Every finding on record at Mulberry Health & Rehabilitation

Based on record review, facility document review, and interviews, the facility failed to ensure proper transfer methods were used for 1 (Resident #1) of 3 residents reviewed for falls. Findings included: Review of Resident #1's Resident Face Sheet revealed the facility admitted the resident on 11/02/2022, with diagnoses that included unspecified intellectual disabilities and anxiety disorder. Review of Resident #1's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/26/2023, revealed the Staff Assessment for Mental Status (SAMS) indicated the resident had a short and long term memory problem and their cognitive skills for daily decision making were severely impaired. The MDS indicated Resident #1 required extensive assistance from staff for bed mobility and transfers and was totally dependent on staff for locomotion on and off the unit, dressing, eating, toilet use, personal hygiene, and bathing. Review of a facility Occurrence Report dated 07/09/2023, revealed Registered Nurse (RN) #2 indicated Certified Nursing Assistant (CNA) #9 reported to her that Resident #1 flipped themselves out of their chair. The report revealed during the three hours prior to the fall, the resident was very restless. The report revealed CNA #9 was with the resident in the dining room at 1:00 AM, rolling the resident in the hallway at 2:00 AM, in the hallway with the resident near their room at 3:00 AM, and at approximately 3:15 AM, Resident #1 flipped themselves over the side of the chair onto the floor. The report revealed CNA #9 reported Resident #1 flipped over the side of the chair when CNA #9 went to the back of the chair to pull the resident back in the seat because the resident was leaning forward in the chair. Review of a statement dated 07/11/2023, handwritten by CNA #9 revealed that on 07/09/2023, at 2:00 AM to 3:00 AM, she was sitting with Resident #1. The statement revealed the resident was irritated, restless, and squirmy in their chair. The statement revealed that CNA #9 went around to the back of the chair, and by that time, the resident had flipped over the arm of the chair. The statement revealed CNA #9 called for the nurse and could not find the nurse, so another CNA helped her get Resident #1 off the floor and back in their chair. The statement revealed that CNA #9 took the resident to the nurse and informed the nurse of what happened. During a telephone interview on 10/26/2023 at 2:18 PM, CNA #10 stated CNA #9 came and found her because she could not find the nurse and told her Resident #1 had thrown themself out of their chair, so she went in to help CNA #9. CNA #10 stated they changed the resident and then put the resident back in the wheelchair. CNA #10 stated the resident was sitting on the floor on their bottom when she entered the room. CNA #10 stated she did not see the resident fall. CNA #10 stated they kind of scooped Resident #1 up, putting one of their arms under each arm of the resident, and they grabbed the resident's pants and pulled the resident up. CNA #10 stated she did not remember if they used a gait belt but thought they did. CNA #10 stated she did remember they grabbed underneath the resident's arm. CNA #10 stated that is not how they should have transferred a resident. During a joint interview on 10/26/2023 at 2:30 PM with the Administrator and Director of Nursing (DON), the DON stated she asked the CNAs how they transferred the resident back into the wheelchair, but they did not get very descriptive. The DON stated the CNAs only said they lifted the resident back into the geriatric chair. The DON stated she did not press for more answers to determine how the CNAs specifically transferred the resident back into the chair. During a telephone interview on 10/26/2023 at 3:00 PM, CNA #9 stated they transferred Resident #1 back to the geriatric chair by pulling the resident up under the arms and lifting. CNA #9 stated they did not have a gait belt on them. CNA #9 stated they just kind of chicken-winged the resident. CNA #9 stated she was just trying to get the resident up off the floor in any way they could get the resident up into the chair. During a joint interview on 10/26/2023 at 4:10 PM with the Administrator and the DON, the DON stated she should have asked more specifically how the CNAs got the resident up. The DON stated the CNAs should not have chicken-winged the resident to get them up off the floor.

Based on policy review, document review, record review, and interview, the facility failed to ensure allegations of abuse and injuries of unknown origin were reported to the State Agency within two hours of learning of the allegations for 1 (Resident #1) of 7 residents reviewed for abuse. Findings included: 1. A review of an undated facility policy titled Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedures revealed, When the facility has identified abuse, the facility will take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. The Facility will increase enforcement action, including, but not limited to: A. Taking steps to prevent further potential abuse. B. Reporting alleged violations and investigation within required timeframes pursuant to Federal and State statutes and regulations. Section, XIII. Response revealed A. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility shall: a. Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment of resident property, are reported in the proper timeframe pursuant to this policy. A review of a facility policy titled Abuse Prevention and Intervention Strategies Nursing Policy and Procedures, revised in September 2016, revealed, 5. Investigation: The facility will investigate all injuries of unknown origin and all allegations of mistreatment, neglect, or abuse. All investigations will be conducted in a timely, thorough and objective manner. Further review revealed, 7. Report/Respond: Any incidents of substantiated abuse and neglect are reported and analyzed and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State, or Federal law. 2. Review of Resident #1's Resident Face Sheet revealed the facility admitted the resident on 11/02/2022, with diagnoses that included unspecified intellectual disabilities and anxiety disorder. Review of Resident #1's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/26/2023, revealed the Staff Assessment for Mental Status (SAMS) indicated the resident had short and long term memory problems and their cognitive skills for daily decision making were severely impaired. The MDS indicated the resident exhibited behaviors not directed towards others daily during the assessment period. The MDS indicated Resident #1 required extensive assistance from staff for bed mobility and transfers and was totally dependent on staff for locomotion on and off the unit, dressing, eating, toilet use, personal hygiene, and bathing. Review of a facility Occurrence Report dated 07/09/2023 at 12:30 PM, revealed Licensed Practical Nurse (LPN) #4 documented she observed a bruised and swollen right-hand 5th digit and right shoulder on Resident #1, after the Certified Nursing Assistant (CNA) reported the resident had swelling and bruises on the fifth finger and right shoulder and no range of motion. Review of Resident #1's Progress Notes dated 07/09/2023 at 3:25 PM, signed by LPN #4, revealed that during routine care, a CNA discovered Resident #1's fifth digit was swollen, and the right shoulder was different from normal with bluish bruises. The note revealed the nurse assessed the resident with no range of motion of the right shoulder. The note revealed the Provider was notified and recommended the resident be sent to the hospital for further evaluation. The note revealed the resident was transferred to the hospital via ambulance at 1:30 PM. The note revealed the Director of Nursing (DON) and the resident's family were notified. A review of a file provided by the facility labeled Soft File, a file which contained the facility's investigation into Resident #1's injury of unknown origin, revealed no Incident Reporting System (IRS) form to verify the facility reported to the State Agency when they became aware of an injury of unknown origin. During an interview on 10/27/2023 at 2:26 PM, the Administrator stated she did not report the injury of unknown origin within 2 hours, because she knew what happened to Resident #1. The Administrator stated that their state had a rule that if they knew what happened or could determine no abuse within those two hours, they did not have to report it. The Administrator stated she knew within a short amount of time that Resident #1 had fallen on the night shift. The Administrator stated once she knew Resident #1 fell , she turned the investigation into a fall investigation instead of following the injury of unknown origin pathway, reporting to the State Agency, and sending the 5-day follow-up as required. Review of a file provided by the facility labeled Soft File, a file which contained the facility's investigation into Resident #1's injury of unknown origin, revealed no documentation of the exact time the Administrator became aware of Resident #1's fall.

Based on policy review, document review, record review, and interview, the facility failed to protect the resident's right to be free from verbal abuse for 1 (Resident #4) of 7 residents reviewed for abuse. Dietary Staff (DS) DS #3 used profanity directed toward Resident #4 and called the resident a derogatory name. Findings included: 1. Review of the facility policy titled Resident Rights, revised in February 2021, indicated Employees shall treat all residents with kindness, respect and dignity . The policy further indicated that residents had the right to .b. be free from abuse, neglect, misappropriation of property, and exploitation . 2. Record review of the Resident Face Sheet revealed Resident #4 was admitted to the facility 01/13/2023, with diagnoses that included cognitive communication deficit, bipolar disorder, and pain disorder with related psychological factors. A review of Resident #4's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/20/2023, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident exhibited verbal behavioral symptoms directed toward others, which occurred four to six days but less than daily during the assessment period. The MDS indicated the resident utilized a wheelchair for mobilization. Review of Resident #4's Care Plan Activity Report initiated on 3/23/2023 revealed a focus area of non-compliance. The care plan indicated Resident #4 had aggressive behaviors, could be very loud and was verbally abusive towards staff, embellished at times, and was accusatory to staff. Interventions directed staff to explain the benefits of allowing staff to perform their job, educate the resident regarding compliance with treatment and care, encourage and allow the resident to express their feelings and concerns when they refuse treatment, always tell the resident what you are going to help with and encourage the resident to help with decision making and care. Review of a facility Occurrence Report, dated 09/05/2023, revealed Resident #4 had a verbal altercation with a staff member. The report indicated DS #3 bumped into Resident #4's wheelchair with the food cart, and Resident #4 cursed at DS #3. The report revealed Resident #4 stated DS #3 did not apologize. Review of an undated typed statement completed by the Administrator, indicated that on 09/05/2023, Resident #4 reported to the Administrator that DS #3 hit their wheelchair while pushing the meal cart down the hall. The statement revealed that the resident stated they did not think it was done intentionally, and they were not hurt but was upset because DS #3 did not apologize to them. The statement indicated on 09/11/2023, Resident #4 told the Administrator that DS #3 cursed at the resident after he bumped into their wheelchair. The statement indicated the Administrator reminded the resident of their previous conversation regarding the incident in which the resident did not mention DS #3 cursing at them. The statement revealed that Resident #4 stated they did not want to make a big deal out of it. The statement indicated DS #3 was removed from the schedule while the facility investigated the incident. A review of a facility Occurrence Report, dated 09/11/2023, revealed Resident #4 reported DS #3 used profanity towards them. The report indicated the previous week, the resident reported DS #3 bumped into their wheelchair with the dietary meal cart. The resident stated they cursed at DS #3 because he did not say sorry, and DS #3 used profanity directed at the resident. Review of the typed statement of an interview with Resident #5, dated 09/12/2023 and conducted by the Director of Nursing (DON), revealed Resident #5 witnessed the incident between Resident #4 and DS #3. The statement indicated Resident #5 witnessed DS #3 come around the corner pushing the dietary cart and bump into Resident #4's wheelchair. The statement indicated DS #3 acknowledged he did not mean to bump into Resident #4. The statement indicated Resident #4 started cursing at DS #3, and every time DS #3 came onto the unit, Resident #4 would start cursing at him again. The statement indicated the last time DS #3 came down the hall with the cart, Resident #4 began cursing loudly at him, and DS #3 asked Resident #4, Why do you have to be such a [derogatory name]. A review of Resident #5's annual MDS, with an ARD of 08/01/2023, revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. During an interview on 09/27/2023 at 4:30 PM, Resident #5 stated they witnessed an issue between a young man in dietary and Resident #4. Resident #5 stated the young man accidentally bumped into Resident #4's wheelchair, and Resident #4 got upset and started cursing at him. Resident #5 stated the young man from dietary walked by multiple times, and each time, Resident #4 would curse at him. Resident #5 said the young man did not say anything back to Resident #4 until the last time he walked by, and Resident #4 told him they would make sure he was fired. Resident #5 stated at that point, the young man said, Why do you have to be such a [derogatory name?] directed at Resident #4. Review of the undated handwritten statement from an interview with DS #3 conducted by the Administrator, revealed DS #3 stated he was pushing the hall cart and mistakenly bumped into Resident #4's chair. The statement revealed the resident started yelling and cursing at DS #3. The statement revealed DS #3 stated he said, My bad, and continued down the hall. The statement indicated every time DS #3 walked past Resident #4, they would curse at him, and the resident stated they would have him fired. The statement indicated DS #3 told Resident #4 to go lay [his/her] [expletive] down and be quiet and asked Resident #4, Why are you [expletive] at me. During an interview on 09/27/2023 at 4:11 PM, DS #3 stated he was coming out of the kitchen and accidentally bumped into Resident #4. DS #3 stated he said, My bad, and Resident #4 did not take the apology well. DS #3 stated he made several more trips, and Resident #4 cursed at him each time. DS #3 stated the last time he walked past Resident #4, they followed him to the kitchen door, cursing at him. DS #3 stated he told Resident #4 to Quit [expletive] and go lay down. DS #3 stated he could have just kept walking. He stated Resident #4 threatened they would get him fired. Review of a Disciplinary Warning issued to DS #3 dated 09/12/2023, indicated he received a warning related to the incident on 09/05/2023. The warning stated DS #3 admitted to speaking inappropriately to a resident while the resident was angry and speaking inappropriately to him. The warning indicated any other such infraction would result in immediate termination. The warning was signed by DS #3. During an interview on 09/27/2023 at 6:30 PM, the DON and Administrator stated Resident #4 did not initially report DS #3 cursed at them during the incident when DS #3 bumped the wheelchair of Resident #4. The DON and Administrator indicated they immediately sent DS #3 home, began their investigation, and did not feel the incident was abuse but more of a customer service issue. They indicated DS #3 did not act appropriately when the resident continued to yell at him repeatedly, and they provided education on customer service.

Based on policy review, document review, record review, and interview, the facility failed to ensure a thorough investigation of an injury of unknown origin was completed for 1 (Resident #1) of 7 residents reviewed for abuse. Findings included: 1. A review of an undated facility policy titled Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedures, revealed, IV. When the facility has identified abuse, the facility will take all appropriate steps to remediate the noncompliance and protect residents additional abuse immediately. The facility will increase enforcement action including, but not limited to: C. Conducting a thorough investigation of the alleged violation. Further review revealed, V. The facility will develop written policies and procedures that define how staff will communicate and coordinate situations of abuse, neglect, misappropriation of resident property, and exploitation with the Quality Assurance and Performance Improvement (QAPI) program to allow the QAA (Quality Assessment and Assurance) committee to determine: a. If a thorough investigation is conducted. The policy revealed IX. The facility will investigate any allegations made alleging abuse, neglect, and exploitation of residents and misappropriation of resident property. Additionally, XIII. In response to allegation of abuse, neglect, exploitation, or mistreatment, the facility shall: B. Have evidence that all alleged violations are thoroughly investigated. A review of a facility policy titled Abuse Prevention and Intervention Strategies Nursing Policy and Procedures, revised in September 2016, revealed, It is the policy of this facility to protect its residents from abuse, neglect, involuntary seclusion, and misappropriation of property. In order to facilitate the above, the facility has implemented a program of abuse prevention and intervention strategies. The procedure included, 4. Identification: The facility will identify patterns or isolated incidents of unexplained functional regression or other evidence of physical, verbal, sexual or psychological abuse or punishment posing a serious and immediate threat to individuals. The facility will also identify events such as suspicious bruising of residents, occurrences, patterns and trends that may constitute abuse; and determine the direction of the investigation. 5. Investigation: The facility will investigate all injuries of unknown origin and all allegations of mistreatment, neglect, or abuse. All investigations will be conducted in a timely, through and objective manner. 2. A review of Resident #1's Resident Face Sheet revealed the facility admitted the resident on 11/02/2022 with diagnoses that included unspecified intellectual disabilities and anxiety disorder. Review of Resident #1's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/26/2023, revealed the Staff Assessment for Mental Status (SAMS) indicated the resident had a short and long term memory problem and their cognitive skills for daily decision making were severely impaired. The MDS indicated the resident exhibited behaviors not directed towards others daily during the assessment period. The MDS indicated Resident #1 required extensive assistance from staff for bed mobility and transfers and was totally dependent on staff for locomotion on and off the unit, dressing, eating, toilet use, personal hygiene, and bathing. Review of an Occurrence Report dated 07/09/2023 at 12:30 PM, revealed Licensed Practical Nurse (LPN) #4 documented she observed a bruised and swollen right hand 5th digit and right shoulder on Resident #1 after the Certified Nursing Assistant (CNA) reported the resident had swelling and bruises on the fifth finger and right shoulder and no range of motion. Review of a CNT [certified nurse technician] OBSERVATION form dated 07/09/2023, revealed CNA #13 took Resident #1 from CNA #6 to change the resident. The form revealed CNA #13 attempted to assist Resident #1 with standing, the resident did not want to stand, which CNA #13 documented as unusual. The form revealed CNA #13 noticed the resident was not moving their right arm, and there was discoloration and a dip in the arm. The form revealed CNA #13 immediately notified the nurse. Review of a facility Occurrence Report, dated 07/09/2023, revealed Registered Nurse (RN) #2 indicated CNA #9 reported to her that Resident #1 flipped themselves out of their chair. The report revealed RN #2 assessed Resident #1 and saw a red mark on the resident's left heel but no other injuries. The report revealed during the three hours before the fall, the resident was very restless. The report revealed CNA #9 was with the resident in the dining room at 1:00 AM, rolling the resident in the hallway at 2:00 AM, in the hallway with the resident near their room at 3:00 AM, and at approximately 3:15 AM, Resident #1 flipped themselves over the side of the chair onto the floor. The report revealed CNA #9 reported Resident #1 flipped over the side of the chair when CNA #9 went to the back of the chair to pull the resident back in the seat because the resident was leaning forward in the chair. Review of Resident #1's Progress Notes dated 07/09/2023 at 3:25 PM, signed by LPN #4, revealed that during routine care, a CNA discovered Resident #1's fifth digit was swollen, and the right shoulder was different from normal with bluish bruises. The note revealed the nurse assessed the resident with no range of motion of the right shoulder. The note revealed the Provider was notified and recommended the resident be sent to the hospital for further evaluation. The note revealed the resident was transferred to the hospital via ambulance at 1:30 PM. The note revealed the Director of Nursing (DON) and the resident's family were notified. During a telephone interview on 09/27/2023 at 10:52 AM, the Hospital Social Worker stated Resident #1 was admitted to their facility in July 2023 due to significant injuries. The Hospital Social Worker indicated he did not get information from the facility on how the injuries occurred. He stated Resident #1 was non-verbal and severely developmentally delayed. He stated he did not think the resident could pitch themselves out of the wheelchair but did not know for sure. During an interview on 09/27/2023 at 1:43 PM, RN #7 stated the resident had to be on a one-on-one (1:1) with staff at all times due to being a fall risk and the family's concern for the resident's safety. RN #7 stated she was working as the nurse on the second floor when the injury was discovered. RN #7 stated CNA #13 came and got her to look at the resident's arm. RN #7 stated the resident was not acting like their normal self and was just different like something was wrong with them. RN #7 stated to her knowledge, nothing was reported, but she was taking care of the residents on the west side. RN #7 stated from what she understood, CNA #13 was changing the resident, and the resident's arm just flopped. She stated she told CNA #13 to tell LPN #4 and that they needed to contact the Director of Nursing (DON). During a telephone interview on 09/27/2023 at 2:49 PM, CNA #9 stated Resident #1 was 1:1 with staff and had always been. CNA #9 stated the CNAs would alternate who cared for Resident #1 an hour at a time. CNA #9 stated she cared for the resident when the resident fell (07/09/2023). CNA #9 stated the resident was in their geriatric chair, it was between 2:00 AM and 3:00 AM, and the resident was screaming, yelling, fidgety, agitated, and sleepy but just seemed restless. CNA #9 stated she was sitting beside Resident #1 when the resident slid down in the chair. CNA #9 stated she went around the chair to pull the resident up, and in the time, it took her to get around the chair, the resident had flipped over the armrest. CNA #9 stated she yelled for help, but no one responded. CNA #9 stated she could not find the nurse, so she got the resident up. CNA #9 stated after she got the resident up, she went and told the nurse. CNA #9 stated the resident was agitated, even on the floor, moving around, and fidgeting. During a follow-up telephone interview on 10/26/2023 at 3:00 PM, CNA #9 stated they transferred Resident #1 back to the geriatric chair by pulling the resident up under the arms and lifting. CNA #9 stated they did not have a gait belt on them. CNA #9 stated they just kind of chicken-winged the resident. CNA #9 stated they did change the resident maybe two or three times during the shift. CNA #9 stated she did not notice any bruising or swelling when she changed the resident. CNA #9 stated she was just trying to get the resident up off the floor in any way they could get the resident up into the chair. During a telephone interview on 10/26/2023 at 2:18 PM, CNA #10 stated she did 1:1 with Resident #1, and the facility had a sheet staff initialed every 15-20 minutes on a two-hour rotation. CNA #10 stated CNA #9 came and found her because she could not find the nurse and told her Resident #1 had thrown themself out of their chair, so she went in to help CNA #9. CNA #10 stated they changed the resident and then put the resident back in the wheelchair. CNA #10 stated she did not notice any swelling, discoloration, or bruising at that time. CNA #10 stated the resident was sitting on the floor on their bottom when she entered the room. CNA #10 stated she did not see the resident fall. CNA #10 stated they kind of scooped Resident #1 up, putting one of their arms under each arm of the resident, and they grabbed the resident's pants and pulled the resident up. CNA #10 stated she did not remember if they used a gait belt but thought they did. CNA #10 stated she did remember they grabbed underneath the resident's arm. CNA #10 stated that is not how they should have transferred a resident. CNA #10 stated she had to write a statement about what her part was in the incident. CNA #10 stated the supervisor called her, she thought, and asked her about this. CNA #10 stated she thought CNA #9 changed the resident. CNA #10 stated she had 1:1 with the resident from 5:30 AM to 7:00 AM that morning, and the resident was fine and had no signs of pain. During a joint interview on 10/26/2023 at 2:30 PM with the Administrator and DON, the Administrator stated they talked to staff who took care of Resident #1 on Saturday (07/08/2023) and Sunday (07/09/2023), and no one noticed anything like bruising. The DON stated she asked the CNAs how they transferred the resident back into the wheelchair, but they did not get very descriptive. The DON stated the CNAs only said they lifted the resident back into the geriatric chair. The DON stated she did not press for more answers to determine how they specifically transferred the resident back into the chair. During a joint interview on 10/26/2023 at 4:10 PM with the Administrator and the DON, the Administrator stated she did not remember which side the CNA said the resident fell on . The DON stated she should have asked more specifically how the CNAs got the resident up. The DON stated the CNAs should not have chicken-winged the resident to get them up off the floor. During an interview on 09/27/2023 at 6:30 PM, the Administrator stated they investigated the incident as a fall with injury since staff reported the following day that the resident had flipped themself out of the wheelchair. During an interview on 10/26/2023 at 10:50 AM, the DON stated the CNAs had a sign-out sheet for those who did 1:1 with Resident #1. The DON stated she reviewed the sign-out sheets and tried to determine who had signed out as providing 1:1 with the resident but could not make out all names. During a joint interview on 10/27/2012 at 2:26 PM with the DON and the Administrator, the DON stated she did not remember doing any audits officially after Resident #1 fell out of the chair. The Administrator stated that because the incident with Resident #1 was an isolated incident, they felt they did not need to do audits or retraining. The Administrator stated once they knew Resident #1 fell , they turned this into a fall investigation instead of following the injury of unknown origin pathway, reporting to the state agency, and sending the 5-day follow-up as required.

