chronic left hip postoperative infection . ************************************************ The facility submitted a plan to remove the immediacy of the identified deficient practice that included: ************************************************* Assessments 1. RI #9 was discharged from the facility on 5/19/25. 2. The new Director of Nursing Services placed RN #25 on administrative leave on 5/28/25. 3. On 5/24/25, the Market Clinical Advisor placed DON #2 on administrative leave and on 5/29/25, DON #2 was informed of employment separation. 4. Effective 5/25/25, the facility will not administer IV hydration and IV medications. The Administrator updated the Facility Assessment on 5/29/25. Audits 1. On 5/23/25, the Market Clinical Advisor conducted an audit of residents receiving intravenous antibiotic medications, no other residents were identified as receiving intravenous medications. 2. On 5/30/25, the Market Clinical Advisor clarified there were no other specialized procedures required only an RN. In-services 1. On 5/24/25, the Market Clinical Advisor and Market Clinical Lead educated 19 of 22 full-time licensed nurses on the medication administration policy related to administering medications in accordance to the physician orders, documenting medications at the time of administration, late entry process, and medication errors. Education included types of medication errors to include omissions, wrong dose, incorrect duration, wrong time, incorrect dose, incorrect route of administration, and wrong patient. Education completed on acceptable professional standards and practices related to documentation of medications to include accurate and complete medication records. In addition, the education included not documenting medication services not performed, not documenting medication services before they are performed, and timely medication documentation. Education included performing nursing care within the scope of practice and in accordance with nursing standards of care. The facility has 12 PRN licensed nurses; 3 of 12 PRN licensed nurses received the education on 5/24/25. The facility attempted to contact the 9 PRN licensed nurses via phone; the DON will monitor the schedule and provide 1:1 in-services before their next scheduled shift. Active licensed nurses, licensed nurses on leave of absence (FMLA), and PRN nurses who have not received the education aforementioned will be educated prior to returning to their assigned shift by the NPE or designee. 2. On 5/24/25, the Market Clinical Advisor and/or Market Clinical Lead educated 6 of 6 full-time RNs on the medication administration policy related to administering intravenous medications in accordance to the physician orders, documenting medications at the time of administration, and medication errors. Education included types of medication errors to include omissions, wrong dose, incorrect duration, wrong time, incorrect dose, incorrect route of administration, and wrong patient. Education completed on acceptable professional standards and practices related to documentation of medications to include accurate and complete medication records. In addition, the education included not documenting medication services not performed, not documenting medication services before they are performed, and timely medication documentation. Education included performing nursing care within the scope of practice and in accordance with nursing standards of care. The facility has 4 RNs who work on a PRN basis, the facility was able to reach 1 of 4 via phone; attempts were made to contact the remaining 3 RNs that did not receive the education via phone. The Director of Nursing will monitor the schedule and provide the 1:1 in-services to the PRN RNs before their next scheduled shift begins. 3. On 5/29/25 and 5/30/25, the Administrator educated 1 Medical Director, 2 Certified Registered Nurse Practitioners, 1 Pharmacy, 4 Optum Partners, and 1 Lumina (after hour physician group) that the facility will not administer IV hydration or IV medication. 4. On 5/29/25, the Market Clinical Advisor educated the Director of Admissions and Director of Marketing on the admission process related to IV hydration therapy and antibiotics to include the facility will not admit, readmit patients, or treat patients with orders for IV hydration or IV medications. 5. On 5/30/25, the Administrator communicated to 31 licensed nurses that the facility will not admit and/or readmit patients with orders for IV hydration or IV medications via regroup messaging. 6. On 5/30/25, the Market Clinical Advisor educated the DON and/or designee regarding the responsibility of monitoring orders and care needs Monday thru Friday and communicating with the Scheduler to ensure sufficient staff to provide the necessary care. *********************************************** After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team verified onsite that the immediate corrective actions had been implemented the Immediate Jeopardy was removed on 05/31/2025. The scope/severity level of F725 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on interviews, resident record reviews, and review of a facility policy titled Behaviors: Management of Symptoms, the facility failed to ensure a behavior management process was implemented. Specifically, the facility failed to ensure staff understood what steps to take when resident behaviors were observed or reported, and staff took action to address behaviors and implement interventions and supervision instructions to protect residents in the facility from abuse and prevent escalation of RI #119's behaviors.RI #119 had a history of unmanaged behaviors in the facility including on 03/18/2025 when RI #119 threatened to kill people in the facility. RI #119 was evaluated at the hospital and returned to the facility on the same day without any new orders except a newly ordered medication. The facility failed to develop any plans for intervention or increased supervision of RI #119 to prevent RI #119 from having behaviors affecting others. RI #119's behaviors continued to escalate and on 04/01/2025 RI #119 physically abused RI #53 when RI #119 hit RI #53 in the face twice with a fist on each side of RI #53's face.Because the facility failed to take actions to protect RI #53 from RI #119's abusive behaviors, during the survey RI #119 continued to target RI #53 with verbal and aggressive behavior as observed on 05/08/2025.The facility failed to ensure verbal behavior of cursing and yelling was captured in sufficient detail in behavior documentation to explain frequency, what RI #119 actually said, what RI #119's intentions were, if there were any underlying causes, and to whom the cursing and yelling was directed. The facility Behaviors: Management of Symptoms policy directed staff to . monitor for and document in the medical records any exhibited behavioral symptoms which include, . Verbally aggressive behaviors, such as threatening, screaming, cursing, insulting, or intimidating others .It was determined the facility's noncompliance with one or more requirements of participation has cause, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.40 Behavioral Health. On 05/13/2025 at 3:30 PM, the Administrator and the Director or Nursing (DON) were provided a copy of the IJ template and notified of the findings of immediate jeopardy in the area of Behavioral Health and at F740- Behavioral Health Services.On 05/19/2025, after the facility submitted the removal plan for the above non-compliance and while the removal plan was being validated, the facility submitted another allegation of resident-on-resident verbal abuse that alleged that RI #9 verbally abuses his/her roommate RI #87.During the investigation it was determined that RI #9 had history of incapability with his/her roommate and had a history of using derogatory names. On 05/17/2025 and 05/18/2025 RI #9 called his/her roommate, RI #87, derogatory names including n*gger and bitch. The facility had not developed a care plan that included interventions to protect other residents from RI #9. The care plan did not include the level of supervision required to supervise RI #9 in a manner to ensure other residents were protected. RI #9's behavior monitoring documentation indicated RI #9 did not have any behaviors on 05/18/2025. It was determined the facility's ongoing noncompliance with one or more requirements of participation has cause, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.40 Behavioral Health.On 05/28/2025 at 9:37 PM, the interim Administrator, interim Director or Nursing (DON), Regulatory Compliance Advisor, Clinical Lead and the Market Clinical Advisor were provided a copy of an updated IJ template and notified of the additional findings of immediate jeopardy in the area of Freedom from Abuse Neglect, and Exploitation at F600- Free from Abuse and Neglect.The IJ began on 04/01/2025 and continued until 05/30/2025 when the survey team verified onsite that corrective actions had been implemented. On 05/31/2025 the immediate jeopardy was removed. F740 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revised their corrective actions as necessary to achieve substantial compliance.This deficient practice affected RI #119, RI #53, RI #9, and RI #87; four of ten residents sampled residents for behavior management.Findings include:Cross-reference F600 and F835.A facility policy titled Behaviors: Management of Symptoms dated 07/01/2024, documented: . Policy Patients exhibiting behavioral symptoms will be individually evaluated to determine the behavior. The interdisciplinary team identifies underlying medical, physical, functional, psychosocial, emotional, psychiatric, or environmental causes that contribute to the patient's behavior. Mental Disorder is a syndrome characterized by a clinically significant disturbance. in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in psychological, biological, or developmental process underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. Non-pharmacological Intervention refers to approaches to care that do not involve medications, generally directed toward stabilizing and/or improving a patient's mental, physical, and psychosocial well being.Based on the comprehensive assessment, staff must ensure that a patient:Who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being; .PURPOSETo identify, prevent, and manage behavioral symptoms by:Using non-pharmacological approaches as initial interventions and ongoing;Promoting a therapeutic and safe environment for patients and staff;Monitoring outcomes of care plan interventions.PRACTICE STANDARDS .2. Staff will monitor for and document in the medical records any exhibited behavioral symptoms which include, but are not limited to:2.1 Verbally aggressive behaviors such as threatening, screaming, cursing, insulting, or intimidating others;2.2 Physically aggressive behaviors, such as hitting, kicking, grabbing, scratching, pushing, biting, spitting, threatening gestures, throwing objects; .3. Identify, to the extent possible, potential underlying causes of behavioral symptoms ( . pain, delirium, environmental factors, .). 4. Implement individualized, person-centered, non-pharmacologic interventions as the initial behavior mitigation strategy and update care plan accordingly.4.11 Providing support with skills related to verbal de-escalation, coping skills, and stress management.1) On 04/01/2025 at 3:40 PM the State Agency received a FRI alleging RI #119 hit RI #53 in the face with his/her hand. RI #53 was admitted to the facility 01/14/2025.RI #53's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 04/17/2025 documented a Brief Interview for Mental Status (BIMS) score of 3 of 15 which indicated severe cognitive impairment.RI #119 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnoses to include: Schizophrenia, Insomnia, and Severe Dementia with Agitation.A review of RI #119's MDS assessment with an ARD of 01/02/2025 revealed RI #119 scored a 14 of 15 on the Brief Interview for Mental Status (BIMS) which indicated intact cognition.RI #119's progress notes were reviewed and revealed behaviors documented as follows:On 01/02/2025 an entry by CRNP . Yelling and having conversations with self. Per staff yelling out since 5 pm yesterday. Other residents complaining. Possible need for psych [psychiatric] admission; . Yelling out over night.The facility provided a Behavior Documentation list dated January through May 2025 that included the following entries of documented behaviors:01/03/2025 at 3:31 PM Resident is agitated; experiencing unwanted behaviors .01/07/2025 at 11:25 AM Appropriate mood and affect. Agitation and delirium improving on Invega01/08/2025 at 4:46 AM Schizophrenia; yells out at times .02/11/2025 at 11:57 AM tearful, anxious - no change in mood .02/17/2025 at 3:31 PM psych consulted for agitation and delirium - improved with Invega .Further progress notes reviewed for RI #119 revealed the following: On 03/17/2025 the Assistant Director of Nursing (ADON) documented the following: . Resident outside cursing. The resident refused to come back to the building from the doctors appointment. [He/she] states [he/she] wants to go home.On 03/17/2025 at 2:26 PM the ADON documented: . Dr. [doctor] . notified of resident elopement and agitation. The resident is cursing in the hallway. No aggression noted.On 03/17/2025 a change in condition documentation note included RI #119 had verbal aggression and other behavioral symptoms.On 03/18/2025 at 6:37 PM LPN #57 documented RI #119's behavior as follows: Resident observed to have increased agitation, yelling out constantly at staff and other residents, cursing loudly. Resident threatening staff with violence and repeatedly threatening to kill staff and random people in hallway. DON and MD notified. Received order to transfer resident to ER (hospital emergency room) for further evaluation and treatment.An interview was conducted with the ADON on 05/10/2025 at 5:54 PM. The ADON was questioned regarding the behaviors of RI #119. The ADON was asked about a nurse's note dated 3/17/2025, which documented that RI #119 was using profanity outside and refused to enter the building, as well as cursing in the hallway. The ADON explained that RI #119 had attended an appointment that was canceled, and he/she was unwilling to return to the facility. RI #119 expressed a desire to go home, was using foul language, and requested that a family member be contacted. When asked what measures were taken to ensure the safety of residents upon RI #119's return to the facility on [DATE], she indicated that she was unaware. The ADON also said that she did not know the level of supervision required for RI #119.On 03/19/2025 at 10:50 PM LPN #76 documented RI #119's behavior as follows: . Mood and Behavior: Resident is agitated. Agitated - No recent change in mood.Resident sleeps intermittently. Resident wanders at night.Resident's psycho-spiritual needs are met.Resident is currently experiencing unwanted behavior(s).Disruptive: Chronic.Wandering: Chronic.An interview was conducted with LPN #76 on 05/10/2025 at 7:15 PM. LPN #76 was asked about the behaviors of RI #119. LPN #76 said, RI #119 often sat in the hallway in front of the nurses' station. LPN #76 described RI #119's behaviors as including cursing, with no words considered off-limits, mother fucker, God damn, and bitch. LPN #76 said, these words were directed at staff and residents, every day that she worked with RI #119, that was RI #119's everyday language. LPN #76 said, the note she documented meant RI #119 had outbursts sometimes, was not sleeping at night, was constantly back and forth from room to nurses' desk, chronic meant it was ongoing and RI #119 had those types of behaviors since RI #119 was admitted the first time on 12/30/2024. LPN #76 said, RI #119 had behaviors of yelling, talking under his/her breath, crying for his/her daughter, and cursing. LPN #76 said, she had told a CRNP, the unit manager and FDON #2 that RI #119 and RI #88 would feed off each other and they needed to move one of them because she could not keep them apart. LPN #76 said, when RI #119 was cursing in the presence of other residents, the facility was not fostering an environment conducive to mental and psychosocial well-being.On 04/01/2025 at 2:15 PM LPN #57 documented RI #119's behavior as follows: Resident was witnessed striking another resident twice in both occipital regions. Resident was immediately removed from areas and placed on observation. MD, CRNP, and supervisor notified of occurrence. Cross-reference F600.On 05/07/2025 at 2:45 PM LPN #57 was asked about the abuse on 04/01/2025 involving RI #119 and RI #53. LPN #57 said, she was at the desk, and she heard MAC #58 say, oh no, and RI #119 had rolled down in front of RI #53. LPN #57 said, she did not see the first hit, but she saw the second hit and it looked to be a closed fist and went to separate them. LPN #57 said, RI #119 had behaviors to include having an argument with himself/herself, was verbally aggressive and used profanity. When asked if RI #119 was on behavior monitoring at the time of the incident, LPN #57 said, behavior health had seen RI #119 and placed RI #119 on Depakote daily. On 05/07/2025 at 3:02 PM LPN #57 was asked follow-up questions about the behaviors RI #119 had before the incident. LPN #57 said, RI #119 yelled out, talked to himself/herself, and cursing, which continued. LPN #57 said, RI #119 interacted with other residents before that incident by cursing other residents, prior to the incidents and currently. LPN #57 said, some residents have said, for RI #119 to get away from them that they did not want to hear that mess. LPN #57 said, RI #88 had said that before. When asked if she should have reported RI #119 cursing RI #88, LPN #57 said, if she reported every time RI #119 cursed someone, that was all she would be doing all day. When asked how RI #119 was care planned for behavior management, before the incident on 04/01/2025, LPN #57 said, she did not know. When asked how RI #119 had changed since then, LPN #57 said, they had doubled RI #119's dose of Depakote, and RI #119 was more easily managed, milder, but verbally cussing had not changed. LPN #57 said, she did not know about RI #119's behavior monitoring and she did not know about RI #119's plan of care. LPN #57 said, she did not read care plans, she used nursing judgement and followed the orders. When asked if yelling and cursing were behaviors, LPN #57 said, yelling was but the cussing was just RI #119. LPN #57 said, she had called the Certified Registered Nurse Practitioner (CRNP) or a physician multiple times on RI #119 but she had not documented the conversations until just recently. LPN #57 was not aware of a facility behavior policy. LPN #57 said, when RI #119 had days of cursing and agitation, they did their best pulling residents apart.On 05/07/2025 at 10:18 AM MAC #58 was asked about the incident involving RI #119 and RI #53. MAC #58 said, RI #119 was in a wheelchair at the nurses' station and RI #119 was rowdy and would sit in the hallway and curse and was often angry and would argue with anyone. MAC #58 said, RI #119 started cursing RI #53 and she saw RI #119 hit RI #53 on both sides of RI #53's face with his/her fist. On 05/07/2025 at 10:33 AM MAC #58 was asked follow up questions about RI #119 being rowdy. MAC #58 said, RI #119 was always rowdy, always aggressive, angry, and cussing the staff out, using loud cursing and yelling at the top of his/her lungs. When asked about the day RI #119 hit RI #53, MAC #58 said, RI #119 had been rowdy all day. The Nurse was LPN #57 and there was not anything they could do, and RI #119 did not have anything prescribed. MAC #58 said, they tried to encourage RI #119 not to be aggressive and would ask RI #119 not to yell or curse. RI #119 said, she believed RI #119 was ready to explode on someone and was angry about being in the facility. MAC #58 said, she saw RI #119 rolling toward RI #53 and she knew it was not a good situation, RI #119 was cursing at RI #53 and then started rolling toward RI #53 and she knew something was about to happen, like RI #119 was going to put his/her hands on RI #53 and she ran to stop it but RI #119 had already hit RI #53 two times with his/her right hand. MAC #58 said, she heard the contact of the hit. MAC #58 said, she was not sure what RI #119 was care planned for, the nurse kept up with that. On 04/01/2025 at 9:30 PM LPN #57 documented: Resident returned to facility per stretcher via EMS (Emergency Medical Services). No new orders received. Resident placed on observation immediately.RI #119's care plans were reviewed and revealed RI #119 did not have a plan of care or interventions in place to address behavior management of agitation and cursing until 04/02/2025, after RI #119 hit RI #53. Further, RI #119 did not have a plan of care or interventions to address mood change related to Schizophrenia until 04/24/2025. RI #119's plan of care did not include interventions or supervision required to keep RI #53 and other residents safe from RI #119.On 05/08/2025 at 4:30 PM RI #119 was observed near the nursing station with other residents. LPN #57 was at the medication cart. RI #119 was in a wheelchair yelling loudly, but unable to hear exactly what RI #119 was saying. MAC #58 pushed RI #119 in the wheelchair away from RI #53 and MAC #58 stood between them and took RI #119 to his/her room. LPN #57 stood at the medication cart continuing to prepare medications. RI #53 had a facial expression of sad confusion and lifted his/her arms and shrugged his/her shoulders. On 05/08/2025 at 4:35 PM MAC #58 was asked about the observation. MAC #58 said, she asked RI #119 if he/she wanted to go to his/her room because she thought there was going to be another episode like 04/01/2025 between the two of them because RI #119 was cursing RI #53. MAC #58 said, RI #119 was cursing RI #53 because RI #53 tried to talk to RI #119. MAC #58 said, RI #119 just did not like some people and RI #53 was one of them. On 05/09/2025 at 9:36 AM CNA #105 was asked about RI #119's behaviors. CNA #105 said, RI #119 yelled out in the hall, cussed, called RI #53 a bitch sometime in April after RI #53 had been hit. When asked what she did the day RI #119 called RI #53 a bitch, CNA #105 said, she went down the hallway and there were nurses and CNAs there already, they intervened, and she did not know if it was written up or not. CNA #105 said, it was verbal abuse when a resident cursed another resident. When asked about the environment where residents were cursing, CNA #105 said, some people would be fearful of so much chaos going on. CNA #105 said, staff were instructed to address behaviors of aggressive residents by separating them, this was not specifically about RI #119, but just in general.An interview was conducted with RN #4 on 05/12/2025 at 12:17 PM. RN #4 was asked about the facility's behavior management program. RN #4 confirmed that the facility had a behavior management program. She explained that it involved printing documented behaviors and discussing them during daily and weekly meetings. She mentioned that the care plans for residents with identified behaviors would be reviewed to ensure that interventions were in place. RN #4 was asked about RI #119. RN #4 stated, she was familiar with RI #119 and noted RI #119's behaviors included yelling and cursing which was part of RI #119's personality.On 05/10/2025 at 4:17 PM the Social Services Director (SSD) was asked about the behavior program. The SSD said, all departments were involved, there was opportunity to be discussed daily, there was a meeting weekly for behaviors that started the end of March 2025, and educations on behavior management was given to all departments. The SSD said, social and nursing were responsible for behavior management. When asked how well the behavior program would work if the staff did not document the resident's behaviors, the SSD said, it would not work, because they would not know what was going on with the residents. The SSD said, residents could not be properly cared for without the documentation of the behaviors. An interview was conducted with the Administrator (ADM #1) on 05/13/2025 at 7:45 PM. During the interview, the Administrator was questioned regarding the behaviors of RI #119. The Administrator acknowledged her awareness of RI #119's use of profanity. She indicated that staff should document behaviors, particularly when residents exhibit agitation, inappropriate conduct, or display anger towards others, and emphasized that such actions should be classified as abuse. The Administrator defined behaviors to include spitting, throwing, self-scratching, picking at self, cursing, yelling, elopement, seeking exits, and experiencing hallucinations. When asked to identify a resident behavior that impacts others, she stated it involved actions that infringed upon another person's rights. The Administrator said it was her responsibility to ensure that residents who exhibited behaviors were effectively managed, monitored, and supervised. She noted that this was a collaborative effort and that she oversaw all staff involved. When asked about the responsibilities towards residents at the facility, she responded that it was essential to ensure they were properly cared for, safe, and protected from harm.An interview was conducted with FDON #2 on 05/12/2025 at 6:46 PM. FDON #2 said, her responsibilities included supervising the nursing department, staffing, and overseeing daily operations. When questioned about the behaviors associated with RI #119, she said they involved yelling and the use of profanity. FDON #2 said, she became aware of those issues through the unit manager and relevant documentation. FDON #2 stated, what she considered behaviors would depend on the patient and could include actions such as yelling, kicking, resisting care, hitting, and biting. She said, those behaviors could impact others and should be properly documented. FDON #2 said, if a nurse failed to document behaviors, it would be hard to implement appropriate interventions, which could lead to ineffective behavior management. 2) On 05/19/2025 at 4:40 PM the State Agency received a Facility Reported Incident (FRI) alleging verbal abuse occurred on 05/17/2025 when RI #9 yelled and screamed and demanded RI #87 turn off the television. RI #87 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnosis to include: Malignant Neoplasm of Larynx, Anxiety, Major Depressive Disorder, and Mood Disorder. RI #87's quarterly MDS assessment with an Assessment Reference Date ARD of 05/01/2025 documented RI #87's hearing was adequate and a BIMS score of 12 of 15 which indicated moderate cognitive impairment. RI #9 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnosis to include: Depression, Insomnia, Anxiety and Schizophrenia. RI #9's quarterly MDS assessment with an ARD of 05/09/2025 documented a Brief Interview for Mental Status BIMS score of 12 of 15 which indicated moderate cognitive impairment. A review of RI #9's comprehensive care plans revealed a care plan with an initiation date of 09/13/2020, with a focus area of distressed and fluctuating mood symptoms with screaming and yelling at roommate. Interventions included RI #9 was receiving mental health services through Integrated Behavioral, RI #9 played bingo, and staff was to observe for worsening signs/symptoms of existing psychiatric disorder such as: mania, hypomania, and frequent mood changes; staff were to notify physician/advanced Practice Practitioner as needed. The care plan did not provide specific interventions for staff use or the level of supervision required to prevent RI #9 from abusing other residents or prevent RI #9's behaviors from affecting others.RI #9's progress notes were reviewed, and an entry dated 05/17/2025 at 10:44 PM signed by LPN #100 documented behavior as follows: . Was a behavior observed? YESResident yelling and screaming out at roommate Demanding roommate turn off T.V (television) .Further review of RI #9's progress notes revealed no behaviors were documented on 05/18/2025.A review of RI #9's Behavior Monitoring and Intervention Report revealed no behaviors were documented on the evenings on 05/17/2025 and 05/18/2025. RI #9's progress notes contained an entry dated 05/19/2025 at 09:53 AM signed by the Social Services Director that documented: . expected to transfer rooms on Reason for transfer: Screaming and yelling at roommate 05/19/2025 Patient was notified. The patient's responsible party was notified.On 05/21/2025 at 11:13 AM, an interview was conducted with RI #87 who said the TV was not loud, RI #9 would holler just to be hollering. RI #87 stated, the nurse had to tell RI #9 to be quiet due to RI #9 hollering like a baby. RI #87 stated, RI #9 was mean. RI #87 stated, he/she was told by a nurse RI #9 did not like black people. On 05/21/2025 at 1:44 PM LPN #100 was asked about RI #9's behaviors. LPN #100 said, RI #9 would scream at roommates and call them names. LPN #100 said, RI #9 had a previous roommate and RI #9 would not let the previous roommate watch TV. LPN #100 said, RI #9 moved in with RI #87. LPN #100 told the surveyor RI #87 was hard of hearing and could not talk. LPN #100 said, RI #9 called RI #87 names and demand RI #87 turn off the TV. LPN #100 said, RI #9 was racist and used derogatory terms, but not all the time. LPN #100 said, when RI #9 moved into the room with RI #87 it got worse. LPN #100 stated, RI #9 called RI #87 the N word and the B word demanding, RI #87 turn off the TV. LPN #100 stated, she closed the privacy curtain and told RI #9 that he/she had to be nice. LPN #100 stated this incident happened over the weekend and she witnessed RI #9 call RI #87 those derogatory names on both Saturday and Sunday night. When asked what it was called when RI #9 called RI #87 the N word and B word, LPN #100 stated racist. LPN said, she had received abuse education recently and it was verbal abuse when someone calls another resident the N word or the B word. LPN #100 stated, she felt like RI #87 was protected from abuse when RI #9 remained in the room after calling RI #87 derogatory names because RI #9 could not get up or move around, she closed the privacy curtain, RI #87 was hard of hearing, and since it happened on night shift, that was all they could do. When asked how a reasonable person would have felt being called those names, LPN #100 stated They would feel very awful. They wouldn't like. I don't like when I'm called names. But you have to grin and bear it and go about your business.On 05/23/2025 at 9:11 AM an interview was conducted with LPN/Unit Supervisor #27. When asked what RI #9's care plan for yelling at other residents directed staff to do, LPN #27 stated staff were to observe for worsening signs and symptoms and notify physician and NP. In a follow-up interview on 05/23/2025 at 12:30 PM, LPN #27 stated according to the facility's behavior management program, if staff observe residents with a behavior they should document, notify/report(nurse) and follow-up.On 05/28/2025 at 4:31 PM, an interview was conducted with the interim Administrator. She stated that QA revealed staff had not documented RI #9 had behaviors on 05/18/2025.************************************************The facility submitted an acceptable plan to remove the immediacy of the identified deficient practice that included:*******************************************Assessment 1. On 3/18/25, RI #119 exhibited an increase in agitation and behaviors; the Physician was notified, and a new order was received to transfer to UAB hospital for evaluation and treatment. Chief complaint at ER: AMS from Magnolia Ridge, sent for being combative and agitated towards staff. Patient calm and cooperative. AMS workup initiated to include EKG, lab work, chest x-ray, and CT scan. During his/her visit, he/she did become a little more agitated and was treated with oral olanzapine. The final diagnosis was Dementia. RI #119 was discharged back to the facility on 3/19/25 at 4:00 am approximately with no new orders. 2. On 3/19/25, RI #119 was assessed by the Certified Registered Nurse Practitioner and the following interventions and orders were implemented: obtain a CBC and CMP, avoid any additional benzos, start Divalproex 125 mg BID for psychiatric conditions, and Integrated Behavioral Health to evaluate. 3. On 3/19/25, RI #119 was evaluated by Integrated Behavioral Health Services, a new order was initiated to start Divalproex (Depakote) 125 mg BID for mood stabilization.4. On 3/19/25 to 3/23/25, RI #119 was assessed and monitored daily by a Licensed Nurse to assess medical condition and mood/behavior status. Documentation of assessment was recorded on the skilled evaluation progress note. 5. On 3/23/25, RI #119 was assessed and monitored every 72 hours until 4/1/25 by a Licensed Nurse or Practitioner to assess medical condition and monitor mood/behavior status. Documentation of assessment was recorded on the skilled evaluation progress note.6. On 4/1/25, at 1:45 pm RI #119 hit RI #53 in the face and RI #119 and RI #53 were immediately separated by the nursing staff, RI #119 was removed from the area of occurrence and escorted back to him/her assigned room and placed on 1 to 1 supervision until he/she was transferred to UAB hospital for evaluation.7. Licensed Nurse updated RI #119 and RI #53 plan of care related to the resident-to-resident interaction on 5/8/25. RI #53's care plan was updated to include the resident touching and gently rubbing another resident on the hand to say hello resulting in the other resident becoming upset. Interventions added included encouraging engagement in activities of choice/preference; Integrated Behavioral Health referral as needed, psychosocial review completed on resident after encounter with another resident; redirect resident from touching other residents without permission, and behavior monitoring for unwanted touching. RI #119's care plan was updated to include the resident exhibiting verbal behaviors as evidence by yelling and cursing when a resident touched his/her hand. Interventions added included a psychosocial evaluation completed by Social Services. The resident moved from the Rehab Unit to the [NAME] Wing on 5/8/25. The resident moved to [NAME] Hall to be in a less stimulating area to help decrease behaviors. Additional interventions included placing the resident on 1:1 supervision on 5/8/25 and offering the resident a snack for redirection.8. The Social Service Director facilitated a room move for RI #9 on 5/19/25. RI #9 was transferred to the hospital on 5/19/25 related to a change of condition.9. Social Service Director and/or designee completed a psychosocial assessment on RI #87 on 5/20/25 and no psychosocial concerns were noted. RI #87 was interviewed on 5/20/25 by the Market Resource Operator and RI #87 denied being abused, afraid, or experiencing mental anguish. 10. The Administrator educated LPN #100 on 5/26/25 on promptly reporting allegations of abuse to the Abuse Prevention Coordinator. 11. RI #9 was discharged from the facility on 5/19/25, return anticipated if RI #9 meets the clinical admission criteria and clinical capabilities of the facility. Upon return, RI #9's plan of care will be updated to include interventions to protect other residents.Audits 1. On 5/8/25, the Director of Nursing (DON), Social Service Director, Activity Director, Nurse Managers, and Clinical Reimbursement Coordinator conducted an audit of all current residents. Based on this audit, 60 residents were identified with a history of behaviors, or active behaviors based on the behavior monitoring flowsheet, MDS, and resident history to validate appropriate interventions and supervision instructions were in place to protect residents in the facility. Revisions were made to 10 residents' behavior care plans by the Interdisciplinary Team on 5/8/25. 2. On 5/13/25, the Social Service Director and/or designee interviewed 63 residents with a BIMs of 8 or > regarding resident to resident or staff to resident verbal interactions/allegations of abuse. No additional concerns were verbalized.3. Facility staff to include 46 employees in Nursing, Social Services, Activity, Dietary, Therapy, Medical Records, and Housekeeping were interviewed regarding any unreported behavior observations by the Director of Nursing and/or designee on 5/14/25. Active employees, employees on leave of absence (FMLA), and PRN staff who have not been interviewed regarding unreported behaviors, will be interviewed prior to returning to duty. Any unreported behaviors will be investigated to determine if an abusive incident was witnessed and not identified as potential abuse or reported.Behavior Management Process1. Interdi