Based on review of facility policy, medical record review, facility investigations and interview, the facility failed to report the investigative outcome within 5 working days of the alleged violation for 3 of 3 allegations reviewed involving 5 residents (Resident #82, Resident #64, Resident #62, Resident #44, and #241) sampled for abuse. The findings include: 1. Review of the facility policy Abuse, Neglect and Exploitation undated showed .The results of all investigations must be reported to the Administrator, designee to the appropriate state agency, as required by state law, within five (5) working days of the alleged violation . 2. Review of the medical record revealed Resident #62 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Altered Mental Status, Dementia with Behavioral Disturbances, and Psychosis. A quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 8 indicating moderate cognitive impairment and exhibits wandering behaviors daily. Review of the medical record revealed Resident #44 was admitted to the facility on [DATE], with diagnoses including Diabetes and Dementia with Agitation. An admission MDS dated [DATE], revealed a staff assessment for mental status indicated moderate impairment for decision making and exhibits wandering behaviors daily. Review of the facility investigation dated 2/25/2023 at 10:22 PM, revealed .[Resident #62] was hollering .I [LPN] entered the room, witnessed [Resident #44] grabbing him [Resident #62] on his back telling him to shut up. I immediately separated residents .each placed 1:1 resident monitoring .family notified 2/25/2023 10:25 PM .Physician notified 2/25/2023 10:25 PM .Admin [Administrator] notified .resident separated from roommate. Sent to psych services 2/28/2023 .Resident 1:1 behavior monitoring until sent out . 3. Review of the medical record revealed Resident #82 was admitted to the facility on [DATE], readmission on 3/16/2023, with diagnoses including Surgical Aftercare following surgery of Digestive System, Intellectual Disabilities, Congestive Heart Failure, Anxiety Disorder, and Chronic Pain Syndrome. A quarterly MDS dated [DATE], revealed severe cognitive impairment mental status and exhibits behaviors not directed at others daily. Review of the medical record revealed Resident #64 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Depressive Episodes, Generalized Anxiety Disorder, Pain and Dementia with Agitation. An annual MDS dated [DATE], revealed a staff assessment for mental status indicated moderate impairment for decision making. Resident #64 exhibited no behavior symptoms. Review of the facility investigation of the incident dated 5/25/2023 6:45 PM, revealed .Resident to Resident Altercation .Resident [Resident #64] witnessed by CNT [Certified Nurse Technician] striking another resident [Resident #820 on the right side of cheek (face) without provocation .residents immediately separated .assessed both residents .Physician noted 5/25/2023 6:55 PM new orders received .family member notified 5/25/2023 7 PM .Resident placed on 1:1 behavior monitoring . There is no documentation of the facility reporting the alleged allegations to Adult Protective Services (APS) or law enforcement. There is no documentation the outcome of the facility's investigation was reported to the State Agency within 5 working days. 4. Review of the medial record revealed Resident #241 was admitted to the facility on [DATE], with diagnoses including Diabetes, Congestive Heart Failure, Nephropathy, End Stage Renal Disease, and Cellulitis of Right and Left Lower Limbs. Resident #241 was discharged to the hospital on 5/29/2023. Review of the facility investigation of the incident dated 5/30/2023 6:45 PM, revealed, .Staff/Resident complaint .Resident reported to his dtr [daughter] that a nurse threw pudding on his clothing when in his room attempting to administer medications .mental status alert [with] confusion .Resident was transferred to the hospital on 5/30/2023 . The investigation did not contain documentation of the outcome findings reported to the State Agency within 5 working days of the alleged violation. During an interview on 6/13/2023 at 4:25 PM, the Director of Nursing confirmed the outcome of the facility's investigation was not reported to the State Incident Reporting System within 5 working days of the alleged violation. 5. During an interview on 6/13/2023 at 5:01 PM, the Administrator stated, .I responsible for reporting allegations of abuse .did not report the outcome of the investigation . During an interview on 6/15/2023 at 6:27 PM, the Administrator confirmed the alleged violations involving resident abuse were not reported to APS or law enforcement.

Based on medical record review and interview, the facility failed to accurately assess residents for hospice for 2 of 2 (Resident #36 and #88) sampled residents reviewed. The findings include: 1. Review of the facility's policy titled, Resident Assessment, dated 2001, revealed .A comprehensive assessment of every resident's needs is made at intervals designated by OBRA and PPS requirements .The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments .All person who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information . 2. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE], with diagnoses of Lung Cancer, Depression, Pain, Hypertension, and Dementia. Review of the Physician's Order dated 3/27/2023, revealed [Name Hospice] . Review of the admission MDS dated [DATE], revealed Resident #36 had a Brief Interview for Mental Status (BIMS) 6 indicating she had severe cognitive impairment and not coded for hospice care. Review of the Physician's Order dated 5/21/2023, revealed Admit to [named Hospice] .for Lung Cancer . 3. Closed medical record, showed Resident #88 was admitted on [DATE], with a diagnoses of Alzheimer's Disease Dysphagia, Dementia, Hypertension, and Anxiety Disorder. Review of the (Named Hospice Company) dated 9/1/2022, revealed .HOSPICE PHYSICIAN GIVING VERBAL CERTIFICATION .PROGNOSIS IS FOR A LIFE EXPECTANCY OF SIX (6) MONGHS OR LESS . Review of the Progress note dated 9/1/2022, revealed .Resident admitted to [Name Hospice Company] this evening, no [evening, no] apparent change in overall condition,son [condition, son] made aware of hospice visit and admission this evening . Review of the quarterly MDS dated [DATE], and 3/16/2023, revealed Resident #88 was not coded for hospice care. During an interview on 6/15/2023 at 12:59 PM, the Regional MDS Coordinator was asked should Resident #88 be coded for hospice on the quarterly MDS dated [DATE], and 3/16/2023. The Regional MDS Coordinator stated .Yes .

Based on policy review, medical record review and interview, the facility failed to maintain and monitor an effective infection prevention and control program for 3 of 3 sample resident (Resident #9, #60 and #141) reviewed for Legionella Disease. The findings include: 1. Review of the facility's policy titled, Legionella Surveillance and Detection dated 2001, revealed .Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. Legionnaire's disease is included as part of our infection surveillance activity .As part of the infection prevention and control program, all cases of pneumonia that are diagnosed in the residents > [greater than] 48 hours after admission are investigated for possible Legionnaire's disease . 2. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of Diabetes, Major Depression, Hypertension, Chronic Pain and Chronic Obstructive Pulmonary Disease. Review of the (Named Imaging) dated 3/1/2023, revealed .XRAY [Electromagnetic radiation] CHEST .a mild right lung base infiltrate . Review of the INFECTION PREVENTION and CONTROL SURVEILLANCE DATA COLLECTION, dated 3/1/2023, revealed .Antibiotic treatment Pneumonia . 3. Review of the medical record revealed Resident #60 was admitted to the facility on [DATE] with a readmission on 6/13/2023 with diagnoses of Hypertension, Gastrostomy, Retention of Urine, and Heart Failure. Review of the (Named Imaging) dated 5/17/2023, revealed .XRAY [Electromagnetic radiation] CHEST .Bibasilar airspace disease .DX [diagnosis] Babasilar [Bibasilar] pneumonia atelectasis . Review of the INFECTION PREVENTION and CONTROL SURVEILLANCE DATA COLLECTION, dated 5/18/2023, revealed .Antibiotic treatment Pneumonia . 4. Review of the medical record revealed Resident #141 was admitted to the facility on [DATE] with diagnoses of Dementia, Pain, Major Depressive Disorder, Hypertension and Dysphagia. Review of the (Named Imaging) dated 3/2/2023, revealed .XRAY [Electromagnetic radiation] CHEST .Nonspecific interstitial infiltrate right lung base could be acute or chronic . Review of the INFECTION PREVENTION and CONTROL SURVEILLANCE DATA COLLECTION, dated 3/6/2023, revealed .Antibiotic treatment Pneumonia . 5. During an interview on 6/15/23 at 5:32 PM, the Administrator was asked if the facility had an effective Legionella Surveillance and Detection Program. The Administrator stated .No .

Based on policy review, medical record review, observation, and interview, the facility failed to ensure food preferences and menu choices for 2 of 8 (Resident #17, and #75) sampled residents. The findings include: 1. Review of the facility's policy titled, Resident Food Preferences revised 7/2017, revealed .Upon the resident's admission .the Dietary staff will identify a resident's food preferences .The Dietary department will offer a variety of foods at each scheduled meal . 2. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease, Dysphagia, Dependence on Renal Dialysis, Diabetes Mellitus and Asthma. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated she was cognitively intact. Review of Resident #17's breakfast meal ticket dated 6/14/2023 revealed, .DOUBLE BACON .EGG .3 OZ [ounce] .TURKEY .2 LINKS .JUICE .4OZ .COFFEE .8 OZ . Observation on 6/14/2023 at 8:19 AM, revealed Resident #17 sitting on the side of her bed, with her breakfast tray on the overbed table, there were only bacon and toast on her plate. During an interview on 6/14/2023 at 8:19 AM, Resident #17 stated, .didn't get eggs .coffee . 3. Review of the medical record revealed Resident #75 was admitted to the facility on [DATE] with diagnoses of Congestive Heart Failure, Diabetes Mellitus, Anxiety, and Atrial Fibrillation. Review of the admission MDS dated [DATE], revealed Resident #75 had a BIMS score of 15, which indicated that he was cognitively intact. Review of RESIDENT IN-SERVICE dated 6/1/2023 revealed, .This in-service is to inform staff of the following: 1. Please ensure that [Named Resident #75] gets everything as stated on his meal ticket. 2. Please ensure that [Named Resident #75] .gets a chef salad and a bowl of chicken noodle soup at lunch and dinner, along with his regular meal . Review of Resident #75's meal ticket on 6/11/2023 for lunch revealed, .SALAD-CHEF 6 OZ .2X [times] SOUP-CHICKEN NOODL [noodle] . During an observation in the residents room on 6/14/2023 at 12:57 PM, revealed Resident #75 did not get his chicken noodle soup according to his meal ticket. During an interview on 6/11/2023 at 12:48 PM, Resident #75 stated, .didn't get my chef salad and chicken noodle soup . During an interview on 6/14/2023 at 12:57 PM, Resident #75 stated, .didn't get my chicken noodle soup . 4. During an interview on 6/15/2023 at 4:07 PM, the Registered Dietitian (RD) confirmed that Residents #17 and #75 should have gotten what was on their meal tickets. The RD was asked why Resident's aren't getting what's on their meal tickets. The RD stated, .I'm not sure . During an interview on 6/15/2023 at 5:09 PM, the Director of Nursing (DON) was asked should residents get their food preferences and choices. The DON stated, Yes .meals are important .

Based on policy review, observation, and interview, the facility failed to ensure medications were properly labeled and stored in 1 of 4 medication storage areas (One East Nurse Station Medication Storage Room) when there were no clear identifiers on an insulin pen's label and when there were no documented temperatures for the medication refrigerator from 6/1/2023 thru 6/13/2023. The findings include: 1. Review of the facility's policy titled, Medication Labeling and Storage, with a revision date of 2/2023, revealed .The facility stores all medications and biologicals in locked compartments under proper temperature .medications requiring refrigeration are stored in a refrigerator and are labeled . the medication label includes medication name .expiration date .residents name .route .appropriate instructions . 2. During an observation and interview at the One East Nurse Station Medication Storage Room, on 6/14/2023 at 4:19 PM, Licensed Practical Nurse #3 confirmed a Levemir Insulin Pen's label did not have a first name, there were missing letters on the last name, the expiration date was missing, and only the first 3 letters of the word Levemir was on the insulin pen. During an observation and interview at the One East Nurse Station Medication Storage Room, on 6/14/2023 at 6:28 PM, the Director of Nurses (DON) was asked should the resident's first and last name and dates be clearly visible on the medication labels. The DON stated, Yes. During an observation and interview on 6/15/2023 at 10:25 AM, the DON confirmed there was no daily monitoring of the medication room refrigerator temperatures at the One East Nurse Station Medication Storage Room from 6/1/2023 thru 6/13/2023.

Based on policy review, medical record review, and interview, the facility failed to monitor for the side effects of antipsychotic medications for 2 of 5 sampled residents (Resident #44 and #391) reviewed for unnecessary medication. The findings include: 1. Review of the facility's policy titled, Antipsychotic Medication Use, revised on 7/2022, revealed .Nursing staff shall monitor for and report .side effects and adverse consequences of antipsychotic medications . Review of the facility's policy title, Behavioral Assessment Intervention and Monitoring, revised on 3/2019, revealed .if antipsychotic medications are used .will monitor for side effects and complications related to psychoactive medication . 2. Review of the medical record revealed Resident #44 was admitted to the facility on [DATE], with diagnoses of Schizophrenia, Dementia, and Alzheimer's Disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #44 had moderately impaired cognition and received Antipsychotics for 6 of 7 days reviewed. Review of the Physician's Order dated 5/23/2023, revealed .Quetiapine [an Antipsychotic] 25mg [milligrams] .give 2 tablets (50 mg) by oral route once daily at bedtime . The Facility failed to monitor Resident #44 for the adverse side effects of an antipsychotic medication. During an interview on 6/15/2023 at 5:54 PM, Licensed Practical Nurse (LPN) #2 confirmed Resident #44 should have an order for monitoring of the adverse side effects of antipsychotics medications. During an interview on 6/15/2023 at 6:05 PM, the Director of Nurses (DON) confirmed that Resident #44 is taking an antipsychotic and does not have any documentation for monitoring of the adverse side effects of an antipsychotic medication. 3. Review of the medical record revealed Resident #391 was admitted to the facility on [DATE], with diagnoses of Parkinson's Disease, Alzheimer's Disease, Anxiety, Hypertension, and Depression. Review of the Physician's Order dated 6/7/2023, revealed .Quetiapine [Antipsychotic] 25 mg [milligram] tablet .give 0.5 .daily . Review of the Physician's Order dated 6/7/2023, revealed Resident #391 did not have an order to monitor for the side effects of an antipsychotic medication. Review of the Medication Administration Record for 6/2023, revealed the facility did not monitor Resident #391 for the side effects of an antipsychotic medication. The Facility failed to monitor Resident #391 for the adverse side effects of an antipsychotic medication. During an interview on 6/15/2023 at 1:43 PM, the DON confirmed Resident #391 is taking an antipsychotic and does not have any documentation for monitoring of the side effects of an antipsychotic medication.