Based on interviews, record review, and Review of Mosby's 2017 Nursing Drug Reference Book, the facility failed to ensure Resident Identifier (RI) 9's Apixaban (Eliquis) was not resumed on 04/10/2025 at 8:00 PM when RI #9 had an actively bleeding surgical incision and abnormal laboratory (lab) blood values. On 04/07/2025, a change of condition was noted in RI #9's medical record related to bleeding from a surgical incision. Certified Registered Nurse Practitioner (CRNP) #75 was notified, and orders were obtained to hold RI #9's Eliquis for three days. RI #9's Eliquis was held on 04/07/2025 at 8 PM until 04/10/2025 at 8 PM.On 04/09/2025 at 10:41 AM, the lab reported the Complete Blood Count (CBC) results that included hemoglobin of 7.7 g/dL (grams per deciliter), hematocrit of 25.9% (percent) and Red Blood Count (RBC) of 2.6 10 6/uL (microliters).On 04/09/2025 the Medical Director (MD) made an acute care visit for RI #9. The MD's note indicated that he was not aware of ongoing concerns regarding bleeding from RI #9's surgical wound. The MD also reported that he was unaware that RI #9's surgical incision was bleeding and unaware of the 04/09/2025 CBC results. The MD reported RI #9's Eliquis should have continued to be held beyond 04/10/2025.RI #9's Eliquis was resumed at 8 PM on 04/10/2025.The Orthopedic surgeon said he would have not resumed the Eliquis on 04/10/2025, but he left those decisions to the facility's Medical Director.On 04/16/2025 a repeat hemoglobin was drawn and resulted on 04/17/2025 with value of 4.9 g/dL. RI #9 was transferred to the hospital on [DATE].It was determined the facility's noncompliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.45 Drug Regimen is Free From Unnecessary Drugs.On 05/31/2025 at 7:08 PM, the interim Administrator and the Market Clinical Advisor were provided a copy of the IJ template and notified of the findings of immediate jeopardy and substandard quality of care in the area of Pharmacy Services at 757- Drug Regimen is Free From Unnecessary Drugs.The IJ began on 04/10/2025 and continued until 06/03/2025. On 06/04/2025 the immediate jeopardy was removed. F757 was lowered to the lower severity of no actual harm with a potential for more that minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revised their corrective actions as necessary to achieve substantial compliance.This deficient practice affected RI #9 one of 18 sampled residents.Findings Include:Cross Reference F580 and F841Mosby's 2025 Nursing Drug Reference 38th Edition (drug manual) indicated Apixaban (Eliquis) was classified as an Anticoagulant that was a High Alert medication. The drug manual documented:apixaban . CONTRAINDICATIONS: active bleeding. INTERACTIONS . Increase: bleeding .NURSING CONSIDERATIONS Assess: Bleeding: bleeding may occur from any body system, may be fatal if severe. Bleeding to report bleeding, bruising, confusion, weakness, numbness of limbs.RI #9 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnoses to include Unspecified Atrial Fibrillation and Displaced Intertrochanteric Fracture of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing. RI #9's Order Summary Report (Physicians Orders) revealed RI #9 had an order dated 02/26/2021 for Eliquis 5 mg (milligram) by mouth two times a day for Atrial Fibrillation.On 03/28/2025 RI #9 was readmitted to the facility post hospital stay. Licensed Practical Nurse (LPN) #68 documented RI #9 had 14 staples plus five more staples at left hip surgical incision. The LPN indicated RI #9 arrived with a surgical dressing over the site.On 05/29/2025 at 4:57 PM, an interview was conducted with LPN #101 who said that when RI #9 first came back they did not discontinue his/her anticoagulant until the CRNP did labs and gave an order to hold it. LPN #101 said that the wound had staples, but fluid was seeping out when she came in on the evening shift and a CNA reported to her that RI #9's gown, the bed, and the pad were wet from the bloody-tinged fluid. She further stated that there was a pretty good amount of drainage because she helped the CNA change the resident's bed. LPN #101 stated that she passed the information on in report to LPN #74. A review of RI #9's Progress Notes dated 04/07/2025 revealed RI #9 had bleeding from the left hip incision site. RI #9's Primary Care Provider was informed and gave an order to hold RI #9's Eliquis 5 mg for three days.RI #9's Lab Results Report revealed the lab was collected on 04/08/2025 and resulted on 04/09/2025. The results included that RI #9 had a hemoglobin of 7.7 g/dL which was low. The normal range for a hemoglobin level was 12.0 g/dL - 16.0 g/dL. RI #9's hematocrit level was 25.9% which was also low. The normal range for a hematocrit level was 36.0% - 48.0%. RI #9's Progress notes dated 04/09/2025 7:13 by LPN #74 documented that wound care was provided to left hip surgical site and a medium amount of serous drainage was noted.A review of the MD's progress notes dated 04/09/2025 did not reveal RI #9's low hemoglobin and hematocrit had been addressed by the MD when he visited, nor was the bleeding from RI #9's left hip surgical site addressed.A review of RI #9's April 2025 eMAR revealed RI #9's Eliquis was held on 04/07/2025 at 8:00 PM; on 04/08/2025 at 8:00 AM and 8:00 PM; on 04/09/2025 at 8:00 AM and 8:00 PM; on 04/10/2025 at 8:00 AM and resumed on 04/10/2025 at 8:00 PM. Review of another Lab Results Report for RI #9 dated 04/17/2025 documented that RI #9 had a hemoglobin of less than 5.0 g/dL and a hematocrit level of 16.6%.A Progress Note for RI #9 dated 04/17/2025 documented that RI #9 was sent to the hospital related to a hemoglobin level of 4.9 g/dL.On 04/17/2025, RI #9 was admitted to the hospital with diagnosis of Symptomatic Anemia, hypotension, and bleeding from wound.RI #9's History and Physical from the hospital, dated 04/18/2025, revealed the following:Chief Complaintpt [patient] c/o [complained of] recent left hip replacement site has been bleeding for the past several days. pt also states [he/she] is SOB [short of breath] . History of Present Illness . Upon presentation, patient with hypotension 85/53 . tachycardia 113. Blood work significant for hgb [hemoglobin] of 5.5 .Patient ordered 2 units PRBC [Packed Red Blood Cells]. Patient developed hypotension and tachycardia. Patient given fluids with some improvement . Assessment/Plan 1. Symptomatic anemia .-In setting of bleeding from surgical site . Patient dropped 3 g [grams] in hemoglobin, apparently has been bleeding from surgical site since surgery .-Ordered for 2 units PRBC .On 05/30/2025 at 5:00 PM, a telephone interview was conducted with RI #9's Orthopedic Surgeon. The Orthopedic doctor said he was not aware RI #9 had a Hemoglobin level of 7.7 when RI #9 came to his office on 04/10/2025. The Orthopedic doctor said from a doctor's perspective he would not have resumed RI #9's Eliquis when the Hemoglobin was 7.7 g/dL.05/30/2025 at 5:10 PM, a telephone interview was conducted with the Medical Director (MD). The MD said he would not have resumed RI #9's Eliquis on 04/10/2025.On 05/31/2025 at 2:14 PM, another interview was conducted with the MD. When asked if RI #9's Eliquis should have automatically restarted without the results of the follow-up labs that were ordered since RI #9 was bleeding, the MD stated if the resident was bleeding, no.**********************************************************************The facility submitted an acceptable plan to remove the immediacy of the identified deficient practice that included:*******************************************Assessments1. RI #9 was discharged from the facility on 5/19/25. Audits1. On 5/31/25, the facility conducted an audit of 118 residents from 04/01/04 to 06/01/25 to identify residents receiving anticoagulant therapy with laboratory orders to verify physician notification. Of 118 residents, 13 residents were identified receiving anticoagulant medications with 1 resident identified with abnormal labs. Based on review, the Physician and/or Certified Registered Nurse Practitioner (CRNP) was notified of abnormal laboratory values and changes were made to the medication regimen by the Provider as needed. 2. On 6/01/25, Nurse Managers and/or designee conducted an audit of 118 residents to identify residents with surgical incisions. 3 of 118 residents were identified with a surgical incision. On 6/1/25, an assessment was completed with no abnormalitiesIn-services1. On 6/01/25, the Director of Nursing and/or designee educated 15 of 16 full-time on licensed nurses assessment of surgical incisions to include redness, warmth, swelling, pain, drainage (color, odor, amount) and signs of wound dehiscence and notifying the Physician and/or Certified Registered Nurse Practitioner of changes in condition. If the Certified Registered Nurse Practitioner (CRNP) is notified of a significant change, the (CRNP) will consult with the Physician/Medical Director within 24 hours and document the consultation in the resident's medical record. Additional education included monitoring residents receiving anticoagulant therapy per the plan of care and notifying the Physician and/or Certified Registered Nurse Practitioner of abnormal lab values that may warrant a change in medication regimen. The facility has 14 PRN/Part-time licensed nurses; 5 of 14 PRN/Part-time licensed nurses received the education on 6/01/25. The facility attempted to contact the 9 PRN/Part-time licensed nurses via phone; the DON and/or designee will monitor the schedule and provide 1:1 in-services before their next scheduled shift. Education on the aforementioned topics was sent to all Licensed Nurses via regroup message. Active licensed nurses, licensed nurses on leave of absence (FMLA), and PRN nurses who have not received the education aforementioned will be educated prior to returning to their assigned shift by the DON and/or designee.2. On 6/1/25, Director of Nursing educated the Assistant Director of Nursing and Unit/Nurse Managers on monitoring residents on anticoagulant therapy three times a week in the clinical meeting to ensure the Physician and/or Certified Registered Nurse Practitioner has been notified of changes in condition that may prompt a change in medication regimen. If the Certified Registered Nurse Practitioner (CRNP) is notified of the significant change; the CRNP will consult with the Physician/Medical Director within 24 hours and document the consultation in the medical record. 3. On 6/3/25, the Physician, 2 of 2 Certified Registered Nurse Practitioners', 1 of 1 Optum Nurse Practitioners' and Licensed Nurses were educated on the policy and process related to Change in Condition with specific emphasis on when a Certified Registered Nurse Practitioner (CRNP) is notified of a significant change in condition, the CRNP will consult with the Physician/Medical Director within 24 hours y possible following the immediate care of the patient and document the consultation. Licensed Nurses were educated via regroup message on 6/3/25.4. On 06/01/25, the Regional Medical Director educated the Medical Director on his/her role in facilitating and coordinating medical care to ensure the appropriateness and quality of medical care. Education consisted of monitoring residents' post-surgery, evaluating surgical incisions, assessing appropriateness of medications, duration, and adequate monitoring. Additional education included monitoring and following up on abnormal lab values and collaborating with other medical providers as needed. 5. On 06/01/25, the Director of AlignMed Partners educated 2 of 2 Certified Registered Nurse Practitioner's and 1 of 1 Optum Certified Registered Nurse Practitioner on his/her role in facilitating and coordinating medical care to ensure the appropriateness of medical care. Education included specific emphasis on monitoring residents' post-surgery, evaluating surgical incisions, assessing appropriateness of medications, duration, and adequate monitoring. Additional education included monitoring and following up on abnormal lab values and collaborating with other medical providers as needed.*****************************************************************************After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team verified onsite that the immediate corrective actions had been implemented the Immediate Jeopardy was removed on 06/04/2025. The scope/severity level of F757 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on interviews, record review, and review of a facility policy titled, Center Quality Assurance Performance Improvement (QAPI) Process, the facility's QAPI committee failed to identify that appropriate corrective actions had not been taken and no interventions were developed to ensure RI #53 was protected from RI #119 after RI #119 hit RI #53 in the face twice with a closed fist on 04/01/2025. RI #119 continued to have access to RI #53 until 05/08/2025 after a staff intervened to separate the residents when RI #119 was observed yelling, cussing, and behaving aggressively toward RI #53. RI #119 was placed on 1 to 1 supervision, resident RI #119 room assignment was changed to an alternate unit and room on the [NAME] Wing. It was determined the facility's noncompliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.75 Quality Assurance and Performance Improvement.On 05/15/2025 at 5:00 PM the Administrator (ADM) and the Director of Nursing (DON) were provided a copy of the IJ template and notified of the findings of immediate jeopardy in the area of Quality Assurance and Performance Improvement and at F867-QAPI/QAA Improvement Activities. The IJ began on 04/01/2025 and continued until 05/29/2025 when the survey team verified onsite that corrective actions had been implemented. On 05/30/2025 the immediate jeopardy was removed. F867 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy to allow the facility time to monitor and/or revised their corrective actions as necessary to achieve substantial compliance. This deficient practice had the potential to affect all residents who resided at the facility.Findings Include:Cross-Reference F600, F609, F610, F835, F760.The facility's Policy titled, Center Quality Assurance Performance Improvement Process, with a revision date of 10/24/2022, documented, POLICY Centers are committed to incorporating the principles of Quality Assurance and Performance Improvement (QAPI) into all aspects of the Center work processes, service lines, and departments. QAPI activities will be integrated across all care and service areas and include clinical care, quality of life, and patient/resident (hereinafter patient) choice.PURPOSE To standardize the Center's approach to QAPI culture and processes by implementing the following key elements.QAPI principles will drive the decision making within each Center. The Administrator leads the Center's QAPI processes and involves all departments, staff, and stakeholders- balancing a culture of safety, quality, and patient centeredness.The QAPI processes and improvements are based on evidence, drawing data from multiple sources, prioritizing improvement opportunities, and benchmarking results against developed targets.Improvement Activities (IAS) and Performance Improvement Projects (PIPS) are the structure and means through which identified problem areas are addressed with data analysis, process improvements, and ongoing monitoring whenever necessary using an interdisciplinary team. PROCESS1. The Administrator, along with the Director of Nursing, directs the development and documentation of the Center QAPI Plan and is responsible for development, maintenance, and ongoing evaluation of an active and effective Quality Assessment and Assurance (QAA) Committee.2. The QAA Committee: 2.1 Functions under the authority of the Administrator and the Governing Body and is composed of: . 2.8 Assesses, evaluates, and identifies potential improvement opportunities based on: . 2.8.2 All current regulatory on-site assessments, including plans of correction, both state/federal surveys and peer review surveys including a review of the plan of correction.2.8.3 Adverse events since the past meeting including prevention opportunities, investigation, and corrective actions.On 04/01/2025 at 3:40 PM the State Agency received a FRI alleging physical abuse occurred when RI #119 hit RI #53 in the face with his/her hand and the residents were separated. Licensed Practical Nurse (LPN) #57, the Administrator, and the Director of Nursing (DON) were made aware of the incident.On 05/12/2025 at 12:45 PM an interview was conducted with the Director of Nursing (FDON #2) who reported the 04/01/2025 incident involving RI #119 and RI #53. FDON #2 reported the incident was reviewed by QAPI Committee on 04/30/2025. FDON #2 said the facility conducted a root cause and offered to bring survey team a copy of the documentation.The DON provided the QAPI documentation of the 04/30/2025 QAPI meeting. The root cause of the incident was identified on the documentation as onset of delusions secondary to Vascular Dementia and Schizophrenia as evidenced by the resident was tearful and referenced working in the cotton fields since she was [AGE] years old and said a white [man/woman] was sitting on the porch. The facility's IMMEDIATE PLAN included interventions completed on 04/01/2025. The interventions included one-on-one with RI #119 until he/she was transferred to hospital on [DATE]. The interventions included transferring RI #119 to a Psychiatric Center on 04/02/2025. There were no long-term interventions to ensure RI #119 did not have continued access to RI #53. PLAN EMPLOYEE TRAINING included educating staff on the facility's abuse policy, Resident to Resident abuse, and behavior management. The facility's SMART GOALS included . staff will intervene with strategies to reduce resident-to-resident interaction and/or abuse . The QAPI document did not include any resident specific interventions to be implemented at the facility to protect RI #53 from RI #119.On 05/06/2025 RI #119 and RI #53 were observed sitting side by side in their wheelchairs.On 05/08/2025 RI #119 and RI #53 were observed sitting beside each other in their wheelchairs and RI #119 yelled and cursed at RI #53. *****************************************The facility submitted an acceptable plan to remove the immediacy of the identified deficient practice that included:*******************************************In-services1. The Market Operations Advisor and/or Market Clinical Advisor educated the Administrator on OPS300 Abuse Prohibition Policy on 5/13/25 to ensure the Administrator understands her role in operationalizing and overseeing policies within the Center, specifically the Abuse Prohibition Policy. The Administrator plays a vital role in ensuring staff are properly trained on identification and reporting abuse. The Administrator will ensure staff are properly educated on behaviors that can be potential abuse and ensure reporting is completed promptly. The Administrator will lead the investigation process and will follow up with outstanding activities needed for a thorough investigation. The Administrator will also ensure that each reportable event is taken to the QAPI committee for thorough review of completion, deliberation on investigation findings, and development of appropriate actions to take regarding elimination of future recurrence. 2. On 5/15/25, the governing body to include Market Clinical Advisor and Market Clinical Lead educated the Nursing Home Administrator on the Quality Assurance Performance Improvement process to include systematic identification, reporting, investigation, analysis, and prevention of abuse or allegations of abuse; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities related to abuse. 3. On 5/15/25, the Administrator educated the Quality Assurance Performance Improvement members to include the Administrator, Director of Nursing, Medical Director, Infection Preventionist, Nurse Managers, Nurse Practice Educator, MDS Nurse, Skin Team Lead, Social Worker, Dietary Lead, Housekeeping Lead, Admissions Director, Business Office Manager, Rehab Director, and C.N.A. were trained on their role in reviewing incidents of abuse, reviewing the investigations, conducting root cause analysis, identifying causative factors, and implementing corrective actions to address the causative factors identified. a. In QAPI, notes, assessments, interviews, care plans, etc. will be reviewed and corrective actions will address factors identified. b. QAPI members were in-serviced on the facility's investigative process which includes the investigation checklist. In-servicing included what a root cause analysis is. In QAPI, a Root Cause analysis tool will be used to conduct the review. The Root Cause analysis tool utilizes the fishbone and/or 5 whys method. The QAPI members were in-serviced on the root cause analysis process that includes review of staffing levels, policies, ETC. Common documentation that will be reviewed includes but not limited to the following: Resident/ Staff signed statements, MDS with BIMS score, nurses' notes, hospital records, documentation of resident's behaviors, Social Services notes, Psych notes, Staff trainings, resident care plans, face sheets with diagnoses etc. c. The Administrator and other QAPI Team Members are responsible for bringing all identified concerns to QAPId. QAPI review will take place within a week after a reportable event. e. The DON will revise each care plan with interventions and educate direct care staff on the intervention. MDS will revise assessments, and other Team Members will review and address areas in their specialty as needed. On 05/14/2025 the QAPI committee reviewed staff in-services that were not completed for IJ removal plans. Active employees, employees on leave of absence (FMLA), and PRN staff who have not received the education will be educated prior to returning to duty. The facility has attempted to contact the remaining 11 staff that have not received the in-service. The Nurse Practice Educator will monitor the schedule and ensure each staff member is trained during the on-boarding process prior to starting the assigned shift on the floor.4. On 5/24/25, the Market Clinical Advisor educated the new Administrator on conducting a thorough investigation, identifying causative factors, and developing and implementing corrective actions. The Administrator was educated on the Alabama abuse checklist and to place a copy of the investigation checklist in all abuse allegation files to ensure allegations are thoroughly investigated, causative factors are identified, and corrective actions are developed and implemented to ensure resident safety.5. On 5/29/25, the Senior Market President educated the Market Clinical Advisor, Market Clinical Lead, Administrator, and Director of Nursing on ensuring the facility QA committee review allegations of abuse allegations within one week after occurrence to identify causative factors, ensure a thorough investigation has been completed, and verify the development and implementation of corrective actionsQuality AssuranceThe Administrator hosted an AD HOC QAPI on 5/29/25 to review allegations of abuse from 5/19/25 thru current which consisted of a review of 10 instances of resident to resident and/or staff to resident allegations of abuse. The QAPI team reviewed causative factors and/or root cause, barriers to comprehension of education, identification of abuse, reporting, investigation, and proactive strategies/corrective actions. QAPI team recommended to continue verbal education and post-test to ascertain comprehension of education. Signage was created to provide a visual reminder of reporting requirements and the Administrator's contact information. Social Services and/or designee conducted 62 interviews with interviewable residents related to any care concerns that may rise to the level of abuse. During QAPI review concerns were identified with reporting clear and concise information to include what was said, when it was said, what the patient's reaction was, and if any previous incidents are known to allow for timely reporting of abuse allegations. Participants included the Administrator, Director of Nursing, Nurse Managers, Director of Memory Support, MDS Nurse, a Licensed Nurse, and a Certified Nursing Assistant.**********************************************************After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team verified onsite that the immediate corrective actions had been implemented the Immediate Jeopardy was removed on 05/30/2025. The scope/severity level of F867 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on interviews, record review, and review of a facility policy titled, Change in Condition: Notification of, the facility failed to ensure the physician was when a significant change was identified on 04/07/2025 when Resident Identifier (RI) #9 was noted to have continued bleeding from a surgical incision ten days after being admitted and 13 days after the surgical procedure. The facility further failed to ensure the physician was notified on 04/09/2025 Resident Identifier (RI) #9's hemoglobin was 7.7 g/dL (grams per deciliter). On 04/07/2025 a change of condition was noted in RI #9's medical record related to bleeding from his/her surgical incision. The Certified Registered Nurse Practitioner (CRNP) was notified, and orders were obtained to hold RI #9's Eliquis for three days and obtain Complete Blood Count (CBC) on 04/08/2025. RI #9's Abixipan (Eliquis) was held on 04/07/2025 at 8 PM until 04/10/2025 at 8 PM. On 04/09/2025 at 10:41 AM the lab reported hemoglobin of 7.7 g/dL (low at 12, critical at 6.5). The facility did not notify the physician. On 04/10/2025 at 8:00 PM RI #9's Eliquis was resumed and administered. During the Medical Director's interview, he said the Eliquis should not have been resumed on 04/10/2025. On 04/16/2025 a repeat hemoglobin was drawn and resulted on 04/17/2025 with a value of 4.9 g/dL. RI #9 was transferred to the hospital on [DATE]. It was determined the facility's noncompliance with one or more requirements of participation has cause, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.10 Resident Rights at F580 - Notify of Change (Injury/Decline/Room, Etc.). On 05/31/2025 at 7:08 PM, the interim Administrator and the Market Clinical Advisor were provided a copy of the IJ template and notified of the findings of immediate jeopardy in the area of Resident Rights at F580- Notify Changes (Injury/Decline/Room, Etc.) The IJ began on 04/09/2025 and continued until 06/03/2025 when the survey team verified onsite that corrective actions had been implemented. On 06/04/2025 the immediate jeopardy was removed. F580 was lowered to the lower severity of no actual harm with a potential for more that minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revised their corrective actions as necessary to achieve substantial compliance. This deficient practice affected RI #9 one of 18 sampled residents. Findings Include Cross reference F757 and F841 Review of the facility's policy titled, Change in Condition: Notification of, with a revision date of 07/01/2024 documented the following: . POLICY A Center must immediately inform the patient, consult with the patient's physician, and notify, consistent with their authority, the patient's representative, where there is: . A Significant change in the patient's physical mental, . (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complication); . A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment); . When making notification of above, the Center must ensure that all pertinent information is available and provided upon request to the physician. PURPOSE To provide appropriate and timely information about changes relevant to the patient's condition. On 05/29/2025 at 12:27 PM an interview was conducted with Registered Nurse (RN) #61, Unit Manager. RN #61 was asked, what was the facility's policy for notifying the physician. RN #61 said the physician was to be notified immediately if a resident had a significant change. RN #61 was asked, how did staff know whether to contact the physician or Medical Director and the Certified Registered Nurse Practioner (CRNP). RN #61 said it was nursing judgement. RN #61 was asked, was their a policy and RN #61 said, nursing judgment. RI #9 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Atrial Fibrillation and Displaced Intertrochanteric Fracture of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing. RI #9's face sheet identified the Medical Director (MD) as RI #9's Primary/Attending physician. RI #9's hospital medical record indicated that on 03/25/2025 RI #9 had an Open Reduction Internal Fixation (ORIF) of his/her left hip to repair femur fracture. RI #9 was transferred back to the facility on [DATE]. On 05/28/2025 at 12:00 PM an interview was conducted with Certified Nursing Assistant (CNA) #103 who reported that she provided care to RI #9 after he/she returned from the hospital. CNA #103 reported when RI #9 returned from the hospital the first time, he/she had staples and not a wound vaccum. CNA #103 said that one weekend in April 2025 when she reported to work, the off-going CNA told her to watch RI #9's leg because it was bleeding. CNA #103 said during that shift, RI #9's incision would not stop bleeding. CNA #103 reported the bleeding filled half of a regular bath towel three different times that day during the 7 AM to 3 PM shift. CNA #103 said it looked like a crime scene and she had to change RI #9's sheets every time she changed the bath towel. CNA #103 said she notified the nurse, LPN #62, and thought the nurse notified someone, but she did not know who. CNA #103 did not recall the date, but said it was a weekend. On 05/28/2025 at 2:56 PM an interview was conducted with LPN #62 who said RI #9 returned from the hospital with staples to a surgical wound on his/her left hip. LPN #62 said the wound dressing had to be changed multiple times per shift due to drainage. LPN #62 said the drainage would saturate a four by four (4x4) gauze dressing. LPN #62 said he notified CRNP #75 who came and saw RI #9. On 05/29/2025 at 4:57 PM an interview was conducted with LPN #101. LPN #101 said when RI #9 first returned from hip surgery, his/her anticoagulant were not held or discontinued. LPN #101 said RI #9's wound was closed with staples and was seeping. LPN #101 said she came in on an evening shift and the CNA reported to her that the bed, the gown, and the pad were wet with bloody tinged fluid. LPN #101 said it was reported to her that a CRNP had said that it was normal, and they were waiting on lab work. LPN #101 said she did not notify the CRNP or the physician. Progress Notes for RI #9 dated 04/07/2025, revealed a SBAR (Situation Background Assessment Recommendation) Summary for Providers that documented: Situation: The Change in Condition/s reported on this CIC [Change in Condition] are/were: Bleeding (other than GI [gastrointestinal]) . Nursing observation, evaluation, and recommendations are: Bleeding at incision site left hip . The note indicated that the Primary Care Provider was notified and ordered RI #9's Eliquis 5 mg (milligram) to be held for three days, a hemoglobin and hematocrit to be obtained on 04/08/2025, and apply three drops of Afrin to 4x4 gauze and apply left hip. A Lab Results Report for RI #9 revealed the lab was collected on 04/08/2025 and was reported on 04/09/2025 at 10:41 AM. The results indicated RI #9 had a hemoglobin of 7.7 g/dL which was low. The normal range for a hemoglobin level was 12.0 - 16.0 g/dL. RI #9's hematocrit level was 25.9% (percent) which was also low. The normal range for a hematocrit level was 36.0 - 48.0%. A Progress Note for RI #9 with an effective date of 04/09/2025 at 11:00 AM electronically signed by LPN #26 documented that the MD and CRNP #75 visited RI #9. The note indicated a follow-up X-Ray of RI #9's left hip was ordered and no other orders were indicated. The note also indicated that RI #9 had a follow-up appointment with the orthopedic doctor on 04/10/2025. A Progress Note for RI #9 with an effective date of 04/09/2025 at 11:00 AM electronically signed by the Medical Director (MD) documented: . Continue current POC [Plan of Care] . Nursing staff voices no new concerns. The patient and all other medical conditions are stable at this time . Medications: . Apixaban Oral Tablet 5 MG Give 1 tablet by mouth two times a day for anticoagulants . Physical Exam: . Heart Rate: 106 bpm [beats per minute] . The patient is well developed and in no acute distress . Labs . 7/10/2024 HGB [Hemoglobin] 12.3 and HCT [Hematocrit] 39.5 and 1/6/2025 indicated H&H 11/38. A Progress Note for RI #9 with an effective date of 04/16/2025 at 11:48 electronically signed by the Medical Director (MD) documented: . Continue current POC [Plan of Care] . Nursing staff voices no new concerns. The patient and all other medical conditions are stable at this time . Medications: . Apixaban Oral Tablet 5 MG Give 1 tablet by mouth two times a day for anticoagulants . Physical Exam: . Heart Rate: 62 bpm . The patient is well developed and in no acute distress . Labs . 7/10/2024 HGB [Hemoglobin] 12.3 and HCT [Hematocrit] 39.5 and 1/6/2025 indicated H&H 11/38. Progress Notes for RI #9 dated 04/16/2025 at 3:59 PM documented another Summary for Providers that documented a change in condition was reported to CRNP #75 by LPN #26. The note indicated that RI #9 had poor appetite, confusion, lethargy. CRNP #75 gave order to hold Eliquis x three (3) days, obtain CBC and Comprehensive Metabolic Panel (CMP) labs on 04/17/2025. Another Lab Results Report for RI #9 dated 04/17/2025 documented RI #9 had a hemoglobin of 4.9 g/dL and a hematocrit level of 16.6%. A Progress Note for RI #9 dated 04/17/2025 documented that RI #9 was sent to the hospital related to a hemoglobin level of 4.9. RI #9's History and Physical from the hospital, dated 04/18/2025, revealed the following: Chief Complaint pt (patient) c/o (complained of) recent left hip replacement site has been bleeding for the past several days. pt also states (he/she) is SOB (short of breath) . History of Present Illness . Upon presentation, patient with hypotension 85/53 . tachycardia 113. Blood work significant for hgb (hemoglobin) of 5.5 . Patient ordered 2 units PRBC (Packed Red Blood Cells). Patient developed hypotension and tachycardia. Patient given fluids with some improvement . Assessment/Plan 1. Symptomatic anemia . -In setting of bleeding from surgical site . Patient dropped 3 g in hemoglobin, apparently has been bleeding from surgical site since surgery . -Ordered for 2 units PRBC . On 05/30/2025 at 5:00 PM, a telephone interview was conducted with RI #9's Orthopedic Surgeon. The Orthopedic Surgeon said he was not aware RI #9 had a Hemoglobin level of 7.7 g/dL when RI #9 came to his office on 04/10/2025 and he would have liked to have been notified. On 05/30/2025 at 5:10 PM, a telephone interview was conducted with the MD. The MD said he was not notified on 04/08/2025 of RI #9's hemoglobin of 7.7 g/dL and hematocrit of 26.9% and he would have wanted to be notified. The MD said he should be notified when nursing staff identified a change of condition with a resident, but the facility had CRNPs. The MD said he wanted to be notified, and they could call him at any time and sometimes they call the CRNPs and they handled it. The MD said he would not have resumed RI #9's Eliquis on 04/10/2025 at 8 PM. The MD said the Eliquis should have been held for a longer period of time. The MD was asked, on 04/17/2025 RI #9's hemoglobin was 4.9 g/dL and hematocrit was 16.6% he/she was sent to the hospital, when should the facility have notified him. The MD said they should have notified him immediately. The MD was asked, why was it important for the physician to be notified in instances such as discussed with RI #9. The MD said the physician needed to monitor the resident. On 05/31/2025 at 2:14 PM a follow-up interview was conducted with the MD. The MD said he was not aware that notes he signed in RI #9's medical record in April 2024 included labs from 07/10/2024. The MD said the facility was responsible for notifying him if there were any labs for review. ************************************************************** The facility submitted an acceptable plan to remove the immediacy of the identified deficient practice that included: ************************************************************* Assessments 1. RI #9 was discharged from the facility on 5/19/25. Audits 1. On 5/31/25, the facility conducted an audit of 118 residents from 04/01/04 to 06/01/25 to identify residents receiving anticoagulant therapy with laboratory orders to verify physician notification. Of 118 residents, 13 residents were identified receiving anticoagulant medications with 1 resident identified with laboratory orders and abnormal lab values. Based on review, the Physician and/or Certified Registered Nurse Practitioner was notified of the abnormal lab values. 2. On 6/01/25, Nurse Managers and/or designee conducted an audit of 118 residents to identify residents with surgical incisions. 3 of 118 residents identified with a surgical incision. On 06/01/25, an assessment was completed with no abnormalities. In-services 1. On 6/01/25, the Director of Nursing and/or designee educated 15 of 16 full-time licensed nurses on the Change in Condition policy with specific emphasis on assessment of surgical incisions to include redness, warmth, swelling, pain, drainage (color, odor, amount) and signs of wound dehiscence and notifying the Physician and/or Certified Registered Nurse Practitioner. If the Certified Registered Nurse Practitioner (CRNP) is notified of a significant change, the (CRNP) will consult with the Physician/Medical Director within 24 hours and document the consultation in the resident's medical record. Additional education included monitoring residents receiving anticoagulant therapy per the plan of care and notifying the Physician and/or Provider of abnormal lab values within 24-48 hours. The facility has 14 PRN/Part-time licensed nurses; 5 of 14 PRN/Part-time licensed nurses received the education on 6/01/25. The facility attempted to contact the 9 PRN/Part-time licensed nurses via phone; the DON and/or designee will monitor the schedule and provide 1:1 in-services before their next scheduled shift. Education on the aforementioned topics was sent to all Licensed Nurses via regroup message. Active licensed nurses, licensed nurses on leave of absence (FMLA), and PRN nurses who have not received the education aforementioned will be educated prior to returning to their assigned shift by the DON and/or designee. 2. On 6/1/25, the Director of Nursing educated the Assistant Director of Nursing and Unit/Nurse Managers on monitoring residents on anticoagulant therapy three times a week in the clinical meeting to ensure the Physician and/or Certified Registered Nurse Practitioner has been notified of changes in condition. If the Certified Registered Nurse Practitioner (CRNP) is notified of a significant change; the CRNP will consult with the Physician/Medical Director as soon as reasonably possible and document the consultation. 3. On 6/3/24, the Medical Director, 2 of 2 Certified Registered Nurse Practitioners', 1 of 1 Optum Nurse Practitioners' and Licensed Nurses were educated on the policy and process related to Change in Condition with specific emphasis on when a Certified Registered Nurse Practitioner (CRNP) is notified of a significant change in condition, the CRNP will consult with the Physician/Medical Director within 24 hours and document the consultation in the medical record. The Licensed Nurse will be educated via regroup message on 6/3/25. 4. On 06/01/25, the Regional Medical Director educated the Medical Director on his/her role in facilitating and coordinating medical care to ensure the appropriateness and quality of medical care. Education consisted of monitoring residents' post-surgery, evaluating surgical incisions, assessing appropriateness of medications, duration, and adequate monitoring. Additional education included monitoring and following up on abnormal lab values and collaborating with other medical providers as needed. Additionally, the Medical Director was educated to review the discharge summary from the hospital records to ascertain pertinent medical information. 5. On 06/01/25, the Director of AlignMed Partners educated 2 of 2 Certified Registered Nurse Practitioner and 1 of 1 Optum Certified Registered Nurse Practitioner on his/her role in facilitating and coordinating medical care to ensure the appropriateness of medical care. Education included specific emphasis on monitoring residents' post-surgery, evaluating surgical incisions, assessing appropriateness of medications, duration, and adequate monitoring. Additional education included monitoring and following up on abnormal lab values and collaborating with other medical providers as needed. *********************************************** After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team verified onsite that the immediate corrective actions had been implemented the Immediate Jeopardy was removed on 06/04/2025. The scope/severity level of F580 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on interviews, resident record reviews, review of a facility policy titled Abuse Prohibition, review of Facility Reported Incidents (FRI) received by the State Agency, and review of the facility investigative file, the facility failed to ensure residents were free from abuse perpetrated by other residents and failed to ensure Resident Identifier (RI) #9 was free from neglect.Specifically the facility failed to ensure:1) Resident Identifier (RI) #53 was free from verbal and physical abuse perpetrated by RI #119 on 04/01/2025 when RI #119 hit RI #53 in the face twice with a closed fist, as witnessed by several staff members. RI #53 had a red mark on his/her face. Staff said, someone hit in that manner would feel hurt and confused.During the investigation, it was revealed that RI #119 was admitted to the facility with diagnoses to include Schizoaffective Disorder. The facility failed to ensure the required Preadmission Screening and Resident Review (PASRR) screening process was completed for RI #119 prior to admission to the facility to identify services in the most integrated setting appropriate for RI #119's needs for mental disorders. The facility failed to ensure RI #119's monthly injection of antipsychotic medication had been administered as ordered for treatment and management of RI #119's Schizoaffective Disorder. Licensed Nurses failed to administer RI #119's monthly injection dose in January and February of 2025 prior to escalating behaviors.Interviews with staff and review of RI #119's facility medical record revealed RI #119 had daily behaviors of cursing and yelling in the facility since RI #119 was admitted on [DATE]. Because the facility failed to report and manage RI #119's daily behaviors, on 03/18/2025 RI #119's behaviors escalated and RI #119 threatened to kill people in the facility. After verbalizing the threat, RI #119 was sent to the hospital for evaluation and returned from the hospital the same day, without any new orders. Because the facility failed to report or investigate the threat and failed to develop or implement any new interventions or supervision of RI #119, to prevent RI #119 from harming or abusing other residents, RI #119's behaviors further escalated to physical abuse against RI #53 on 04/01/2025. Further, the facility failed to prevent RI #119 from continuing to target RI #53, as observed during the survey on 05/08/2025 when RI #119 yelled, cursed, and aggressively responded to RI #53 while in close interaction in the hallway.It was determined the facility's noncompliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.12 Freedom from Abuse, Neglect and Exploitation.On 05/13/2025 at 3:30 PM, the Administrator, Director or Nursing (DON), Regulatory Compliance Advisor, Clinical Lead and the Market Clinical Advisor were provided a copy of the IJ template and notified of the findings of immediate jeopardy in the area of Freedom from Abuse, Neglect, and Exploitation at F600- Free from Abuse and Neglect.This deficient practice was cited as a result of the investigation of complaint/report/FRI number AL00050808.2) On 05/19/2025, after the facility submitted the removal plan for the above non-compliance and while the removal plan was being validated, the facility submitted another allegation of resident on resident verbal abuse alleging RI #9 screamed and demanded his/her roommate, RI #87, turn off the television.During the investigation of the FRI, it was reported that RI #9 had a history of using derogatory language and incompatibility concerns with his/her previous roommate and was moved into the room with RI #87.The Licensed Practical Nurse (LPN) who witnessed the incident reported that on 05/17/2025 and 05/18/2025, RI #9 yelled at RI #87, his/her roommate, and called RI #87 a bitch and nigg*r. The LPN said she did not identify the incident as abusive. When asked how a reasonable person would feel about being called those names she said, they would feel very awful. RI #9 and RI #87 remained roommates until 05/19/2025 when the incident was reported to the Abuse Coordinator.This deficient practice was cited as a result of the investigation of complaint/report/FRI number AL00051254.3) The facility further failed to ensure RI #9 was free from neglect when the facility failed to ensure antibiotics were ordered and available for administration upon RI #9's re-admission on [DATE]. The facility further failed to ensure sufficient staff were scheduled to administer RI #9's 12:00 AM scheduled dose of Piperacillin-Tazobactam (Zosyn).Specifically, seven doses of Zosyn were not administered on 05/03/2025, 05/04/2025, and 05/05/2025 and two doses of Daptomycin were not administered on 05/03/2025 and 05/04/2025 after RI #9 was re-admitted on [DATE] at 6:18 PM. Further of the 42 times the facility's staff documented that Zosyn was administered to RI #9, five doses were documented as administered days later on 05/14/2025 by RN #25 who was not clocked in at the time the doses were due, two doses were documented as administered days later on 05/14/2025 by the Former Director of Nursing (FDON) #2, and three doses were documented as administered by LPN #101 who was not qualified to administer the antibiotic and reported she did not administer the medication. RI #9's scheduled dose of Zosyn 05/17/2025 at 12 AM was not administered. A total of 18 doses of Zosyn were not administered from 05/03/2025 at 12 AM until RI #9 was discharged on 05/19/2025.It was determined the facility's continued noncompliance with one or more requirements of participation has cause, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.12 Freedom from Abuse, Neglect and Exploitation.On 05/28/2025 at 9:37 PM, the interim ADM, the interim DON, and the Market Clinical Advisor were provided a copy of an updated IJ template and notified of the additional findings of immediate jeopardy in the area of Freedom from Abuse Neglect, and Exploitation at F600- Free from Abuse and Neglect.The IJ began on 04/01/2025 and continued until 06/01/2025 when the survey team verified onsite that corrective actions had been implemented. On 06/02/2025 the immediate jeopardy was removed. F600 was lowered to the lower severity of no actual harm with a potential for more that minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revised their corrective actions as necessary to achieve substantial compliance.This deficient practice affected RI #119, RI #53, RI #87, and RI #9 four of ten residents sampled for abuse. Finding include:Review of the facility's policy titled, Abuse Prohibition, with a revision date of 10/24/20222, revealed:POLICYCenters prohibit abuse, mistreatment, neglect, misappropriation of resident/patient (hereinafter patient) property, and exploitation for all all patients .Federal Definitions:Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, injury, or mental anguish. Instances of abuse of all patients, irrespective of any mental or physical condition, cause physical harm, pain or mental anguished. It includes verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled through use of technology .Verbal Abuse is any use of oral, written, or gestured language that willful includes disparaging and derogatory terms to patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability.Physical Abuse includes hitting, slapping, pinching, kicking, etc., as well as controlling behavior through corporal punishment .Neglect is defined as the failure, indifference, or disregard of the Center, its employees, or services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.PURPOSETo ensure that Center staff are doing all that is within their control to prevent occurrences of abuse, mistreatment, neglect, exploitation, involuntary seclusion, injuries of unknown sources and misappropriation of property for all patients.PROCESS1. The Administrator, or designee, is responsible for operationalizing policies and procedures that prohibit abuse, neglect, . The Center must ensure that all staff are aware of reporting requirements and must support an environment in which covered individuals report a reasonable suspicions of a crime .4. Training and reporting obligations will be provided to all employees . and will include4.1 the Abuse Prohibition policy: 4.2 appropriate interventions to deal with aggressive and/or catastrophic reactions of patients; .4.9 understanding behavioral symptoms of patients that my increase the risk of abuse and neglect and how to respond. 5. Actions to prevent abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of patient property, will include: .5.2 identifying, correcting, and intervening in situations in which abuse, neglect, . is more likely to occur .6. Staff will identify events --- such as suspicious bruising of patients, occurrences, patterns, and trends that may constitute abuse --- and determine the direction of the investigation. This also includes patient-to-patient abuse.6.1 Anyone who witnesses an incident of suspected abuse, neglect . is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately, regardless of shift worked .8. The Center will protect patient from further harm during an investigation.8.1 Provided the patient with a safe environment by identifying persons with whom he/she feels safe and conditions that would feel safe.9. The Administrator or designee will:9.1 Take all necessary corrective action depending on the results of the investigation: .9.3 Take steps to revise patient's care plan where indicated if there is a change in the patient's medical, nursing, physical, mental, or psychosocial needs or preferences as a result of an incident of abuse .9.5 Take appropriate corrective actions . 1.) Cross-Reference F645, F760, F740.On 04/01/2025 at 3:40 PM the State Agency received a FRI alleging physical abuse occurred when RI #119 hit RI #53 in the face with his/her hand and the residents were separated. LPN #57, the Administrator, and the Director of Nursing (FDON #2) were made aware of the incident. RI #53 was admitted to the facility 01/14/2025 and had diagnoses to include: Dementia with Anxiety, Weakness, and Adult Failure to Thrive.RI #53's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 04/17/2025 documented a Brief Interview for Mental Status (BIMS) score of three indicating severe cognitive impairment.RI #119 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnoses to include Schizophrenia, Insomnia, and Severe Dementia with Agitation.RI #119's MDS assessment with an ARD of 01/02/2025 documented RI #119 had a Brief Interview for Mental Status (BIMS) score of 14 of 15 which indicated intact cognition.RI #119's PASRR records were reviewed and the facility failed to complete the Level I and Level II screening process for RI #119, as required for admission to the facility, to identify services in the most integrated setting appropriate for RI #119's needs for mental disorders, until during the survey on 05/08/2025. Cross-reference F645. RI #119's physician orders and Medication Administration Record (MAR) were reviewed and revealed the facility failed to ensure RI #119's monthly injection of antipsychotic medication (Invega) had been administered as ordered for treatment and management of RI #119's Schizoaffective Disorder. Licensed Nurses failed to administer RI #119's monthly injection dose in January and February of 2025 prior to escalating behaviors. Cross-reference F760Review of RI #119's Progress Notes and interviews with staff caring for RI #119, revealed RI #119 had verbally abusive unmanaged behaviors from the time RI #119 was initially admitted ; RI #119 cursed staff and other residents on a daily basis which was reported by the staff to be a part of RI #119's personality. RI #119 did not have a plan of care to address and manage aggressive verbal behaviors until 04/02/2025, after RI #119 hit RI #53. Cross reference F740.RI #119's Progress Note dated 03/18/2025 at 6:37 PM documented: Resident observed to have increased agitation, yelling out constantly at staff and other residents, cursing loudly. Resident threatening staff with violence and repeatedly threatening to kill staff and random people in hallway. DON (Director of Nursing) and MD (medical doctor) notified. received order to transfer resident to ER (hospital emergency room) for further evaluation and treatment. RI #119's medical record review revealed a new order for Divalproex 125 mg BID for psychiatric conditions. No other new orders and no new interventions were put in place to protect residents in the facility from RI #119 following the escalation in RI #119's behaviors on 03/18/2025.On 04/01/2025 at 2:15 PM LPN #57 documented RI #119's behavior as follows: Resident was witnessed striking another resident twice in both occipital regions. Resident was immediately removed from areas and placed on observation. MD, CRNP, and supervisor notified of occurrence.An interview was conducted with RI #119 on 05/06/2025 at 11:40 AM and RI #119 denied hitting RI #53 on 04/01/2025. On 05/06/2025 at 4:50 PM an interview was conducted with RI #53 who did not recall the incident.On 05/07/2025 at 9:56 AM Certified Nursing Assistant (CNA) #59, who witnessed RI #119 hit RI #53, was asked about the incident. CNA #59 said, on 04/01/2025 RI #119 was sitting at the nurses' station in a wheelchair and RI #53 approached and spoke to RI #119. In response, RI #119 shouted for RI #53 to leave him/her alone. RI #119 moved closer to RI #53 and struck RI #53 in the face with his/her hand. CNA #59 said, the sound of the hit was loud.On 05/07/2025 at 10:32 AM Medication Administration Technician (MAC) #58 who witnessed RI #119 hit RI #53 said, RI #119 was at the nurses' station and began to curse at RI #53, rolled towards RI #53 and struck RI #53 on both sides of RI #53's face with his/her fist. MAC #58 said, RI #119 often sat in the hallway, used profanity, and often displayed anger, engaging in arguments with anyone nearby.On 05/07/2025 at 3:02 PM LPN #57 was asked about the incident involving RI #53 and RI #119. LPN #57 said, while at the nurses' desk with MAC #58, she witnessed RI #119 hit RI #53 with what appeared to be a closed fist. LPN #57 said she intervened and evaluated the residents, and noted RI #53 had a small red mark on his/her right cheek.On 05/08/2025 at 12:35 PM Certified Registered Nurse Practitioner (CRNP) #52 was asked about the incident involving RI #53 and RI #119. CRNP #52 stated, she was informed of the incident on 04/02/2025 upon her arrival at work, was informed RI #119 struck RI #53 twice in the face, and said a reasonable individual would feel hurt and confused if they were struck in the face, and she considered this physical abuse.On 05/08/2025 at 4:30 PM RI #119 was observed near the nursing station with other residents. LPN #57 was at the medication cart. RI #119 was observed in a wheelchair yelling loudly. MAC #58 pushed RI #119 in the wheelchair away from RI #53 and MAC #58 stood between them and then took RI #119 to his/her room. LPN #57 stood at the medication cart continuing to prepare medications. RI #53 had a facial expression of sad confusion and lifted his/her arms and shrugged his/her shoulders. On 05/08/2025 at 4:35 PM MAC #58 was asked about the observation. MAC #58 said, she asked RI #119 if he/she wanted to go to his/her room because she thought there was going to be another episode like 04/01/2025 between the two of them because RI #119 was cursing RI #53. MAC #58 said, RI #119 was cursing RI #53 because RI #53 tried to talk to RI #119. MAC #58 said, RI #119 just did not like some people and RI #53 was one of them. An interview was conducted with the Former Director of Nursing (FDON) on 05/12/2025 at 6:46 PM. The FDON said, her responsibilities included supervising the nursing department, staffing, and overseeing daily operations. When questioned about the behaviors associated with RI #119, she said, they involved yelling and the use of profanity. She stated, she became aware of those issues through the unit manager and relevant documentation. The FDON stated, what she considered behaviors would depend on the patient and could include actions such as yelling, kicking, resisting care, hitting, and biting. The FDON said, those behaviors could impact others and should be properly documented. The FDON said, if a nurse failed to document behaviors, it would be hard to implement appropriate interventions, which could lead to ineffective behavior management.A follow up interview was conducted with the FDON on 05/15/2025. The FDON was asked about the incident involving RI #119 and RI #53. The FDON stated resident to resident physical abuse was substantiated because it was witnessed. When asked about the investigation conducted for the physical abuse, the FDON said, she thought a thorough investigation was conducted because it was taken to Quality Assurance and Performance Improvement (QAPI) committee, and they determined the root cause was RI #119's diagnoses of Dementia and Mood Disturbance. 2) On 05/19/2025 at 4:40 PM the State Agency received a Facility Reported Incident (FRI) alleging verbal abuse occurred on 05/17/2025 when RI #9 yelled and screamed and demanded RI #87 turn off the television. RI #87 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnoses to include: Malignant Neoplasm of Larynx, Anxiety, Major Depressive Disorder, and Mood Disorder. RI #87's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/01/2025 documented RI #87's hearing was adequate and a Brief Interview for Mental Status (BIMS) score of 12 of 15 which indicated moderate cognitive impairment. RI #9 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnoses to include: Depression, Insomnia, Anxiety, and Schizophrenia. RI #9's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/09/2025 documented a Brief Interview for Mental Status (BIMS) score of 12 of 15 which indicated moderate cognitive impairment. A review of RI #9's comprehensive care plan revealed a care plan with date initiated of 09/13/2020, with a focus area of distressed and fluctuating mood symptoms with screaming and yelling at roommate. The care plan did not provide specific interventions for staff use or the level of supervision required to prevent RI #9 from abusing other residents. RI #9's progress notes contained an entry dated 05/17/2025 at 10:44 PM signed by LPN #100 as follows: . Was a behavior observed? YESResident yelling and screaming out at roommate Demanding roommate turn off T.V (television) .RI #9's progress notes contained an entry dated 05/19/2025 at 09:53 AM signed by the Social Services Director as follows: . expected to transfer rooms on Reason for transfer: Screaming and yelling at roommate 05/19/2025 Patient was notified. The patient's responsible party was notified.The facility investigative file contained a summary of the investigation dated 05/22/2025 which included a statement from LPN #100 that stated, . she witnessed the incident between (RI #87) and (RI #9) on 5/17/25 at (approximately) 6pm and stated that (RI #9) was calling (RI #87) the N word while also yelling loudly at (RI #87) to turn (his/her) T.V. down. (LPN #100), LPN stated that (RI #87) can be hard of hearing at times, so she redirected (RI #9) from yelling at and calling (RI #87) vulgar names, calmed (his/her) down and closed the privacy curtain between the two residents. (LPN #100) stated that there was no further incidents between (RI #9) and (RI #87).On 05/21/2025 at 1:44 PM LPN #100 was asked about RI #9's behaviors. LPN #100 said, RI #9 would scream at roommates and call them names. LPN #100 said, RI #9 had a previous roommate and RI #9 would not let the previous roommate watch TV. LPN #100 said, RI #9 moved in with RI #87. LPN #100 told the surveyor RI #87 was hard of hearing and could not talk. LPN #100 said, RI #9 called RI #87 names and demanded RI #87 turn off the TV. LPN #100 said, RI #9 was racist and used derogatory terms, but not all the time. LPN #100 said, when RI #9 moved into the room with RI #87 it got worse. LPN #100 stated, RI #9 called RI #87 the N word and the B word demanding, RI #87 turn off the TV. LPN #100 stated, she closed the privacy curtain and told RI #9 that he/she had to be nice. LPN #100 stated this incident happened over the weekend and she witnessed RI #9 call RI #87 those derogatory names on both Saturday and Sunday night. When asked what it was called when RI #9 called RI #87 the N word and B word, LPN #100 stated racist. LPN said, she had received abuse education recently and it was verbal abuse when someone called a resident the N word or the B word. LPN #100 stated, she felt like RI #87 was protected from abuse when RI #9 remained in the room after calling RI #87 derogatory names because RI #9 could not get up or move around, she closed the privacy curtain, RI #87 was hard of hearing, and since it happened on night shift, that was all they could do. When asked how a reasonable person would have felt being called those names, LPN #100 stated They would feel very awful. They wouldn't like. I don't like when I'm called names. But you have to grin and bear it and go about your business.On 05/21/2025 at 11:13 AM, an interview was conducted with RI #87 who was able to communicate with the surveyor. RI #87 said, the TV was not loud and that RI #9 would holler just to be hollering. RI #87 stated, the nurse had to tell RI #9 to be quiet due to RI #9 hollering like a baby. RI #87 stated, RI #9 was mean. RI #87 stated, he/she was told by a nurse RI #9 did not like black people. The facility investigative file contained a conclusion that documented, . the allegation of resident-to-resident abuse is substantiated. LPN was re-educated by the Administrator regarding . identification of abuse with a focus on resident-to-resident communication.On 05/28/2025 at 4:31 PM, an interview was conducted with interim Administrator. The interim ADM stated LPN #100 failed to identify RI #9 behaviors of calling RI #87 the N word and B Word as abuse and failed to report within two hours.3) Cross-Reference F760, F694, and F658.******************************************************************The facility submitted an acceptable removal plan that included:******************************************************************Assessment1. On 3/18/25, RI #119 exhibited an increase in agitation and behaviors; the Physician was notified, and a new order was received to transfer to UAB hospital for evaluation and treatment. Chief complaint at ER: AMS from Magnolia Ridge, sent for being combative and agitated towards staff. Patient calm and cooperative. AMS workup initiated to include EKG, lab work, chest x-ray, and CT scan. During his/her visit, he/she did become a little more agitated and was treated with oral olanzapine. The final diagnosis was Dementia. RI #119 was discharged back to the facility.2. On 3/19/25, RI #119 was assessed by the Certified Registered Nurse Practitioner and the following interventions and orders were implemented: obtain a CBC and CMP, avoid any additional benzos, start Divalproex 125 mg BID for psychiatric conditions, and Integrated Behavioral Health to evaluate. 3. On 3/19/25, RI #119 was evaluated by Integrated Behavioral Health Services, a new order was initiated to start Divalproex (Depakote) 125 mg BID for mood stabilization.4. On 3/19/25 to 3/23/25, RI #119 was assessed and monitored daily by a Licensed Nurse to assess medical condition and mood/behavior status. Documentation of assessment was recorded on the skilled evaluation progress note. 5. On 3/23/25 to 04/01/2025, RI #119 was assessed and monitored every 72 hours by a Licensed Nurse to assess medical condition and monitor mood/behavior status. Documentation of assessment was recorded on the skilled evaluation progress note. 6. On 4/1/25 at 1:45 pm, RI #119 and RI #53 were immediately separated by the nursing staff, RI #119 was removed from the area of occurrence and escorted back to her assigned room and placed on 1 to 1 supervision at 1:50 pm until he/she was transferred to UAB hospital for evaluation at 2:25 pm.7. On 4/1/25 at 2:30 pm an x-ray was ordered and obtained at 11:44 pm on #53 without evidence of fractures and/or any injuries in skin alteration or edema.8. On 4/1/2025, Gardendale Law Enforcement, Ombudsman, Medical Provider, and Resident Representatives were notified by the Administrator.9. The licensed nurse obtained an order from the Medical Provider to facilitate transfer of resident RI #119 to the Emergency Department for evaluation, EMS transported RI #119 as ordered on 4/1/2025 at 2:25 pm.10. Investigation initiated by the Administrator and Director of Nursing; report submitted per requirement to ADPH on 4/1/2025 at 3:40 pm within required timeframe by the Administrator.11. On 5/8/2025 at 4:45 pm resident RI #53 was witnessed placing his/her hand gently on RI #119's hand resulting in RI #119 having an outburst and using profanity overheard by the licensed nurse in the vicinity. Residents were immediately separated, RI #119 was placed on 1 to 1 supervision, resident RI #119 room assignment was changed to an alternate unit and room on the [NAME] Wing. Medical Provider, Resident Representative, and Behavioral Health were notified on 5/8/25 at 5:29 pm. Telehealth Psych Evaluation was ordered and executed by Lumina. 12. RI #53 was immediately assessed by the assigned nurse on 5/08/2025, no evidence of injury including any soft tissue alteration and/or discolored areas in conjunction with no signs/symptoms of discomfort. In conjunction with the aforementioned, the resident was given a psychosocial assessment without any change in mood, behavior, no display of fear, and no change in daily routine to include intake of food and fluids, sleeping, or engagement in activities of choice. There was no change in resident baseline after the event.13. Licensed Nurse updated RI #119 and RI #53 plan of care related to the resident-to-resident interaction on 5/8/25. RI #53's care plan was updated to include the resident touching and gently rubbing another resident on the hand to say hello resulting in the other resident becoming upset. Interventions added included encouraging engagement in activities of choice/preference; Integrated Behavior Health referral as needed, psychosocial review completed on resident after encounter with another resident; re-direct resident from touching other residents without permission, and behavior monitoring for unwanted touching. RI #119's care plan was updated to include the resident exhibiting verbal behaviors as evidence by yelling and cursing when a resident touched his/her hand. Interventions added included a psychosocial evaluation completed by Social Services. The resident moved from the Rehab Unit to the [NAME] Wing on 5/8/25. The resident moved to [NAME] Hall to be in a less stimulating area to help decrease behaviors. Additional interventions included placing the resident on 1:1 supervision on 5/8/25 and offering the resident a snack for re-direction. 14. On 5/9/25, at 12:10 pm, a report was filed with the ADPH for an allegation of verbal abuse.15. The Social Service Director facilitated a room move for RI #9 on 5/19/25. RI #9 was transferred to the hospital on 5/19/25 related to a change of condition. Return anticipated if RI #9 meets the clinical admission criteria and clinical capabilities of the facility. Upon return, RI #9's plan of care will be updated to include interventions to protect other residents. 16. Social Service Director and/or designee completed a psychosocial assessment on RI #87 on 5/20/25 and no psychosocial concerns were noted. RI #87 was interviewed on 5/20/25 by the Market Resource Operator and RI #87 denied being abused, afraid, or experiencing mental anguish. 17. On 5/24/25, the Market Clinical Advisor educated the new Administrator on abuse, abuse reporting, conducting a thorough investigation, identifying causative factors, and developing and implementing corrective actions. The Administrator was educated on the Alabama abuse checklist to serve as a guide to ensure allegations are thoroughly investigated and all components are included to ensure resident safety.18. The Administrator educated LPN #100 on 5/26/25 on promptly reporting allegations of abuse to the Abuse Prevention Coordinator. 19. RI #9 was discharged from the facility on 5/19/25.20. Effective 5/25/25, the facility will not administer IV hydration and IV medications. The Administrator updated the Facility Assessment on 5/29/25.Audits 1. Licensed nurses-initiated skin checks on 4/1/2025 for 17 residents with BIMs of < 8 to ascertain any alterations in skin integrity that could be suspicious of change in resident baseline and evaluated for abuse. No further signs/symptoms were noted. 2. The Social Service Director and/or designee conducted 106 resident interviews on 4/1/2025 for residents with BIMs 9 > to ascertain care concerns or any resident-to-resident altercations. No further events verbalized. 3. On 5/13/25, the Social Service Director and/or designee interviewed 63 residents with a BIMs of 8 or > regarding resident to resident or staff to resident verbal interactions/allegations of abuse. No additional concerns were verbalized. 4. The Clinical Reimbursement Coordinator, Social Service Director, Nurse Managers, and/or designee, audited the plan of care for 60 residents with a history of behaviors or active behaviors based on the behavior monitoring flowsheets, MDS, and resident history and revised 10 care plans on 5/12/25 to ensure any residents with identified behavioral episodes had a resident-specific care plan with interventions5. On 5/21/25 thru 5/24/25, Licensed Nurses initiated skin checks for 30 residents with BIMS of <8 to ascertain any alterations in skin integrity that could be suspicious of change in resident baseline and evaluated for abuse. 6. On 5/21/25 thru 5/24/25, the Social Service Director and/or designee conducted interviews with 34 residents with a BIMS >8 to ascertain care concerns or any resident-to-resident altercations. No additional concerns were identified. 7. On 5/23/25, the Market Clinical Advisor conducted an audit of residents receiving intravenous antibiotic medications, no other residents were identified as receiving intravenous medications. In-services 1. On 5/8/25, the Nurse Practice Educator and/or designee initiated 100% education with employees (full-time, part-time) in all disciplines (Nursing, Therapy, Housekeeping, Dietary, Laundry, Activities, and Administration) on Abuse Prohibition policy and procedure, including but not limited to, the definition, types of Abuse (Physical, Verbal, Mental/Emotional, Neglect, Sexual, and Financial), abuse identification, mental/verbal abuse including threats of harm to resident within hearing distance, regardless of age, ability to comprehend, or disability; prevention and supervision, identification, reporting of abuse, and trauma. Identification includes knowing the types of abuse, recognizing deliberate acts (willful or intentional), noticing suspicious behaviors, suspicious events, suspicious injuries, trends or patterns. Additionally, the education conducted emphasized immediately protecting the residents when abuse is identified and that anyone can be a perpetrator of abuse. The primary method for protecting residents, related to resident-to-resident abuse allegations or incidents, will be immediately separating the residents, implementing interventions to protect the victim, such as initiating one on one supervision.2. On 5/8/25, the Nurse Practice Educator and/or designee initiated 100% education with employees (full-ti