Based on policy review, medical record, observation, and interview, the facility failed to ensure residents received appropriate respiratory and trach care for 1 of 1 sampled resident (Resident #11) reviewed for respiratory services. The findings include: 1. Review of the facility's policy titled, Tracheostomy Care-Self Care, dated 2001, revealed .The purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas . 2. Review of medical record showed Resident #37 was admitted on [DATE], with a diagnoses of End Stage Renal Disease, Hyperkalemia, Atrial Fibrillation, Hypertension, Gastroesophageal Reflux Disease, and Tracheostomy. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE], Resident #37 had a Brief Interview for Mental Status of (BIMS) 15 indicating she was cognitively intact and coded for tracheostomy. Review of Physician's Orders dated 9/2/2022, revealed Tracheostomy present .5 Shiley (Tracheostomy Tube) cuffed .Tracheostomy - Trach Care Q [every] shift (patient Provide self-care) . Review of the Care Plan dated 9/3/2022, revealed .RESPIRATORY: Tracheostomy .Ensure emergency kit with secondary airway, ambu bag (artificial manual breathing unit that forces air into the lungs of patient), suction machine present in room . The facility failed to have an emergency kit, ambu bag and suction machine present at Resident #37's bedside. Review of the Care Plan dated 9/23/2022, revealed .Tracheostomy/Voice .Monitor for signs and symptoms of respiratory distress such as cyanosis, shortness of breath, decrease oxygen saturation . The facility failed to monitor Resident #37 for signs and symptoms of respiratory distress. Review of the Resident Medication Administration Record dated June 2023, revealed .Monitor for s/s [signs and symptoms] of respiratory distress r/t [related to] tracheostomy q [every] shift Start Date: 6/13/2023 . The Facility was not able to provide physicians orders or documentation for maintaining and monitoring of the tracheostomy care. Observation and interview in the residents room on 6/14/2023 at 10:28 AM, with the Unit Manager revealed Resident #37 had a size 7 inner cannula instead of a size 5 as ordered and documented in the medical records. The Unit Manager stated .the order is for a size 5 inner cannula .I did not know she had a size 7 . During an interview on 6/14/2023 at 4:12 PM, Resident #37 was asked if she was willing to perform self-tracheostomy care. Resident #37 stated she completed tracheostomy care two minutes ago and refused. During an observation and interview on 6/14/2023 at 3:16 PM and 6/14/2023 at 4:14 PM, with Unit Manager #1 in Resident #37's room there was not emergency kit, suction machine, or ambu bag at the Resident #37's bedside. Unit Manager #1 was asked should the facility follow the care plan for tracheostomy care. Unit manager #1 stated .Yes . The Unit Manager was asked how often the facility should complete the tracheostomy assessment for Resident #37 who provide self-care. The Unit manager stated .quarterly and prn [as needed] .she [Resident #37] should have had an assessment in December 2022 and March 2023 . The Unit Manager was asked if there was documentation on the Medication Administration Records (MAR) for monitoring of signs and symptoms of respiratory distress. The Unit manager stated .there is no documentation on the MAR for April and May 2023 .it was started on 6/13/2023 .

Based on policy review, medical record review, observation, and interview, the facility failed to follow the facility's policy for monitoring weights for 2 of 5 sampled residents (Resident #20 and #41) reviewed for nutrition. The findings include: 1. Review of the facility's policy titled, Weight Assessment and Intervention, revised March 2022, revealed .Residents are weighed upon admission and at intervals established by the interdisciplinary team . 2. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of Aphasia, Dysphagia, Chronic Kidney Disease Stage 3, and Hypothyroidism. Review of the Care Plan dated 2/20/2023, revealed .Risk for Weight Loss .related to .Declining mental status and mechanically altered diet .likes most foods, especially coffee and .oreos .Monitor weights as per MD [Medical Doctor] order . Review of the Physician's Orders revealed .Weigh Monthly .Original Order Date .05/04/2022 . Review of the Clinical Monitoring Detail Report revealed, .10/12/2022 .137 lbs [pounds] .5/5/2023 .195 lbs .6/12/2023 .129.6 lbs . Review of the Clinical Monitoring Detail Graph dated 2/6/2023 revealed .134.00 . The facility failed to obtain January, March, and April 2023 weights. Observation in Resident #20's room on 6/12/2023 at 8:24 AM, revealed Resident #20 sitting in the recliner next to his bed with a partially eaten breakfast on the overbed table. During an interview on 6/13/2023 at 8:38 AM, the Social Worker confirmed weights should have been documented and stated, .He came off hospice some time ago .don't know where the misunderstanding is [obtaining and recording of the weights] . During an interview on 6/15/2023 at 8:06 AM, the Registered Dietician (RD) confirmed Resident #20 was at risk for weight loss. The RD was asked if a resident is at risk for weight loss do you get monthly weights. The RD stated, Absolutely. During an interview on 6/15/2023 at 11:04 PM, Nurse Practitioner (NP) #1 confirmed the Physician orders should be followed for obtaining the residents weights. During an interview on 6/15/2023 at 5:09 PM, the Director of Nursing (DON) was asked do you expect your staff to follow physician orders. The DON stated, Yes, ma'am . The DON confirmed Resident #20 went off of hospice in April 2022 .when he came off hospice .we treated him like he was comfort care, but he wasn't .it was confusing .we take full responsibility . The facility Failed to obtain Resident #20's weights according to the Physicians Orders. 3. Review of medical record showed Resident #41 was admitted to the facility on [DATE], with a readmission on 4/5/2023, with a diagnoses of Diabetes, End Stage Renal Failure, Major Depressive Disorder, Dependence On Renal Dialysis, Heart Failure, Atrial Fibrillation, Dysphagia, Hypertension, Chronic Pain. Review of the Physician's Orders dated 4/5/2023 revealed .Monthly Weight . Review of the Clinical Monitoring Detail Report revealed .2/6/2023 .Weight .191 lbs [pounds] .3/10/2023 .Weight .188.6 lbs .5/18/2023 .166.4 lbs . Review of the Progress Notes dated 4/6/2023, revealed .This [AGE] year-old gentleman returns to [Named Hospital] after having been hospitalized for hypotension and weakness. It was felt that his problems stem from decreased vascular flow to his gastric organs . The Facility failed to obtain admission weight on return to the facility on [DATE]. Review of the Care Plan dated 6/14/2023, revealed .Resident is at risk for weight loss related to dx [disease] of ESRD [End Stage Renal Disease] on HD [Hemodialysis] with recent sig. [significant] weight loss . The Facility failed to revise the care plan for significant weight loss. Review of the Dietary - Dietitian assessment completed on 1/15/2023, revealed .Weight .195 lbs . Review of the Dietary - Dietitian assessment completed on 6/14/2023, revealed .Annual .Weight .166 lbs .Does resident have history of significant weight loss .True .significant weight loss of 13 % [percent] over the past 3 months . The facility failed to complete timely Nutrition Assessments. Review of the 5 -day admission Minimum Data Set (MDS) dated [DATE], revealed Resident #41 had BIMS of 15 indicating he is cognitively intact and weighed 195 pounds. Observation in Resident #41's room on 6/15/2023 at 2:52 PM, with Licensed Practical Nurse (LPN) #1 and Restorative Aide #1 revealed Resident #41's had a weight of 155.4 pounds. During an interview on 6/15/2023 at 9:23 AM, the Registered Dietitian (RD) was asked to tell me about Resident #41 weight management. The RD stated .I was made aware of his decrease in appetite .weight triggered 2 weeks ago for 3 month at 13 % [percent] .5/18/2023 his weight was 166 lbs on 1/9/2023 his weight was 192 lbs .in 6 months the resident had a 15 % weight loss .I added Nepro bid [twice a day] .he gets might shake bid and reg diet .he is still monthly . The RD was asked if have a resident that trigger for a significant weight, should the resident be weighed more frequently. The Rd stated .Yes .we should go to weekly until weights until stabilizes . The RD was asked if the care plan should be updated to reflect the significant weight loss. The RD stated .Yes . The RD was asked how often complete nutrition assessments. The RD stated .quarterly .I completed a nutrition assessment yesterday .the yearly .the one before that was a quarterly in January 2023 .should have completed one in April 2023 . The RD was asked when the resident are weighted on return from the hospital. The RD stated .On return from the hospital admission and readmission . The facility was unable to provide documentation of weekly weights for Resident #41.

Based on review of the facility policy, medical record review and interview the facility failed to monitor blood glucose levels as prescribed for 1 of 3 residents (Resident #13) reviewed related to blood glucose monitoring. The findings include: 1. Review of the facility policy Diabetes-Clinical Protocol revealed, .the Physician will order appropriate lab tests ( .finger sticks) [Accucheck] and adjust treatments based on these results . 2. Review of the signed physician's orders for Resident #13 dated 12/2022, 2/2023, 3/2023, and 4/2023 revealed .blood glucose monitoring .Schedule 11:30 AM; 4:30 PM; 6:00 AM; 9:00 PM . Review of the January 2023, Medication Administration Record (MAR) revealed there was no documentation the blood glucose level was obtained on the following days/times: On 1/2/2023 and 1/17/2023 at 11:30 AM before lunch l) no documentation of blood glucose level. On 1/16/2023 at 11:30 AM and 4:30 PM (before meal) and 9:00 PM (at bedtime check) blood glucose level. Review of the February 2023, MAR revealed there was no documentation the blood glucose level was obtained on the following days/times: On 2/3/2023 at 9:00 PM, bedtime. On 2/4/2023 at 6:00 AM before breakfast. On 2/20/2023 at 11:30 AM before lunch. On 2/21/2023 at 4:30 PM before supper/dinner. On 2/23/2023 at 11:30 AM before lunch. Review of the March 2023, MAR revealed there was no documentation the blood glucose level was obtained on the following days/times: On 3/4/2023 At 6:00 AM on 3/4/2023, 3/13/2023 and 3/29/2023. Review of the April 2023 MAR revealed there was no documentation the blood glucose level was obtained on the following days/times: On 4/5/2023, 4/16/2023, and 4/21/2023 at 6:00 AM. On 4/28/2023 at 11:30 AM and 4:30 PM. During an interview on 6/13/2023 at 4:25 PM, the Director of Nursing (DON) confirmed the physician's orders for blood glucose monitoring should be completed and documented on the MAR.

Based on policy review, medical record review, observation, and interview, the facility failed to conduct Care Plan meetings for 3 of 8 sampled residents (Resident #9, #44, and #50) and failed to revise the Care Plan for 1 of 19 sampled residents (Resident #41) reviewed for care planning. The findings include: 1. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated 2001, revealed .A comprehensive, person-centered care plan that includes measurable objectives and timetabled to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The Interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care . 2. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE], with diagnoses of Diabetes, Seizures, Hypertension and Hyperlipidemia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #9 was cognitively intact. Review of the medical record revealed there were no quarterly Care Plan meetings held for Resident #9 for the month of December 2022. During an interview on 6/13/2023 at 4:25 PM, the Social Worker was asked for is she had documentation of Resident #9's care plan meeting for December 2022. The Social Worker stated, .No .I have not been able to find the documentation . 3. Review of medical record, showed Resident #41 was admitted to the facility on [DATE], with a readmission on 4/5/2023, with a diagnoses of Diabetes, End Stage Renal Failure, Major Depressive Disorder, Dependence On Renal Dialysis, Heart Failure, Atrial Fibrillation, Dysphagia, Hypertension, and Chronic Pain. Review of the Care Plan dated 6/14/2023, revealed .Resident is at risk for weight loss related to dx [disease] of ESRD [End Stage Renal Disease] on HD [Hemodialysis] with recent sig. [significant] weight loss . The Facility failed to revise the care plan timely for significant weight loss until 6/14/2023. Review of the 5-day admission MDS assessment dated [DATE], revealed Resident #41 had BIMS of 15 indicating he was cognitively intact. During an interview on 6/15/2023 at 9:23 AM, the Registered Dietitian (RD) was asked to tell me about Resident #41 weight management. The RD stated, .I was made aware of his decrease in appetite .weight triggered 2 weeks ago for 3 months at 13 % [percent] .5/18/2023 his weight was 166 lbs on 1/9/2023 his weight was 192 lbs .in 6 months the resident had a 15 % weight loss . The RD was asked if the care plan should be updated to reflect the significant weight loss. The RD stated .Yes . 4. Review of the medical record revealed Resident #44 was admitted to the facility on [DATE], with diagnoses of Schizophrenia, Alzheimer's Disease, Atrial Fibrillation, and Hyperlipidemia. Review of the quarterly MDS assessment dated [DATE], revealed Resident #44 was severely cognitively impaired. Review of the medical record revealed there were no quarterly Care Plan meetings held for Resident #44 for the month of December 2022, and March 2023. During an interview on 6/15/2023 at 2:43 PM, the Social Worker confirmed Resident #44 did not have a care plan meeting for the month of December 2022 and March 2023. During an interview on 6/15/2023 at 2:02 PM, Receptionist #1 confirmed she sends out letters to Residents Responsible Party with the date and time for the care plan meeting and stated, .I'm sure I didn't send out anything for month of December, January, February, March and April .I keep everything .I don't have anything [Named Resident #9] .in December .[Named Resident #44] .don't have anything for December and March . 5. Review of medical record, showed Resident #50 was admitted on [DATE], with a readmission on 1/17/2020, with a diagnoses of Atrial Fibrillation, Diabetes, Anxiety Disorder, Repeated Falls, Major Depressive Disorder, Gastroesophageal Reflux, and Chronic Pain. Review of the ADR (Assessment Reference Date) Assessment schedule revealed Resident #50 was schedule for a care plan meeting on 2/1/2023, and 5/1/2023. Review of the Progress Notes dated 2/3/2023, through 5/17/2023, revealed no documentation that Resident #50 refusing to attend the IDT (Interdisciplinary Team) Conference meetings. Review of quarterly MDS assessment dated [DATE], revealed Resident #50 had a BIMS 15 indicating she was cognitively intact. The facility was unable to provide documentation of the IDT conference meetings. During an interview 6/13/2023 at 4:49 PM, the Social Worker was asked how often the Care Plan meetings are held. The Social Worker stated .quarterly and prn . The social work was asked if she had any documentation Resident #50 attended or refusing to attend the Care plan meeting in February and May 2023. The Social worker stated .No .it would be documented .

Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete the admission assessment, using the Centers for Medicare & Medicaid Services-specific RAI (Resident Assessment Instrument) process within the regulatory time frames for 1 of 20 sampled residents (Resident #66) reviewed for completion of the MDS. The findings include: 1. Review of the MDS 3.0 RAI Manual v (version) 1.17.1 October 2019, page 2-37 revealed .using the Centers for Medicare & Medicaid Services-specific RAI process within the regulatory time frames. 2. Review of the medical record revealed Resident #66 was admitted to the facility on [DATE], with diagnoses of Dementia, Psychotic Disturbance, Anxiety, Bipolar Disorder, and Chronic Pain Syndrome. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], Resident #66 had moderately impaired cognition. Review of Resident #66's admission MDS with an Assessment Reference Date (ARD) date of 1/20/2021, revealed Item Z0500B was completed 3/21/2021. The admission MDS should have been completed by 1/28/2021, but had not been submitted until 3/21/2021. During a telephone interview with Regional MDS Nurse was asked about the 2 resident assessments that triggered as late submission. She confirmed Resident #1's Admission MDS was submitted during the timeframe. She confirmed that Resident #66 had Admission MDS dated [DATE], completed on 1/26/2022, was not submitted until 78 days from admission on 3/21/2021. That being past the timeframe requirement.