Based on interviews, resident record reviews, review of a facility policy titled, Abuse Prohibition, review of Facility Reported Incidents (FRI) received by the State Agency (SA) and review of the facility investigative file, the facility failed to ensure nurses and staff reported verbal abuse to the abuse coordinator and the SA and took actions to prevent escalating resident on resident abuse in the facility.During the investigation of the FRI alleging physical abuse occurred on 04/01/2025 when Resident Identifier (RI) #119 hit RI #53 in the face, staff told surveyors they did not always document or report RI #119's behavior of yelling and cursing, which was a daily behavior since admission on [DATE], even when it was directed at other residents.Because RI #119's verbally abusive behaviors continued, and escalated, on 03/18/2025 RI #119 threatened to kill people in the facility. The incident was not identified as potential abuse, was not reported as an allegation of abuse, and was not investigated in a manner to prevent further abuse. After a visit to the hospital emergency department RI #119 returned to the facility without any new orders except a new medication order. Because the facility failed to implement new interventions or provide supervision instructions after the threat, abusive behaviors further escalated on 04/01/2025 when RI #119 hit RI #53 in the face twice with a fist.During the survey, on 05/08/2025 at 4:30 PM, RI #119 was observed continuing to target and verbally abuse RI #53. The surveyor verified the Administrator had been made aware of the incident. Still, the facility failed to report the verbal abuse to the State Agency until the next day, 05/09/2025, after 12:00 PM. The facility summary of the incident submitted in the five day report documented the facility did not substantiate the verbal abuse when RI #119 yelled at and used obscene language toward RI #53.It was determined the facility's noncompliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.12 Freedom from Abuse, Neglect and Exploitation.On 05/13/2025 at 3:30 PM, the Administrator (ADM) and Director or Nursing (DON) were provided a copy of the IJ template and notified of the findings of immediate jeopardy in the area of Freedom from Abuse, Neglect, and Exploitation at F609- Reporting of Alleged Violations.On 05/19/2025, after the facility submitted the removal plan for the above non-compliance and while the removal plan was being validated, the facility submitted another allegation of resident on resident verbal abuse alleging RI #9 screamed and demanded his/her roommate, RI #87 turn off the television.During the investigation it was determined RI #9 did verbally abuse RI #87, calling RI #87 a bitch and a nigger. According to Licensed Practical Nurse (LPN) #100, the incident of verbal abuse occurred on 05/17/2025 and 05/18/2025, but was not reported to the State Agency until 05/19/2025 and RI #9 remained in the room with RI #87 until 05/19/2025.It was determined the facility's noncompliance with one or more requirements of participation has cause, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.12 Freedom from Abuse, Neglect and Exploitation.On 05/28/2025 at 9:37 PM, the interim Administrator, the interim DON, and the Market Clinical Advisor were provided a copy of an updated IJ template and notified of the additional findings of immediate jeopardy in the area of Freedom from Abuse Neglect, and Exploitation at F609- Free from Abuse and Neglect.The IJ began on 04/01/2025 and continued until 06/01/2025 when the survey team verified onsite that corrective actions had been implemented. On 06/02/2025 the immediate jeopardy was removed. F600 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.This deficient practice affected RI #53 and RI #87 two of ten sampled residents for abuse.Findings Include:Cross-Reference F600 and F610Review of the facility's policy titled, Abuse Prohibition, with a revision date of 10/24/2022, revealed:POLICYCenters prohibit abuse, mistreatment, neglect, misappropriation of resident/patient (hereinafter patient) property, and exploitation for all patients .PROCESS1. The Administrator, or designee, is responsible for operationalizing policies and procedures that prohibit abuse, neglect, . The Center must ensure that all staff are aware of reporting requirements and must support an environment in which covered individuals report a reasonable suspicion of a crime .7. 2. Report allegations involving abuse (physical, verbal, sexual, mental) not later than 2 hours after the allegation is made.7. 3. Report allegations to the appropriate state and local authority(s) involving neglect, exploitation or mistreatment (including injuries of unknown source), suspected criminal activity, and misappropriation of patient property not later than two (2) hours after the allegation is made if the event results in serious bodily injury.Example - an allegation of neglect that results in hospitalization must be reportedwithin two hours.1) On 04/01/2025 at 3:40 PM the State Agency received a FRI alleging physical abuse occurred when RI #119 hit RI #53 in the face with his/her hand.RI #53 was admitted to the facility 01/14/2025.RI #119 was initially admitted to the facility on [DATE] and readmitted on [DATE].During the investigation of the FRI alleging physical abuse occurred on 04/01/2025 when Resident Identifier (RI) #119 hit RI #53 in the face, staff were interviewed and told surveyors they did not always document or report RI #119's behavior of yelling and cursing, even when it was directed at other residents.On 05/09/2025 at 9:36 AM CNA #105 was asked about RI #119's behaviors. CNA #105 said, RI #119 yells out in the hall, cussing, and called RI #53 a bitch sometime in April, after RI #53 had been hit. When asked what she did the day RI #119 called RI #53 a bitch, CNA #105 said, she went down the hallway and there were nurses and CNAs there already, they intervened, and she did not know if it was written up or not. CNA #105 said, it was verbal abuse when a resident cursed another resident. When asked about the environment where residents are cursing, CNA #105 said, some people would be fearful of so much chaos going on.The State Agency did not receive any allegations of abuse in which RI #119 called RI #53 a bitch in April, other than 04/01/2025 when RI #119 hit RI #53.On 05/08/2025 at 4:30 PM RI #119 was observed near the nursing station with other residents. LPN #57 was at the medication cart. RI #119 was in a wheelchair yelling loudly, but unable to hear exactly what RI #119 was saying. MAC #58 pushed RI #119 in the wheelchair away from RI #53 and MAC #58 stood between them and took RI #119 to his/her room. LPN #57 stood at the medication cart continuing to prepare medications. RI #53 had a facial expression of sad confusion and lifted his/her arms and shrugged his/her shoulders.On 05/08/2025 at 4:35 PM MAC #58 was asked about the observation. MAC #58 said, she asked RI #119 if he/she wanted to go to his/her room because she thought there was going to be another episode like 04/01/2025 between the two of them because RI #119 was cursing RI #53. MAC #58 said, RI #119 was cursing RI #53 because because RI #53 tried to talk to RI #119. MAC #58 said, RI #119 just did not like some people and RI #53 was one of them.On 05/08/2025 at 6:15 PM the surveyor asked the ADM if she had been made aware of the incident that had occurred between RI #119 and RI #53. The ADM said, yes, RI #119 was being moved to a different room and was placed one-on-one.The facility failed to report the incident of verbal abuse to the SA until the next day, 05/09/2025, after 12:00 PM.Review of the facility summary of the incident dated 05/15/2025 in the facility five day submission revealed the facility failed to identify and substantiate the verbal abuse against RI #53, who was yelled and cursed at by RI #119.RI #119's progress notes dated 03/18/2025 at 6:37 PM documented: Resident observed to have increased agitation, yelling out constantly at staff and other residents, cursing loudly. Resident threatening staff with violence and repeatedly threatening to kill staff and random people in hallway. DON and MD notified. received order to transfer resident to ER for further evaluation and treatment. On 05/10/2025 at 3:30 PM an interview was conducted with CRNP #52 who stated she had witnessed RI #119 yelling in the past. CRNP #52 stated she knew RI #119 yelled out, but did not know he/she was aggressive. CRNP #52 stated she did not know how Integrated Behavioral Health would know if staff were aware of RI #119's behaviors if the staff did not document because it was normal for RI #119 to be cursing, yelling out and being aggressive. CRNP #52 stated it was a concern when RI #119's behaviors were not documented.On 05/10/2025 at 7:15 PM an interview was conducted with LPN #76. She stated no words were off limits for RI #119 and RI #119 would direct cursing toward residents and staff. LPN #76 stated cursing was RI #119's everyday language, RI #119 and RI #88 would go back and forth with each other, saying bitch shut up. LPN #76 stated, RI #119 would start the altercations. LPN #76 admitted she did not report the verbal abuse to the abuse coordinator, but did tell the DON. LPN #76 said she was not sure she told the DON residents were going back and forth. LPN #76 stated the DON response was just chart it.2) On 05/19/2025 at 4:40 PM the State Agency received a Facility Reported Incident (FRI) alleging verbal abuse occurred on 05/17/2025 when RI #9 yelled and screamed and demanded RI #87 turn off the television.RI #87 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnosis to include: Malignant Neoplasm of Larynx, Anxiety, Major Depressive Disorder and Mood Disorder.RI #87's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/01/2025 documented RI #87's hearing was adequate and a Brief Interview for Mental Status (BIMS) score of 12 of 15 which indicated moderate cognitive impairment.RI #9 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnosis to include: Depression, Insomnia, Anxiety and Schizophrenia.RI #9's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/09/2025 documented a Brief Interview for Mental Status (BIMS) score of 12 of 15 which indicated moderate cognitive impairment. A review of RI #9's comprehensive care plan revealed a care plan with an initiation date of 09/13/2020, with a focus area of distressed and fluctuating mood symptoms with screaming and yelling at roommate. The care plan did not provide specific interventions for staff use or the level of supervision required to prevent RI #9 from abusing other residents. RI #9's progress notes contained an entry dated 05/17/2025 at 10:44 PM signed by LPN #100 as follows: . Was a behavior observed? YESResident yelling and screaming out at room mate Demanding room mate turn off T.V (television) .On 05/21/2025 at 11:13 AM, an interview was conducted with RI #87. RI #87 was able to communicate with the surveyor. RI #87 said, the TV was not loud, RI #9 would holler just to be hollering. RI #87 stated, the nurse had to tell RI #9 to be quiet due to RI #9 hollering like a baby. RI #87 stated, RI #9 was mean. RI #87 stated, he/she was told by a nurse RI #9 did not like black people.On 05/21/2025 at 1:44 PM LPN #100 was asked about RI #9's behaviors. LPN #100 said, RI #9 would scream at roommates and call them names. LPN #100 said, RI #9 had a previous roommate and RI #9 would not let the previous roommate watch TV. LPN #100 said, RI #9 moved in with RI #87 and it got worse. LPN #100 said, RI #9 called RI #87 names and demanded RI #87 turn off the TV. LPN #100 said, RI #9 was racist and used derogatory terms. LPN #100 stated, RI #9 called RI #87 the N word and the B word demanding, RI #87 turn off the TV. LPN #100 stated, she closed the privacy curtain and told RI #9 that he/she had to be nice. LPN #100 stated this incident happened over the weekend and she witnessed RI #9 call RI #87 those derogatory names on both Saturday and Sunday (05/17/2025 and 05/18/2025) night. LPN said she had received abuse education recently and it was verbal abuse when someone calls another resident the N word or the B word. LPN #100 said, since it happened on night shift there was nothing they could do. LPN #100 said, according to the abuse policy she should report abuse immediately to the abuse coordinator but she did not since RI #87 was deaf. LPN #100 said, if abuse was reported late, it could escalate.On 05/28/2025 at 4:31 PM, an interview was conducted with the interim Administrator. She stated based on the investigation completed by the facility, the incident between RI #9 and RI #87, that occurred on 05/17/2025 and 05/18/2025, was not reported until 05/19/2025 by LPN #100. The interim Administrator stated the incident was not reported timely due to the LPN not identifying the behaviors as abuse. ********************************************The facility submitted an acceptable plan to remove the immediacy of the identified deficient practice that included:*******************************************Audits1. Facility staff to include 158 employees in Nursing, Social Services, Activity, Dietary, Therapy, Medical Records, and Housekeeping were interviewed regarding any unreported behavior observations by the Director of Nursing and/or designee on 5/14/25. Active employees, employees on leave of absence (FMLA), and PRN staff who have not been interviewed regarding unreported behaviors, will be interviewed prior to returning to duty. Based on the interviews, one staff member referenced 1 unreported behavior was identified and investigated to determine if an abusive incident was witnessed and not identified as potential abuse or reported. It was determined that this was not reportable as abuse. 2. The Social Service Director initiated 106 Resident interviews on 4/1/25 for residents with BIMs 9> to ascertain care concerns or any resident-to-resident altercations or reports of verbal abuse. No further events verbalized.3. On 5/13/25, the Social Service Director and/or designee interviewed 63 residents with a BIMs of 8 or > regarding resident to resident or staff to resident verbal interactions/allegations of abuse. No additional concerns were verbalized4. The Director of Nursing and/or designee reviewed the documented behavior monitoring in the last 14 days to determine if any documented behavior was abusive to other residents. Based on the results, two residents were identified with behaviors; one noted to be screaming at others. An interview was conducted with the staff member who documented the behavior and the behavior was not directed at other residents. The second resident was identified as cursing at others. An interview was conducted with the staff member who documented this behavior on the resident and the behavior was directed at other residents. 5. The Administrator completed 1:1 education with LPN #100 on 05/26/25 on promptly reporting allegations of abuse to the Abuse Prevention Coordinator. In-services 1. On 5/16/25, the Director of Nursing Service, Assistant Director of Nursing Service, and/or designee initiated a 2nd in-service on Mental and Verbal abuse, what constitutes abuse, and reporting of all suspected abuse to the abuse coordinator for investigation. The education included examples of verbal abuse and what should be reported to the Administrator immediately for investigation. Of 159 employees, 144 total employees have received the education (this includes 107 direct care staff and 37 non-direct care staff. Active employees, employees on leave of absence (FMLA), and PRN staff who have not received the education will be educated prior to returning to duty. The facility has attempted to contact the remaining 11 staff that have not received the in-service. The DON will monitor the schedule and communicate with the Nurse Practice Educator to ensure each staff member is trained prior to starting their assigned shift on the floor. 2. The Administrator educated LPN #100 on 5/26/25 on promptly reporting allegations of abuse to the Abuse Prevention Coordinator. 3. On 5/22/25 thru 5/27/25, the Administrator and/or designee initiated education with staff, on the abuse prohibition policy with examples of what constitutes abuse, with laser focus on verbal abuse and behaviors that should be reported promptly that may have a negative impact on patients. Of 159 employees, 126 employees have received the education. Active employees, employees on leave of absence (FMLA), and PRN staff who have not received the education will be educated prior to returning to duty. The DON will monitor the schedule and communicate with the Nurse Managers and/or designee to ensure each staff member is trained prior to starting their assigned shift on the floor.4. On 5/28/25 to 06/01/2025, 131 of 151 active employees completed a post-test to validate comprehension and understanding to include examples of abuse, who to report to, identification of behaviors that potentially rise to the level of abuse. Active employees, employees on leave of absence, and PRN staff who have not received the post-test will be educated upon return to duty by the DON and/or designee6. On 5/30/25, the Administrator educated the QAPI members on reviewing investigations to determine when staff became aware of allegation or made observation of a reportable incident and when the staff reported to ensure it was reported timely. QAPI members included DON, Nurse Managers, Social Services, Nurse Practice Educator and Clinical Reimbursement Coordinators.5. On 06/01/25, the Administrator educated the Social Service Director and/or designee on monitoring for unreported allegations of abuse by making resident rounds two times per week on 5/30/25.*********************************************After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team verified onsite that the immediate corrective actions had been implemented the Immediate Jeopardy was removed on 06/02/2025. The scope/severity level of F609 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on interviews, resident record review, review of a facility policy titled Abuse Prohibition, during and after the facility investigation, the facility failed to ensure thorough investigations were conducted and appropriate corrective actions were taken or interventions were developed to ensure residents in the facility were protected from residents with unmanaged, escalating abusive behaviors and to prevent further abuse.Resident Identifier (RI) #119 had verbally abusive behaviors which escalated on 03/18/2025 when RI #119 threatened to kill people in the facility. The incident was not identified as potential abuse, was not reported as an allegation of abuse, and was not investigated in a manner to prevent further abuse. On 04/01/2025 RI #119 hit RI #53 in the face twice with a closed fist. The facility investigation was not thorough and effective corrective actions were not developed to ensure the protection and prevention of abuse of residents. RI #119 continued to have access to RI #53 during the survey on 05/08/2025 when RI #119 verbally abused RI #53.It was determined the facility's noncompliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.12 Freedom from Abuse, Neglect and Exploitation.On 05/15/2025 at 5:00 PM, the Administrator (ADM) and the Director or Nursing (DON) were provided a copy of the IJ template and notified of the findings of immediate jeopardy in the area of Freedom from Abuse, Neglect, and Exploitation at F610- Investigate/Prevent/Correct Alleged Violation.On 05/19/2025, after the facility submitted the removal plan for the above non-compliance and while the removal plan was being validated, the facility submitted another allegation of resident-on-resident verbal abuse after RI #9 screamed and demanded his/her roommate, RI #87, turn off the TV.During the investigation surveyors determined the verbal abuse included derogatory racial language in which RI #9 called RI #87 a bitch and a n*gger. The abuse was witnessed by Licensed Practical Nurse (LPN) #100 on 05/17/2025 and 05/18/2025 and was not reported until 05/19/2025. The facility's investigation did not include a thorough interview or statement from LPN #100 and did not include details about what LPN #100 witnessed RI #9 say to RI #87. On 05/28/2025 at 9:37 PM, the interim Administrator (ADM), the interim DON, and the Market Clinical Advisor were provided a copy of an updated IJ template and notified of the additional findings of immediate jeopardy in the area of Freedom from Abuse Neglect, and Exploitation at F610- Investigate/Prevent/Correct Alleged Violation.The IJ began on 04/01/2025 and continued until 05/30/2025. On 05/31/2025 the immediate jeopardy was removed. F610 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.This deficient practice affected RI #53, RI #87, RI #9 and RI #119 four of 10 residents sampled for abuse.Findings Include:Cross-Reference F600, F609, F835, F867.Review of the facility's policy titled, Abuse Prohibition, with a revision date of 10/24/2022, revealed:POLICYCenters prohibit abuse, mistreatment, neglect, misappropriation of resident/patient (hereinafter patient) property, and exploitation for all patients .PROCESS1. The Administrator, or designee, is responsible for operationalizing policies and procedures that prohibit abuse, neglect, . The Center must ensure that all staff are aware of reporting requirements and must support an environment in which covered individuals report a reasonable suspicion of a crime .7. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee will perform the following.7.7 Initiate an investigation within 24 hours of an allegation of abuse that focuses on:7.7.1 whether abuse or neglect occurred and to what extent;7.7.2 clinical examination for signs of injuries, if indicated;7.7.3 causative factors; and7.7.4 interventions to prevent further injury.7.8 The investigation will be thoroughly documented within the Risk Management Portal. Ensure that documentation of witnessed interviews is included.9. The Administrator or designee will:9.1 Take all necessary corrective action depending on the results of the investigation; .1) On 04/01/2025 at 3:40 PM the State Agency received a Facility Reported Incident (FRI) that alleged physical abuse had occurred when RI #119 hit RI #53 in the face with his/her hand.RI #53 was admitted to the facility 01/14/2025.A review of RI #53's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/17/2025 revealed RI #53 had a Brief Interview for Mental Status (BIMS) of three of 15 which indicated severe cognitive impairment.RI #119 was initially admitted to the facility on [DATE] and readmitted on [DATE].A review of RI #119's MDS assessment with an ARD of 01/02/2025 revealed RI #119's BIMS was 14 of 15 which indicated intact cognition.Cross-reference F600RI #119's progress notes for 03/17/2025 at 1:00 PM documented, Resident outside cursing . RI #119's progress notes for 03/17/2025 at 2:26 PM documented, . The resident is cursing in the hallway .RI #119's progress notes for 03/18/2025 at 6:37 PM documented, Resident observed to have increased agitation, yelling out constantly at staff and other residents, cursing loudly. Resident threatening staff with violence and repeatedly threatening to kill staff and random people in hallway. DON [Director of Nursing] and MD notified. received order to transfer resident to ER [emergency room] for further evaluation and treatment. RI #119's progress notes for 03/19/2025 at 6:30 AM documented, . being seen today for readmission to long term care after being sent to ED [hospital] for behaviors 3/18. No behaviors this AM. Patient received a one time dose of ativan which may have caused delirium or provoked agitation. Sent to ED and returned within 12 hours with no new orders. Would avoid Benzos at this time.RI #119's care plan for combative behaviors was not initiated until 04/02/2025 after RI #119 had a physical altercation with RI #53.05/06/2025 at 4:45 PM, Surveyor on unit and observed residents RI #119 and RI #53 sitting in their wheelchairs side by side in front of the nurse's station.On 05/08/2025 at 4:30 PM an observation was made in the hallway near the nursing station. LPN #57 was observed near RI #119 who was in a wheelchair yelling at RI #53. Medication Administration Assistant (MAC) #58 moved RI #119 away from RI #53. MAC #58 stood in-between the residents and then pushed RI #119 to his/her room. LPN #57 continued to stand at the medication cart. RI #53 put his/her hands and forearms face up and shrugged his/her shoulders.On 05/08/2025 at 4:35 PM an interview was conducted with MAC #58 who identified the residents. MAC #58 said she took RI #119 to his/her room because she thought there was going to be another episode like 04/01/2025 between the residents because RI #119 was cursing at RI #53. MAC #58 said RI #119 was cursing at RI #53 because RI #53 tried to talk to him/her. MAC #58 was asked, was there any reason why RI #119 did not want RI #53 to talk to him/her. MAC #58 said, no there were just some people RI #119 just did not like and RI #53 was one of them.On 05/08/2025 at 6:05 PM a follow-up interview was conducted with MAC #58. who said she did not remember what curse words RI #119 said to RI #53; she just knew they were cuss words. MAC #58 said RI #119 began yelling and cussing RI #53 after RI #53 touched RI #119's left hand.On 05/09/2025 at 12:10 PM, during the survey, the State Agency received another FRI alleging verbal abuse occurred when, . Resident, [RI #53] touched Resident, [RI #119] on the hand. [RI #119] began verbally using profanity in the hallway.05/09/2025 at 12:20 PM, an interview was conducted with the Social Services Director (SSD). The SSD stated interventions put in place to protect other residents from RI #119's behaviors included: being seen by IBH (Integrated Behavioral Health) monthly (only note produce was from March 2025), if RI #119 ask for food to provide it, if RI #119 was swearing to provide emotional support, utilize diversion techniques as needed, and evaluate medication. The SSD admitted the facility did not protect RI #53 from RI #119 after the 04/01/2025 incident.The facility determined from the root cause analysis that RI #119 behaviors were due to dementia. Review of the facility investigation revealed the facility did not identify any behavior triggers and according to the facility investigation, RI #119 did not seem angry, agitated or frustrated even though RI #119 continued to target RI #53 with verbal abuse, yelling and cussing. 2) During the survey on 05/19/2025 at 4:40 PM, while the immediate jeopardy was ongoing and unabated, the State Agency received another FRI that alleged verbal abuse occurred on 05/17/2025 when RI #9 yelled and screamed and demanded RI #87 turn off the television. The facility investigative file contained a summary of the investigation dated 05/22/2025 which included a statement from LPN #100 which documented: . she witnessed the incident between [RI #87] and [RI #9] on 5/17/25 at [approximately] 6pm and stated that [RI #9] was calling [RI #87] the N word while also yelling loudly at [RI #87] to turn [his/her] T.V. down. [LPN #100], LPN stated that [RI #87] can be hard of hearing at times, so she redirected (RI #9) from yelling at and calling [RI #87] vulgar names, calmed [him/her] down and closed the privacy curtain between the two residents. [LPN #100] stated that there was no further incidents between [RI #9] and [RI #87].On 05/21/2025 at 1:44 PM LPN #100 stated RI #9 called his/her roommate, RI #87 the N word and B word, on both 05/17/2025 and 05/18/2025 and she did not report it until 05/19/2025.Review of the facility investigation revealed the facility did not identify the language used when RI #9 called RI #87 vulgar names. The investigation did not identify that the incident had occurred on two different dates. ******************************************The facility submitted an acceptable plan to remove the immediacy of the identified deficient practice that included:*******************************************Assessment1. On 4/1/25 at 1:45 pm, RI #119 and RI #53 were immediately separated by the nursing staff, RI #119 was removed from the area of occurrence and escorted back to his/her assigned room and placed on 1 to 1 supervision at 1:50 pm until he/she was transferred to UAB hospital for evaluation at 2:25 pm.2. Investigation initiated by the Administrator and Director of Nursing; report submitted per requirement to ADPH on 4/1/2025 at 3:40 pm within required timeframe by the Administrator.3. On 5/8/25, RI 119 was placed on 1:1 supervision and moved to another unit at approximately 5:30 pm. 4. Licensed Nurse updated RI #119 and RI #53 plan of care related to the resident-to-resident interaction on 5/8/25. RI #53's care plan was updated to include the resident touching and gently rubbing another resident on the hand to say hello resulting in the other resident becoming upset. Interventions added included encouraging engagement in activities of choice/preference; Integrated Behavioral Health referral as needed, psychosocial review completed on resident after encounter with another resident; redirect resident from touching other residents without permission, and behavior monitoring for unwanted touching. RI #119's care plan was updated to include the resident exhibiting verbal behaviors as evidence by yelling and cursing when a resident touched his/her hand. Interventions added included a psychosocial evaluation completed by Social Services. The resident moved from the Rehab Unit to the [NAME] Wing on 5/8/25. The resident moved to [NAME] Hall to be in a less stimulating area to help decrease behaviors. Additional interventions included placing the resident on 1:1 supervision on 5/8/25 and offering the resident a snack for redirection. 5. The Social Service Director facilitated a room move for RI #9 on 5/19/25. RI #9 was transferred to the hospital on 5/19/25 related to a change of condition.6. Social Service Director and/or designee completed a psychosocial assessment on RI #87 on 5/20/25 and no psychosocial concerns were noted. RI #87 was interviewed on 5/20/25 by the Market Resource Operator and RI #87 denied being abused, afraid, or experiencing mental anguish. 7. The Administrator completed 1:1 education with LPN #100 on 5/26/25 on promptly reporting allegations of abuse to the Abuse Prevention Coordinator.Audits 1. Licensed nurses-initiated skin checks on 4/1/2025 for 17 residents with BIMs of < 8 to ascertain any alterations in skin integrity that could be suspicious of change in resident baseline and evaluated for abuse. No further signs/symptoms were noted. 2. The Social Service Director and/or designee conducted 106 resident interviews on 4/1/2025 for residents with BIMs 9 > to ascertain care concerns or any resident-to-resident altercations. No further events verbalized. 3. On 5/13/25, the Social Service Director and/or designee interviewed 63 residents with a BIMs of 8 or > regarding resident to resident or staff to resident verbal interactions/allegations of abuse. No additional concerns were verbalized. 4. On 5/21/25 thru 5/24/25, Licensed Nurses initiated skin checks for 30 residents with BIMS of <8 to ascertain any alterations in skin integrity that could be suspicious of change in resident baseline and evaluated for abuse. 5. On 5/21/25 thru 5/24/25, the Social Service Director and/or designee conducted interviews with 34 residents with a BIMS >8 to ascertain care concerns or any resident-to-resident altercations. No additional concerns were identified. In-services 1. Facility staff received the education by 5/9/24. The facility has a total of 158 active employees of 158 employees 156 employees have received the education by 5/9/25. Active employees, employees on leave of absence (FMLA), and PRN staff who have not received the education aforementioned will be educated prior to returning to their assigned shift by the Nurse Practice Educator. New employees will receive the education during their on-boarding process prior to starting the assigned shift on the floor. 2. On 5/16/25, the Director of Nursing Service, Assistant Director of Nursing Service, and/or designee initiated a 2nd in-service on Mental and Verbal abuse, what constitutes abuse, and reporting of all suspected abuse to the abuse coordinator for investigation. The education included examples of verbal abuse and what should be reported to the Administrator immediately for investigation. Active employees, employees on leave of absence (FMLA), and PRN staff who have not received the education will be educated prior to returning to duty. 3. On 5/15/25, the Market Clinical Advisor educated the Administrator that he/she is responsible for conducting abuse investigations, identifying causative factors, and developing and implementing corrective actions. The education consisted of utilizing the abuse prevention checklist to ensure the following has been completed: an initial report, resident/ staff interviews signed and dated, Resident care plans pertaining to the investigation, Record of training after incident, Nurses notes, Social and Psych notes if applicable, documentation of resident's behaviors, resident's outcome and corrective actions taken by the facility. The Administrator was educated to place a copy of the investigation checklist in all abuse allegation files to ensure allegations are thoroughly investigated, causative factors are identified, and corrective actions are developed and implemented to ensure resident safety. The Administrator was educated on the following responsibilities: Leading in the investigation process and following up with outstanding activities needed for a thorough investigation. The Investigation checklist will be used which includes but not limited to the following: initial report, resident/ staff interviews signed and dated, Resident care plans pertaining to the investigation, Record of training after incident, Nurses notes, Social and Psych notes if applicable, documentation of resident's behaviors, resident's outcome and corrective actions taken by the facility. A copy of the investigation checklist will be placed in all abuse allegation files.4. On 5/24/25, the Market Clinical Advisor educated the new Administrator on conducting a thorough investigation, identifying causative factors, and developing and implementing corrective actions. The Administrator was educated on the Alabama abuse checklist as a guide to ensure allegations are thoroughly investigated, causative factors are identified, and corrective actions are developed and implemented to ensure resident safety. 5. On 5/26/25, the Administrator completed 1:1 education with LPN #100 on abuse prohibition policy and promptly notifying the supervisor or Abuse Prevention Coordinator of abuse reporting policy and behaviors that could potentially rise to the level of abuse.6. On 5/22/25 thru 5/27/25, the Administrator and/or designee initiated education with staff, on the abuse prohibition policy with examples of what constitutes abuse, with laser focus on verbal abuse and behaviors that should be reported promptly that may have a negative impact on patients. Of 159 employees, 126 employees have received the education. Active employees, employees on leave of absence (FMLA), and PRN staff who have not received the education will be educated prior to returning to duty. The DON will monitor the schedule and communicate with the Nurse Practice Educator to ensure each staff member is trained during the on-boarding process prior to starting the assigned shift on the floor.7. On 5/28/25 thru 5/30/25, 131 of 151 employees completed a post-test to validate comprehension and understanding to include examples of abuse, who to report to, and identification of behaviors that may rise to the level of abuse. Active employees, employees on leave of absence, and PRN staff will receive the post-test upon return to duty. The DON and/or designee will monitor the schedule and provide education upon returning to duty.Quality Assurance 1. The Market Operations Advisor and/or Market Clinical Advisor educated the Administrator on OPS300 Abuse Prohibition Policy on 5/13/25 as part of the Quality Assurance program to ensure the Administrator understands her role in operationalizing and overseeing policies within the Center, specifically the Abuse Prohibition Policy. The Administrator plays a vital role in ensuring staff are properly trained on what behaviors and abuse should be reported and communicated. The Administrator will lead in the investigation process; she will follow up with outstanding activities needed for a thorough investigation. The Administrator will also ensure that each reportable event is taken to the QAPI committee for thorough review of completion, deliberation on investigation findings, and development of appropriate actions to take regarding elimination of future recurrence.2. On 5/15/25, the Market Clinical Advisor educated the Administrator as part of the Quality Assurance program on the Administrator's role with specific emphasis on performing a thorough investigation to determine causative factors and implementing appropriate interventions based on the investigative findings. The abuse checklist sent by the Alabama Health Care Association will be utilized to provide guidance and ensure a thorough investigation has been completed3. On 5/30/25, the Market Clinical Advisor educated the New Administrator and Market Resource Operator on conducting an interview to include details of the allegation; specifics on what occurred, when the incident occurred, and whether there are any other relevant details including previously unreported incidents or precipitating events or behaviors. The new Administrator was educated on sending the investigation to the governing body after the facility's five-day investigation. If a thorough investigation has not been completed, the governing body will provide additional guidance and direction. 4. The Administrator hosted an AD HOC QAPI on 5/29/25 to review 10 instances of allegations of abuse from 5/19/25 thru current to include causative factors and/or root cause, barriers to comprehension of education, identification of abuse, reporting, and investigations. The QAPI team recommended the following strategies to include: continue verbal education and post-test to ascertain comprehension of education. Signage was created to provide a visual reminder of reporting requirements and the Administrator's contact information. Social Services and/or designee conducted 62 interviews with interviewable residents related to care and concerns that potentially rise to the level of abuse. Participants included the Director of Nursing, Nurse Managers, Director of Memory Support, MDS Nurse, a Licensed Nurse, and a Certified Nursing Assistant.****************************After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team verified onsite that the immediate corrective actions had been implemented the Immediate Jeopardy was removed on 05/31/2025. The scope/severity level of F610 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on medical record review, interviews, and review of a facility policy titled, Change in Condition: Notification of, the facility failed to notify Resident Identifier (RI) #237's family/responsible party when RI #237's Ativan 1 mg (milligram) was decreased to 0.5 mg on 12/12/2024. This affected RI #237 one of one sampled resident reviewed for notification of change. This deficiency was cited as a result of the investigation of complaint/report number AL00042921. Finding Include: Review of a policy titled Change in Condition: Notification of, with an effective date of 11/28/2016, documented: . POLICY A Center must immediately inform the patient, . and notify, consistent with their authority, the patient's representative, where there is: . A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment) . PURPOSE To provide appropriate and timely information about changes relevant to the patient's condition. RI #237 was admitted to the facility on [DATE] with a diagnoses to include Generalized Anxiety Disorder and Restlessness and Agitation. RI #237's November 2022 Order Summary Report (Physicians Orders) documented: . LORazepam Oral Tablet 1 MG . Start Date 11/04/2022 . RI #237's November 2022 Physician Orders documented: . Ativan Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth at bedtime for anxiety . Start Date 12/12/2022 . A review of RI #237's progress notes dated 12/12/2022 revealed RI #237's Ativan was being decreased to 0.5 mg as a gradual dose reduction (GDR). There was no evidence in the progress notes that RI #237's family/responsible party had been notified of a decrease in the Ativan. A telephone interview was conducted with RI #237's family on 03/04/2025 at 10:31 AM. RI #237's family was asked about RI #237's Ativan order. RI #237's family reported RI #237 was admitted to the facility with an order for Ativan and she/he nor the responsible party were notified of a decrease in the Ativan. A telephone interview was conducted with RI #237's emergency contact (responsible party) on 03/12/2025 at 7:10 PM. The responsible party said he/she was not informed of RI #237's decrease in Ativan to 0.5 mg on 12/12/2022. An interview was completed with Registered Nurse (RN) #4 on 03/11/2025 at 10:36 AM. RN #4 stated RI #237 was admitted to the facility on Ativan 1 mg at bedtime. RN #4 said the progress notes dated 12/12/2022 documented the Ativan was decreased to 0.5 mg. RN #4 said the family/sponsor should be notified when there was a change in the resident's medication. RN #4 said there was no evidence in the nursing notes the family had been notified of the decrease in RI #237's Ativan. RN #4 said it was important for the family to be notified so they would be aware of changes in the resident's plan of care.