Based on policy review, medical record review, and interview, the facility failed to inform of/or provide written information regarding a resident's right to formulate an advanced directive for 12 of 24 sample residents (Resident #8, #12, #18, #19, #20, #37, #41, #44, #50, #61, #73, and #82) residents reviewed. The findings include: 1. Review of the facility's policy titled, Advance Directives, with a revised date of 9/2022, revealed .The resident has the right to formulate an advance directive .upon admission of a resident, the social services director or designee inquires of the resident, his/her family .about the existence of any written advance directive .The resident or representative is provided with written information concerning the right to refuse or accept .and to formulate an advance directive . 2. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses of Cerebral Infarction and Epilepsy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 had moderate cognitive impairment. Review of Resident #8's medical record revealed there was no advance directive and there was no documentation that upon admission the resident or his/her legal representative was informed of/or provided written information regarding his right to formulate an advanced directive. 3. Review of the medical records revealed Resident #12 was admitted to the facility on [DATE], with diagnoses of Alzheimer's Disease, Diabetes, Anxiety, and Schizophrenia Disorder. Review of the annual MDS assessment dated [DATE], revealed Resident #12 had moderate cognitive impairment. Review of Resident #12's medical record revealed there was no advance directive and there was no documentation that upon admission the resident or his/her legal representative was informed of/or provided written information regarding his right to formulate an advanced directive. 4. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE], with diagnoses of Alzheimer's Disease, Diabetes Mellitus, Dysphagia and Osteoporosis. Review of the annual MDS assessment dated [DATE], revealed Resident #18 had moderate cognitive impairment. Review of Resident #18's medical record revealed there was no advance directive and there was no documentation that upon admission the resident or his/her legal representative was informed of/or provided written information regarding his right to formulate an advanced directive. 5. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE], with diagnoses of Seizures, Schizoaffective Disorder, Diabetes, and Anxiety. Review the significant change in status MDS assessment dated [DATE], revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 8, indicating severe cognitive impairment. Review of Resident #19's medical record revealed there was no advance directive and there was no documentation that upon admission the resident or his/her legal representative was informed of/or provided written information regarding his right to formulate an advanced directive. 6. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE], with diagnoses of Aphasia, Dysphagia, and Chronic Kidney Disease Stage III. Review of the quarterly MDS assessment dated [DATE], revealed Resident #20 had moderate cognitive impairment. Review of Resident #20's medical record revealed there was no advance directive and there was no documentation that upon admission the resident or his/her legal representative was informed of/or provided written information regarding his right to formulate an advanced directive. 7. Review of the medical record revealed Resident #37 was admitted to the facility on [DATE], with diagnoses of End Stage Renal Disease, Diabetes, and Hypertension. Review of the quarterly MDS assessment dated [DATE], revealed Resident #37 had a BIMS score of 15, indicating intact cognition. Review of Resident #37's medical record revealed there was no advance directive and there was no documentation that upon admission the resident or his/her legal representative was informed of/or provided written information regarding his right to formulate an advanced directive. 8. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE], with diagnoses of End Stage Renal Disease, Diabetes, and Hypertension. Review of the reentry MDS assessment dated [DATE], revealed Resident #41 had a BIMS score of 15, indicating intact cognition. Review of Resident #41's medical record revealed there was no advance directive and there was no documentation that upon admission the resident or his/her legal representative was informed of/or provided written information regarding his right to formulate an advanced directive. 9. Review of the medical record revealed Resident #44 was admitted to the facility on [DATE], with diagnoses of Diabetes, Alzheimer's, and Schizophrenia. Review of the quarterly MDS assessment dated [DATE], revealed Resident #44 had moderate cognitive impairment. Review of Resident #44's medical record revealed there was no advance directive and there was no documentation that upon admission the resident or his/her legal representative was informed of/or provided written information regarding his right to formulate an advanced directive. 10. Review of the medical record, revealed Resident #50 was admitted to the facility on [DATE], with a readmission on 1/17/2020, with diagnoses of Atrial Fibrillation, Diabetes, and Anxiety. Review of quarterly MDS assessment dated [DATE], revealed Resident #50 had a BIMS 15, indicating intact cognition. Review of Resident #50's medical record revealed there was no advance directive and there was no documentation that upon admission the resident or his/her legal representative was informed of/or provided written information regarding his right to formulate an advanced directive. 11. Review of the medical record revealed Resident #61 was admitted to the facility on [DATE], with diagnoses of Diabetes, Depression, and Atherosclerotic Heart Disease. Review of the admission MDS assessment dated [DATE], revealed Resident #61 had a BIMS score of 9, which indicated moderate cognitive impairment. Review of Resident #61's medical record revealed there was no advance directive and there was no documentation that upon admission the resident or his/her legal representative was informed of/or provided written information regarding his right to formulate an advanced directive. 12. Review of the medical record revealed Resident #73 was admitted to the facility on [DATE], with diagnoses of Dementia, Bipolar Disorder, Anxiety, and Hypertension. Review of the annual MDS assessment dated [DATE], revealed Resident #73 had moderate cognitive impairment. Review of Resident #73's medical record revealed there was no advance directive and there was no documentation that upon admission the resident or his/her legal representative was informed of/or provided written information regarding his right to formulate an advanced directive. 13. Review of the medical record revealed Resident #82 was admitted to the facility on [DATE], with diagnoses of Anxiety, Intellectual Disabilities, and Congestive Heart Failure. Review of the quarterly MDS assessment dated [DATE], revealed Resident #82 had severe cognitive impairment. Review of Resident #82's medical record revealed there was no advance directive and there was no documentation that upon admission the resident or his/her legal representative was informed of/or provided written information regarding his right to formulate an advanced directive. 14. During an interview on 6/12/2023 at 3:11 PM, the Administrator confirmed the facility had not educated the residents and their family regarding the right to formulate an advance directive.

Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services to meet each resident's Dementia care and behavior needs for 6 of 16 residents (Resident #34, #80, #81, #91, #96, and #303) reviewed for Dementia care and behaviors. The facility's failure to provide care and services for Dementia and behaviors resulted in Immediate Jeopardy when a physical altercation occurred between Resident #80 and #81, Resident #80 willfully pushed Resident #81, Resident #81 fell to the floor, hit his head, began having seizures, was transferred to the hospital, and expired at the hospital. A physical altercation occurred between Resident #96 and Resident #74, inappropriate sexual behavior occurred between Resident #303 and Resident #36, Resident #34 ran her wheelchair into Resident #16, Resident #85, ran over Resident #94's foot, and the state surveyors, and Resident #91, a cognitively impaired vulnerable resident with a history of behaviors and had verbalized the desire to leave the facility, was found unsupervised on another floor of the facility. The facility's failure resulted in Immediate Jeopardy (IJ) for Resident Resident #34, #80, #81, #91, #96, and #303. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator was notified of the Immediate Jeopardy for F-744 per telephone on [DATE] at 2:30 PM. The facility was cited Immediate Jeopardy at F-744. The facility was cited at F-744 at a scope and severity of K, which is Substandard Quality of Care. The IJ was effective [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE] at 2:47 PM and [DATE] at 10:19 AM, and was validated onsite by the surveyors on [DATE] through [DATE] through observations, review of audits, meeting minutes, and staff interviews. The findings include: Review of the facility's undated policy titled, Behavior Policy, revealed .Each resident will be provided with a safe place of residence .Should a resident's behavior become abusive, hostile, assaultive, or unmanageable in any way that would jeopardize his or her safety or the safety of others, the Nurse Supervisor/Charge Nurse must immediately: provide for the safety of all concerned . Review of the facility's undated policy titled, Abuse, Neglect and Exploitation, revealed .The resident has the right to be free from verbal, sexual, physical, and mental abuse .The resident has the right to be free from mistreatment, neglect .Abuse includes the depravation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being .Sexual Abuse includes sexual harassment, sexual coercion, or sexual assault .Ways to protect a resident from harm during an investigation of abuse, neglect and exploitation may include temporary one on one supervision of a resident . Review of the medical record, revealed Resident #34 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set, dated dated dated [DATE], revealed Resident #34 to have moderate cognitive impairment for decision making, inattention, and disorganized thinking. Resident #34 was coded for physical behavioral symptoms and other behavioral symptoms directed toward others ,d+[DATE] days during the assessment period, was short tempered and easily annoyed. Review of the quarterly Minimum Data Set, dated dated dated [DATE], revealed Resident #34 to have severe cognitive impairment for decision making, inattention, and disorganized thinking. Resident #34 was coded to have physical behavioral symptoms and other behavioral symptoms directed toward others ,d+[DATE] days during the assessment period, was short tempered and easily annoyed. Review of a Progress Note dated [DATE], revealed Resident #34 tried to hold people's hands when up in a wheelchair (WC) and some residents do not like this. Review of a Progress Note dated [DATE], revealed Resident #34 continuously wheeled around in her WC cursing and crying out for help. Review of a Nurse Practitioner Progress Note dated [DATE], revealed Resident #34 was evaluated on [DATE] for a pharmacy recommendation to attempt a [MEDICATION(S)] gradual dose reduction (GDR). The nurse states that she has regular behaviors of cursing and using profane language, and rolling her WC into other people. The nurse requested not to attempt GDR at this time. Resident #34 had poor insight, confusion, anxiousness, depression, agitation, inattention, abnormal heightened affect, and visual hallucinations, pulling hair, and taking off clothes. The assessment/plan revealed her [CONDITION(S)] was stable and would attempt a GDR in the future. Review of a Nurse Practitioner Progress Note dated [DATE], revealed Resident #34 was seen for a concern of increased behaviors reported by the weekend nurse who reported the resident was rolling her WC into other people. Review of a Nurse Practitioner Progress Note dated [DATE], revealed Resident #34 was seen on [DATE] for a psychiatric recommendation to discontinue [MEDICATION(S)] and start [MEDICATION(S)] (sedative medication) 0.5 mg for anxiety. She was noted to have increased behaviors over the weekend, which included the resident rolling her WC into other people. The assessment/plan was to discontinue [MEDICATION(S)] and to start [MEDICATION(S)] 0.5 mg by mouth twice daily. Review of Progress Note dated [DATE], revealed Resident #34 was up in her WC propelling on the 2nd floor unit, yelling and cursing loudly. The other residents were getting offended by the things that she yelled out. There were multiple attempts to redirect behavior without any success. Review of Nurse Practitioner Progress note dated [DATE], revealed Resident #34 was seen for bruising to her upper chest on the left side. It was unknown how the resident obtained the bruise but was consistent with bumping into another person. A medication change was made recently at the Psychiatric Nurse Practitioner's (PNP) recommendation. An order to discontinue the [MEDICATION(S)] and start [MEDICATION(S)] 0.5 mg twice daily for anxiety after the resident was noted by staff to have increased behaviors. The nurse reported the resident was rolling her WC into other people. Staff stated that behaviors have not decreased but have perhaps increased. She is still using her WC to bump into other residents and staff and is difficult to redirect. The assessment/plan was to see PNP when she was in facility the next time to see if her medication should be adjusted. Review of a Nurse Practitioner Progress note dated [DATE], revealed Resident #34 was seen related to increased behaviors. The nurses noted she used foul language and used her WC to run into other patients and staff. The assessment/plan included a Urinalysis with a Culture and Sensitivity to rule out infection, and additional blood work ordered. Review of a Nurse progress note dated [DATE], revealed Resident #34 was running over staff and residents with her WC. Review of a Nurse Practitioner Progress note dated [DATE], revealed Resident #34 was seen today for use of foul language and use of her WC to run into other patients and staff. The assessment/plan was to discontinue the [MEDICATION(S)] 0.5 mg by mouth twice daily and to start [MEDICATION(S)] (sedative medication) 0.25 mg by mouth twice daily. Review of Resident #34's Care Plan reviewed [DATE], revealed Focus Behavior Symptoms of Socially Inappropriate Behavior Resident exhibits socially inappropriate behavior. There were no interventions related to Resident #34's assessed physical behavioral symptoms on the Care Plan. Observation on the 200 Hall on [DATE] beginning at 5:00 PM, revealed Resident #34 rolled into the surveyor's legs with her wheelchair. The surveyor moved and Resident #34 followed the surveyor for several minutes. Observation on the 200 Hall on [DATE] beginning at 5:30 PM, revealed Resident #34 rolled into the surveyor with her wheelchair and stared at the surveyor, directly in the eyes. The surveyor was unable to move from her position due to the close proximity of the resident's wheelchair. After a few seconds, the resident rolled away and the surveyor walked to another area of the West side of the 200 Hall. The resident turned her wheelchair and rolled into the surveyor once again and stared directly into the surveyor's eyes. The surveyor was unable to move until the resident rolled away in her wheelchair. Observation in the 200 East Hall on [DATE] at 12:03 PM, revealed Resident #34 rolled onto Resident #94's left foot and stopped. Resident #94 waved her on and stated under his breath, .stupid .stupid .go . Resident #34 rolled off of Resident #94's foot. Observation on the 200 Hall on [DATE] at 1:55 PM, revealed Resident #34 ran into Resident #85 in the hall and the nurse separated them. Observation on the 200 Hall on [DATE] at 2:01 PM, revealed Resident #34 ran into Resident #27. Observation on the 200 Hall on [DATE] at 2:04 PM, Resident #34 threw her snack cake on the floor and rolled away down the hall toward the East Nurses' Station. As she approached the corner of the hall near the East Nurses' Station, Resident #84 waved her away from him. Resident #16 was sitting in a chair and Resident #34 rolled into Resident #16. Observation on the 200 Hall on [DATE] at 2:06 PM, Resident #34 rolled back down the hall toward the elevator, Resident #99 was sitting by the elevator in her wheelchair as Resident #34 came toward Resident #99. Resident #99 stated, .please don't hit me .please don't hit me . A staff member moved Resident #34 around to the other side of Resident #99. Resident #34 turned toward Resident #99, and Resident #99 stated, .don't hit me . Resident #34 ran into Resident #99. The staff member took Resident #34 to her room. Observation on the 200 Hall on [DATE] at 10:00 AM, revealed Resident #34 rolled her wheelchair right up on the surveyor, grabbed the surveyor's shirt with both hands, and stared in the surveyor's eyes. Review of the medical record, revealed Resident #80 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Level I Pre-Admission Screening Resident Review (PASRR) dated [DATE], revealed .Pt [patient] will go into SNF [Skilled Nursing Facility] given progressed dementia and alcoholism . Review of Resident #80's Care Plan dated [DATE] revealed .Behaviors: yells at others, aggressive behaviors at times, argumentative with staff at times . Review of a Psychotherapy Progress Note dated [DATE], revealed .see for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .SESSION CONTENT AND FOCUS .This patient is being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . He explored his current stressors. He was given support and encouragement and taught some about how a person's thinking about a situation contributes to their mood. He seemed receptive to the new information .LENGTH OF SESSION .38 minutes . Review of Resident #80's Psychotherapy Progress Note dated [DATE], revealed .see