Based on interviews, resident record reviews, review of a facility policy titled Abuse Prohibition, review of Facility Reported Incidents (FRIs) received by the State Agency, and review of the facility's investigative files, the facility failed to protect the residents' right to be free from physical, mental, and verbal abuse perpetrated by staff and residents. On 07/25/2023 around 9:15 AM Resident Identifier (RI) #60 was mentally abused by Certified Nursing Assistant (CNA) #41 and RI #287 was physically abused by RI #60 while outside at the smoking area with other residents and staff present to witness the abuse. RI #60, a resident with a history of behaviors toward staff, called CNA #41 names and CNA #41 responded by throwing a metal ashtray weighing over one pound at RI #60. The ashtray thrown by CNA #41 missed RI #60 and hit the wall behind the resident. RI #60 threw the ashtray back at CNA #41. The ashtray struck RI #287 in the head and cause injury. Staff summoned assistance and reported RI #60 hit RI #287 with the ashtray. CNA #39 witnessed the incident and failed to report that CNA #41 had instigated the incident by throwing the ashtray at RI #60. CNA #41 continued working her assigned shift on 07/25/2023 and 07/26/2023, leaving RI #60 and other residents in the facility unprotected from her during that time. Staff who respond to resident behavior by throwing heavy, metal items including ashtrays are likely to inflict serious physical harm and/or serious psychosocial harm upon residents, causing fearfulness and mental anguish. It was determined the facility's noncompliance with one or more requirements of participation had cause, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.12 Freedom from Abuse, Neglect and Exploitation at F600- Free from Abuse and Neglect. On 03/19/2024 at 6:20 PM, the Administrator and Director of Nursing (DON), were provided a copy of the Immediate Jeopardy Template and notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Freedom from Abuse, Neglect, and Exploitation at F600-Free from Abuse. The immediate jeopardy began on 07/25/2023 and continued until 08/21/2023 when the facility implemented corrective actions to remove the immediacy and correct the deficient practice; thus, immediate jeopardy past noncompliance was cited. The facility further failed to ensure RI #3, RI #41, RI #487, and RI #488 were protected from physical and verbal abuse that did not rise to the jeopardy level. 2.) On 05/24/2023, RI #487 and RI #488 was verbally abused by a staff member, Dietary Aid (DA) #49, who told RI #487 and RI #488 he would whoop their ass during an argument in the kitchen and dining room. 3.) On 07/01/2023, the facility failed to protect RI #41 from physical abuse that resulted in a painful broken finger and a hospital admission, when RI #487, a resident with known behavioral health needs, twisted and broke RI #41's left ring finger. 4.) On 09/12/2024, the facility failed to protect RI #3 from physical abuse that resulted in a hospital visit when RI #339, a resident with known behavioral health needs, stabbed RI #3 in the left hand with an ink pen causing pain and bleeding. Six of 18 residents sampled for abuse were found to have been abused as determined by the investigations of facility reported incident (FRI)/complaint/report numbers AL00044967, AL00044983, AL00044322, AL00044657, and AL00048800. Findings Include: Review of the facility's abuse policy titled Abuse Prohibition with a revision date of 10/24/2022, revealed the following: POLICY Centers prohibit abuse, mistreatment, neglect . for all patients . Federal Definitions: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish . Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal Abuse is any use of oral, written language that willfully includes disparaging and derogatory terms to patients or their families, or within hearing distance, regardless of their ability to comprehend, or disability . Examples of verbal abuse includes, but are not limited to: threats of harm; saying things to frightened a patient . Physical Abuse includes hitting slapping, pinching, kicking, etc. Mistreatment is defined as inappropriate treatment . of a patient . Mental Abuse includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation. Mental abuse may occur through either verbal or nonverbal conduct which causes or has the potential to cause the patient to experience humiliation, intimidation, fear, shame, agitation, or degradation. PURPOSE To ensure Center staff are doing all that is within their control to prevent occurrences of abuse . for all patients . 6. Staff will identify events . 6.1 Anyone who witnesses an incident of suspected abuse . is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately . 1.) On 07/25/2023 at 10:35 AM the State Agency received a FRI alleging an incident of RI #60 cursing CNA #41 and throwing an ashtray towards CNA #41 and instead hitting RI #287 causing an abrasion on the scalp behind RI #287's right ear. On 07/26/2023 at 7:08 PM the State Agency received a different FRI alleging Abuse-Mistreatment had occurred when CNA #41 threw an ashtray at RI #60 and the ashtray did not make contact with RI #60. RI #60 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnoses to include: Alzheimer's Disease, Dementia with Behavioral Disturbance, Schizoaffective Disorder, Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder. RI #60's annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/06/2023 documented a Brief Interview for Mental Status (BIMS) score of 12 of 15, which indicated moderate cognitive impairment. A review of RI #60's comprehensive care plan revealed RI #60 exhibited verbal behaviors/ outburst directed towards others and had a history of cursing staff and other residents. RI #287 was admitted to the facility on [DATE]. RI #287's significant change MDS assessment with an ARD of 06/02/2023 documented a BIMS score of 14 of 15 which indicated intact cognition. RI #287's progress notes contained an entry dated 07/25/2023 at 9:25 AM signed by LPN #27 as follows: . Called to the smoke porch by a staff member stated that (RI #287) had been hit in the head with (an) ash tray by another resident, . A Skin and Body Audit contained within the facility's investigative file was labeled with RI #287's name indicated RI #287 had a raised area with an abrasion behind his/her right ear. The form was signed by LPN #27. RI #287 no longer resides in the facility. On 03/11/2025 at 3:51 PM LPN #27 was asked about the incident with the ashtray. LPN #27 said, RI #60 would curse at staff and called people names. LPN #27 said, at the time of the incident it was reported that RI #60 threw an ashtray at CNA #41, but they later found that CNA #41 was the one that threw the ashtray first. LPN #27 said, CNA #41 had worked with RI #60 before and knew how to deal with RI #60's behaviors, she was a seasoned CNA and knew how to deal with aggressive residents. LPN #27 said, CNA #41 throwing the ashtray at RI #60 was mental abuse and she triggered RI #60's behavior and it would have made RI #60 feel upset and angry. The facility investigative file contained a typed statement for RI #60 dated 07/26/2023 which documented the following: . Do you remember an incident on the smoking porch that involved an ashtray? . Yes, I threw an ashtray at that black girl and hit another (resident) with it. I didn't mean to hit (him/her) with the ashtray. I was throwing it at that bitch that threw it at me and tried to hit me with it. On 03/17/2025, an interview took place at 2:47 PM, with RI #60. During the interview, RI #60 was questioned regarding the event from 07/25/2023, which involved the throwing of an ashtray. RI #60 stated he/she did not remember the incident. The facility investigative file contained a handwritten witness statement dated 07/27/2023, signed by CNA #39 who witnessed the abuse, which documented: . On 7/25/23 I (CNA #39) was working west wing around 9:20 am. I was on the smoke porch with residents and another employee (CNA #41). (RI #60) was calling (CNA #41) a black bitch and stated she smoke crack and sell drugs. (CNA #41) grabs an ashtray off the table and threw it at (RI #60). it hits the wall and (RI #60) picks up the ashtray and throw it back at her (CNA #41) but it hits (RI #287) in the head (RI #60) apologize to (RI #287) saying (he/she) didn't mean to hit (him/her). Surveyors attempted and were unable to reach CNA #39 for interview during the survey. The facility investigative file contained a typed witness interview signed by CNA #40, who did not witness the abuse, but was informed of what took place by CNA #41, which documented: . On 07/25/23 at (approximately 10:00 PM) . (CNA #41) called me . She said, . I will tell you why that mother fucker, (RI #60), went out today. She then proceeded to tell me that (RI #60) was outside yelling Fuck these bitches . Then (CNA #41) told me that she asked (RI #60) who (he/she) was talking about . I am talking about you, . (CNA #41) then told me that she picked up a metal ashtray and threw it at (RI #60). She said she missed (him/her) and it hit the wall and fell on the ground beside (RI #60's) chair. She said she was throwing it at (RI #60). I asked her why in the world she would do that and she told me that she hated that mother fucking bitch. she said that (RI #60) picked that ashtray up and flung it back at her. She said that m . f . is so stupid that (he/she) missed me and hit another resident with it. On 03/18/2025 at 10:15 AM CNA #40 was asked about the incident involving RI #60 and CNA #41. CNA #40 recalled receiving a phone call from CNA #41 around 10:00 PM on 07/25/2023 when she was informed by CNA #41 that she had thrown an ashtray at RI #60. CNA #40 stated, the next morning she contacted CNA #41 to confirm what happened. CNA #40 said, CNA #41 verified for her that she had thrown an ashtray at RI #60. CNA #40 said, it was then that she reported incident to the facility. CNA #40 said, the incident would cause fear and most likely increase agitation in RI #60, who was known to exhibit behaviors, including cursing at staff. Regarding the facility's abuse policy, she stated any incidents of abuse should be reported immediately. On 03/04/2025 at 4:18 PM an interview was conducted with the Social Services Director (SSD) regarding the incident on 07/25/2023 involving RI #60 and CNA #41. SSD said, she was off that day, but did recall the incident. When asked to describe the ashtray thrown the day of the incident, SSD said they were bulky, metal, circular, and it had a piece that opened where the ashes go inside. The SSD said the ashtray was the same ashtrays used currently at the facility. On 03/17/2025 at 4:15 PM the ADM was questioned about the incident involving RI #60 and CNA #41. The ADM indicated that the report was substantiated as mistreatment and CNA #41 intended to strike RI #60 by throwing an ashtray at him/her. The ADM said prompt reporting of abuse was important for the safety of the residents. The ADM said if staff witnessed another staff member throw an ashtray at a resident, they should act to protect the resident at all times and report the incident immediately. On 03/18/2025 at 10:49 AM the Former Administrator (FADM) who was the Administrator at the time of the incident was questioned about the incident involving RI #60 and CNA #41 on 07/25/2023. The FADM indicated she was initially called by the Director of Nursing (DON) who reported to her that RI #60 had thrown an ashtray at RI #287 and plans were made to send RI #60 out to the hospital for evaluation. The FADM said it was not until the next day she received a call back from the DON stating RI #60 had been the one abused by CNA #41. The FADM said the facility became aware when CNA #40 called the DON and reported that CNA #41 called her on the phone and told her that she, CNA #41, was the one that threw the ashtray at RI #60. The FADM said CNA #41 was then suspended and terminated. The FADM said it was discovered through interviews that CNA #41 actually threw the ashtray a second time at RI #60. The FADM said CNA #39 and CNA #40 were both terminated also for failing to report abuse timely when it occurred. When questioned about what occurred prior to the alteration, the FADM said from what she recalled RI #60 had been cursing CNA #41, who became upset and reacted by throwing the ashtray at RI #60. When asked how staff should respond in a situation when a resident was exhibiting aggressive behavior, FADM said staff should have reported the aggressive behavior to the unit manager, but they did not. The FADM said, if staff got upset and responded by throwing an ashtray at a resident, someone could be harmed. The FADM said the incident involving CNA #41 throwing a metal ashtray at RI #60 was substantiated by the facility. CNA #41's printed time sheet documented CNA #41's last two days worked were on 07/25/2023 from 6:56 AM until 2:55 PM and on 07/26/2023 from 7:18 AM until 2:55 PM. ******************************************** The facility took action to correct the noncompliance including: 07/25/2023, RI #60 was immediately brought into facility and placed on 1:1 with supervisor until sent out for psych evaluation 07/25/2023 - Body audits completed on both residents 07/25/2023 - Report made to ADPH 07/25/2023 - Police report filed with police department 07/25/2023 - Investigation initiated 07/25/2023 - Care Plans updated 07/26/2023 2nd report to ADPH 07/26/2023 - RI #60 seen by provider - medications adjusted for agitation 07/26/2023 - RI #287 assessed by provider - noted as stable 07/27/2023- CNA #41 was suspended until she was terminated on 08/02/2023 07/29/2023- CNA #39 was suspended until she was terminated on 08/02/2023 07/30/2023 - Interview: residents to rule out abuse and with staff members to ensure no unreported abuse 07/31/2023 - RI #60 seen by IBH provider - no behaviors noted; continues on IBH monthly 08/01/2023 - 100 percent of body audits completed - no concerns noted 08/01/2023-CNA #40 was suspended and terminated 08/08/2023- All staff educated on Behavior Management Education. 08/15/2023 - Monitoring behaviors and abuse through QAPI process 08/21/2023 - All staff educated on abuse and reporting abuse - completed by local ombudsman ************************************************** After review of documentation supporting the above corrective actions, including the facility's investigation file, in-service/education records, QAPI documentation, and staff interviews, the survey team verified the facility implemented corrective actions including ongoing monitoring from 07/25/2023 to 08/21/2023 thus immediate jeopardy past non-compliance was cited. 48195 2.) On 05/24/2023 at 10:52 AM the State Agency received a Facility Reported Incident that alleged verbal abuse involving RI #488 and RI #487 and Dietary Aide (DA) #49. The FRI documented . It is reported that (DA #49) . told both these residents he would whip their ass. (DA #49) is suspended pending outcome of the investigation. RI #487 was admitted to the facility on [DATE]. RI #487's annual MDS with an ARD of 03/30/2023 documented a BIMS score of 14 of 15 which indicated intact cognition. The facility investigative file contained a typed witness statement signed by RI #487 dated 05/24/2023 in which RI #487 reported the guy in dietary said he was going to whoop RI #487's ass. RI #488 was admitted to the facility on [DATE] and had diagnoses to include: Dementia without Behavioral Disturbance and Major Depressive Disorder. RI #488's quarterly MDS assessment with an ARD of 05/17/2023 documented RI #488 scored a 13 of 15 on the BIMS which indicated intact cognition. The facility's investigative file contained a typed witness statement signed by RI #488 dated 05/24/2023, which documented: . (RI #487) came to me and said that guy in dietary . told (him/her) he would whoop (his/her) ass. (RI #487) wanted a grilled cheese sandwich and he told . (RI #487) (he/she) could not have one. I went to the kitchen to see why (RI #487) couldn't get a grilled cheese and then it escalated to where he (DA #49) told me he would whoop my ass and I gave him a chance. I got out of my wheelchair and he (DA #49) walked toward me and then I walked toward him and it escalated from there. He told me he was going to whoop my ass too. The facility investigative file contained a typed statement signed by Floor Tech (FT) #30, dated 05/25/2023 which documented: . Yesterday morning when the commotion was taking place in the kitchen doorway, I was coming in from the smoke porch. (DA #49) came in right before me. (RI #488) was sitting in the doorway of the kitchen. (RI #488) stood up and said, I want to see you kick my ass. (DA #49) stated You better stop playing with me before I push you back down in that wheelchair. (RI #488) . said, (RI #487) said you were going to kick my ass and I want to see you kick my ass. I got between the two of them. I was afraid they were actually going to fight. On 03/07/2025 at 9:12 AM an interview was conducted with Floor Tech (FT) #30 who witnessed the incident on 05/24/2023 between DA #49 and RI #488. The FT verified his typed statement. The FT said, when he came in from the back kitchen door, he saw DA #49 and RI #488 arguing in the doorway of the kitchen. The FT said, he saw DA #49 and RI #488 cursing one another and threatening to kick each other's ass. The FT said, the DA was visibly angry and RI #488 was red in the face and he physically got in between the two to prevent a physical altercation. The FT said, the cursing was loud and that it was a seven on a scale of one to ten and it was verbal abuse. The facility investigative file contained a final summary signed and dated 05/26/2023, by the Former Administrator (FADM) which documented . There were several staff members in or around the area when this argument was taking place. Conclusion: Unfortunately, the allegation that (DA #49) told RI #488 that he would whip (his/her) ass is substantiated. verbal abuse is substantiated. The employee (DA #49) has been terminated . ***************************************************** The facility took immediate action to correct the noncompliance including: 05/24/2023- Reporting Abuse timely and suspending DA #49 and terminated on 05/26/2023 05/25/2023 - AD Hoc Residents Rights 05/26/2023-Final summary substantiating verbal abuse and termination of perpetrator 05/29/2023 - Psychosocial Assessment for both residents 05/30/2023 - Resident Statements 06/24/2023 - Resident Rights In-Service 06/24/2023 - How to Manage Difficult People 06/24/2023 - Review Care Plans for both Residents with appropriate revisions 06/05/2023 - RI #487 seen by IBH provider, 06/23/2023, 07/01/2023, and 07/31/2023 09/26/2023 - RI #487 on Behavior Monitoring until discharge 09/28/2023- RI #488 was seen by provider without any documented complications until discharge ************************************************** After review of documentation supporting the above corrective actions, including the facility's investigation file, in-service/education records, QAPI documentation, and staff interviews, the survey team verified the facility implemented corrective actions including ongoing monitoring from 07/25/2023 to 09/28/2023, and past non-compliance was cited. 3.) On 07/01/2023 at 10:05 AM, the State Agency received a FRI which reported and alleged an incident between RI #41 and RI #487 who had an argument. The report alleged that RI #487 bent RI #41's finger, the residents were separated, and RI #487 was placed on one-on-one. The report indicated an x-ray was to be obtained of RI #41's finger. The facility investigative file contained an undated final summary which documented . Complaint: (RI #487) became angry because (he/she) said (RI #41) yelled at (him/her) for turning on a TV and waking (him/her) up. (RI #487) walked over to (RI #41's) side of the room, where (RI #41) was in the bed, and hit (him/her) on the fist with (his/her) fist and twisted (RI #41's) left hand. Staff heard an argument in the room but did not witness the actual event. It has been determined that (RI #487) did hit (RI #41) on the fist and did twist (his/her) finger. The allegation has been substantiated. RI #41 was admitted to the facility on [DATE] with diagnoses to include End State Renal Disease, Congestive Heart Failure, and Diabetes Mellitus. RI #41's quarterly MDS assessment with an ARD date of 05/26/2023 documented a BIMS score of 14 out of 15 which indicated intact cognition. RI #41's Radiology Interpretation with an exam date of 07/01/2023 at 12:11 PM for two views of the left hand documented: . Significant Findings . There is a mildly displaced, comminuted fracture of the proximal phalanx of the ring finger. Impression: Acute fracture of the ring finger. RI #41's hospital record titled Rounds Report dated 07/01/2023 documented: . Reason for Admission: . ASSAULT . RI #487 was admitted to the facility on [DATE] and had diagnoses to include: Vascular Dementia with Behavioral Disturbance, Mood Disorder with Depressive Features, and Adjustment Disorder with Depressed Mood. RI #487's annual MDS with an ARD of 03/30/2023 documented a BIMS score of 14 out of 15 which indicated intact cognition. The MDS also documented that RI #487 had less than daily Behavioral Symptoms of verbal behaviors symptoms directed towards others. A review of RI #487's Comprehensive Behavior Care Plans with a start date of 07/12/2019 documented the following behavior problems for RI #487, but did not include what level of supervision RI #487 would require to keep residents safe. 1) . RI #487 exhibits or has the potential to exhibit verbal behaviors related to cognitive loss/Dementia. RI #487 has a history of verbal outburst. (He/She) is easily frustrated. (He/She) gets agitated, yells out, and curses because (he/she) wants to go home . 2) RI #487 exhibits or has the potential to exhibit physical behaviors related to Dementia . Date initiated 09/22/2021 . 3) RI #487 is resistive to care related to difficulty adjusting to the facility and cognitive loss/Dementia . Date initiated 04/08/2020 . The facility investigative file contained a typed statement signed by RI #487 dated 07/04/2023 which documented: . Last Saturday I was in my room with my roommate. (He/she) woke up and started cursing because I turned on the TV. (He/she) woke up and started bitching like hell and yelled at me. I went over to (his/her) bed because (he/she) was yelling at me. (He/she) had (his/her) fist drawn up and pulled back. I balled my fist up and hit (his/her) fist and then I grabbed (his/her) hand and twisted it. I had had enough of (him/her) yelling at me and I just blew up. We yell out at each other all the time but most of the time it is just playing. The facility investigative file contained a typed statement signed by RI #41 dated 07/03/2023 which documented: . This past weekend there was something that happened between me and my roommate (RI #487). I don't remember saying anything to (him/her) . (He/she . came over to my side of the room, grabbed my fingers on my left hand and started twisting them hard. I am not afraid being here and I am o.k. I just do not want (him/her) to be my roommate anymore. On 03/03/2025 at 9:45 AM RI #41 was questioned about the incident on 07/01/2023 with roommate RI #487. RI #41 recalled the incident and said he/she was lying in bed that morning and RI #487 came over and twisted his/her left ring and pinky finger. RI #41 said, he/she could not recall anything that may have triggered RI #487 to act in that manner. RI #41 said RI #487 was crazy and would do things that did not make sense. RI #41 said, he/she called the staff to report the incident, they sent RI #487 out to the hospital and transferred him/her for an X-ray which showed a fracture. RI #41 said, the pain was a 10 on a scale of 1-10. On 03/14/2025 at 11:26 AM the ADM was interviewed and questioned about the incident on 07/01/2023 between RI #41 and RI #487. The ADM said, she was not present during that time and referred to the reportable and five-day or final investigative summary submitted to the State agency. The ADM said on 07/01/2023 at 10:20 AM the State Agency was notified that roommates RI #41 and RI #487 had an argument (over the TV being turned on). RI #487 bent RI #41's finger, upon staff entrance to the the room, RI #487 admitted to twisting RI #41's finger. The ADM continued, nursing staff intervened, assessed, provided protection, an X-Ray of RI #41's left ring finger was ordered, and once a fracture was detected, RI #41 was sent out for treatment. The ADM said an investigation was conducted and it was determined that the allegation of abuse was substantiated and this was physical abuse. On 03/06/2025 at 12:27 PM an interview was conducted with Social Service Assistant (SSA) regarding the incident on 07/01/2023 between RI #41 and RI #487. SSA said RI #41 and RI #487 had been roommates for a few months. When asked if there had been any disagreements or issues between RI #41 and RI #487, SSA said yes, but that they had always resolved the issue between themselves. The SSA said she spoke with RI #41 after the incident, and RI #41 was very upset. When asked how this could have been prevented, SSA said possibly addressing the signs of the micro aggressive behaviors between RI #41 and RI #487. The SSA said it was physical abuse when RI #487 twisted RI #41's finger. *********************************************************** The facility took immediate action to correct the noncompliance including: 07/01/2023- RI #487 immediately placed on 1:1 Observation 07/01/2023 - RI #487 sent out to Hospital for Psychiatric Evaluation 07/01/2023 - X-Ray of RI #41's finger obtained 07/01/2023 - Body Audits to both residents 07/01/2023 through 07/04/2023 - Interviews with Staff and Residents 07/03/2023 - Interview with RI #41 07/04/2023 - Interview with RI #487 07/15/2023 and 08/15/2023 QAPI to monitor abuse and behaviors. 