for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .SESSION CONTENT AND FOCUS .This patient is being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . He explored his current stressors. He was given support and encouragement and taught some about how a person's thinking about a situation contributes to their mood. He seemed receptive to the new information .LENGTH OF SESSION .38 minutes . Review of the quarterly MDS dated [DATE], revealed the Resident #80 was cognitively intact with verbal behaviors toward others on ,d+[DATE] days of the 7-day look back period and rejection of care behaviors on ,d+[DATE] days of the 7-day look back period. Review of a Psychiatric Periodic Evaluation dated [DATE], revealed Resident #80 was seen for depression follow up, complained of sadness since the pandemic started. He had behaviors of yelling at the nurse on [DATE] because he forgot that he had already taken his medications. He was continued on [MEDICATION(S)] (medication) for depression. Review of a Psychotherapy Progress Note dated [DATE], revealed .see for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .SESSION CONTENT AND FOCUS .This patient is being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . He explored his current stressors. He was given support and encouragement and taught some about how a person's thinking about a situation contributes to their mood. He seemed receptive to the new information .LENGTH OF SESSION .38 minutes . Review of a Psychotherapy Progress Note dated [DATE], revealed .see for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .SESSION CONTENT AND FOCUS .This patient is being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . He explored his current stressors. He was given support and encouragement and taught some about how a person's thinking about a situation contributes to their mood. He seemed receptive to the new information .LENGTH OF SESSION .38 minutes . Review of a Psychotherapy Progress Note dated [DATE], revealed .see for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .SESSION CONTENT AND FOCUS .This patient is being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . He explored his current stressors. He was given support and encouragement and taught some about how a person's thinking about a situation contributes to their mood. He seemed receptive to the new information .LENGTH OF SESSION .38 minutes . Review of a Nurse Progress Note dated [DATE], revealed Resident #80 had to be reminded to please stay out of a female resident's room and to see staff if he needed to go into the clean utility room. Nursing staff documented, .he said he is not supposed to be here and we treat him like an inmate . Review of a Nurse Progress Note dated [DATE], revealed Resident #80 had an altercation with another resident (Resident #81) that he shoved to the floor around 6:30 PM. He confirmed that he shoved the other resident to the floor after the other resident hit him. Resident #81 fell and hit the floor, was transferred to the hospital, and expired. Resident #80 was started on every 15-minute checks. Resident #80 was told to go to his room by staff. There was no facility staff seen on the video footage entering Resident #80's room during the time Resident #81 was on the floor receiving care. Review of a Nurse Progress Note dated [DATE], revealed the DON accompanied the police to Resident #80's room to discuss the alleged incident in which he pushed another resident and the resident fell on the floor. Resident #80 was calm and cooperative and remained on every 15-minute checks until he could be evaluated by the Psychiatric Nurse Practitioner. Review of a Nurse Progress Note dated [DATE], revealed Resident #80 continued every 15-minute checks and had been rude toward staff on [DATE] because a female resident asked the nurse to please have him leave her room because he was playing loud music by her door. Resident #80 said he was a grown man and could do as he wished. Review of a Nurse Progress Note dated [DATE], revealed a Police Detective was in the facility to speak with Resident #80 about the incident with Resident #81. Every 15-minute checks were discontinued (d/c) and he was placed on 1:1 behavior monitoring until further notice. Review of Resident #80's Psychiatric Periodic Evaluation dated [DATE], revealed, .was involved in an incident on ,d+[DATE] [2021] when another resident was hitting him so he pushed the other resident who fell to the floor and later died .states .they're trying to charge me with murder .says he has been very anxious .I'm not doing good .I could use some [MEDICATION(S)] .shows remorse and states .it was a terrible accident .does not appear to be at a risk to himself or others at this time .continues on 1:1 [one on one] observation . Resident #80 was not evaluated by psychiatric services until [DATE], 7 days after the incident with Resident #81 occurred. Review of a Nurse Progress Note dated [DATE], revealed Resident #80 was taken to the police department by the Administrator and DON. He appeared slightly anxious when taken inside the facility. Review of the medical record, revealed Resident #81 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nurse Progress Note dated [DATE], revealed Resident #81 attempted to pull his shirt over his head while he stood in the hallway. His clothing was placed back on by staff. Review of the Physician's Progress Note dated [DATE], revealed Resident #81 wandered the halls. Staff stated the resident did not truly yell but had agitation. His [MEDICATION(S)] (medication) was decreased from 2 milligram (mg) twice a day to 2 mg at bedtime and his [MEDICATION(S)] (medication) was continued. Review of the Nurse Progress Note dated [DATE], revealed Resident #80 had wandering behaviors and episodes of attempting to lay or sit on the floor, he appeared anxious/agitated and had voided in the floor multiple times. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 ambulated in the hall, pulled clothing over his face, and proceeded to run into wall. He was taken back to his room and was assisted to bed but before a staff member exited the room, he was back up and walked out into the hallway. Review of the Nurse Progress Note dated [DATE] at 4:15 AM, revealed Resident ran into door .he did however want to keep walking .finally coaxed into the bed and CNT [Certified Nurse Technician] sat with him until he went to sleep . Review of the Nurse Progress Note dated [DATE], revealed Resident #81 was noted sitting self down on the floor or laying his head down on the floor at intervals. Review of the Psychotherapy Progress Note dated [DATE] revealed, .Focus of Session: This patient was seen due to reports of stripping by the unit manager. It is unlikely that he will be able to recall this conversation but if behavior stops, it may be effective. There has been some decrease in this behavior according to staff reports. He was not able to articulate that he understood .LENGTH OF SESSION .Start Time: 38 minutes . Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #81 had been combative and was sleeping more. The Physician noted they may want to consider decreasing the resident's medication. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 was tearful and anxious, he was noted to be very still and rigid when he attempted to sit, voided in the floor, and had wandering behaviors. Review of the Nurse Progress Note dated [DATE], revealed although staff prompted Resident #81 to toilet, he was disagreeable and would frequently refuse and void in the floor. Resident #81 refused to wear pants/briefs and would frequently undress. He also had tearful, anxious moods and could be aggressive at times. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 voided in the floor after toileting. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 was observed walking without any clothes on and he was not receptive to redirection. He also was found in the floor, was resistant to staff helping him back up and remained in the floor for several minutes. Review of the Psychotherapy Progress Note dated [DATE] revealed, .Focus of Session: This patient [Resident #81] was seen due to reports of stripping by the unit manager. It is unlikely that he will be able to recall this conversation but if behavior stops, it may be effective. There has been some decrease in this behavior according to staff reports. He was not able to articulate that he understood .LENGTH OF SESSION .Start Time: 38 minutes . Review of the Nurse Progress Note dated [DATE], revealed Resident #81 was alert with confusion, would lean backwards when staff attempted to assist him, attempted to remove his clothing, and voided in the floor although he was toileted multiple times. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] ##81 was sometimes calm and other times was more aggressive. He was felt by the nursing staff to be too sedated, but the physician documented he was not changing his medications at this time. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 was very resistant to care and attempted to hit the nurse. Review of the MDS dated [DATE], revealed Resident #81 had severe cognitive impairment for decision making and was coded for physical behavioral symptoms directed towards self and others and rejection of care behaviors on ,d+[DATE] days of the 7-day look back period, and wandered daily. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 was anxious/agitated at times and attempted to lay or sit in floor. Staff intervened multiple times. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 had agitation and was noted to remove clothing. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 walked backwards. Review of the Nurse Progress Note dated [DATE], revealed, Resident #81 was dressed by the CNA [Certified Nursing Assistant] and he became angry that he had to put on clothes. He threw a trash can into the hallway, then walked to Nurses' Station, and threw a computer onto the desk. CNA was unable to give him a shower due to the resident hitting and punching the CNA. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .At times he will agitate other residents .saw him fighting with another resident over a cane .no change in medicine today . Review of the Nurse Progress Note dated [DATE], revealed Resident #81 had self-inflicted sores to his arms. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 was smiling and dancing in the hall, had urinated in the floor multiple times, and staff attempted to toilet the resident, but he refused. Review of the Psychotherapy Progress Note dated [DATE], revealed .Focus of Session: This patient [Resident #81] was seen due to reports of stripping by the unit manager. It is unlikely that he will be able to recall this conversation but if behavior stops, it may be effective. There has been some decrease in this behavior according to staff reports. He was not able to articulate that he understood .LENGTH OF SESSION .Start Time: 38 minutes . Review of the Nurse Progress Note dated [DATE], revealed Resident #81 sat upright on the floor next to his bed. Urine was noted on the floor around the resident. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 had frequent episodes of agitation, was tearful, attempted to lay in the floor multiple times, and was resistant to care at times. Review of the Nurse Progress Note dated [DATE], revealed, Resident #81 was up most of night wandering in the hallway. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 attempted to lay and sit in the floor multiple times, removed clothing, urinated in floor, and was agitated. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 shook his fist at one specific resident and would shoot the bird finger every time he saw that resident. His behaviors caused agitation and anxiety to the other resident. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 had episodes of anxiety/agitation and removed his pants and pull-ups. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 had agitation and mood changes. He was observed throwing books from the desk and attempted to pull the fire extinguisher from the wall. He required constant redirection until calmer. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 was intrusive (causing disruption) and voided in the floor. He was agitated and only slept for short periods. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 voided in the floor and removed clothing. He appeared to be agitated, staff attempted to trim his nails, but he was noncompliant. Review of the Psychotherapy Progress Note dated [DATE], revealed .Focus of Session: This patient was seen due to reports of stripping by the unit manager. It is unlikely that he will be able to recall this conversation but if behavior stops, it may be effective. There has been some decrease in this behavior according to staff reports. He was not able to articulate that he understood .LENGTH OF SESSION .Start Time: 38 minutes . Review of the Nurse Progress Note dated [DATE], revealed, Resident #81 was observed laying on his back on the floor. He was uncooperative at times. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 was up ambulating in the hallway wearing only a shirt and frequently exposed himself. He was agitated, anxious, aggressive, and turned over a table in the Dining Room. He was difficult to redirect. Review of the Nurse Progress Note dated [DATE], revealed, Resident #81 continued to wander and could be intrusive and impulsive. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 was noted with a behavioral outburst this shift with periods of agitation/anxiety, was seen pulling a handrail off of the wall, made multiple attempts to sit or lay in floor, and when he was calm would hug/wave at staff but when angry he could be aggressive. Review of the Psychotherapy Progress Note dated [DATE] revealed .Focus of Session: This patient [Resident #81] was seen due to reports of stripping by the unit manager. It is unlikely that he will be able to recall this conversation but if behavior stops, it may be effective. There has been some decrease in this behavior according to staff reports. He was not able to articulate that he understood .LENGTH OF SESSION .Start Time .38 minutes . Review of the Nurse Progress Note dated [DATE], revealed Resident #81 wandered the hall most of the day, had some agitation/anxiety, and episodes of removing his clothes. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 was very active and wandering in the evening, walked as fast as he could and rammed himself into the wall a couple of times. He was also agitated and swung his fists at the nurse a couple of times. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 was observed lying on his back in the floor, he was noted to have increased behaviors, was more resistant and impulsive. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 was noted to have agitation, anxiety, and aggressiveness, and he attempted to pull items from the walls. Staff applied his helmet multiple times, and he would remove it and throw it. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 had confusion, agitation, anxiety, and aggressiveness. Staff applied his helmet multiple times, but he would remove it from his head and throw it. He tried to push the CNA cart, the nurse medication cart, and the Dining Room cart and pull off the doors. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 refused to allow staff to obtain vital signs, had aggressive and combative behaviors, randomly struck out at staff, and was difficult to redirect. His helmet was placed on him multiple times and he would take it off and throw it. He was on every 15-minute checks. Review of the Psychotherapy Progress Note dated [DATE] revealed .Focus of Session: This patient [Resident #81] was seen due to reports of stripping by the unit manager. It is unlikely that he will be able to recall this conversation but if behavior stops, it may be effective. There has been some decrease in this behavior according to staff reports. He was not able to articulate that he understood .LENGTH OF SESSION .Start Time: 38 minutes . Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .Patient more agitated at times. Nursing staff notes it tends to be very much at random. Some days he can do well and other days not. Patient's [MEDICATION(S)] has been discontinued as he was placed on [MEDICATION(S)] .We will increase echopraxia [[MEDICATION(S)]] to 7.5 mg at bedtime .continue with 5 mg twice daily .Patient may need to return to [MEDICATION(S)] but will observe for now . Review of the Nurse Progress Note dated [DATE], revealed Resident #81's behavior varied from hour to hour, at times he was quiet and cooperative and at other times he was intrusive with staff and residents. The resident was agitated without provocation, continued to refuse to wear shoes or socks and would remove them as soon as they were placed, and attempted to undress repeatedly throughout the day. He was noncompliant with his helmet, removed it and threw it on the floor. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 had episodes of agitation, anxiety, and aggressiveness with others. Resident #81 remained on every 15-minute checks. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 wandered most of the evening. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 was aggressive and combative, and staff would continue to monitor. Review of the Nurse Progress Note dated [DATE], revealed Resident #81 continued to wander and had episodes of agitation and anxiety. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .periods of sleeping versus walking and being agitated. No significant issues regarding contact inappropriately with other residents. Will remove close [clothes] periodically. This is ongoing/old behavior .continue [MEDICATION(S)] .2.5 mg twice daily and 7.5 mg nightly . Review of the Psychotherapy Progress Note dated [DATE] revealed .Focus of Session: This patient was seen due to reports of stripping by the unit manager. The unit manager requested he be seen once weekly. If behavior stops, it may be effective. There has been some decrease in this behavior according to staff reports. He was told the reasons it is important to wear clothes. He seemed to understand. He was reminded of some other general rules/norms due [TRUNCATED]