08/15/2023 - Behavior Antipsychotic Review 08/21/2023 - Ombudsman Abuse In- Service 07/04/2023 - Room change upon RI #487's return from the hospital 07/01/2023 and 07/31/2023 RI #487 seen by IBH Provider 09/26/2023 - RI #487 discharged home. It was recommended on discharge that resident continue IBH services RI #487 remained on Behavior Monitoring from the time of the incident (07/01/2023) until discharge 09/26/2023 RI #487 continued being followed by psychiatric services provider until discharged on [DATE]. ******************************************* After review of documentation supporting the above corrective actions, including the facility's investigation file, in-service/education records, QAPI documentation, and staff interviews, the survey team verified the facility implemented corrective actions including ongoing monitoring from 07/01/2023 through 09/26/2023, thus, past non-compliance was cited. 33738 4.) RI #3 was readmitted to the facility on [DATE] and had diagnoses that included Vascular Dementia. RI #3's admission MDS assessment with an ARD of 07/19/2024 documented long- and short-term memory problems and moderately impaired cognition. RI #339 was admitted to the facility on [DATE] with diagnoses to include Depression and Post-Traumatic Stress Disorder. RI #339's quarterly MDS assessment with an ARD of 07/17/2024 documented a BIMS score of 15 of 15 indicating intact cognition. RI #339 had a care plan initiated 08/15/2024 to address the focus area of exhibiting verbal behaviors, history of verbal outbursts directed at others, uses of abusive language, pattern of challenging/confrontational verbal behavior, but did not include what level of supervision RI #339 required to keep residents safe. Further review of RI #339's medical record revealed comprehensive care plans, progress notes, and IBH notes describing some of RI #339's behaviors leading up to the incident on 09/12/2024. RI #339's IBH notes documented behaviors on several visits. The IBH notes did not include clear recommendations or interventions to manage RI #339's behaviors and mental health symptoms. IBH notes reviewed were dated 08/23/2024 and 09/06/2024. RI #339's progress notes included documented behaviors on 07/02/2024, 08/19/2024, 09/03/2024, 09/12/2024 at 11:31 AM and 9:09 PM. The facility reported a FRI that alleged that on 09/12/2024 at 10:45 PM RI #339 stabbed RI #3 in the left hand with an ink pen causing a gash. The residents were separated, and Emergency Medical Services (EMS) were requested, and the Police were notified. The facility investigative file contained a form titled, INVESTIGATION REPORT for RI #3 dated 09/14/2024 which documented on 09/12/2024 Licensed Practical Nurse (LPN) #38 called and reported to the Administrator (ADM) and Director of Nurses (DON) that RI #339 stabbed RI #3 in the left hand. A Conclusion to the report was documented as follow: In conclusion, the facility completed an investigation and there is sufficient evidence to substantiate an allegation of physical abuse (Resident to Resident). (RI #3) transferred to the hospital on 9/12/24 for evaluation of (his/her) left hand. (RI #3) is monitored for any psychosocial changes. (RI #339) transferred to three different hospitals on 09/13/24. After the incident, the residents were separated as roommates. The facility staff was also reeducated on abuse reporting and reporting any roommate incompatibility. A review of RI #3's hospital medical record indicated he/she was admitted date on 09/12/2024. The hospital medical record document titled ED (Emergency Department) Provider Documentation documented: Chief Complaint: . STABBED IN LEFT HAND/MIDDLE FINGER WITH PEN BY ROOMMATE . History of Present Illness . presents to the ER with a stab wound to . left hand. Patient is currently at a nursing home. states that (he/she) got in a fight with another resident. stabbed . in the left hand with a pen. Wash and repair the wound as necessary. Procedure Laceration repair . Laceration 1 cm (centimeters) in length . left hand . Stab wound to left hand . The facility investigative file contained a handwritten statement signed by RI #3 dated 09/13/2024 which documented: . What happened last night? (RI #339) accused me of stealing (his/her) remote control. I told (him/her) I did not have (his/her) remote control. (RI #339) was very upset. (RI #339) was screaming. (RI #339) pulled my cell phone and charger out of the garbage can and threw them at me. I was sitting in my wheelchair in close proximity to (RI #339). (RI #339) stabbed me with an ink pen in my left hand. I put my hand . up to defend myself. The nurse came in the room and placed me by her cart at the nurses station. On 03/02/2025 at 3:50 PM an interview was conducted with RI #3. RI #3 stated, RI #339 was his/her roommate and would yell out at times. RI #3 stated, on 09/12/2023 RI #339 stabbed his/her hand and he/she was sent to the hospital and r [TRUNCATED]

Based on interviews, resident record reviews, review of a facility policy titled Abuse Prohibition, review of Facility Reported Incidents (FRIs) received by the State Agency, and review of the facility's investigative files, the facility failed to ensure allegations of abuse were reported immediately by staff to a supervisor or the Administrator so action could be taken to investigate abuse and protect residents. Specifically, on 07/25/2023, a Certified Nursing Assistant (CNA) #39 failed to immediately report that she witnessed CNA #41 throw a metal ashtray weighing over one pound at RI #60. Further, CNA #40 failed to report the allegation of abuse immediately on 07/25/2023 around 10:00 PM when CNA #41 made a telephone call to tell CNA #40 she had thrown an ashtray at RI #60. CNA #40 failed to report what CNA #41 told her until the next day on 07/26/2023. Because CNA #39 failed to report abuse immediately, CNA #41 remained in the facility and continued working until almost 3:00 PM when her shift ended on 07/26/2023. Because CNA #39 failed to immediately report witnessed abuse and CNA #40 failed to immediately report alleged abuse, residents were left unprotected when CNA #41 continued to work and have access to RI #60 and other residents. This was likely to result in further abuse and/or serious psychosocial harm, causing fearfulness and mental anguish. It was determined the facility'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 Immediate Jeopardy (IJ) was cited in reference to 483.12 Freedom from Abuse, Neglect and Exploitation at F609-Reporting of Alleged Violations. On 03/19/2024 at 6:20 PM, the Administrator and Director of Nursing (DON), were provided a copy of the Immediate Jeopardy Template and notified of the findings of substandard quality of care at the Immediate Jeopardy level in the area of Freedom from Abuse, Neglect, and Exploitation at F609-Reporting of Alleged Violations. The IJ began on 07/25/2023 and continued until 08/21/2023 when the facility implemented corrective actions to correct the identified deficient practice and prevent recurrence; thus, immediate jeopardy past noncompliance was cited. This deficiency was cited as a result of a Facility Reported Incident/Complaint/Report Number AL00044983. Findings include: Cross-reference F600. Review of the facility's abuse policy titled, Abuse Prohibition, with a revision date of 10/24/2022, revealed the following: POLICY Center prohibit abuse . for all patients . The Center will implement an abuse prohibition program through the following: . Identification of possible incidents or allegations which need investigation; Investigation of incidents and allegations; Protection of patients during investigations; Reporting of incidents, investigations, and Center response to the results of their investigations. Federal Definitions: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . PROCESS . 6. Staff will identify events- such as . occurrences . that may constitute abuse . 6.1 Anyone who witnesses an incident of suspected abuse . is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately, regardless of shift worked. 6.1.1 The notified supervisor will report the suspected abuse immediately to the Administrator . RI #60 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include: Alzheimer's Disease, Dementia with Behavioral Disturbance, Schizoaffective Disorder, Bipolar Disorder, Psychosis, Anxiety Disorder, and Major Depressive Disorder. RI #60's annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/06/2023 documented a 12 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated RI #60 was moderately cognitively impaired. The Online Incident Reporting System Report submitted to the State Agency on 07/26/2023 at 7:08 PM documented: . Incident Type . Abuse - Mistreatment . Name(s) of resident(s) involved: (RI #60) . Name of alleged perpetrator(s): (CNA #41) Date and time of when staff became aware of the incident: 07/26/2023 Time: 05:10 PM Name of staff member who became aware of the incident: (DON) Date and time of when administrator was notified of the incident: 07/26/2023 Time: 06:00 PM . Date and time of incident or alleged incident: 07/26/2023 Time: 09:30 PM Narrative summary of incident: It was reported that the Nursing Assistant, (CNA #41), threw an ashtray at resident, (RI #60). the ashtray did not make contact with (RI #60). Who made the allegation (unless it was reported anonymously), and their relationship to the alleged victim: (CNA #40) What was reported and to whom or which agency/entity: (CNA #40) reported to (DON) that (CNA #41) threw an ashtray at (RI #60) and stated that the ashtray did not make contact with the resident. The facility's investigative file contained a typed statement dated 07/27/2023 signed by CNA #39, who was present and witnessed the abuse, that documented: . On 07/25/23 did you witness (CNA #41) throw an ashtray at (RI #60)? . Yes . Do you know what caused her to throw the astray at (RI #60)? . Yes, (he/she) . was cursing at her calling her a Black Bitch. (RI #41) said to (him/her) who are you calling a bitch? Then she threw the ashtray at (him/her). Did you report to anyone that (RI #41) threw an ashtray at (RI #60)? No . Why did you not report this? . I guess I was scared. On 03/18/2025, at 10:15 AM, a telephone interview was conducted with CNA #40. During the interview, CNA #40 stated CNA #41 called her around 10:00 PM on 07/25/2023 and informed her she had thrown an ashtray at RI #60. CNA #40 said, she was not fully awake when she received the call the night of 07/25/2023, so she contacted CNA #41 the next morning to confirm what she had heard. It was not until after the second phone call with CNA #41 that CNA #40 reported the incident to the facility. Regarding the facility's abuse policy, CNA #40 stated, any incidents of abuse should be reported immediately. On 03/12/2025 at 11:26 AM an interview was conducted with the Administrator (ADM) Abuse Coordinator. The ADM was asked when CNA #39 witnessed CNA #41 throwing an ashtray at RI #60 when should she have reported the incident of alleged abuse. The ADM said CNA #39 should have reported it immediately. She further stated the timeframe for reporting an allegation of abuse was within two hours. The ADM said CNA #39 did not follow the abuse policy for reporting. On 03/18/2025 at 10:49 AM the former Administrator (FADM), who was the Administrator at the time of the incident on 07/25/2023, was asked about the incident. The FADM said, she was at the beach when it occurred and was notified by the DON of the initial report on 07/25/2023. The FADM said, it was the next afternoon on 07/26/2023 when she was made aware CNA #41 had thrown the ashtray first at RI #60. The FADM said the DON became aware when CNA #40 reported that CNA #41 was the one that threw the ashtray at RI #60.The FADM said, CNA #41 had continued to work in the facility on 07/26/2023 because they did not know initially what she had done. CNA #41's printed time sheet documented CNA #41's last two days worked were on 07/25/2023 from 6:56 AM until 2:55 PM and on 07/26/2023 from 7:18 AM until 2:55 PM. ************************************************************ The facility took immediate action to correct the noncompliance including: 07/25/2023, immediately brought into facility and placed on 1:1 with supervisor until sent out for psych evaluation 07/25/2023 - Body audits completed on both residents 07/25/2023 - Report made to ADPH 07/25/2023 - Police report filed with police department 07/25/2023 - Investigation initiated 07/25/2023 - Care Plans updated 07/26/2023 2nd report to ADPH 07/26/2023 - RI #60 seen by provider - medications adjusted for agitation 07/26/2023 - RI #287 assessed by provider - noted as stable 07/27/2023- CNA #41 was suspended 07/29/2023- CNA #39 was suspended 07/30/2023 - Interview: residents to rule out abuse and with staff members to ensure no unreported abuse 07/31/2023 - RI #60 seen by IBH provider - no behaviors noted; continues on IBH monthly 08/01/2023 - 100 percent of body audits completed - no concerns noted 08/01/2023-CNA #40 was suspended and terminated 08/02/2023- CNA #41 and #39 were terminated 08/08/2023- All staff educated on Behavior Management Education. 08/15/2023 - Monitoring behaviors and abuse through QAPI process 08/21/2023 - All staff educated on abuse and reporting abuse - completed by local ombudsman *************************************************************** After review of documentation supporting the above corrective actions, including the facility's investigation file, in-service/education records, QAPI documentation, and staff interviews, the survey team verified the facility implemented corrective actions including ongoing monitoring from 07/25/2023 to 08/21/2023 thus immediate jeopardy past non-compliance was cited. 29671 33738

Based on interview, medical record review, and review of the Preadmission Screening and Resident Review (PASRR), the facility failed to submit a new Level I for Resident Identifier (RI) #339 when a new diagnosis of Post Trauma Stress Disorder (PTSD) was given on 08/30/2024. This deficient practice affected RI #339, one of 29 residents PASRR reviewed. Findings include: RI #339 was admitted to the facility on [DATE] with a diagnosis of Depression. RI #339's medical record documented a PTSD diagnosis with an onset date of 08/30/2024. On 03/07/2025 04:56 PM, while reviewing the residents medical record, a new Level I was not found. On 03/11/2025 at 5:11 PM, an interview was conducted with SSD (Social Service Director). SSD said she was responsible for completing a new PASSR when a resident had a significant change. SSD said when RI #339 was given a diagnosis of PTSD on 08/30/2024, he/she required a new Level I PASSR to be completed, but a new Level I PASSR was not done.

Based on interviews, record review, review of facility policies titled Medication Administration General Guidelines and Medication Administration Controlled Substances and review of the facility's investigative file, the facility failed to ensure Resident Identifier (RI) #'s 15, 21, 40, 76, 79, 103, 108 and 113 received their on the 7 PM to 7 AM shift on 11/13/2024 as ordered by the physician. This deficient practice affected eight of 11 residents residing on the Rehab unit reviewed for not receiving their medications as ordered by the physician. Findings Include: Cross-Reference F 602. Review of a facility policy titled, Medication Administration General Guidelines, dated 2007 and 01/2025, revealed the following: . GENERAL GUIDELINES . PROCEDURES . Medication Administration: 1. Medications are administered in accordance with written orders of the Prescriber . 4. Medications are to be administered at the time they are prepared. 5. The person who prepares the dose for administration is the person who administers the dose . Documentation: 1. The individual who administers the medication dose, records the administration on the resident's MAR (Medication Administration Record) immediately following the medication being given . Review of a facility policy titled, Medication Administration Controlled Substances, dated 2007 and 01/2025, revealed the following: . CONTROLLED SUBSTANCES . PROCEDURES . 5. Administer the controlled medication and document dose administration on the MAR . Review of the facility's INVESTIGATIVE REPORT, dated 11/19/2024, revealed the following: . Investigation Details . In an interview with (RN #35) via (by way of) phone-(RI #35) stated; when she arrived for her 11-7 shift on 11/13/24, none of the 2000 (8 PM) or 2200 (10 PM) medications had been given . The investigation revealed that the nurse (RN #33) had signed out the narcotics for 8 PM, 9 PM and 10 PM on the Controlled Drug Record but failed to administer the narcotic medications to the residents. (RN #33) stated she did not give any narcotic medications prior to her unplanned departure at 9:26 pm. the residents stated they did not get the medicine . Conclusion: . Although we are unable to determine what happened to the narcotic medication, the facility can establish that the Medication Administration Policy and Procedure was violated causing this occurrence . 1) RI #15 was admitted to the facility on [DATE] and had diagnoses to include Depression, Mixed Hyperlipidemia, Epilepsy, Unspecified and Hyperglycemia. A review of RI #15's November 2024 Order Summary Report (Physicians Orders) revealed RI #15 had orders for Atorvastatin Calcium Oral tablet 10 mg (milligrams) by mouth at bedtime for Hyperlipidemia, Insulin Glargine 11 units subcutaneous two times a day for Diabetes, Sertraline HCI (Hydrochloric Acid) Oral tablet 50 mg by mouth two times a day for Depression, and 4 capsules of Valproic Acid Oral capsule 250 mg by mouth two times a day for Seizure Disorder. RI #15's November 2024 MAR revealed on 11/13/2024, Atorvastatin Calcium Oral tablet 10 mg, Insulin Glargine 11 units, Sertraline HCI Oral tablet 50 mg, and 4 capsules of Valproic Acid Oral capsule 250 mg were not administered at 8:00 PM as ordered by the physician. 2) RI #21 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnoses to include Parkinson's Disease, Mixed Hyperlipidemia, Chronic Pain, and Chronic Pain Syndrome. RI #21's November 2024 Physician Orders revealed RI #21 had orders for Atorvastatin Calcium Oral tablet 80 mg at bedtime for Mixed Hyperlipidemia, Carbidopa-Levodopa Oral tablet 25-100 mg by mouth three times a day for Parkinson's Disease, and Gabapentin Oral tablet 600 mg by mouth three times a day for Pain. RI #21's November 2024 MAR revealed on 11/13/2024 the following medications were not administered as ordered: Atorvastatin Calcium Oral tablet 80 mg at 9:00 PM; Carbidopa-Levodopa Oral tablet 25-100 mg at 10:00 PM; and Gabapentin Oral tablet at 10:00 PM. 3) RI #40 was admitted to the facility on [DATE] and had diagnoses to include Chronic Pain Syndrome, Hypotension, Depression, and Constipation. RI #40's November 2024 Physician Orders revealed RI #40 had orders for Cilostazol Tablet 50 mg by mouth two times a day for symptoms of intermittent claudication, Glycolax Powder 17 grams by mouth two times a day for constipation, Hydrocodone-Acetaminophen Oral tablet 5-325 mg every 8 hours for chronic pain, Midodrine HCI tablet 5 mg 2 tablets by mouth three times a day for hypotension, Senna Oral tablet 8.6 mg 2 tablets by mouth at bedtime for constipation, and Trazodone HCL Oral tablet 75 mg by mouth at bedtime for depression. RI #40's November 2024 MAR revealed on 11/13/2024 the following medications were not administered to RI #40 as ordered: Cilostazol Tablet 50 mg at 8:00 PM; Glycolax Powder 17 grams at 8:00 PM; Senna Oral tablet 8.6 mg at 8:00 PM; Trazodone HCL Oral tablet 75 mg at 8:00 PM; Hydrocodone-Acetaminophen Oral tablet 5-325 mg at 10:00 PM; Midodrine HCI tablet 5 mg at 10:00 PM. 4) RI #76 was admitted to the facility on [DATE] and had diagnoses to include Epilepsy, Hyperlipidemia, Essential Hypertension, and Pain. RI #76's November 2024 Physician Orders revealed RI #40 had orders for Atorvastatin Calcium Oral tablet 40 mg by mouth one time a day for Hyperlipidemia, Carvedilol Oral tablet 12.5 mg by mouth two times a day for Hypertension, Isosorbide Dinitrate Oral tablet 40 mg by mouth three times a day for Chest Pain prevention, Lacosamide Oral tablet 150 mg by mouth two times a day for Seizures and Levetiracetam Oral tablet 500 mg by mouth two times a day for Seizures. RI #76's November 2024 MAR revealed on 11/13/2024 the following medications were not administered as ordered by the physician at 8:00 PM: Atorvastatin Calcium Oral tablet 40 mg; Carvedilol Oral tablet 12.5 mg; Isosorbide Dinitrate Oral tablet 40 mg; Lacosamide Oral tablet 150 mg; and Levetiracetam Oral tablet 500 mg. 5) RI #79 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnoses to include Unspecified Atrial Fibrillation (A-Fib), Angina Pectoris, Pain, Essential Hypertension, Chest Pain and Irritable Bowel Syndrome with Diarrhea. RI #79's November 2024 Physician Orders revealed RI #79 had orders for Carvedilol Tablet 25 mg by mouth two times a day for Hypertension, Eliquis Oral tablet 5 mg by mouth two times a day for A-Fib, Florajens3 Oral capsule by mouth at bedtime for Diarrhea/IBS (Irritable Bowel Syndrome), Neurontin Oral capsule 300 mg by mouth two times a day for Pain, Primidone Oral tablet 50 mg by mouth at bedtime for Tremors/Spasms, and Ranolazine ER (Extended Release) Tablet 500 mg by mouth two times a day for Angina. RI #79's November 2024 MAR revealed the following medications were not administered as ordered on 11/13/2024: Carvedilol Tablet 25 mg at 8:00 PM; Eliquis Oral tablet 5 mg at 8:00 PM; Florajens3 Oral capsule at 8:00 PM; Primidone Oral tablet 50 mg at 8:00 PM; Ranolazine ER Tablet 500 mg at 9:00 PM; and Neurontin Oral capsule 300 mg at 9:00 PM. 6) RI #103 was admitted to the facility on [DATE] and had diagnoses to include Seizures, Type 1 Diabetes with Hyperglycemia, Hyperlipidemia, Constipation, and Chronic Pain. RI #103's November 2024 Physician Orders revealed RI #103 had orders for Atorvastatin Calcium Oral tablet 40 mg by mouth at bedtime for HDL (High-Density Lipoprotein), Divalproex Sodium Oral tablet 500 mg 2 tablets by mouth two times a day for Seizures, Humalog Insulin injection per sliding scale before meals, Ibuprofen Tablet 800 mg by mouth two times a day for Inflammation, Glargine Insulin 36 units at bedtime for Diabetes and Sennosides Tablet 8.6 mg by mouth two times a day for Constipation. RI #103's November 2024 MAR revealed on 11/13/2024 the following medications were not administered as ordered: Atorvastatin Calcium Oral tablet 40 mg at 8:00 PM; Divalproex Sodium Oral tablet 500 mg 2 tablets at 8:00 PM; Glargine Insulin 36 units at 8:00 PM; Sennosides Tablet 8.6 mg at 8:00 PM; and Ibuprofen Tablet 800 mg at 9:00 PM. 7) RI #108 was admitted to the facility on [DATE] with diagnosis to include Primary Insomnia and Hyperlipidemia. RI #108's November 2024 Physician Orders revealed RI #108 had orders for Atorvastatin Calcium Oral tablet 20 mg by mouth at bedtime for HDL and Melatonin Tablet 5 mg by mouth at bedtime for Insomnia. RI #108's November 2024 MAR revealed the following medications were not administer as ordered on 11/13/2024: Atorvastatin Calcium Oral tablet 20 mg at 8:00 PM and Melatonin Tablet 5 mg at 8:00 PM. 8) RI #113 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Anxiety Disorder and Vascular Dementia with Other Behavioral Disturbance. A review of RI #113's November 2024 Physician Orders revealed RI #113 had orders for Ativan Oral tablet 0.5 mg by mouth every 4 hours for Anxiety/Agitation. A review of RI #113's November 2024 MAR revealed the Ativan Oral tablet 0.5 mg was not administered as ordered on 11/13/2024 at 9:00 PM. Contained within the facility's investigative file was an unsigned and undated Witness Statement, given by Registered Nurse (RN) #35. The following was documented: . Please give your statement in detail: Last night on 11-13-2024 there were no 2000 (8 PM) or 2200 (10 PM) meds given. All narcotics were signed out on patients but not given or left anywhere . Looking back all meds 8 p and 10 pm were in the red; not charted . On 03/06/2025 and 03/07/2025 unsuccessful attempts were made to contact RN #33. On 03/08/2025 at 1:08 PM a telephone interview was conducted with RN #35 who said on 11/13/2024 the residents were coming into the hall asking about their medications. RN #35 said when she looked on the computer on the eMAR (electronic Medication Administration Record) everything was in red showing the medications had not been given, both controlled drugs and other medications. RN #35 said the standard of practice nurses should use when administering medications was to pop the pill from the medication card, give it to the resident, and sign the MAR that they administered the medication. RN #35 said the standard of practice nurses should use when administering a narcotic medication was to pop the pill, sign the narcotic sheet, administered the medication to the resident, and sign the MAR that it had been administered. RN #35 said the facility's Medication Administration policy indicated that medications should be administered when removed from the pill pack and the person that prepared the medication should administer it. On 03/12/2025 at 4:11 PM, an interview was conducted with the DON. The DON said the standard of practice nurses use when administering medications was to make sure: the right patient, right medicine, right time, right route; obtain the medication, and stay and with the resident to ensure the resident took the medication. The DON said staff documented on the MAR after the resident took the medication. The DON said the standard of practice nurses used when administering controlled drugs was the same but with narcotic medications staff signed out on the narcotic sheet when staff pulled the medication, administer the medication, and stay with the patient until the patient took the medication, then sign the MAR that the resident took the medication.

Based on interviews, medical record review, and review of facility policies titled, OPS111 Elopement of Patient, and OPS100 Accidents/Incidents, facility failed to ensure Resident Identifier (RI) #48 was supervised in a manner that staff knew of his/her whereabouts and that he/she did not leave the facility without staff knowledge. The facility failed to have a system to ensure residents were unable to exit the facility without staff's knowledge and without supervision. The facility further failed to ensure the Physical Therapy Assistant (PTA) did not leave RI #48 in an unsafe area without taking measures to ensure the resident's safety when he observed RI #48 off the facility property on 02/01/2025. On 02/01/2025 around 8:40 AM, the PTA observed RI #48 in his/her wheelchair near the road, across the street from the facility. The PTA did not take immediate action, but instead parked his vehicle in the facility parking lot and entered the facility to report RI #48's whereabouts to nursing staff. The facility's investigation concluded that RI #48 exited through the facility's secured doors before the Receptionist's shift began and was unable to determine who opened the door to allow RI #48 to exit. This deficient practice affected RI #48, one of three sampled residents reviewed for elopement. It was determined the facility'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. The Immediate Jeopardy (IJ) was cited in reference to 483.25(d) Free of Accident Hazards/Supervision/Devices at a scope and severity of J. On 03/13/2025 at 6:09 PM, the Administrator (ADM) and the Director of Nursing (DON) were provided a copy of the Immediate Jeopardy (IJ) Template and notified of the findings of substandard quality of care at the Immediate Jeopardy level at F689 Free of Accidents Hazards/Supervision/Devices. The IJ began on 02/01/2025 and continued until 03/14/2025. On 03/15/2025 the Immediate Jeopardy was removed, F689 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of facility reported incident (FRI)/complaint/report number AL00050249. Findings include: Review of a facility policy titled, OPS111 Elopement of Patient, with a revision date of 10/24/2022, documented: . POLICY . Elopement is defined as any situation in which a patient leaves the premises or a safe area without the facility's knowledge and supervision, if necessary . 2.1 Staff witnessing a confused patient or an identified elopement risk patient attempting to leave the Unit and/or Center unaccompanied will intervene as appropriate to redirect the patient to a safe area and prevent elopement . Review of a facility policy titled,OPS100 Accidents/Incidents, with a revision date of 03/01/2024, documented: . POLICY . An incident is defined as any occurrence not consistent with the routine operation of the Center or normal care of the patient . 1. Response: . 1.1 If an employee witnesses a patient accident/incident within or outside the center premises, the employee will: 1.1.1 Provide immediate assistance and remove the individual from immediate harm . 1.1.2 Stay with the individual and summon help . RI #48 was admitted to the facility on [DATE], with diagnoses including cerebral infarction, depressed mood, psychotic disorder with delusions and muscle weakness. Review of RI #48's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 01/04/2025 revealed RI #48 had a Brief Interview for Mental Status (BIMS) score of 14, indicating he/she was cognitively intact. On 02/03/2025 at 8:48 PM, the facility report to the Alabama State Survey Agency an incident of elopement. According to the initial report, RI #48 left the facility unsupervised by staff. He/She was observed by staff and then escorted back into the facility. The facility INVESTIGATION REPORT dated 02/07/2025 documented: . Allegation Details: On February 1, 2025 (RI #48) self-propelled in (his/her) wheelchair out of the facility. Conclusion: . (RI #48) was assessed . (he/she) was confused. (he/she) stated; (he/she) was going to work . (He/she) self-propels throughout the facility at times . At the time of the occurrence (he/she) had started treatment for Urinary Tract Infection . On 03/10/2025, at 6:43 PM, the Administrator (ADM) and the Market Clinical Advisor, measured and determined that RI #48 was found 49 feet off the facility property on 02/01/2025. On 03/02/2025, at 3:30 PM, an interview was conducted with RI #48 who was unable to remember the incident. On 03/06/2025, at 4:42 PM, an interview was conducted with LPN (Licensed Practical Nurse) #43 who said that upon her arrival at work around 7 AM, she observed RI #48 seated in the hallway. At approximately 8:30 AM, she was informed by a PT staff that he had seen RI #48 outside the building upon his arrival to work. LPN #43 and LPN #42 went outside, found RI #48 in his/her wheelchair about 100 feet from the property line, and brought RI #48 inside the facility. LPN #43 said she was unaware of how he/she had exited. An interview was conducted with LPN #42 on 03/06/2025 at 5:53 PM. LPN #42 reported that at approximately 8:30 AM on 02/01/2025, she was informed by a staff member from the PT department that RI #48 was outside the facility. LPN #42 said that LPN #43 and herself went outside and found RI #48 off the facility's premises. LPN #42 said that upon reaching RI #48, the resident expressed an intention to go to work and appeared to be confused. LPN #42 said RI #48 was assisted back to the facility and assessed for injury. An interview with the PTA was conducted on 03/11/2025 at 12:32 PM. The PTA said that on 02/01/2025, at approximately 8:30 AM, he observed RI #48 in a wheelchair on the road near the stop sign. The PTA stated he recognized RI #48 as a resident of the facility and he slowed his vehicle down, but he did not stop to check on RI #48's condition. The PTA said he parked his vehicle, entered the building, and then notified a nurse that he observed a resident off the facility's premises. The PTA said that it was important for staff to stop when a resident was seen of the facility's premises to ensure the resident's safety, as the resident might not be in a normal state of mind. He acknowledged that he should have stopped to ensure RI #48's safety. An interview with the ADM took place on 03/11/2025 at 4:48 PM. The ADM stated that RI #48 had not been identified as an elopement risk and had never attempted to leave the facility previously. The ADM said the facility's investigation concluded that RI #48 exited through the front door. The ADM said the front door was secured and locked at the time RI #48 exited. The facility's investigation did not determine who let RI #48 outside. The ADM said RI #48 normally went outside. The ADM said the PTA should have stopped to check on the resident when he saw RI #48 in the wheelchair off of the facility's property. The ADM said the expectation was that staff should remain with residents and notify the facility if they observed a resident off property. A follow-up interview with the ADM was conducted on 03/13/2025 at 3:11 PM. During the interview, she was questioned about how a confused resident managed to leave the facility in a wheelchair without the staff's knowledge. The ADM indicated that to her knowledge, RI #48 either followed someone out or was permitted to exit by a staff member. When asked about the root cause of the incident, she confirmed the investigation revealed RI #48 had left the building and was off the property. Since the doors were locked, it was concluded that either a staff member or a visitor facilitated the exit. However, it remained unclear who specifically allowed RI #48 to leave the building. The ADM said there was no signage at the front door alerting staff and visitors to not allow residents to exit. The ADM said she had been the Administrator of the facility for about 11 months and it had been the facility's policy to allow residents to exit the facility to the front porch unsupervised. The ADM said residents identified as elopement risk in the elopement book at the desk were not allowed to go outside. The ADM said the Receptionist normal day started at 9:00 AM and the Receptionist would open the front door to allow visitors and residents to enter and exit the building. The ADM said the Receptionist was not working when RI #48 exited on 02/01/2025. The ADM said staff were trained to allow residents to exit the facility and go outside on the porch unsupervised unless the resident was in the elopement book. ************************************************ On 03/14/2025, the facility submitted the following as their removal plan for the identified Immediate Jeopardy: *********************************************** Assessments: 1. Licensed Nurse completed an assessment, obtained vital signs, and completed a skin audit on RI#48 on February 1, 2025, and no injury, distress, or fatigue was noted. The Physician and Responsible Party were notified and 1:1 supervision was initiated. 2. Licensed Nurse received and executed an order for STAT CMP and CBC with diff for RI#48 on February 1, 2025. 3. The Nurse Manager and Licensed Nurses completed a 100% head count on February 1, 2025, to verify all residents were accounted for, and no additional concerns were identified. 4. Nurse Manager and/or designee completed a new Elopement Assessment on RI #48, placed a wander guard bracelet, and revised the plan of care on February 3, 2025. The Director of Nursing Services and/or designee completed an Elopement Risk Identification form for RI #48 and placed the form in the Elopement binders on February 3, 2025. Audits: 5. Licensed Nurses completed an Elopement Assessment on all residents on February 3, 2025, to identify other residents at risk for Elopement. No additional concerns were identified. The care plans were reviewed and updated as needed. 6. The Director of Nursing Services and Nurse Managers reviewed the elopement binders on February 3, 2025, to validate at risk residents had an Elopement Risk Identification form completed. 7. The Maintenance Assistant inspected 14 of 14 exit doors on February 3, 2025 to ensure doors were operational. 14 of 14 doors functioned properly with maglock keypad in place. Keypads were checked for proper opening and closing and no concerns were identified with security and/or alarms of the doors. In-services: 8. Administrator and/or designee completed one on one education with the Physical Therapist Assistant on February 4, 2025, on the Elopement Policy with emphasis on immediate actions to take if a resident is observed off the facility premises. Education included remaining with the resident, notifying the center staff by phone, and assisting the resident back into the center. Additional education was completed on Resident Safety/Supervision and Change of Condition. 9. The Nurse Practice Educator and/or designee educated all active employees on February 3, 2025, on the Elopement Policy. Education consisted of the following subcategories and topics: a. Assessment/Evaluation: Licensed Nurses will complete an Elopement Risk Assessment to identify resident elopement risk upon admission, re-admission, quarterly, or with a significant change in condition. b. For residents identified as at risk; an interdisciplinary elopement prevention patient-centered care plan will be developed by a Licensed Nurse. A Licensed Nurse and/or designee will obtain a current photograph of the resident and complete the Elopement Risk Identification form to alert staff of residents considered at risk of elopement. The Elopement Risk Identification form will be place in a binder that is easily accessible to staff in designated area(s). c. Staff witnessing a confused patient or an identified elopement risk patient attempting to leave the Center unaccompanied will intervene as appropriate to redirect the resident to a safe area and prevent elopement. If staff observe a resident off the Center premises, remain with the resident, notify the center staff by phone, and assist the resident to a safe area. Unwitnessed Elopement: Staff will notify the Supervisor that the patient is missing. The Supervisor will alert all staff of the missing resident with an announcement to activate a missing resident protocol. Staff will search the interior of the Center and the exterior building perimeter and grounds. If the patient is not found after the search of the Center and grounds, law enforcement will be contacted, and Center staff will follow directions and guidance offered by law enforcement until the resident is located. Once the resident is found, a Licensed Nurse will perform a physical examination. The Licensed Nurse will notify the Physician/Advanced Practice Provider (APP) of any changes from baseline. The Licensed Nurse and/or designee will notify all parties previously contacted (resident representative, law enforcement, etc.) to inform them of the resident return or status. The nurse will document the elopement in the Nurses Notes including date, time, place, notification, and other pertinent information. d. The Nurse Practice Educator and/or designee educated all active employees on February 3, 2025, on Change in Condition and Active Infections that may contribute to cognitive changes. The team determined that when an active infection exists that results in a change in cognition a new Elopement Assessment will be completed. If the resident is identified as at risk for an elopement, the Licensed Nurse will complete an Elopement Risk Identification form and add to the elopement binders. The plan of care will be updated to alert staff of the change in elopement status by a Licensed Nurse. Active employees and employees on leave of absence (FMLA), vacation, or PRN staff who have not been educated, will be trained prior to returning to duty by the Nurse Practice Educator. Education was completed on February 5, 2025 with 106 employees; 5 employees were identified as not educated due to leave of absence, vacation or PRN status. Porch Process: 10. The Interdisciplinary Team to include the Administrator, Director of Nursing Services, Social Service Director, and Recreation Director created a Porch List consisting of residents who can be given access by staff to go out on the front porch and sit unaccompanied by staff. The determination was made based on the residents Elopement Assessment, cognitive function, and desire to sit on the front porch. The list currently includes 15-20 residents. The residents will be monitored by staff, family members, or the receptionist at the front desk. Residents will sign out on a log titled Resident Sign Out/In Form and this log will be maintained at the receptionist desk. Residents who are not listed on the Porch List and residents identified as an elopement risk will not be permitted to go outside unless accompanied by a staff member, family member, or visitor. The Interdisciplinary team will update the Porch List as needed based on Elopement Assessment, cognitive function, and desire to sit on the front porch. 11. While the Receptionist is working and at the front desk during the hours of 8:00 am to 4:30 pm Monday through Friday and 8:00 am to 6:00 pm on the weekends. Residents who are listed on the Porch List will be able to go to the Receptionist and verbally request access to the front porch. The Receptionist will verify that the residents are on the Porch List and then allow resident access to the front porch. The Receptionist is able to see the residents on the front porch from the desk and will monitor to ensure each resident who has exited is accounted for on the porch every 15 minutes. If the Receptionist is away from the desk for more than 15 minutes another staff will be responsible for monitoring the residents every 15 minutes. The Center will ensure another staff is available to monitor the residents as indicated above. Other staff may include activity staff, nursing staff, business office staff, medical records, and scheduler. During times the Receptionist is not working and at the front desk during the hours of 4:30 pm to 8:00 am on Monday through Friday and 6:00 pm to 8:00 am on the weekends, no resident will be permitted to exit the Center unless accompanied by staff or family. Residents that are not included on the Porch list and express a desire to sit on the front porch will be accompanied and supervised by staff or family while outside of the Center. Porch Process Education 12. The Nurse Practice Educator and/or designee educated all active employees on March 14, 2025. Active employees and employees on leave of absence (FMLA), vacation, or PRN staff who have not been educated, will be trained prior to returning to duty by the Nurse Practice Educator. Education was completed on March 14, 2025, with 62 employees by the Nurse Practice Educator on the above process including: a. While the Receptionist is working and at the front desk during the hours of 8:00 am to 4:30 pm Monday through Friday and 8:00 am to 6:00 pm on the weekends. i.Residents who are listed on the Porch will be able to go to the Receptionist and verbally request access to the front porch. ii. The Receptionist will verify that the residents are on the Porch Listed then allow resident access to the front porch. iii. Receptionist is able to see the residents on the front porch from the desk and will monitor to ensure each resident who has exit is accounted for on the porch every 15 minutes. iv. If the Receptionist is away from the desk for more than 15 minutes another staff will be responsible for monitoring the residents every 15 minutes. The Center will ensure another staff is available to monitor the residents as indicated above. Other staff may include activity staff, nursing staff, business office staff, medical records, and scheduler. v. During times the Receptionist is not working and at the front desk during the hours of 4:30 pm to 8:00 am on Monday through Friday and 6:00 pm to 8:00 am on the weekends, no resident will be permitted to exit the Center unless accompanied by staff or family. vi. Residents that are not included on the Porch List and express a desire to sit on the front porch will be accompanied and supervised by staff or family while outside of the Center. b. The Administrator educated the Receptionist who works Monday through Friday on March 14, 2025, and provided the following instructions: residents will voice their desire or intent to sit on the front porch, the Porch List will then be reviewed to verify the resident name is listed. The date, resident name, time out and time in will be documented on the Porch Sign Out/In Form. The resident will then be allowed to sit on the front porch unaccompanied by staff. The resident will be monitored by the receptionist, staff, family or visitor. The education also included: While the Receptionist is working and at the front desk during the hours of 8:00 am to 4:30 pm Monday through Friday and 8:00 am to 6:00 pm on the weekends. Residents who are listed on the Porch List will be able to go the Receptionist and verbally request access to the front porch. The Receptionist will verify that the resident is on the Magnolia Ridge Porch List and then allow resident access to the porch. The Receptionist will monitor to ensure each resident who has exited is accounted for on the porch every 15 minutes. If the Receptionist is away from the desk for more than 15 minutes, another staff member will be responsible for monitoring the residents every 15 minutes. The Center will ensure another staff is available to monitor the residents as indicated above. Other staff may include activity staff, nursing staff, business office staff, medical records and scheduler. Residents that are not included on the Porch and express a desire to sit on the front porch must be accompanied and supervised by staff or family while outside of the Center. The Administrator or Nurse Practice Educator will provide 1:1 education with the weekend Receptionist and other employees who relieve the Receptionist during lunch break or scheduled time off will receive one on one education before relieving the receptionist and being responsible for monitoring residents on the front porch. Quality Assurance 13. Nurse Practice Educator and/or designee performed an Elopement Drill on each shift on February 5, 2025. Additional Elopement Drills were completed on February 7th and February 8th, 2025. 14. The Administrator placed a visual sign on 14 of 14 exit doors to alert visitors to not allow residents outside without staff supervision and adjusted the receptionist hours on the weekend to increase supervision on March 14, 2025. 15. The Administrator hosted an AD HOC Quality Assurance Performance Improvement (QAPI) meeting on February 3, 2025, with Interdisciplinary Team members to include the following: Director of Nursing Services, Assistant Director of Nursing Services, Regional Clinical Lead, and Nurse Managers. The Interdisciplinary team discussed measures and corrective actions to be executed to prevent further elopement occurrences. The Administrator reviewed the corrective actions with the Medical Director via phone. 16. The Administrator hosted an AD HOC Quality Assurance Performance Improvement (QAPI) meeting on March 13, 2025, with the Interdisciplinary Team members to include the following disciplines: Director of Nursing Services, Regional Clinical Lead, and Nurse Mangers to review additional recommendations to prevent elopement and ensure resident safety. The facility alleges all immediate correction actions were implemented on March 14, 2025. *********************************************************** After reviewing the facility's information provided in their Removal Plan and verifying the immediate corrective actions had been implemented the Immediate Jeopardy was removed on 03/15/2025. The scope/severity level of F689 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on interviews, resident record review, and review of a facility policy titled Behavioral Health Care Services, the facility failed to ensure staff utilized and implemented behavior management care plan approaches to manage Resident Identifier (RI) #60's verbal behaviors, outbursts, and cursing. Specifically, on 07/25/2023 RI #60 was outside in the smoking area with other residents (RI #287 and RI #488) and staff Certified Nursing Assistant (CNA #39 and CNA #41). RI #60 was cursing and calling staff names. CNA #41 failed to respond to RI #60 calmly and gently, and instead, CNA #41 picked up an ashtray and threw it at RI #60. The ashtray did not hit RI #60 but caused RI #60's behavior to escalate. RI #60 picked up the ashtray and threw it back at CNA #41. The ashtray did not hit the CNA, but the ashtray did hit another resident, RI #287 on the head and caused injury. It was determined the facility's noncompliance with one or more requirements of participation had cause, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 443.40 Behavioral Health Services. On 03/19/2024 at 6:20 PM, the Administrator and Director of Nursing (DON), were provided a copy of the Immediate Jeopardy Template and notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Behavioral Health at F740-Behavioral Health Services. The immediate jeopardy began on 07/25/2023 and continued until 08/21/2024 when the facility implemented corrective actions to remove the immediacy; thus, immediate jeopardy past noncompliance was cited. The facility failed to manage other residents' behavioral concerns to prevent physical and verbal abuse in instances not rising to the immediate jeopardy level. 2.) Specifically, on 05/24/2023 RI #487, a resident with a history of behaviors had an altercation with a staff member which resulted in RI #487 being verbally abused by a staff member. Following the incident on 05/24/2023, the facility did not review RI #487's care plan to determine whether additional interventions were needed to manage RI #487's behaviors. On 07/01/2023 RI #487 had an altercation with his/her roommate, RI #41, which resulted in a fractured left finger. 3.) On 09/12/2024 RI #339 stabbed his/her roommate RI #3 with a pen causing pain and bleeding and RI #3 had to be transported to the hospital for evaluation. RI #339's care plans did not include the level of supervison required to ensure the safety of RI #339's roommate or other residents in the facility and did not include any focus areas, interventions, approaches, or guidance to staff to address physical aggression, throwing things, night terrors, flashbacks, or sleeplessness. RI #60, RI #487, and RI #339 were three of four residents sampled for behavioral concerns. The facility's failure to manage RI #60's, RI #487's, and RI #339's behaviors resulted in injury of RI #41, RI #287, and RI #3, three of 29 residents sampled. Findings include: Cross-reference F600 A facility policy titled Behavioral Health Care and Services with a review date of 10/24/2022 documented: POLICY Each patient/resident . must receive and the Center must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a patient's whole emotional and mental well-being, . PURPOSE To provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. To provide comprehensive. collaborative, and integrated behavioral health care and services to patients utilizing an interdisciplinary care approach. PRACTICE STANDARDS . 1.2 Ensuring that direct care staff interact and communicate in a manner that promotes mental and psychosocial well being; . 1.4 Providing an environment and atmosphere that is conducive to mental and psychosocial well being; . 1.) RI #60 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnoses to include: Alzheimer's Disease, Dementia with Behavioral Disturbance, Schizoaffective Disorder, Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder. RI #60's annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/06/2023 documented a Brief Interview for Mental Status (BIMS) score of 12 of 15 indicating moderate cognitive impairment. RI #60's care plan with a focus area of . exhibits verbal behaviors related to: History of verbal outbursts directed toward others. history of cursing staff and other residents. had an initiated date of 06/26/2018 and a revision date of 03/09/2022 and included interventions initiated on 06/26/2018 that guided all staff to . Remove resident/patient from environment, if needed. Gently guide the resident from the environment while speaking in a calm, reassuring voice. RI #60's progress notes contained an entry dated 07/25/2023 at 9:25 AM signed by Licensed Practical Nurse (LPN) #27 as follows: . Called to smoke porch . it was alleged . (RI #60) had thrown (an) ash tray at a staff member and it hit (RI #287) on the right side of (his/her)head and ear . (he/she) continue to curse at staff and was place on one on one and was in (his/her) room. (RI #60) came out of the room again was cursing out loud at unseen people, the DON tried to assist (RI #60) back to (his/her) room with the assisted cna, (RI #60) left the room again and the cna was following (him/her) at this time (he/she) was uneasy to redirect, the DON was trying to (assist) (RI #60) back to (his/her) room, . assisted to the shower by the cna then (he/she) (cursed) her out and told her to get out and don't come back . On 03/11/2025 at 3:51 PM LPN #27 was asked about RI #60's behavior. LPN #27 said, RI #60 would curse at staff and called people names. LPN #27 said, at the time of the incident staff reported that RI #60 threw an ashtray at CNA #41, but they discovered that CNA #41 was the one that threw the ashtray first. LPN #27 said, RI #60 did talk to people not present and might have been talking to the voices in his/her head. LPN #27 said, if RI #60 was talking to the staff member on the porch and calling her names, she should have brought RI #60 inside. LPN #27 said, she triggered him/her. LPN #27 said, CNA #41 had worked with RI #60 before and knew how to deal with RI #60's behaviors, she was a seasoned CNA and knew how to deal with aggressive residents. LPN #27 said, CNA #41 was familiar with RI #60's behaviors and knew how to approach RI #60. LPN #27 said, CNA #41 throwing the ashtray at RI #60 was mental abuse and she triggered RI #60's behavior, and it would have made RI #60 feel upset and angry. On 03/18/2025 at 10:15 AM an interview was held with CNA #40. CNA #40 said someone in the situation of being confronted by a caregiver who had thrown an ashtray would cause fear and most likely increase agitation. CNA #40 said RI #60 was known to exhibit behaviors, including cursing at staff. CNA #40 said, everyone knew to ignore those behaviors. CNA #40 said, the protocol was to walk away, ignore the behavior, and report it to the nurse. On 03/05/2025 at 3:45 PM the Nurse Educator/Registered Nurse (RN) #18 was asked about the incident on 07/25/2023 with RI #60. RN #18 said, the staff should have walked away if they were getting upset and certainly should not have acted aggressive back toward the resident and thrown anything. RN #18 said, it was not an appropriate way to respond. RN #18 said, the harm was potential for physical injury to the resident or anyone around. RN #18 said the staff was aggravating the situation and made it worse by escalating the behavior and overall situation. RN #18 said, it would frighten the resident and make them more upset if they were already agitated. RN #18 said, an employee who was feeling frustrated with a resident should tell their supervisor they are feeling burned out and ask for a reassignment. On 03/17/2025, at 4:15 PM, an interview was held with the Administrator (ADM). During the interview, the ADM was questioned about the incident involving RI #60 and CNA #41. The ADM indicated that the report was substantiated as mistreatment and CNA #41 intended to strike RI #60 by throwing an ashtray. The ADM said, it was an inappropriate response to the resident's behavior and if staff witnessed another staff member throw an ashtray at a resident they should act to protect the resident at all times and report the incident immediately. On 03/18/2025 at 10:49 AM an interview with the Former Administrator (FADM) was conducted. During the interview, the FADM was questioned about what occurred prior to the incident, the FADM said, from what she recalled RI #60 had been cursing CNA #41 who became upset and reacted by throwing the ashtray. When asked how staff should respond in a situation when a resident was exhibiting aggressive behavior, the FADM said, staff should report the aggressive behavior to the unit manager. The FADM said, staff failed to report to the unit manager. The FADM said, staff failed to report to the unit manager. The FADM said someone could get hurt when staff became upset and responded by throwing an ashtray at a resident. *********************************************** The facility took immediate action to correct the noncompliance including: 07/25/2023, immediately brought into facility and placed on 1:1 with supervisor until sent out for psych evaluation 07/25/2023 - Body audits completed on both residents 07/25/2023 - Report made to ADPH 07/25/2023 - Police report filed with police department 07/25/2023 - Investigation initiated 07/25/2023 - Care Plans updated 07/26/2023 2nd report to ADPH 07/26/2023 - RI #60 seen by provider - medications adjusted for agitation 07/26/2023 - RI #287 assessed by provider - noted as stable 07/27/2023- CNA #41 was suspended 07/29/2023- CNA #39 was suspended 07/30/2023 - Interview: residents to rule out abuse and with staff members to ensure no unreported abuse 07/31/2023 - RI #60 seen by IBH provider - no behaviors noted; continues on IBH monthly 08/01/2023 - 100 percent of body audits completed - no concerns noted 08/01/2023-CNA #40 was suspended and terminated 08/02/2023- CNA #41 and #39 were terminated 08/08/2023- All staff educated on Behavior Management Education. 08/15/2023 - Monitoring behaviors and abuse through QAPI process 08/21/2023 - All staff educated on abuse and reporting abuse - completed by local ombudsman ********************************************************* 2) RI #487 was admitted to the facility on [DATE] with a diagnosis to include Vascular Dementia with Behavioral Disturbance, Mood Disorder Due to Known Physiological Disorder with Depressive Features, Adjustment Disorder with Depressed Mood. A review of RI #487's Annual MDS with an ARD of 3/30/2023 documented a score of 14 of 15 on the BIMS which indicated RI #487 was cognitively intact. Section E0200 Behavioral Symptoms- Presence and Frequency was coded 2 for Verbal behaviors symptoms directed towards others (e.g. threatening others, screaming at others, cursing at others. Section D0100 Resident Mood Interview documented feeling down, depressed or hopeless 7 out of 11 days in the past two weeks of this assessment period. A review of RI #487's Comprehensive Behavior Care Plans included a Focus of . (RI #487) exhibits or has the potential to exhibit verbal behaviors related to cognitive loss/Dementia. (RI #487) as a history of verbal outburst. (He/She) is easily frustrated. (He/She) gets agitated, yells out, and curses because (he/she) wants to go home . Date Initiated: 07/12/2019 . Revision on: 10/04/2022 . Interventions . Social Services visits to provide support as needed, and/or as requested . On 05/24/2023 at 10:52 AM the State Agency received a FRI alleging verbal abuse involving RI #487, RI #488, and a Dietary Aide (DA) #49 occurred when it was reported that DA #49 told both these residents he would whip their ass. On 05/24/2023 a hand written document from Dietary Manager Assistant (DMA) documented, On this day (05/24/23) RI #487 came to me about not getting a grill cheese sandwich. I turns (RI 487) curse me calling me the (B) work. I (DMA) said you don't have to say all of that . (RI # 487) said yes (B) cause you can't read I (DMA) just fixed the toast and gave it to him/her ( RI #487) and went on my way . A review of RI #487's behavior monitoring document revealed RI #487 exhibited behaviors nine out of 31 days in May 2023. Further review of RI #487's Comprehensive Care Plan including behavioral care plans indicated no updates were made after the incident on 05/24/2023. On 07/01/2023 at 10:05 AM, the State Agency received a Facility Reported Incident (FRI) that documented . Roommates (RI #487) and (RI #41) had an argument and (RI #487) bent (RI #41)'s finger Was there serious bodily injury? Yes . The facility immediately separated the residents, assessed for injuries, made notifications, and initiated an investigation. A review of a hospital record date 07/1/2023 of RI #41 documented, . Reason for Admission: ASSAULT . A review of a hospital X- Ray record of RI #41's Left hand documented, Significant Findings . Impression: Acute fracture of the ring finger . A review of the facility's final summary dated 07/03/2023 documented . Complaint: (RI #487) became angry because (he/she) said (RI #41) yelled at (him/her) for turning on a TV and waking (him/her) up (RI #487) walked over to (RI #41's) side of the room, where (RI #41) was in the bed, and hit (him/her) on the fist with (his/her) fist and twisted (RI #41's) left hand . The document stated the incident was not witnessed; however, staff heard an argument in the room prior to the incident. A review of the Integrated Behavioral Health (IBH) documentation indicated that Resident RI #487 was seen on 03/06/2023, for a follow-up concerning agitation and depression. The records indicated that RI #487 exhibited irritability and was uncooperative with staff. On 04/24/2023, RI #487 was again seen by IBH for a follow-up regarding the same issues of agitation and depression. The resident continued to display signs of agitation, used excessive profanity, and remained uncooperative with the staff. On 05/11/2023, IBH conducted another follow-up for RI #487 concerning agitation and depression. During this visit, RI #487 expressed frustration with his/her stay at the facility, used profanity, and reported experiencing poor sleep due to noise disturbances from his/her roommate. On 03/06/2025 at 11:55AM the Social Services Assistant (SSA) #19. The SSA said RI #487 had behaviors that included verbal and physical aggression. The SSA said RI #487's became physically aggressive when he/she got to a point of anger. The SSA said RI #487 exhibited verbal aggression almost daily that included cursing, and he/she had an angry personality in general. When asked what would provoke RI #487, the SSA said it would have to be a situation that got him/her fired up and start to curse; he/she was easily angered. The SSA said interventions included for staff would try to redirect him/her and he/she was a smoker so staff would try to take him to smoke. The SSA said staff should redirect, calm, and remove from RI #487 the situation. The SSA said she vaguely remembered RI #487's behavioral incident on 05/24/2023 when RI #487 went into the kitchen, asked for a grilled cheese, and got into an argument with staff. The SSA said the incident should have been documented in RI #487's care plan and nurses' notes, but she did not see it documented in the nursing notes or the care plan. The SSA did not see any specific interventions following the incident in May 2023. The SSA said it was important to document incidents so staff would know how to handle his/her care and what may trigger him/her. The SSA said knowing how to handle resident's care and potential triggers was important so staff could avoid potential future situations that may impact a resident. The documentation would also support the need to send the resident for inpatient services. The SSA said RI #487's care plan was not updated following the 05/24/2023 incident, but it should have been, and she did not know why it was not. The SSA said had the incident on 05/24/2023 been documented appropriately it could have possibly prevented the incident on 07/01/2023. The SSA said not communicating or documenting behaviors could lead to other behaviors and aggression that may impact residents. The SSA added, when new staff came in they need to be aware of the resident behaviors for protection of all. On 03/14/2025 at 11:53 AM an interview was conducted with the Social Worker (SW) #17. The SW said RI #487 had care plans for verbal and physical behaviors. The SW said she was not aware of RI #487 being involved in the incident on 05/24/2023 and was only aware of the incident that occurred on 07/01/2023. The SW said she was not aware of any prior altercations between RI #487 and RI #41. The SW said the unit managers should let her know if there were any concerns. The SW said if she had been made aware and the facility was unable to come up with a resolution then a room change would be initiated. The SW said a room change was not offered until after the 07/01/2023 incident. ***************************************** The facility took immediate action to correct the noncompliance including: 07/01/2023- RI #487 immediately placed on 1:1 Observation 07/01/2023 - RI #487 sent out to Hospital for Psychiatric Evaluation 07/01/2023 - X-Ray of RI #41's finger obtained 07/01/2023 - Body Audits to both residents 07/01/2023 through 07/04/2023 - Interviews with Staff and Residents 07/03/2023 - Interview with RI #41 07/04/2023 - Interview with RI #487 06/24/2023 - Review Care Plans for both Residents 07/15/2023 - QAPI 08/15/2023 - Behavior Antipsychotic Review 07/04/2023 - Room change upon RI #487's return from the hospital 315A 06/05/2023, 06/23/2023, 07/01/2023, and 7/31/2023 RI #487 was seen by IBH Provider 08/15/2023 - Monitoring behaviors and abuse through QAPI process 08/21/2023 - All staff educated on abuse and reporting abuse - completed by local ombudsman May 2023 until 09/26/2023 RI #487 remained on Behavior Monitoring until discharge 09/26/2023 RI #487 continued being followed by psychiatric services until discharged on [DATE]. 09/26/2023 - RI #487 discharged home. It was recommended on discharge that resident continue IBH services. ******************************************* After review of documentation supporting the above corrective actions, including the facility's investigation file, in-service/education records, QAPI documentation, and staff interviews, the survey team verified the facility implemented corrective actions including ongoing monitoring from May 2023 to 09/26/2023, and past non-compliance was cited. 29671 3.) On 09/13/2024 the State Agency received a FRI alleging physical abuse occurred the day before on 09/12/2024 at 10:45 PM when RI #339 stabbed RI #3 in the left hand with an ink pen causing a gash, the residents were separated, and Emergency Medical Services (EMS) were requested and the Police were notified. RI #3 was readmitted to the facility on [DATE] and had diagnoses to include: Vascular Dementia. RI #3's admission MDS assessment with an ARD of 07/19/2024 documented long and short term memory problems and moderately impaired cognition. RI #339 was admitted to the facility on [DATE] with diagnoses to include Depression and Post-Traumatic Stress Disorder. RI #339's quarterly MDS assessment with an ARD of 07/17/2024 documented a BIMS score of 15 out of 15 indicating intact cognition. Further review of RI #339's medical record revealed comprehensive care plans and progress notes describing some of RI #339's behaviors leading up to the incident on 09/12/2024. RI #339 had a care plan initiated 08/15/2024 to address the focus area of exhibiting verbal behaviors, history of verbal outbursts directed at others, use of abusive language, pattern of challenging/confrontational verbal behavior. RI #339's care plans did not include any focus areas, interventions, approaches, or guidance to staff to address physical aggression, throwing things, night terrors, flashbacks, or sleeplessness; and did not address the level of supervision required to ensure RI #339's roommate and other residents were safe in the facility. RI #339's progress notes included documented behaviors as follows: 07/02/2024 Resident has had increased yelling and cursing staff members. Refusing medications at times, refusing . care . 08/19/2024 Resident threw (his/her) phone at CNA . Gave the unit manager the middle finger and said f@@k you. 09/03/2024 Hell no I'm not taking a shower. 09/12/2024 at 11:31 AM .up in (wheelchair) .stated, (roommate) took my remote. cursing this writer and another resident in the hallway. Attempts to redirect (RI #339) are unsuccessful. 09/12/2024 at 9:09 PM Resident refused to go to bed after telling the CNA (he/she) was ready to go to bed. Cursed and yelled at the CNA and then went back outside. The behavior documented at 9:09 PM occurred less than two hours prior to RI #3 being stabbed with the pen. RI #339's IBH note dated 08/23/2024 documented: Reason for Appointment 1. Initial encounter for psychiatric evaluation for medication management . Caregivers report that patient threw a phone across (his/her) room. frequent episodes of cursing at staff. patient stays awake late at night . (RI #339) Endorses some irritability (related to) living in the facility. (He/she) states that (his/her) cellphone wasn't working, and (he/she) did throw it across (his/her) room. (He/she) states that (he/she) got in a fuss with some people this morning, just messing with me. Reports trouble staying asleep at night, . Endorses night terrors . flashbacks . terrors are through my lens shooting people. Assessments 1. Post-traumatic stress disorder . 2. Depression . RI #339's IBH report dated 09/06/2024 documented: Reason for Appointment 1. (follow-up) for depression and PTSD . Describes mood as irritable. Endorses irritability due to not sleeping well at night. Endorses nightmares of past combat . no longer nightly. monitor for improvement in night terrors. IBH reports recommended treatment should include non-pharmacological interventions and coping strategies, but the reports did not specify any examples or discussion of these with RI #339. The facility investigative file contained a form titled, INVESTIGATION REPORT for RI #3 dated 09/14/2024 which documented on 09/12/2024 Licensed Practical Nurse (LPN) #38 called and reported to the Administrator (ADM) and Director of Nurses (DON) that RI #339 stabbed RI #3 in the left hand. A Conclusion to the report documented: . the facility completed an investigation and there is sufficient evidence to substantiate an allegation of physical abuse (Resident to Resident). (RI #3) transferred to the hospital on 9/12/24 for evaluation of (his/her) left hand. (RI #3) is monitored for any psychosocial changes. (RI #339) transferred to three different hospitals on 09/13/24. After the incident, the residents were separated as roommates. The facility staff was also reeducated on abuse reporting and reporting any roommate incompatibility. On 03/02/2025 at 3:50 PM an interview was conducted with RI #3. RI #3 stated, RI #339 was his/her roommate and would yell out at times. RI #3 stated, on 09/12/2023 RI #339 stabbed his/her hand and he/she was sent to the hospital and required three stitches. RI #3 further stated that he/she tried to defend himself/herself from the roommate. RI #3 stated his/her hand was hurt and bleeding. RI #3 stated, at the time of the incident he was scared. The facility investigative file contained a handwritten statement signed by RI #339 dated 09/12/2024 which documented: . (RI #3), my roommate said something about a phone charger while we were on the smoking patio earlier today. I looked for my notepad and my remote control. They were missing. After we came from the smoking patio, I got (RI #3's) phone and charger out of the garbage can and threw both of them at (him/her). I accused (RI #3) of stealing my stuff. I told (him/her) I will kill (him/he) if (he/she) goes through my stuff. (RI #3) rolled (his/her) wheelchair towards me and I stabbed (him/her) in the hand. On 03/07/2025 at 9:33 AM Social Services Assistant (SSA) #19 said, she was aware that occasionally RI #3 and RI #339 would have a disagreement. SSA #19 said, RI #339 had diagnoses to include PTSD, Depression, and was seen by IBH/psychiatric on 08/23/2024 and 09/06/2024 because behaviors were getting worse, he/she was cursing more and refusing treatment. **************************************************************************** The facility took immediate action to correct the noncompliance including: 09/12/2024- Separated the residents 09/12/2024- One on One observation with RI #339; RI #339 sent to inpatient psych services for evaluation. 09/12/2024- RI #339 did not return to facility after this incident. 09/12/2024- Body Audit Completed 09/12/2024- Police Notified 09/12/2024- Sent RI #3 to ER for evaluation 09/12/2024-Investigation initiated/Reported to ADPH/Ombudsman 09/13/2024- Employees Training on Abuse Policy Education, Roommate Incompatibility, Early Identification of residents concerns. Roommate Incompatibility reviewed on 09/13/2024 conducted by IDT during Stand up. Roommate Incompatibility monitoring continued weekly during the Partner Round program. 09/17/2024 - Employee Training on Behavior Management 09/23/2024- ADHOC QAPI-Completed 10/04/2024-Town Hall Meeting with all Staff. After review of documentation supporting the above corrective actions, including the facility's investigation file, in-service/education records, QAPI documentation, and staff interviews, the survey team verified the facility implemented corrective actions including ongoing monitoring from 09/12/2024 to 10/04/2024 and past non-compliance was cited.