Based on policy review, video camera footage review, medical record review, observation, and interview, the facility failed to ensure adequate supervision of residents and ensure interventions were implemented for residents with physically aggressive and wandering/exit-seeking behaviors for 5 of 14 sampled residents (Resident #34, #80, #81, #91 and #96) reviewed for abuse. The facility's failure resulted in Immediate Jeopardy when Resident #80 willfully pushed Resident #81. Resident #81 fell to the floor, hit his head, began having seizures, was transferred to the hospital, and expired at the hospital. The facility's failure resulted in Immediate Jeopardy when Resident #34, #80, #81, #91 and #96 did not have supervision and interventions implemented for their behaviors. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy for F-600 on [DATE] at 11:52 AM, in the Administrator's office. The facility was cited Immediate Jeopardy at F-600. The facility was cited F-600 at a scope and severity of K, which is Substandard Quality of Care. The IJ was effective from [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE] at 2:47 PM and was validated onsite by the surveyors on [DATE] through [DATE] through observations, review of audits, meeting minutes, and staff interviews conducted on all shifts. The findings include: Review of the facility's undated policy titled, Abuse, Neglect and Exploitation, revealed .The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The resident has the right to be free from mistreatment, neglect, and misappropriation of property .the center must take appropriate corrective action to protect residents. The center should oversee the implementation of corrective action and evaluate whether it is effective .The Director of Nursing in conjunction with other clinical team members shall initiate or revise plan of care to reflect the resident/patient's condition and measures to be taken to prevent recurrence, where appropriate .Appropriate steps shall be taken to prevent recurrence of the incident .The Quality Assessment and Assurance committee should monitor the reporting and investigation of the alleged violations, including assurances that residents are protected from further occurrences and that corrective actions are implemented as necessary . Review of the facility's undated policy titled, Behavior Policy, revealed .Each resident will be provided with a safe place of residence .Should a resident's behavior become abusive, hostile, assaultive, or unmanageable in any way that would jeopardize his or her safety or the safety of others, the Nurse Supervisor/Charge Nurse must immediately: provide for the safety of all concerned . Review of the medical record, revealed Resident #34 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #34's Certified Nursing Assistant (CNA) care card revealed there was no date on the care card and there were no interventions for running into other residents/staff. Review of Resident #34's Care Plan with a review date of [DATE], revealed the resident had behavior symptoms and exhibited socially inappropriate behavior. Interventions included staff were to document in the medical record the intensity, duration, and frequency of the behavior. The Medical Doctor (MD) was to assess the resident medically for signs of inappropriate behavior and encourage participation in Activities of Daily Living (ADLs). The staff were to redirect Resident #34 when exhibiting negative behaviors, refer the resident to psychiatric services as needed, administer the medications as ordered by the physician, escort the resident to a private area if needed, try to take her to a quiet and calm environment during periods of agitation, and offer activities that would change her mood and behaviors. There were no interventions noted on Resident #34's Care Plan for her aggressive behavior of running into staff and other residents with her wheelchair. Review of the Psychiatric Periodic Evaluation dated [DATE], revealed Resident #34 was up in a wheelchair (WC), going up and down the halls yelling, asking for water, and had intrusive behavior. The resident was observed almost running over people at times with her wheelchair, was agitated and aggressive, had anxiety, disinhibition, and motor disturbance. The psychiatric evaluation recommended to discontinue the [MEDICATION(S)] and start [MEDICATION(S)] (sedative medications) 0.5 milligrams (mg) by mouth twice daily for the anxiety. Review of the Nurse Practitioner Progress note dated [DATE] and [DATE] revealed the nurse reported Resident #34 was rolling her WC into other people. Review of the Nursing Progress Note dated [DATE], revealed Resident #34 was up in her WC, self-propelled the WC on the unit yelling and cursing loudly. Other residents were offended by the things that she yelled out. There were multiple attempts made to redirect the behavior without any success. Review of the Nurse Practitioner Progress Note dated [DATE], revealed Resident #34 was evaluated for bruising to the left upper chest and it was unknown how she got the bruise, but it was consistent with bumping into another person. Medication changes were made recently due to psychiatric (psych) recommendations. The [MEDICATION(S)] order was discontinued, and [MEDICATION(S)] 0.5 mg started two times daily for the anxiety, after the resident was noted by staff to have increased behaviors. The nurse reported the resident was rolling her WC into other people and stated .staff states that behaviors have not decreased, but have perhaps increased. Resident was using WC to bump into patients and staff. Difficult to redirect . Review of the Nurse Practitioner Progress Note dated [DATE], revealed Resident #34 was evaluated for increased behaviors. The nurses noted she used foul language and used her WC to run into other patients and staff. Review of the Progress Note dated [DATE], revealed Resident #34 continued to independently wheel herself around in her WC, and ran over staff and residents with her WC. Review of the Nurse Practitioner Progress Note dated [DATE], also revealed Resident #34 used foul language and her WC to run into other patients and staff. Review of the Nurse Practitioner Progress Note dated [DATE], revealed Resident #34 was evaluated for new .discoloration and scrapes superior to anterior side of R [right] knee. Contusion of right knee the resident noted to self propel in WC often bumping into other residents and staff. Anxiety-likely contributed to bumping into others in WC . Review of the Nurse Progress Notes dated [DATE], revealed Resident #34 was seen by the Nurse Practitioner who ordered an increase in the [MEDICATION(S)] (sedative medication) 0.25 mg from twice a day (BID) to three times daily (TID). Review of the Nurse Progress Note dated [DATE], revealed the Nurse Practitioner evaluated Resident #34 at the psychiatric recommendation to increase the patient's [MEDICATION(S)] order from [MEDICATION(S)] 0.25 mg BID to TID due to (d/t) the resident's anxiety/agitation and reported behaviors. The reported behaviors included bumping into others in her WC. Review of the Nurse Progress Note dated [DATE], at 3:30 AM, revealed the DON .went upstairs this afternoon resident noted bumping her wheelchair into the back of another resident that was sitting in their wheelchair. The other resident did appear to notice their wheelchair had been bumped by this resident. Resident appeared unaware she had bumped into someone. Resident redirected into a less crowded area. Therapy to reevaluate chair for appropriateness. Maintenance padded some parts of residents [resident's] chair to decrease the chance of her bumping into someone and causing injury. IDT [Interdisciplinary Team] team met to discuss interventions resident placed on 1:1 [one on one observation] when oob [out of bed] in her wheelchair until therapy can assess her wheelchair . Observation on the 200 Hall on [DATE] at 5:00 PM, revealed Resident #34 rolled into the surveyor's legs with her wheelchair. The surveyor moved from that location and Resident #34 followed the surveyor for several minutes. Observation on the 200 Hall on [DATE] at 5:30 PM, revealed Resident #34 rolled her wheelchair up to the surveyor, pinning the surveyor against the wall, and stared at the surveyor, directly in the eyes. The surveyor was unable to move from her position due to the close proximity of the resident's wheelchair. After a few seconds, the resident rolled away and the surveyor walked to another area of the West side of the 200 Hall. The resident turned her wheelchair and rolled up to the surveyor once again and stared directly into the surveyor's eyes. The surveyor was unable to move until the resident rolled away in her wheelchair. Observation in the 200 East Hall on [DATE] at 12:03 PM, revealed Resident #34 rolled onto Resident #94's left foot and stopped. Resident #94 waved her on and stated under his breath, .stupid .stupid .go . Resident #34 rolled off of Resident #94's foot. Observation on the 200 Hall on [DATE] at 1:55 PM, revealed Resident #34 ran into Resident #85 in the hall and the nurse separated them. Observation on the 200 Hall on [DATE] at 2:01 PM, revealed Resident #34 ran into Resident #27. Observation on the 200 Hall on [DATE] at 2:04 PM revealed, Resident #34 threw her snack cake on the floor and rolled down the hall toward the East Nurses' Station. As she approached the corner of the hall near the East Nurses' Station, Resident #84 waved Resident #34 away from him. Resident #16 was seated in a chair and Resident #34 rolled into Resident #16. Observation on the 200 Hall on [DATE] at 2:06 PM revealed, Resident #34 rolled down the hall toward the elevator, Resident #99 was seated in a wheelchair by the elevator as Resident #34 came toward Resident #99. Resident #99 stated, .please don't hit me .please don't hit me . A staff member moved Resident #34 to the other side of Resident #99. Resident #34 turned toward Resident #99, and Resident #99 stated, .don't hit me . Resident #34 ran her wheelchair into Resident #99. A staff member took Resident #34 to her room. During an interview on [DATE] at 8:27 AM, Licensed Practical Nurse (LPN) #1 stated, .on ,d+[DATE] [2021] I saw [Named Resident #34] running over you and the other surveyor .so I called the DON and asked is there not a wheelchair guard we can put on her WC .she's getting out of hand .hurting her own self .bruises on her hand .but I really didn't get a clear response .she kind of brushed me off . Review of the medical record, revealed Resident #80 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #80 was assessed to have a Brief Interview of Mental Status (BIMS) score of 15, which indicated Resident #80 had no cognitive impairment for decision making, had verbal behavioral symptoms that were directed toward others, threatened others, screamed at others, rejected care, and walked with supervision but required no physical help. Review of Resident #80's Care Plan dated [DATE] revealed .Behaviors: yells at others, aggressive behaviors at times, argumentative with staff at times . Review of the medical record, revealed Resident #81 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], revealed Resident #81 was assessed to have a BIMS score of 2, which indicated the resident had severely impaired cognition, had poor decision making skills, required cues/supervision, had physical behaviors directed toward others which included hitting, pushing, grabbing and behaviors of pacing, disrobing, wandering, rejecting care, walked with limited assistance of 1 person, and required extensive assistance of staff for dressing and eating activities. Review of Resident #81's Care Plan reviewed [DATE], revealed .Behaviors: wandering and exit seeking .likes to disrobe through the day and wanders inappropriate places naked. Becomes agitated when staff tries to put clothes back on, family aware, can be hard to redirect him, can be combative and resist care, easily agitated when redirected, will place self on floor in various places . Review of the facility's video camera footage dated [DATE] beginning at 6:30 PM, revealed the following: At 6:30 PM and 59 seconds, Resident #81 appeared in view of the camera at the 2 East Nurses' Station hallway wearing a long t-shirt with a [NAME] emblem that reached above the knees and was not wearing pants. Resident #81 was facing the camera. At 6:31 PM and 45 seconds, Resident #80 appeared in view of the camera wearing jeans with red suspenders, a shirt, hat, and shoes. Resident #80 had his back to the camera. Resident #80 appeared to be talking to Resident #81 because Resident #80's head was moving side to side as if talking. At 6:32 PM and 4 seconds, Resident #81 took his right hand and swung at Resident #80 at his waist level and Resident #80 stepped back. At 6:32 PM and 10 seconds, Resident #80 stepped forward to the original position while he appeared to be talking as his head was moving side to side. Resident #81 took his left hand, swung at Resident #80, and hit Resident #80 on the right side of his chest. At 6:32 PM and 12 seconds, Resident #80 stepped forward and with his right open hand, shoved Resident #81 in the chest causing Resident #81 to fall back, with his body straight. There was no flexing or bending of Resident #81's body as he fell to the floor, striking his head. At 6:32 PM and 15 seconds and 6:32 PM and 16 seconds, CNA #1, CNA #2, and LPN #1 appeared in camera view responding to the incident. CNA #1 and #2 went to Resident #81's side on the floor and began to care for the resident. LPN #1 went to Resident #80 and appeared to be talking with him. Resident #80 threw up his arms and appeared to be talking with his head moving side to side. Resident #80 walked to his room alone and was seen entering the door of his room. No one escorted Resident #80 to his room. At 6:32 PM and 20 seconds, Resident #81 appeared to move his right arm. At 6:32 PM and 29 seconds, CNA #3 appeared in camera view and kneeled at Resident #81's side on the floor. Resident #81 had no pants on. At 6:32 PM and 37 seconds, CNA #4 appeared in camera view and walked around the area. At 6:32 PM and 40 seconds, Resident #81 appeared to move his left leg and toes. At 6:33 PM and 13 seconds, Resident #81 appeared to move his left arm. At 6:33 PM and 30 seconds, LPN #2 appeared in camera view and went behind the Nurses' Station. At 6:34 PM and 33 seconds, CNA #2 and CNA #3 appeared to position Resident #81 on his right side. At 6:35 PM and 34 seconds, Registered Nurse (RN) #1 appeared to take Resident #81's blood pressure on the right arm. At 6:36 PM and 30 seconds, the police appeared in camera view at the 2 East Nurses' Station, walked to Resident #80's room, and stood outside his door. There was no staff member seen on the video entering Resident #80's room. At 6:37 PM and 43 seconds, Resident #81 appeared to move his legs. At 6:38 PM and 30 seconds, facility staff applied oxygen to Resident #81 while LPN #1 was on the telephone at the Nurses' Station and pointed toward Resident #81 lying on the floor. At 6:39 PM and 17 seconds, the Emergency Medical Services (EMS) and Fire personnel appeared in camera view and assumed care of Resident #81. The resident was placed on a stretcher and was transported by EMS out of camera view. Review of the EMS Prehospital Patient Record dated [DATE] at 6:40 PM, revealed .Convulsions fall Nursing home [DATE] at 19:01 PM [7:01 PM] alert nonverbal facial grimace when head palpated, PERRLA [pupils equal, round, reactive to light accommodate] . Review of the emergency room (ER) visit note dated [DATE] at 8:19 PM, revealed .He [Resident #81] apparently was involved in altercation with another resident and was found on the floor per EMS .alert, nonverbal, [baseline nonverbal], alert/awake .CT [computerized tomography] of head bilateral acute subarachnoid hemorrhage [bleeding in the space between the brain and the tissue covering the brain] with subdural hemorrhage [a pool of blood between the brain and its covering] along the flax, right middle cranial fossa. Right tentorium and left frontal intraparenchymal hematoma [bleeding within the brain and more likely to result in death], no midline shift or herniation overall favor post traumatic etiology .subdural and subarachnoid and several contusions .needs to be monitored in neuro ICU [intensive care unit], contacted [Named Hospital] .clinical impression: intracranial hemorrhage . Review of the (Named Hospital) Emergency Department note dated [DATE] at 12:38 AM, revealed, .GCS [Glasco coma scale to assess depth and duration of coma with ,d+[DATE] assessed as moderate brain injury] 10 at baseline, vital signs stable, awake, nonverbal, roving eye movements with right sided gaze deviation .bradycardic [slow heart rate] 45 .CT no skull fracture .enlarging intraparenchymal hemorrhage [a potentially life threatening condition in which a [MEDICATION(S)] force injury causes blood to pool within the brain tissue] in the frontal lobes, subdural [under the membrane covering the brain] and subarachnoid [space between the brain and the surrounding tissue] and intraventricular hemorrhage .no evidence of acute traumatic injury to the chest .CT [computerized tomography] notable for worsening intraparenchymal hemorrhage, extensive bilateral subarachnoid and subdural hematomas. Admit trauma surgery in stable condition . Review of the (Named Hospital) Case Management Note dated [DATE], revealed .family conversation [DATE] patient made a DNR/DNI [do not resuscitate/do not intubate] as well as deferring [putting off] any neuro-surgical intervention .On night [DATE] patient [Resident #81] began having seizures, ultimately it progressed into status epilepticus [a [CONDITION(S)] that lasted longer than 5 minutes] as patient did not regain previous GCS [Glasgow Coma Scale]. Patient declined from a respiratory status requiring NRB [nonrebreather] and Opti flow [nasal high flow oxygen] while awaiting family to arrive at hospital. After seeing [Named Resident #81] over facetime, his sister [Named Person] called and requested comfort care. Patient transitioned to Versed and [MEDICATION(S)] drips, decreased oxygen 2 liters per nasal cannula and expired with sister [Named Person] at bedside . Review of Resident #80's Nurses' Note dated [DATE] at 8:16 PM, revealed, .Resident [Resident #80] had an altercation with another resident [Resident #81] that he shoved to the floor around 6:30 PM. when asking the resident [Resident #80] what happened he said yes I shoved him [Resident #81] to the floor he hit me .Resident [Resident #80] has been started on every 15-minute checks . Review of the medical record, revealed 15-minute observation checks were conducted on Resident #80 on [DATE] - [DATE] at 10:15 AM. At 10:15 AM, Resident #80 was placed on one on one observation by the staff. Review of Resident #80's Nurses' Note dated [DATE] at 8:05 PM, revealed, .Every 15 minute check he has been rude towards staff today because a female resident asked the nurse to please have him leave her room because he is playing loud music by her door. He said he is a grown man and can do as he wishes . Review of the medical record, revealed on [DATE] at 10:15 AM, one on one observations of Resident #80 were conducted until [DATE] at 11:00 AM, when the Administrator and DON escorted Resident #80 to the police department. During an interview on [DATE] at 3:09 PM, LPN #1 confirmed her witness statement. She stated, .I was just around the corner and came around and saw [Named Resident #81] going down [falling backwards] and I saw [Named Resident #80] throw his hands up as [Named Resident #81] fell back and I said what are you doing [Named Resident #80] said I didn't do nothing he hit me first .I made sure [Named Resident #81] was OK and told [Named Resident #80] to go to his room . During an interview on [DATE] at 4:45 PM, CNA #2 confirmed her witness statement. She stated, .We had just finished dinner tray pick up and we were just around the corner at room [ROOM NUMBER] talking about a car fire and I heard a loud thud. We ran around the corner and saw [Named Resident #81] lying on the floor and [Named Resident #80] standing near him .No, I never heard any loud talking or yelling before I heard the thud .I have not seen them [Resident #80 and Resident #81] talking or interacting before .I have heard [Named Resident #80] make a threat about [Named Resident #81] if [Named Resident #81] sat on the floor because he was agitated or walk around naked. [Named Resident #80] would say he [Resident #81] shouldn't be naked like that and if up to him [Resident #80] he would take care of him [Resident #81] .I cannot say for sure if anyone else heard it .No, I didn't tell anyone .No, I don't remember when [Named Resident #80] said it . During an interview on [DATE] at 10:17 AM, CNA #1 confirmed her witness statement. She stated, .[Named Resident #80] would yell at staff about smoke breaks .He [Resident #80] did make statements about [Named Resident #81] that [Named Resident #81] knows what he is doing when [Named Resident #81] would sit in the floor because he couldn't get his way. [Named Resident #80] would say when [Named Resident #81] walked around naked [Named Resident #80] would say the ladies don't want to see that. I told him [Resident #80] that [Named Resident #81] is not like everyone else, he don't know better .I never saw [Named Resident #80] interact with [Named Resident #81] he [Resident #80] just told me that [Named Resident #81] knows what he is doing . During an interview on [DATE] at 4:18 PM, CNA #7 stated, .I was on the elevator don't remember the date, taking [Named Resident #80] down for smoke break and I over heard him say about [Named Resident #81] that he [Resident #80] would hit him [Resident #81] .He [Resident #80] said I'm going to hit him .[Named Resident #81] had been walking down the hall naked .We immediately had put him [Resident #81] in a gown .No, I can't recall ever hearing that statement again . During an interview on [DATE] at 11:18 AM, the DON stated, .[Named Resident #81] could get argumentative with staff about smoking .I was not aware of any aggressive interactions between [Named Resident #80] and [Named Resident #81] prior to incident [[DATE]] .After the incident we placed [Named Resident #80] on every fifteen minute checks till psych [psychiatry] saw him. He had no psych issues just the incident .After the police said they were going to charge him [Resident #80] we placed him on one to one observation until he [Resident #80] went to the precinct . During a telephone interview on [DATE] at 11:45 AM, Detective #1 with the (Named) Police Department stated, .[Named Resident #80] is charged with reckless homicide . Review of the medical record, revealed Resident #91 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Elopement Risk assessment dated [DATE], revealed Resident #91 was at low risk for elopement. Review of the MDS dated [DATE], revealed Resident #91 had moderate cognitive impairment and was not coded for behaviors. Review of the Nurse Progress Note dated [DATE] at 9:22 PM, revealed Resident #91 had been .very anxious and cussing at staff. Staff requested a new order for [MEDICATION(S)] [a medication for anxiety] . Review of the Nurse Progress Note dated [DATE] at 10:56 AM, revealed Resident #91 was observed in the resident's room urinating in his roommate's water pitcher. The resident had a hematoma and fresh blood on the right temple, and a small puncture wound that was bleeding. The resident was confused and stated he fell 8 days ago. Review of the Nurse Progress Note dated [DATE] at 2:19 PM, revealed Resident #91 received an [MEDICATION(S)]. He seemed more confused than usual. Review of the Nurse Progress Note dated [DATE] at 12:03 PM, revealed Resident #91 had increased confusion. Review of the Nurse Progress Note dated [DATE] at 9:43 AM, revealed Resident #91 had increased confusion and wanted to go to the bank. The Nurse Practitioner was made aware of the resident's increased confusion. Review of the Nurse Progress Note dated [DATE] at 4:04 PM, revealed the hospice agency was notified of Resident #91's behavior, that he thought his son was up and walking around and was yelling for the kids to come into the room. Resident #91 received [MEDICATION(S)] for increased agitation. Review of the Nurse Progress Note dated [DATE] at 1:33 PM, revealed Resident #91 stated the doctor came and hit him 3 times in the head with a sledgehammer, was slightly confused and talking about violence to other people. Review of the Nurse Progress Note dated [DATE] at 3:33 PM, revealed Resident #91 had increased confusion and was looking for band members and a place to set up equipment. Resident #91 was administered [MEDICATION(S)]. Review of the Nurse Progress Note dated [DATE] at 8:34 AM, revealed Resident #91 ambulated in the hallway, was redirected by staff, was alert with confused episodes, and [MEDICATION(S)] was administered. Review of the Care Plan revised [DATE], revealed Resident #91 was care planned for Cognitive Deficits with interventions which included therapeutic activities, encourage participation in activities throughout the day; [CONDITION(S)] Drug Use with interventions which included monitor for changes in behavior and mood, observe for any signs of decline in functional or cognitive status; and Behavior Symptoms: Wandering/Risk for elopement which included interventions of Wanderguard and monitor placement, placed on every 15 minute checks for 24 hours, and to redirect away from exit doors and elevator was added on [DATE]. Review of the facility's Occurrence Report dated [DATE], revealed Resident #91 was observed by staff on the 1st floor of the facility unsupervised. The staff member assisted him back to the 2nd floor (a secured unit where if a Wanderguard is on a resident, the elevator will not move without a code. Resident #91 did not have a Wanderguard at the time of this incident). The facility's investigation revealed when the elevator arrived at the 1st floor the Occupational Therapist was waiting to go upstairs and retrieve a resident for therapy services. She observed Resident #91 exit the elevator on the 1st floor and at the time did not think anything about it. She proceeded to the 2nd floor to retrieve a resident for therapy, at which time the therapist realized that Resident #91 exited the elevator on the first floor, alone. The Social Worker returned the resident to the 2nd floor. Review of the Elopement Risk assessment dated [DATE], revealed Resident #91 was at high risk for elopement and a Wanderguard was placed on Resident #91. During an interview on [DATE] at 2:17 PM, the Occupational Therapist (OTR/L) was asked about the incident that occurred on the elevator with Resident #91. The OTR/L stated, .[Named Resident #91] never been on [therapy] case load .12:,d+[DATE] [PM] .getting on elevator, he [Resident #91] was getting off .there was no alarm going off upstairs .I proceeded to get a resident I was working with to bring him back down .while upstairs Social Worker had brought him back upstairs . Review of the medical record, revealed Resident #96 was admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #96 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #96 was assessed to have inattention, disorganized thinking, verbal, and physical behavioral symptoms directed toward others, rejected care, and had wandering behaviors. Review of a Nurse Progress Note dated [DATE], revealed Resident #96 was observed in Resident #74's room talking with a female resident. The female resident stated, He hit me. The only intervention was every 15 minute checks. Review of Resident #96's undated CNA Care Plan revealed the resident could become aggressive, one on one observation resolved on [DATE], and only every 15-minute checks were implemented. During an interview on [DATE] at 11:50 AM, RN #2 stated, .Today is my first day here .I received nothing really in regard to orientation .No, no one told me anything about the patient population like behaviors or specifics . During an interview on [DATE] at 12:17 PM, CNA #6 stated, .This is my third day working here .I received no orientation on the type of patients I will care for .They said here is your assignment and told me which residents were continent and who could get up .showers . During an interview on [DATE] at 12:28 PM, CNA #5 stated, .This is my first day working here .I received no orientation .They did not tell me about the type of patient or how to handle .I received no education or information on the type of patient or how to handle behaviors or dementia . Refer to F-726, F-744, F-835, and F-687. The surveyors verified the Removal Plan by: 1. Resident #80 was discharged from the facility on [DATE], return is not anticipated. 2. A facility wide baseline behavior assessment review will be conducted by the Geriatric Psychiatric Nurse Practitioner on [DATE] for all residents in the facility. The surveyors reviewed the behavior assessments. 3. A comprehensive review of the medical record and Care Plan will be conducted by the Director of Nursing and Nurse Supervisor to ensure compliance. The surveyors reviewed the Care Plans and medical records and interviewed the DON. 4. An audit was conducted of all residents with behaviors to ensure appropriate interventions were in place for noted behaviors and were care planned. This audit will be conducted monthly for 3 months and until 100% compliance. The surveyors reviewed the audits. 5. Quality Assurance Performance Improvement (QAPI) was initiated to review the effectiveness of interventions that had been in place. Failed interventions were reviewed and adjusted for appropriateness. Interventions will be updated if it is noted that behaviors continued. The surveyors reviewed the audits. 6. Residents placed on gradual dose reductions will be monitored weekly by psychiatric services for behavioral changes for a minimum of 14 days for any negative outcomes. All residents that have been [TRUNCATED]