Based on interviews, resident record review, review of facility policies titled Cardiac and/or Respiratory Arrest and Emergency Cart, and review of the Adult Basic Life Support Algorithm for Healthcare Providers provided by the American Heart Association, the facility failed to ensure staff provided cardiopulmonary resuscitation (CPR) to Resident Identifier (RI) #1 on [DATE] in accordance with the American Heart Association (AHA) recommendations and facility policy. On [DATE], RI #1 was found unresponsive by Employee Identifier (EI) #10, a Certified Nursing Assistant (CNA). EI #10 notified EI #6, the Registered Nurse (RN) on duty who was responsible for the care of RI #1. EI #6 assessed RI #1 to have no pulse and no respirations, then called 911 and initiated a code (A code is typically called when cardiopulmonary arrest is happening to a patient in a hospital or clinic, requiring a team of providers (sometimes called a code team) to rush to the specific location and begin immediate resuscitative efforts). During the code, the emergency cart on the Rehab Hall where RI #1 resided, could not be located. Instead, an emergency cart from the West Hall was brought to RI #1's room; however, there was not an Ambu bag (a handheld tool that is used to deliver positive pressure ventilation to any subject with insufficient or ineffective breaths. It consists of a self-inflating bag, one-way valve, mask, and an oxygen reservoir) on the cart. RI #1 did not receive any rescue breaths, only chest compressions. After Emergency Medical Services (EMS) arrived to the facility, they confirmed the resident had no heartbeat and RI #1 was pronounced dead on the scene at 5:14 AM. This deficient practice affected RI #1, one of three sampled residents reviewed for the provision of CPR, and placed RI #1 and all other 89 residents in the facility with a Full Code Status in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment, or death. Findings Include: A review of the American Heart Association's Adult Basic Life Support Algorithm for Healthcare Providers, copyright 2020, revealed the following: Adult Basic Life Support Algorithm for Healthcare Providers . * Check for responsiveness. * Shout for nearby help . * Get .emergency equipment (or send someone to do so) . No breathing . pulse not felt . Start CPR * Perform cycles of 30 compressions (chest) and 2 breaths. The facility policy titled Emergency Cart, with a revision date of [DATE], documented: .PRACTICE STANDARDS . 1. The emergency cart is stored in a location where it is readily accessible . 3.1 Equipment/supplies used are noted and replaced promptly. 4. The emergency cart is checked every 24 hours and after every use. Missing or expired items are replaced . The facility policy titled Cardiac and/or Respiratory Arrest , with a revision date of [DATE], documented: .2. Witnessed Arrest: 2.1 If there is no visual identification of DNR (do not resuscitate) status or no DNR order on the patient's medical record (meaning they have a FULL CODE status): 2.1.1 CPR .certified staff will initiate CPR . 2.1.2 Call 911 . 2.1.4 Continue CPR until one of the following occurs: . 2.1.4.3 Care is transferred to a team providing advanced life support (emergency medical services (EMS) . RI #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #1 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #1's Progress Notes documented the following: . [DATE] . Informed by CNA that resident was unresponsive, at 5am. Checked resident for response none noted. Call code blue and called EMS . Review of RI #1's CPR/AED (Automated External Defibrillator) FLOW SHEET, dated [DATE], documented the following: . Arrest recognized by (Employee Identifier (EI) #10's name, Certified Nursing Assistant (CNA)) . Ventilations initiated by: Patient placed on O2 (oxygen) via nasal cannula . Compressions initiated by (EI #9's name, Licensed Practical Nurse (LPN)) . 911 called by (EI #6's name, Registered Nurse (RN)) . Patient left via: . Funeral Home (checked) . This flow sheet indicated EI #6, the RN, was the recorder and EI #s 9 and 11, LPNs, performed CPR during the code called for RI #1 on [DATE]. Review of the EMS run report dated [DATE] revealed EMS was dispatched on [DATE] at 4:58 AM due to cardiac arrest/death. EMS arrived at RI #1's bedside at 5:10 AM. The run report documented RI #1 was not breathing and pulseless. EMS staff confirmed RI #1 had no heartbeat, and the time of death was called at 5:14 AM. An interview was conducted on [DATE] at 6:54 AM with EI #10, the CNA assigned to care for RI #1 during the nightshift on ,d+[DATE]-[DATE]. EI #10 said she checked on RI #1 sometime between 4:00 AM and 5:00 AM, but could not pinpoint an exact time. EI #10 said, while checking on RI #1, RI #1 was not responding to her, and indicated RI #1's stomach was initially rising and falling, but then stopped. EI #10 said she immediately went to get EI #6, the RN, who responded to RI #1's room within seconds. EI #10 said EI #6 assessed RI #1 and found that he/she had no respirations, and EI #6 then left the room to call 911 and to initiate a code. EI #10 said as EI #6 was leaving the room to do that, EI #9, an LPN entered the room. EI #10 said she assisted EI #9 in preparing RI #1 for CPR by removing the sheet and positioning the bed. EI #10 said EI #11, another LPN, also responded and brought the emergency cart from the West Hall. EI #10 said once the nurses were in the room and attending to RI #1, she left the room. EI #10 said as she left, she saw that EI #9 was doing chest compressions on RI #1. An interview was conducted with EI #6, RN on [DATE] at 6:50 PM. EI #6 was asked, what he could recall about RI #1 on [DATE]. EI #6 replied, EI #10, CNA, informed him sometime around 4:45 AM that RI #1 was unresponsive. EI #6 indicated he went into the room where he observed the resident was not breathing. EI #6 further indicated RI #1 was unresponsive and there was no pulse. EI #6 said he then left the room to call a code using the intercom at the nurses station and called 911 before returning to the resident's room. EI #6 said, when he got back to RI #1's room, EI #9, LPN, had already started CPR chest compressions. A phone interview was conducted on [DATE] at 9:50 AM with EI #9, LPN. EI #9 said she was getting ready for medication pass on [DATE] sometime between late 4:00 AM and early 5:00 AM, and heard EI #6 yelling in the hall that RI #1 was unresponsive. EI #9 said she responded to the room, lowered RI #1's bed, checked for a pulse and started CPR. When asked the procedure for CPR, EI #9 said administer 30 compressions, then two breaths with an Ambu bag, then check for a pulse, and start again. EI #9 explained she was unable to locate the emergency cart for RI #1's hall during the code (Rehab Hall), but a nurse from the West Hall brought the emergency cart from that hall. However, they could not locate an Ambu bag. EI #9 was asked who was responsible for checking the emergency carts to make sure they were stocked with the necessary supplies. EI #9 replied, it was the nurses' responsibility. EI #9 indicated an Ambu bag should be available during every code. When asked what the risk was of not having a fully stocked emergency cart during an emergency code, EI #9 replied, the person might not get the help they need and they could die. During a follow-up interview with EI #9 on [DATE] at 4:45 PM, EI #9 said she began compressions for RI #1 around 4:50 AM or 5:00 AM, and continued until EI #7 and EI #11, both LPNs, responded to the room approximately a minute and a half to two minutes later, and they started taking turns doing compressions. When asked who was attending to RI #1's airway/providing breaths, EI #9 said they did not have an Ambu bag to do the airway. EI #9 said they also could have provided breaths via mouth to mouth if they had a mouthpiece, but they did not. EI #9 indicated as soon as she was relieved of doing compressions by EI #7 and EI #11, she went to look for an Ambu bag, but that was when she could not find the emergency cart for the Rehab Hall, and they could not locate an Ambu bag on the emergency cart brought from the West Hall. On [DATE] at 7:10 AM EI #11, LPN, said she assisted with RI #1's code on [DATE]. EI #11 was asked what she could recall about the incident. EI #11 said, they called a code and she grabbed her emergency cart and responded to RI #1's room. She said when she arrived to the room, EI #9 was already doing compressions, and she grabbed her back board, and they placed it under RI #1. EI #11 said she then placed a nasal cannula on RI #1 and attached it to the oxygen concentrator, and then took turns with EI #9 providing chest compressions. When asked who was doing airway/providing breaths, EI #11 said, they did not have an Ambu bag on her cart so no one was doing airway. On [DATE] at 8:13 AM EI #7, LPN, was asked what kind of care she provided for RI #1 on [DATE]. EI #7 said she responded to the code for RI #1 and checked vitals using the vital machine. EI #7 said she then joined EI #9 and EI #11, and assisted with doing chest compressions. When asked who was doing airway/providing breaths, EI #7 said she did not know of anyone doing airway for RI #1. When asked why not, EI #7 said, there was no Ambu bag. EI #7 said it was important for the Ambu bag to be on the emergency cart because without one, you cannot provide breaths unless you do mouth to mouth. During a follow-up interview on [DATE] at 5:50 PM, EI #7 said during the code, they should have had an Ambu bag or a mouth piece to provide breaths. EI #7 said it was not correct to provide CPR with compressions only and no breaths, since both should have been done. EI #7 said the problem with the code for RI #1 was the emergency cart not having the necessary supplies. A review of [DATE] and [DATE] Rehab Hall (where RI #1 resided) Emergency Cart Checklist revealed that staff were supposed to check for missing or expired items on the emergency cart, replace them, then initial the checklist. No one initialed as checking the emergency cart for the Rehab Hall on [DATE]-5, ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] or [DATE]-26. The last time a staff member checked the emergency cart for the Rehab Hall prior to RI #1's code on [DATE] was [DATE]. A review of the [DATE] West Hall Emergency Cart Checklist revealed staff checked off and initialed that an Ambu bag was present on both [DATE] and [DATE]. On [DATE] at 6:36 AM, a follow up interview was conducted with EI #6. EI #6 was asked what he recalled about an Ambu bag during RI #1's code. EI #6 confirmed he had not not seen one, and indicated no one provided breaths to RI #1 during the code, just continuous chest compressions until EMS arrived on scene. EI #6 was asked where the Ambu bag should have been located. EI #6 said every unit's emergency cart should have an Ambu bag on it, but they could not find one during RI #1's code. An interview was conducted on [DATE] at 10:21 AM with EI #2, Certified Nursing Executive (CNE)/Director of Nursing (DON). EI #2 was asked if CPR should be done with an Ambu bag. EI #2 replied, yes. EI #2 was asked, what was the risk of not having an Ambu bag during CPR. EI #2 replied, not doing respirations/providing breaths. EI #2 was asked, who was responsible for checking supplies on the emergency carts. EI #2 replied, night shift nurses. EI #2 was asked, what was the risk of the emergency cart not being checked daily. EI #2 replied, nurses may not have items that were needed. EI #2 was asked why no breaths were given during the code for RI #1. EI #2 replied, they did not have an Ambu bag. When asked why there was not an Ambu bag on the emergency cart, EI #2 replied, she did not know. A follow-up interview was conducted on [DATE] at 5:37 PM with EI #2. EI #2 was asked, why was the policy not followed on the code for RI #1. EI #2 replied, the emergency cart on the Rehab Hall was not readily available, and when EI #11 brought the emergency cart from the West Hall it did not have an Ambu bag on it. *********** On [DATE], the facility began reviewing and addressing the concerns with the facility's response to RI #1's code. Concerns identified by the facility included: . Rehab Emergency Cart not located during a code that occurred on [DATE] . The West Wing Emergency Cart did not have an Ambu bag on it . There were blanks noted on the Rehab Cart Checklist to ensure that all supplies were present . The Cardiac and/or Respiratory Arrest Policy was not fully followed . The following corrective actions were implemented by the facility: - Audit of CPR Certification for all Licensed Nurses done by EI #3, Workforce Manager. Audit began on [DATE] and was completed on [DATE]. - Weekly Medical Director/DON Meeting held on [DATE]. - Facility will initiate Mock Code within the next week and continue with Mock Code Training until one Mock Code is done on each shift. This was initiated on [DATE]. - The Rehab Emergency Cart was located and checked by EI #2, RN/DON, to ensure all supplies were on the cart. The Cart Checklist was signed by EI #2, RN/DON, that all items were present on the cart. - The Rehab Emergency Cart was placed in a designated area by EI #2, RN/DON, across from the nursing station by the water fountain, and is to be kept in that location when not in use. These was completed on [DATE]. - Monitor Sheet began on [DATE] to monitor the placement of the Emergency Carts twice weekly by the Unit Managers/DON. - An Ambu Bag was retrieved from Central Supply by EI #2, RN/DON, and placed on the West Wing Emergency Cart on [DATE]. One Ambu Bag was taken from Central Supply leaving 3 additional Ambu Bags left in Central Supply. This was completed on [DATE]. - The Rehab Cart was audited to ensure all supplies were on the cart and the Emergency Cart Checklist was signed by EI #2, RN/DON, on [DATE]. Monitor sheet was initiated on [DATE] for the Unit Managers/DON to check twice weekly to ensure that the Emergency Cart Checklist was being signed off on by the Charge Nurses. - An In-service was initiated by EI #2, RN/DON, on [DATE] for Licensed Nurses on the Cardiac and/or Respiratory Arrest Policy, Designated placement of the Emergency Crash Carts, Emergency Cart Checklist, AED, CPR, Flow Sheet, Do not leave an unresponsive resident, Designate an individual to record on the AED/Code flow sheet, designate an individual to call 911, restock the crash cart and check it off on the checklist when it has been restocked. In-servicing began on [DATE] and was completed on [DATE]. - In-servicing began on [DATE] ending on [DATE] educating Nursing assistants to call out for help if they find a resident unresponsive and to not leave that resident until a nurse arrives and directs them to do other duties. Education done by EI #2, RN/DON, and EI #19, RN/ Assistant Director of Nursing (ADON). After review of documentation supporting the above corrective actions, including inservice records, mock code documentation, staff interviews, and observations of the facility's emergency carts, the survey team verified the facility had implemented corrective actions from [DATE] through [DATE] and had ongoing monitoring systems in place; thus immediate jeopardy past noncompliance was cited. This deficiency was cited as a result of complaint/report number AL 885.

Based on interviews and review of Resident Identifier (RI) #52's medical record, the facility failed to notify the physician of bruising on RI #52's inner right groin area in a timely manner. On 1/4/2018, it was documented RI #52 had bruising on the right inner groin area, that continued to spread. Five days later, on 1/9/2018, the bruising was reported to the physician, at which time he ordered X-rays that revealed a fractured femur. This affected RI #52, one of one sampled residents reviewed for notification. Findings include: RI #52 was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. RI #52 has a medical history to include: Joint Stiffness, Abnormal Posture, [MEDICAL CONDITION] and Muscle Weakness. The Magnolia Ridge Progress Notes for RI #52 documented: . 1/4/2018 17:13 (5:13 PM) . bruising noted on (RI #52's) inner right groin area . 1/5/2018 08:46 (8:46 AM) . Bruising still noted to right groin area . 1/8/2018 12:04 (12:04 PM) . pt (patient) has yellow bruising to R (right) thigh . 1/9/2018 10:22 (10:22 AM) . bruising appears to have spread on the inner right groin and buttock area, (doctor) notified, will obtain xrays of the pelvis and bilateral hips to r/o (rule out) any fractures . 1/9/2018 12:08 (12:08 PM) . Requested by bath team to check upper inner thighs. purplish in color. Dr. (EI #11) in to assess. X-rays ordered . RI #52's X-ray report of the bilateral hips dated 1/9/2018, revealed an acute [MEDICAL CONDITION] right femur. In a telephone interview on 1/31/2018 at 5:20 PM, Employee Identifier (EI) #11, RI #52's Attending/Primary Physician was asked, when was the first time he was made aware by facility staff of bruising to RI #52's groin and thigh area. EI #11 answered, the first time he was aware was the day the fracture was found (1/9/2018). During an interview on 2/1/2018 at 9:45 AM, EI #9, a Licensed Practical Nurse (LPN) stated she was off for the Christmas holiday and returned to work on 1/2/2018. EI #9 was asked was she told RI #52 had bruising when she returned to work on 1/2/2018. EI #9 said, no ma'am not at that time. When asked when she first was made aware of bruising on RI #52, EI #9 explained that on 1/4/2018 she was called into the shower room and it was bought to her attention. EI #9 stated the purplish blue in color bruising was on RI #52's right inner thigh, from the front perineal area, pelvic area to the buttocks. EI #9 said she told the unit manager, EI #10, and she thought EI #10 notified the doctor. In a follow-up telephone interview on 2/1/2018 at 5:35 PM, EI #11, RI #52's Attending/Primary Physician was asked when did he observe bruising on RI #52. EI #11 said he came to see the resident the day the X-ray was ordered (1/9/2018). According to EI #11, he asked EI #10 (Unit Manager) via text how RI #52 got the bruise on the perineal and right leg but got no answer. EI #11 was asked to verify that he did not know about RI #52's bruising in the perineal area until 1/9/2018. EI #11 stated, That is my recollection. This deficiency was cited as a result of the investigation of complaint/report number AL 547.

Based on interviews, review of Resident Identifier (RI) #52's medical record, the RMS (Risk Management System) Event Summary Report, FUNDAMENTALS OF NURSING and RI #52's emergency room (ER) record, the facility failed to develop individualized care plans with resident centered interventions on the level of staff assistance needed when the staff provided a bath to RI #52, a resident with spastic-type movements who required the use of wedges/positioning devices. During the provision of a bed bath on 12/30/2017, positioning devices were not utilized and the resident slid off the bed and sustained a laceration to the head and a skin tear to the arm. This deficient practice affected RI #52, one of two sampled residents whose care plans were reviewed. Findings included: Page 241 of Chapter 18 titled Planning Nursing Care of FUNDAMENTALS OF NURSING with a copyright date of 2017, documented . Planning requires critical thinking applied through deliberate decision making and problem solving. Perhaps the most important principle to learn about planning is the need to individualize a plan of care for a patient's unique needs. This requires communicating closely with patients, their families and the health care team and ongoing consultation with team members. The nursing [DIAGNOSES REDACTED]. RI #52 was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. RI #52 has a medical history to include: Joint Stiffness, Abnormal Posture, [MEDICAL CONDITION] and Muscle Weakness. RI #52's Minimum Data Set (MDS) with an assessment reference date of 12/28/2017, revealed RI #52 was severely impaired cognitive skills for daily decision making. RI #52 was assessed as requiring extensive assistance for all Activities of Daily Living (ADLs), with the exception of walking in room and corridor, which did not occur and bathing as this task did not occur during this assessment period. The MDS indicated RI #52 had functional limitations in range of motion on both sides in the upper and lower extremities. There were no individualized interventions or instructions for using positioning devices (i.e. wedges, pillows) when RI #52 had spastic-type movement on RI #52's FALL: Resident is at risk for falls: Advanced dementia. Contractures upper and lower ext (extremities), Dependent with daily needs. Impaired mobility care plan that was initiated on 4/12/2017, and revised on 10/23/2017. There were no individualized interventions or instructions on how to position RI #52 when in bed, how to bathe RI #52 when in bed, or the number of staff needed to safely provide RI #52 a bath when in bed on RI #52's ADL's . care plan that was initiated on 4/12/2017 and last revised 10/23/2017. The RMS Event Summary Report for RI #52 revealed on 12/30/2017 at 9:15 AM, . CNA reports that while she was cleaning resident up for AM (morning) care she went into the bathroom to get a wash cloth the resident started sliding off the side of the bed. CNA states that she had to put the lower part of (RI #52's) body back in bed and that what caused the skin tear to (RI #52's) left arm . Daughter request resident be transferred to ER for further evaluation . resident has spastic movements of all 4 extremities, all 4 extremities are severely contracted, . Summary of investigation: Root cause/conclusion: resident health and mental status, staff handling Corrective Actions: . inservice staff on proper handling, 2 person staff assistance The local Hospital's emergency room record revealed on 12/30/2017, RI #52 was seen in the ER with a chief complaint of EMS (Emergency Medical Services) stated pt (patient) was sent here from Magnolia Ridge with lacerations (to) the scalp . RI #52's Magnolia Ridge Progress Notes dated 12/30/2017 6:09 PM, documented . Resident has returned to the facility via ambulance stretcher. Resident has 3 staples in the left side of the top of (his/her) head. (RI #52) has a dressing with zerofoam and kerlix on (his/her) left upper arm . In an interview on 2/1/2018 at 11:40 AM, Employee Identifier (EI) #5, the CNA who provided care to RI #52 on 12/30/2017 when the accident occurred was asked, how often she took care of RI #52. EI #5 replied, on Tuesdays and Thursdays. EI #5 was asked what was on the care plan that would explain what to do for RI #52 for a bed bath. EI #5 said, she never looked at that because RI #52 did not get a bed bath often. During an interview on 2/1/2018 at 12:15 PM, EI #7, a CNA said she used to take care of RI #52 all the time. EI #7 was asked what she did to position RI #52 to make sure the resident was safe. EI #7 said, she made sure the resident was in the middle of the bed and turned to the side. When asked what would happen if RI #52's back was placed in the middle of the bed, EI #7 said, without any support the resident would roll to one side or the other. EI #7 further stated, RI #52 had pillows and wedges used for support. In an interview on 2/1/2018 at 12:20 PM, EI #8, a CNA stated she took care of RI #52 often. When asked what kind of movements RI #52 would make, EI #8 stated, the resident would sometimes jerk a little, like a shiver. EI #8 was asked what was required for positioning RI #52 in bed. EI #8 replied, RI #52 would have a wedge on each side and due to the contractures the resident could not really be positioned on his/her back. When asked what would happen if RI #52 was positioned in the middle of the bed without any support devices, EI #8 said, RI #52 would not stay in that position without the wedges. When asked if RI #52 could support himself/herself, EI #8 said no. On 2/1/2018 at 7:30 PM, an interview was conducted with EI #3, the Registered Nurse (RN) MDS Coordinator. EI #3 was asked what was included on a resident's care plan that described the level of assistance the CNA provided during a bath. EI #3 replied, the care plan was not specific. EI #3 was asked why RI #52's care plan did not include the level of care required for the bath care. EI #3 replied, the nurses could add it to the tasks list. On 2/1/2018, the Magnolia Ridge Task List Report for RI #52 was provided to the State Surveyor. There was no individualized, person centered care interventions or instructions for the CNA staff on the level of assistance RI #52 required for bathing. This deficiency was cited as a result of the investigation of complaint/report number AL 547.

Based on interviews, review of Resident Identifier (RI) #52's medical record, RI #52's emergency room record and the RMS (Resident Management System) Event Summary Report, the facility failed to ensure Employee Identifier (EI) #5, a Certified Nursing Assistant (CNA), had all necessary bath equipment when she provided a bed bath to RI #52, a resident identified as being at risk for falls, on 12/30/2017. EI #5 left the severely contracted resident with spastic movement in all four extremities, unattended and without positioning devices, when she left to get a washcloth. RI #52 slid off the bed and sustained a laceration to the head and a skin tear to the arm. This affected RI #52, one of three sampled residents reviewed for accidents. Findings include: RI #52 was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. RI #52 has a medical history to include: Joint Stiffness, Abnormal Posture, [MEDICAL CONDITION] and Muscle Weakness. RI #52's Minimum Data Set (MDS) with an assessment reference date of 12/28/2017, revealed RI #52 was severely impaired cognitive skills for daily decision making. RI #52 was assessed as requiring extensive assistance for all Activities of Daily Living (ADLs), with the exception of walking in room and corridor, which did not occur and bathing as this task did not occur during this assessment period. The MDS indicated RI #52 had functional limitations in range of motion on both sides in the upper and lower extremities. There were no individualized interventions or instructions for using positioning devices (i.e. wedges, pillows) when RI #52 had spastic-type movement on RI #52's FALL: Resident is at risk for falls: Advanced dementia. Contractures upper and lower ext (extremities), Dependent with daily needs. Impaired mobility care plan that was initiated on 4/12/2017, and revised on 10/23/2017. There were no individualized interventions or instructions on how to position RI #52 when in bed, how to bathe RI #52 when in bed, or the number of staff needed to safely provide RI #52 a bath when in bed on RI #52's ADL's . care plan that was initiated on 4/12/2017 and last revised 10/23/2017. The RMS Event Summary Report for RI #52 revealed on 12/30/2017 at 9:15 AM, . called to Room (RI #52's room) by the CNA, (EI #5), to assess the resident. CNA reports that while she was cleaning resident up for AM (morning) care she went into the bathroom to get a wash cloth the resident started sliding off the side of the bed. CNA states that she had to put the lower part of (RI #52's) body back in bed and that what caused the skin tear to (RI #52's) left arm . Daughter request resident be transferred to ER for further evaluation . resident has spastic movements of all 4 extremities, all 4 extremities are severely contracted, . Activity during incident: resident slid off the bed Was fall related to seating/positioning: Yes Explain: resident slid off the bed . Summary of investigation: Root cause/conclusion: resident health and mental status, staff handling Corrective Actions: . inservice staff on proper handling, 2 person staff assistance In an interview on 1/31/2018 at 8:15 AM, Employee Identifier (EI) #5, the CNA who provided care to RI #52 on 12/30/2017 when the accident occurred was asked, what happened. EI #5 said, she was giving RI #52 a bed bath on the right side of the bed. EI #5 explained that she went to grab a wash cloth from the sink in the bathroom, RI #52 had clinched up both upper and lower extremities, as the resident normally did, so EI #5 placed RI #52 on his/her back in the middle of bed. EI #5 said before she could get to the sink she heard the resident. When asked what she heard, EI #5 replied, a thump and when she turned around RI #52's legs were hanging off the bed and the resident's head was resting on the bed rail that was in the up position on the right side of the bed. EI #5 stated, she placed RI #52's legs back onto the bed and grabbed the resident's arms to position the resident back over in the bed. According to EI #5, RI #52's family had provided pillows to put all around RI #52 to position the resident. In a follow-up interview on 2/1/2018 at 11:40 AM, EI #5 was asked, how often she took care of RI #52. EI #5 replied, on Tuesdays and Thursdays. EI #5 was asked what was on the care plan that would explain what to do for RI #52 for a bed bath. EI #5 said, she never looked at that because RI #52 did not get a bed bath often. When asked why she did not have everything she needed to give the bed bath, EI #5 replied, she thought she was close enough to maneuver around the room without incident. EI #5 was asked what she should have done to prevent RI #52 from falling off the bed. EI #5 stated, she should have had all the supplies at the bedside and she should have never left the resident unattended. EI #5 explained she thought RI #52 would be okay on his/her back in the middle of the bed. When asked what the facility's procedure was for a bed bath, EI #5 said to get all your supplies ready before the bath. During an interview on 2/1/2018 at 2:15 PM, EI #2, the Director of Nursing was asked how the accident with RI #52 on 12/30/2017 could have been prevented. EI #2 said, it was possible that if the CNA had gathered all her supplies it would have prevented the accident. The local Hospital's emergency room record revealed on 12/30/2017, RI #52 was seen in the ER with a chief complaint of EMS (Emergency Medical Services) stated pt (patient) was sent here from Magnolia Ridge with lacerations (to) the scalp . RI #52's Magnolia Ridge Progress Notes dated 12/30/2017 6:09 PM, documented . Resident has returned to the facility via ambulance stretcher. Resident has 3 staples in the left side of the top of (his/her) head. (RI #52) has a dressing with zerofoam and kerlix on (his/her) left upper arm . This deficiency was cited as a result of the investigation of complaint/report number AL 547.