Based on policy review, agency contract review, employee personnel file review, observation, and interview, the facility failed to ensure licensed nurses and certified nursing assistants (CNA) had the knowledge and skills necessary to assess residents, prevent abuse, and provide appropriate care to meet the residents needs for 5 of 16 sampled residents (Resident #34, #80, #81, #91, and #96) with physically aggressive and wandering/exit-seeking behaviors. The facility's failure resulted in Immediate Jeopardy when Resident #80 willfully pushed Resident #81. Resident #81 fell to the floor, hit his head, began having seizures, was transferred to the hospital, and expired at the hospital. The facility's failure resulted in Immediate Jeopardy when Resident #34, #80, #81, #91, and #96 did not have supervision and interventions implemented for their aggressive behaviors. The failure of the licensed nurses and CNAs to identify behaviors and respond to those behaviors and the potential/likelihood of continued behaviors could result in serious injury to others in the facility. The failure to provide competent staff to meet resident needs, failure to provide orientation and/or training for staff, failure to oversee implementation of resident care policies and the failure to provide supervision and/or monitoring of the delivery and implementation of care could result in serious injury to others in the facility. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy for F-726 on [DATE] at 5:22 PM, in the Administrator's Office. The facility was cited Immediate Jeopardy at F-726. The IJ was effective from [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE] at 10:19 AM, and was validated onsite by the surveyors on [DATE] through [DATE] through observations, review of education provided, audits, meeting minutes, and staff interviews conducted on all shifts. The findings include: Review of the facility's undated policy titled, Behavior Policy, revealed .Each resident will be provided with a safe place of residence .Should a resident's behavior become abusive, hostile, assaultive, or unmanageable in any way that would jeopardize his or her safety or the safety of others, the Nurse Supervisor/Charge Nurse must immediately .provide for the safety of all concerned . Review of the facility's undated policy titled, Administering Medications, revealed .New personnel authorized to administer medications will not be permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility .The Charge Nurse must accompany new nursing personnel on their medication rounds for a minimum of three (3) days to ensure established procedures are followed and proper resident identification methods are learned . Review of agency company #1's contract dated [DATE], revealed .Obligations of Client .Supervision and Instruction, client is responsible for supervision and instruction of the Personnel regarding policies, procedures, and Client operation, specifically including, but not limited to all necessary Client safety procedures, equipment handling, and services to be rendered. Client shall remain solely liable for the safe working conditions and supervision of those entrusted to operate equipment and provide services hereunder . Review of agency company #1's Comprehensive Core Competency Certified Nursing Assistant (CNA) test dated [DATE], revealed there was no documentation on the test that included Dementia or Behaviors. Review of employee personnel files, Contract Registered Nurse (RN) #2, Contract Certified Nursing Assistant (CNA) #5 and #6, revealed the employee files had no documentation of a competency evaluation to ensure they had the knowledge skills related to care of residents with dementia, care of residents with behaviors such as physical aggression, or nursing assessment skills. Observation during medication administration on the 1 East Hall on [DATE] at 8:55 AM, Licensed Practical Nurse (LPN) #4 looked in the medication cart for artificial tears and was unable to find them. LPN #4 stated, .I will have to go get some .do you know where the med [medication] room is . Observation and interview during medication administration on the 2 East Hall on [DATE] at 11:28 AM, RN #2 stated, .hard because don't know these residents that well . RN #2 removed [MEDICATION(S)] from the medication cart and put it in the cup. RN #2 realized the medication was not due and was unsure of the facility's policy regarding wasting a medication. During an interview on [DATE] at 11:50 AM, RN #2 stated, .Today is my first day here .I received nothing really in regard to orientation. Just here is the medication cart and here is the computer. I am not familiar with the system they use .No, no one told me anything about the patient population like behaviors or specifics . Observation during medication administration on the 1 East Hall on [DATE] at 12:15 PM, LPN #4 stated, .it is hard because I don't know these residents that well . During an interview on [DATE] at 12:17 PM, CNA #6 stated, .This is my third day working here .I received no orientation on the type of patients I will care for .They said here is your assignment and told me which residents were continent and who could get up .showers . During an interview on [DATE] at 12:28 PM, CNA #5 stated, .This is my first day working here .I received no orientation .They told me what rooms I had and who were incontinent .They did not tell me about the type of patient or how to handle .I received no education or information on the type of patient or how to handle behaviors or dementia . During an interview on [DATE] at 1:22 PM, the Administrator stated, .For the agency staff we usually hand them a packet up front [kept at the front desk] on abuse, fire, codes .I can't remember what else it has in it .for them to be familiar with the facility .the agency does the background checks, abuse [checks], training for abuse, resident rights .I can't think of them off the top of my head I have not looked at them in a while .We expect them [agency employee] to provide the same level of service we provide, not be abusive to the residents, to treat the residents with dignity and respect, to supplement our staff and to do everything we do .The orientation we provide is the packet. When the nurse walks them to their unit, they receive their assignment, they are shown the Nurses' Station, where they can get supplies, the clean and dirty utility rooms .they get report on their patients . Review of the packet given to agency staff on [DATE] at 1:50 PM, revealed documentation of fire, elopement, and abuse. There was no documentation of education or information on the care of residents with behaviors or dementia. During an interview on [DATE] at 1:50 PM, the Administrator stated, .No we don't have signatures that show the employee received the packet .No there is no education about behaviors, dementia or anything care related . The facility was unable to provide a contract for agency company #2. During a telephone interview on [DATE] at 10:05 AM, agency company #2's representative stated, .We provide no training prior to the staff assignments .We make sure the staff we send are licensed .We provide no training on behaviors . Review of agency company #3's contract dated [DATE], revealed .Responsibilities of Client .Provide orientation which, at minimum, includes the review of policies and procedures regarding medication administration, documentation procedures, patient rights, Infection Control, and Fire and Safety .and EMR [Electronic Medical Record]/Charting (if applicable) . During a telephone interview on [DATE] at 10:10 AM, agency company #3's representative stated, .we credential our staff such as if have license .if there is special training that has to be done by the facility .no, we don't do dementia or behavior training . Review of agency company #4's contract dated [DATE], revealed .Facility obligations .Communication with Staff. Clearly communicate to Staff duties, shifts, unit assignments, and other working details during Staff's assignment .Orientation. Provide orientation to Staff for each unit to which Staff is assigned . During a telephone interview on [DATE] at 10:15 AM, agency company #4's representative stated, .We do the typical credential process .No, we haven't been told about the facility's patient population .We don't do education about dementia or behavior. We expect them [employee] to have their license. We don't do education . Observation and interview on [DATE] at 3:55 PM, revealed RN #3 (Agency Nurse) and LPN #6 (Agency Nurse) stood at the 2 East Nurses' Station talking. RN #3 and LPN #6 were notified by the surveyor that there was someone standing outside the facility door who needed to be screened to come into the facility and a resident who had completed visitation with his family and needed to be transported back to his room. RN #3 stated, We're Agency .so we don't know the code, and resumed their conversation. RN #3 and LPN #6 did not attempt to notify a facility staff member that someone was at the door who needed assistance or help the resident who needed assistance back to his room. Refer to F-600, F-744, F-835, and F-867. The surveyors verified the Removal Plan by: 1. An audit of personnel files will be conducted by the management team to determine whether all staff have received training on dementia and behaviors by [DATE]. The surveyors verified the removal plan by review of the personnel files audit, in-service sign-in sheets, and interview of staff on all shifts. 2. An audit of all facility agency contracts were conducted on [DATE] to determine whether the contracted staff have received dementia and behavior training. The surveyors verified the removal plan by review of the audits, in-service sign-in sheets, and interviews with agency staff. 3. Facility shall provide staff with the appropriate training, education and in-services regarding dementia, behaviors, identification, and management. The surveyors verified the removal plan through review of the in-service sign-in sheets, interview of staff assigned to conduct training, and interviews of staff on all shifts. 4. Dementia and behavior training will be required for all staff including agency personnel and completed quarterly for 6 months and then annually. This training will be part of the orientation process. The surveyors verified the removal plan through interviews with the DON and Human Resources (HR) Director, and review of the training program. 5. All staff including agency personnel shall complete a competency quiz to ensure knowledge and skills necessary to provide care for residents with dementia and behaviors are retained. The surveyors verified the removal plan through review of the competency quiz and interviews with staff on all shifts. 6. All staff are required to obtain a score of 100% to meet competency requirements. The surveyors verified the removal plan through review of the competency quiz and interviews with staff on all shifts. 7. Quality Assurance Performance Improvement (QAPI) will be initiated to ensure 100% compliance of dementia and behavior training for all staff. The surveyors verified the removal plan through review of audit tools developed and interview of the Administrator and DON. 8. All staff will be in-serviced prior to starting their shift. All as needed (PRN) staff and any staff on leave will not be placed on schedule until in-service has been completed. The surveyors verified the removal plan through review of the schedule, daily postings, in-service sign-in sheets, and through interviews with staff on all shifts. 9. A more in-depth training/orientation will be provided to all contract employees who work in the facility. This training will include Abuse, resident rights, fire safety, elopement, dementia, and behavior. The surveyors verified the removal plan by review of the in-service sign-in sheets, the training packet given to agency staff, and interview of agency staff on all shifts. 10. An audit of all new employee files pertaining to dementia and behavior training will be completed weekly for 4 weeks and monthly for 3 months. Results of the audit will be reviewed by the Interdisciplinary Team (IDT) in the QAPI committee meeting. Findings of noncompliance will be addressed immediately. The surveyors verified the removal plan by review of the audit tool developed by the facility for review in the QAPI committee meeting and through interview with the Administrator and DON. The facility's noncompliance at F-726 continues at a scope and severity of E for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, job description review, and interview, facility Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain the highest practicable well-being of the residents with behaviors and dementia. The Administration failed to provide oversight to monitor and provide a safe resident environment related to residents with behaviors and dementia. The Administration failed to provide oversight and training of staff to prevent abuse and provide appropriate care to meet residents needs with behaviors and dementia. These failures resulted in Immediate Jeopardy for Resident #34, #80, #81, #91, #96, and #303. The facility's failure resulted in Immediate Jeopardy when Resident #80 willfully pushed Resident #81. Resident #81 fell to the floor, hit his head, began having seizures, was transferred to the hospital, and expired at the hospital. The facility's failure resulted in Immediate Jeopardy when Resident #34, #80, #81, #91, #96, and #303 did not have supervision and appropriate interventions implemented for their aggressive and exit-seeking behaviors. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on [DATE] at 11:52 AM, in the Administrator's Office. The facility was cited Immediate Jeopardy at F-600, F-744, F-726, F-835, and F-867. The facility was cited at F-600 and F-744 at a scope and severity of K, which is Substandard Quality of Care. The IJ was effective from [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE] at 10:19 AM, and was validated onsite by the surveyors on [DATE] through [DATE], through observations, review of audits, meeting minutes, and staff interviews conducted on all shifts. The findings include: Review of the facility's undated policy titled, Abuse, Neglect and Exploitation, revealed .The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The resident has the right to be free from mistreatment, neglect, and misappropriation of property .the center must take appropriate corrective action to protect residents. The center should oversee the implementation of corrective action and evaluate whether it is effective .The Director of Nursing in conjunction with other clinical team members shall initiate or revise plan of care to reflect the resident/patient's condition and measures to be taken to prevent recurrence, where appropriate .Appropriate steps shall be taken to prevent recurrence of the incident .The Quality Assessment and Assurance committee should monitor the reporting and investigation of the alleged violations, including assurances that residents are protected from further occurrences and that corrective actions are implemented as necessary . Review of the facility's undated policy titled, Behavior Policy, revealed .Each resident will be provided with a safe place of residence .Should a resident's behavior become abusive, hostile, assaultive, or unmanageable in any way that would jeopardize his or her safety or the safety of others, the Nurse Supervisor/Charge Nurse must immediately: provide for the safety of all concerned . Review of the undated Administrator job description, revealed, .Responsible for planning, organizing, staffing, directing, and coordinating of the facility to ensure quality care for residents; be knowledgeable of and implement federal, state, and local laws and regulations applicable to the facility and residents, personnel, and physical plant .Leadership, communication, nursing home regulations and standards, budgeting, personnel and business administration, public and community relations, relations with other health-care providers, ability to handle crisis situations and make judgements and decisions .Select personnel to supervise activities of major departments and consult with them regarding problems; hire, discipline, and terminate department employees; schedule and staff department personnel; ascertain quality of performance .inter-departmental relationships .Observe activities in each department on each shift .Establish, implement, review and update facility policies pertaining to resident care, personnel .public relations, maintenance of physical plant, job descriptions, and procedure manuals .Work with department heads and supervisors to provide staff meetings, in-service training, orientation programs, employee evaluations and supervision .Be an active member of committees .set meeting dates and ascertain that copies of minutes and reports of meetings are maintained and sent to proper officials .Review and evaluate reports from the facility's committees and consultants, and document disposition and implementation of recommendations .Operate, manage, and maintain facility in accordance with established policies and procedures of the governing body .Act as a liaison with .professional and supervisory staff through meetings and reports . Review of the undated Director of Nursing Services job description, revealed, .Responsible for the overall provision of the optimal achievable quality of nursing care for all residents .Must be able to relate to and work with the ill, disabled, elderly; emotionally upset, and at times hostile people within the facility. Requires the ability to appropriately redirect and deescalate individual with inappropriate behaviors .Directs the coordination of all nursing services .Assists Administrator with ongoing updating and review of nursing policies and procedures to assure continued quality of care .Ensure that quality of care provided in the facility meets/exceeds standards .Interprets the facility's Nursing Policies and Procedures for department personnel. Ensures implementation .Makes regular rounds to assure optimal quality of care is provided .Communicates issues regarding resident care as appropriate to the Medical Director .Discusses any problems, needs or concerns which arise with the Administrator .Understands and upholds Resident's Bill of Rights . During an interview on [DATE] at 1:50 PM, the Administrator confirmed agency staff do not receive education or information about the facility's residents with behaviors and dementia. The Administrator confirmed agency staff are not assessed prior to the shift if they are knowledgeable and have the skill sets needed to care for the facility's patient population of behaviors and dementia. She stated, .For new agency staff before they take assignment, we don't provide education or information about anything care related .No nothing for resident's with behaviors or dementia .We give them education packet on fire, abuse, elopement . During an interview on [DATE] at 2:50 PM, the DON was asked how was the competency agency staff assessed. The DON stated, .won't know until they [agency staff] do something incorrectly .even if you do a checklist you still have to monitor them closely .we do not do medication observations with agency staff . During an interview on [DATE] at 2:43 PM, the Administrator was asked why they decided to keep Resident #80 in the facility after the resident-to-resident incident in which Resident #81 was pushed down, hit his head on the floor, began to seize, and expired. The Administrator stated, .it was an isolated incident . The Administrator confirmed Resident #80 was not placed in one-on-one monitoring until 6 days after the resident-to-resident incident occurred, when they were notified by the police detective that Resident #80 was being charged with reckless homicide. The Administrator stated, He [Resident #80] was not having any previous or current aggressive behaviors or anything that would cause us any concerns .was very calm .it was an unfortunate incident .for lack of better terms they did not match .[named Resident #81] very unsteady, smaller .when he [Resident #80] pushed him [Resident #81] .he fell .that's why we put him on q [every] 15-minute checks . The Administrator confirmed that many things could happen in 15 minutes when the resident is not being supervised. Administration failed to maintain the plan of correction to provide a safe environment and provide supervision for vulnerable residents that was submitted to the State Agency on [DATE] following an IJ that was identified for elopement. Refer to F-600, F-726, F-744, and F-867. The surveyors verified the Removal Plan by: 1. A Quality Assurance (QA) meeting was held on [DATE] to discuss the facility's new monitoring systems initiated to identify residents with behaviors and review the effectiveness of interventions. The surveyors reviewed the QA meeting sign in sheet from [DATE] and interviewed QA members. 2. The behavior log and monitoring form will be reviewed daily by nursing management and/or the Administrator to identify any adverse behaviors and appropriate interventions are in place to ensure a safe resident environment related to residents with behaviors and dementia. The surveyors interviewed nurse management about behavior log and the monitoring form to ensure staff would identify any adverse behaviors and appropriate interventions are in place. 3. Facility Administration will ensure all staff are trained regarding dementia and behaviors to ensure the staff has the necessary knowledge and skill set to care for the residents and maintain a safe environment related to residents with behaviors and dementia. The surveyors reviewed the Audit tool and interviewed staff to ensuring training regarding dementia and behaviors was provided to the staff. 4. New Hires and new agency personnel will be provided dementia and behavior training prior to the start of their shift. The surveyors interviewed the Administrator related to the education the new hires and Agency staff received regarding dementia and behaviors to ensure staff are receiving dementia and behavior training, prior to start of shift. 5. An audit of all new employee files pertaining to dementia and behavior training will be completed weekly for 4 weeks and monthly for 3 months. Results of the audit will be reviewed by the Interdisciplinary Team (IDT) in the QA committee meeting. Findings of noncompliance will be addressed immediately. The surveyors reviewed the audit tool used for new employee files pertaining to dementia/behavior training and interviewed the Administrator. 6. The Administrator and Director of Nursing were in-serviced on [DATE] by the Regional Director of Clinical Services regarding training of all staff and contracted staff to prevent abuse and provide appropriate care to meet residents needs with behaviors and dementia. The surveyors reviewed the sign-in sheets and the education provided to the Administrator and DON, and interviewed the Administrator, DON, and staff on all shifts. 7. Administrator and DON will provide daily communication of pertinent information to include training provided to contracted and new staff for the facility. A monthly report detailing the behavior log audit and the number of new hires/ contracted staff training will be reviewed by the Regional Director of Clinical services and the Chief Operating Officer. The surveyors reviewed the daily communication log used to communicate pertinent information about residents behaviors, reviewed the sign-in sheet and the education provided to contracted and new staff by the Administrator & DON. The facility's noncompliance at F-835 continues at a scope and severity of E for the monitoring of the effectiveness of the correction actions. The facility is required to submit a Plan of Correction.

Based on policy review, Administrator job description review, Director of Nursing (DON) job description review, Registered Nurse (RN) job description review, Licensed Practical Nurse (LPN) job description review, medical record review, video camera footage review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program that recognized concerns related to resident to resident abuse, failed to perform follow up on monitoring of residents with behaviors, failed to evaluate and re-evaluate interventions implemented for residents with behaviors, failed to ensure nursing staff were competent to provide care to residents with behaviors and Dementia, and failed to ensure systems and processes were in place and consistently followed by staff to address quality concerns related to abuse, residents with Dementia and behaviors, and competent nursing staff. The QAPI committee failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently. Failure of the QAPI committee to ensure residents were free from abuse, interventions were developed for residents with behaviors, and staff were competent to provide care for residents with Dementia and behaviors, resulted in Immediate Jeopardy (IJ) when Resident #80 willfully pushed Resident #81 to the floor hitting is head on the floor, began having seizures, was transferred to the hospital, expired at the hospital. Resident #34 consistently rolled over other residents with her wheelchair, the facility failed to accurately assess Resident #91 for wandering/exit-seeking behaviors, after he verbalized wanting to leave the facility, exited the 2nd floor secure unit without staff supervision, was found wandering on the 1st floor of the facility, Resident #96 entered a female resident's room and struck the resident, and Resident #303 had inappropriate sexual behaviors. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and DON were notified of the Immediate Jeopardy for F-867 on [DATE] at 7:15 PM, in the Admission Office. The facility was cited Immediate Jeopardy at F-600, F-726, F-744, F-835, and F-867. The facility was cited at F-600 and F-744 at a scope and severity of K, which is Substandard Quality of Care. The facility was previously cited F-600 at a scope and severity of J on a complaint survey completed on [DATE]. The IJ was effective from [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on [DATE] at 9:19 PM, and was validated onsite by the surveyors on [DATE]-[DATE], by review of the auditing tools implemented, in-service training records, and staff interviews conducted on all shifts. The findings include: Review of the facility's policy titled, Quality Assurance Performance Improvement Program, reviewed ,d+[DATE], revealed .The [Named Facility] Quality Assurance Performance Improvement Program is demonstrated through a proactive, comprehensive, ongoing approach to improving the quality and safety of the services it delivers .The Facility employs a systems approach to evaluating all the systems and processes, identifying problems that have occurred or that potentially might result from the Facility's practices and getting to root causes of problems rather than just superficially addressing one problem at a time .It is through this collaborative approach that the organization can plan, implement, and maintain an effective, ongoing, data-driven, systematic and Facility-wide Quality Assurance and Performance Improvement program .The purpose of the Quality Assurance Performance Improvement Program is to facilitate a review of the organization's customers and employees .The Facility will maintain documentary evidence of its quality assurance and performance improvement program and be able to demonstrate its operation .Objectives .Provide a systematic mechanism for the organization's appropriate individuals and professions to function collaboratively in their performance improvement effects .Provide for an organization-wide program that assures the organization designs processes will and systematically measures, assess [assesses], and improves its performance to achieve optimal Resident health outcomes in a collaborative, interdisciplinary approach .To review and analyze collected data and indicators and recommend to the Governing Body .The program will show measurable improvement in resident health outcomes and improvement in resident safety by using quality indicators or performance measures associated with improved health outcomes .The Facility will measure, analyze, and track quality indicators, including adverse resident events, infection control and other aspects of performance that enable the Facility to assess processes of care, Facility services, and operations .The Facility will use the data collected to do the following .Monitor the effectiveness and safety of services and quality of care .Identify opportunities that can lead to improvements and changes in Resident care . Review of the facility's undated policy titled, Abuse, Neglect and Exploitation, revealed .The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion .The Quality Assessment and Assurance committee should monitor the reporting and investigation of the alleged violations, including assurances that residents are protected from further occurrences and that corrective actions are implemented as necessary . Review of the facility's undated Administrator job description, revealed .Responsible for planning, organizing, staffing, directing, and coordinating the facility to ensure quality care for residents; be knowledgeable of and implement federal, state, and local laws and regulations applicable to the facility and residents, personnel, and physical plant .delegated the responsibility for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures .ascertain quality of performance .Work with department heads and supervisors to provide staff meetings, in-service training, orientation programs .and supervision .Review and evaluate reports from the facility's committees and consultants, and document disposition and implementation of recommendations . Review of the facility's undated Director of Nursing Services job description revealed .Responsible for the overall provision of the optimal achievable quality of nursing care for all residents .Has background and understanding of Medicare guidelines .Assists Administrator with ongoing updating and review of nursing policies and procedures to assure continued quality of care . Review of the facility's undated Registered Nurse job description revealed .Make rounds to observe and evaluate physical, emotional, and social needs of residents .communicate with director of nursing and staff .delegate the responsibility for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures .comprehensive knowledge of nursing practices .physical, psychological, social, and medical needs of residents .Recognize changes in conditions of residents during his/her shift . Review of the facility's undated Licensed Practical Nurse job description revealed .maintain records reflecting the residents' conditions .delegate the responsibility for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures .Assume responsibility for residents assigned to his/her care, including regular bed checks to insure that no resident is left unattended or permitted to wander from the premises .Report incidents of suspected resident abuse immediately . Review of the facility's investigation from a resident-to-resident altercation on [DATE], revealed Resident #80 and Resident #81 had an altercation on the 200 hall. Camera footage revealed Resident #80 appeared to be talking to Resident #81. Resident #81 reached out and lightly hit Resident #80 in the chest, Resident #80 continued talking to Resident #81 and shaking his head. Resident #81 then lightly hit Resident #80 in the chest again, and Resident #80 shoved Resident #81. Resident #81 fell to the floor from a standing position, did not attempt to break his fall in any way, and hit his head on the floor. Staff responded to the scene very quickly and Resident #80 returned to his room alone without staff supervision. Video camera footage revealed Resident #81 began to seize. The police arrived at the facility prior to the arrival of Emergency Medical Services (EMS) personnel. EMS personnel transported Resident #81 to the hospital where he later expired. emergency room records revealed Resident #81 had extensive bilateral subarachnoid and subdural hematomas (acute bleeding inside the skull or brain). Resident #80 was placed on every (q) 15-minute checks. 1 on 1 monitoring of the resident was not begun until 6 days after the incident occurred. The facility staff did not have an ad hoc QAPI meeting after the incident, until surveyors from the State agency entered the building to investigate the incident and an Immediate Jeopardy was identified. The facility had a secure unit on the 2nd floor, where a code had to be entered on the elevator in order to exit the floor or the emergency stairs. The case mix of residents on that floor included residents with behaviors, [CONDITION(S)], and elopement risks. During an interview on [DATE] at 1:11 PM, the Administrator confirmed the last QAPI meeting was held [DATE]. Interviews conducted with the staffing agencies revealed facility staff did not provide training of the agency staff for the care and management of dementia and behaviors. The agency expected this to be provided to the agency employees by the facility. During an interview on [DATE] at 1:22 PM, the Administrator was asked what the expectations of the agency staff were when they were practicing in this facility. The Administrator stated, To provide the same level of service we provide .to supplement our staff and to do everything we do . The Administrator confirmed they provided a packet or cheat sheet to agency staff which included abuse and fire codes, the nurse walked them to their unit, gave them their assignment, showed them where to obtain supplies, and the location of the clean and dirty utility rooms. The Administrator was asked if the facility provided any other orientation to agency staff. The Administrator stated, uh-uh [no] and shook her head from side to side. The Administrator confirmed the education was all in the orientation packet and stated, .Their agencies also do a more in-depth competency training for them. During an interview on [DATE] at 2:43 PM, the Administrator and DON confirmed they had quarterly QAPI meetings. The Administrator stated, .When we decided to bring [to the QAPI meeting] the infection control part of COVID .got together a plan .what we wanted to accomplish .Actually did it when we had a COVID outbreak .September/October .did a plan that we were going to do PPE [personal protective equipment] audits . The Administrator confirmed she did not keep quantitative and qualitative data regarding the findings. The Administrator was asked to provide the next Performance Improvement Process (PIP) they had done. The Administrator stated, We did a .kitchen sanitation . The Administrator was asked to provide her quantitative data for the PIP. The Administrator stated, .It's not filled out . The Administrator was unable to provide documented data relating to their PIP on kitchen sanitation. The Administrator was asked what PIPs the facility had in progress at the present time. The Administrator stated, Reportables .wanted to ensure they were put in and put in timely . The Administrator was asked to show the process of the PIP. The Administrator stated, I don't have that . The Administrator and DON were asked if they track the reportables to see what time the incident occurred, what staff were involved, and how they determined what was effective. The Administrator stated, .no proof .Just discussing it with you . The Administrator and DON were asked if they had conducted a Root Cause Analysis (RCA) on any issues recently. The Administrator stated, We looked at behaviors .we've identified the problem . The Administrator was asked when they identified the problem with behaviors. The Administrator stated, It was the weekend of the holiday [[DATE]rd or 4th after the State Surveyor had entered the facility to investigate the resident-to-resident incident] .talked about behaviors in morning clinical meeting .no documentation in the QA committee .were not putting it in qualitative/quantitative .you're right we haven't .I didn't really put it in the minutes .RCA .we don't have it . The Administrator was asked if behaviors were discussed prior to the survey team entering the facility. She stated, .May talk about someone having increased agitation .have the Social Worker there .get a psych [psychiatric] eval [evaluation] .bring it to the team .everybody in the morning . The Administrator confirmed she was speaking hypothetically and there was no documentation to support this. The Administrator was asked once again if the quarterly QAPI meeting included quantitative and qualitative data for the identified issues and problems. She stated, No, you did not hear in the terms you put it in. They were unable to provide data for any QA processes, PIPs, or RCA to the survey team and confirmed the QAPI team had not conducted an RCA on any issues in 2020 and 2021. The Administrator and DON were asked if they had conducted an Ad Hoc [An unplanned meeting that focused on a specific topic] QAPI meeting after the resident-to-resident incident occurred between Resident #80 and #81 on [DATE]. The Administrator stated, We didn't because it was a resident to resident .and was a fall .now once we learned that it was more to it .yes we did .with myself, [Named DON], and upward management .discussed the incident .viewing the cameras . The Administrator was asked if the QAPI committee met, did an RCA, or anything regarding the event that happened on [DATE]. The Administrator stated, Yes .had a meeting on [DATE] [16 days after Resident #81's death and also after the IJ was identified] .[Named Medical Director] involved .talked about it .put something in place for another resident . The DON stated, .talked about that incident and others we're missing the mark on . The Administrator and DON were asked if that was documented. The Administrator stated, .I haven't had time to do it .don't have qualitative or quantitative data .the root cause is we weren't looking at behaviors .identifying them as an isolated incident. The Administrator confirmed the incident was not necessarily isolated. The Administrator and DON were asked if they had a way of identifying if Resident #81 had increased behaviors. The Administrator stated, .[Named Resident #81] not on the behavior log .I did see some notes about smoking .if he didn't get his way he would get upset . The Administrator and DON were asked when the 15-minute checks were implemented and had that always been a facility policy. The DON stated, It's always just been a tool to increase monitoring for a resident for a variety of reasons .this resident needs an extra eye . The DON was asked if she had criteria for 15-minute checks or was it subjective. The DON stated, I guess we don't have criteria .the nursing team [makes the determination] . The Administrator and DON were asked for the facility QA process, who they reported to and what they had learned. The DON stated, .I don't think we're doing it like that . The Administrator was asked why they made the decision to keep Resident #80 in the facility after the resident-to-resident incident in which Resident #81 was pushed down, hit his head on the floor, began to seize, and expired. The Administrator stated, .Rationale .it was an isolated incident .[Named Resident #80] hadn't had any previous aggressive behavior . The Administrator was asked if that would not be more of a reason to put him on 1-on-1 monitoring. The Administrator stated, Well . The Administrator confirmed Resident #80 was not placed in 1-on-1 monitoring until 6 days after the resident-to-resident incident occurred and they were notified by the police detective that Resident #80 was being charged with reckless homicide. The Administrator stated, He [Resident #80] was not having any aggressive behaviors or anything that would cause us any concerns .was very calm .it was an unfortunate incident .for lack of better terms they did not match .[Named Resident #81] very unsteady, smaller .when he [Resident #80] pushed him [Resident #81] .he fell .that's why we put him on q [every] 15-minute checks . The Administrator acknowledged a lot could happen in 15 minutes. The Administrator confirmed that a QAPI meeting was not conducted until [DATE], after the IJ was called. The Administrator and DON were asked if Resident #34 had been discussed in QAPI. The Administrator stated, [Named Resident #34] has been talked about previously yelling out .says kind of inappropriate sexual things .never been maliciously intentional .just wants to get up toward you . The DON confirmed the QAPI committee had not discussed Resident #34's behaviors of running over other residents and staff while in her wheelchair. The Administrator and DON were asked how they assessed the competency of the contract agency staff and communicated that to the agency. The DON stated, .Give them a brief synopsis of our building .I guess we won't know [their competency status] until we find they aren't doing something correctly .Agency people do not get med pass [medication administration] audits .not so far .maybe something we could implement .review the documentation from the night before .make sure they sign out their MARs [Medication Administration Record] and TARs [Treatment Administration Record] . The DON was asked why there were missing pressure ulcer treatments that had not been identified by the facility staff the following day when conducting the chart audits. The DON stated, .Part of being a licensed professional .know you have to sign off your MARs/TARs .should someone have caught that .yes . The DON was asked what she had learned from her MAR/TAR reviews and how often she did those. The DON stated, Not nearly as often as I used to .try to look at them at least twice a week. The DON was asked if she did any tracking or trending of those reviews. The DON stated, I have a feeling I will be from here on out. The Administrator and DON were asked if they thought the incident between Resident #80 and Resident #81 would warrant an RCA to help with future behaviors. The Administrator stated, Yes, it would definitely be beneficial . The DON was asked about the incident where behaviors were identified for Resident #303 and the psychiatric Nurse Practitioner made recommendations for medications, but the recommendations were not followed, and there was no documentation as to why the recommendations were not implemented. The DON stated, It means there's a break somehow in the system . Refer to F-600, F-726, F-744, and F-835. The surveyors verified the Removal Plan by: 1. The facility's QAPI process will be revised to include a systematic approach to tracking and trending, quantitative and qualitative data while evaluating/reevaluating interventions, data and trends. The surveyors verified the revised QAPI process through interview of key facility personnel to determine education provided, how the audit tools developed would be used to track and trend identified issues, how the process would include the use of qualitative and quantitative data analysis, and how facility staff would evaluate/re-evaluate interventions, data, and trends. The audit tools were reviewed, and the Administrator and DON were interviewed. 2. The QAPI team met on [DATE] to discuss and develop a QAPI process that identified residents with adverse behaviors through review of medical records, staff interviews and residents already identified by psychiatric services for adverse behaviors. The surveyors reviewed the behavior assessment conducted by the Psychiatric Nurse Practitioner, the medical record/care plan review conducted by the DON, the sign-in sheet from the QAPI meeting on [DATE], and interviewed members of the QAPI team. 3. The data collection will be obtained daily through review of the behavior monitoring logs to ensure all adverse behaviors have been reported/documented. This information will be reviewed daily in the Interdisciplinary Team (IDT) meeting for a collaborative discussion. The surveyors reviewed the behavior monitoring logs, in-service sign-in sheets, and interviewed staff from all shifts regarding the in-service training received on utilization of the behavior monitoring logs and expectations for reporting of behaviors. 4. The weekly behavior management meeting, which is comprised of the IDT and the geriatric Psychiatric Nurse Practitioner, will review identified resident behavior, interventions, investigation, and the care plan to evaluate/re-evaluate interventions data and trends. This approach will provide the IDT an opportunity to determine underlying causes of behaviors. The surveyors reviewed the geriatric Psychiatric Nurse Practitioner assessments and interviewed members of the IDT to determine the education provided by the facility and the expectations for how data would be reported and covered in the weekly behavior management meeting. 5. The facility will provide all staff with the appropriate education and in-services regarding dementia identification and behavior management. This training will be conducted through lecture, handout, and measured by a competency quiz. Dementia and behavior training will be required for all staff including agency personnel and completed quarterly for 6 months and then annually. This training will be part of the orientation process. The surveyors reviewed the in-service sign-in sheets, the education provided to staff on dementia and behaviors, and the competency quiz administered. Facility staff were interviewed on all shifts to identify knowledge retention and facility expectations for logging and reporting of behaviors. 6. An audit of all new employee files pertaining to dementia and behavior training will be completed weekly for 4 weeks and monthly for 3 months. Results of the audits will be reviewed by the IDT in the QA committee meeting. Findings of noncompliance will be addressed immediately. Results from the audit will be tracked and trended to ensure 100% compliance. The surveyors reviewed the audit tool and interviewed the Human Resources (HR) Director and the DON. The facility incorporated the process of compiling an employee file on all agency staff to ensure they were adequately trained on facility processes and care of residents with dementia and behaviors. The facility's noncompliance at F-867 continues at a scope and severity of E for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, and interview, the facility failed to provide a safe environment necessary to prevent neglect for 1 of 8 sampled residents (Resident #1) reviewed who were at a risk for wandering. The facility's failure to provide care and services necessary to prevent neglect resulted in Immediate Jeopardy (IJ) when Resident #1, a vulnerable resident, exited the facility through a door, and was found unsupervised in the facility parking lot close to the street. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy on [DATE] at 6:00 PM, in the Family Room. The facility was cited Immediate Jeopardy at F-600. The facility was cited F-600 at a scope and severity of J, which is Substandard Quality of Care. The IJ was effective from [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE] at 9:45 AM, and was validated onsite by the surveyors on [DATE] through [DATE] by review of assessments, policies and procedures related to elopement, in-service training records, observations, and staff interviews. The findings include: Review of the facility's undated policy titled, Abuse, Neglect and Exploitation, showed, .the resident has the right to be free from mistreatment, neglect .'Neglect' means failure to provide goods and services necessary to avoid physical harm .when abuse, neglect .is suspected, the Licensed Nurse should .obtain witness statements . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] from a psychiatric hospital with [DIAGNOSES REDACTED]. Review of the Care Plan for Resident #1 dated [DATE], showed, .Resident is at risk for impaired communication r/t (related to) impaired ability to understand others at times. Periods of delusion thoughts .Interventions .Speak slowly and clearly .Allow increased time for time for resident to respond .Provide cues . Review of the Nursing - Risk of Elopement Review dated [DATE], showed that Resident #1 was cognitively impaired with poor decision-making skills, and had a [DIAGNOSES REDACTED]. Review of the Care Plan dated [DATE] and reviewed on [DATE], showed, .Behavioral Symptoms Delusions .Resident presents with delusions. Specifically in regards to her deceased father . Review of the Quarterly Minimum Data Set ((MDS) dated [DATE], showed Resident #1 had a Brief Interview for Mental Status (BIMS) of 12, which indicated moderate cognitive impairment. Resident #1 required extensive one-person assistance for transfers, independent once in a wheelchair, and no impairment to upper or lower extremities. Review of a Physician's Progress Note dated [DATE], showed that Resident #1 had periods of delusions and dementia. Review of a Nurse's Progress Note dated [DATE], showed that Resident #1 was having increased confusion and thought people in another room had a gun. Review of the Progress Note written by Licensed Practical Nurse (LPN) #1 dated [DATE] at 7:57 PM showed, .(Resident #1) noted to be outside of the facility. Resident (Resident #1) brought back in facility . Review of the Elopement Risk assessment dated [DATE] (completed after Resident #1's elopement) showed the following: a. The resident had a [DIAGNOSES REDACTED]. b. The resident was independently mobile and was rated a 3 on the assessment. c. The resident paced, wandered, tried to get out the door, tried to find family or friend was rated as 5 on the assessment. d. The resident did not exhibit signs of sundowners and rated a 0 on the assessment. e. The resident had a history of [REDACTED]. f. If the answer was yes to one or more of the above questions, the resident might be at risk. If the score was 5 or greater, the resident was at risk. g. Resident #1's total score was 15, which indicated she was at risk of elopement. Review of the medical record showed there was not a measurable Elopement Risk Assessment completed for Resident #1, to determine the risk for elopement, prior to [DATE]. During an interview conducted on [DATE] at 2:41 PM, the DON stated, .she (Resident #1) sits in the doorway of my office which is next to the ambulance entrance almost every day .The other day she told to me that her dad was coming to pick her up and they were going to eat if his wife would quit following them. Her father is deceased .after the incident on [DATE], staff found a stick in the floor by the door .used a stick to push the button to go out the door .it was a mop handle . The DON confirmed there were no witness statements obtained the night Resident #1 eloped. She could not recall if she had instructed LPN #1 to get witness statements regarding the incident, and she confirmed she had not interviewed Certified Nursing Assistant (CNA) #1 because she did not know she was involved. The DON stated that LPN #1 had entered a note in the computer about the event which was her statement. During an interview conducted on [DATE] at 3:52 PM, the Laundry Aide stated, .I saw the resident at the corner of the building by the Dietary porch .I asked her what she was doing outside by yourself (herself) and she said 'waiting on my daddy'. I looked around didn't see anyone in a car . During an interview conducted on [DATE] at 4:05 PM, CNA #1 stated .(Named Resident #1) was sitting in her wheelchair by the Nurses Station. The nurse (LPN #1) gave her medications and a snack .The nurse and I stepped away for a brief conversation for maybe 2 minutes .came back .she (Resident #1) was gone. I went and checked in her room, came back, told the nurse she wasn't there. (Named LPN #1) said 'I have a feeling something isn't right' . decided she was missing. Checked out the double doors (by the DON office and ambulance entrance), found a broom stick by the door. Both of us went outside looking. I went up the driveway and the Laundry Aide pointed me around to where (Named Resident #1) was .CNA #2 found the resident .I never heard an alarm (door) go off . During an interview conducted on [DATE] at 2:47 PM, LPN #1 confirmed she was working and was assigned care of Resident #1 on [DATE]. LPN #1 stated, .about 6:30 PM .she (Resident #1) was saying she needed to go take care of her father .I reminded her that she's here with us so we can take care of her and she can't take care of her father. I gave her a snack and juice .she was in her wheelchair by the nurse station .hadn't been 10 minutes, then I got a page overhead saying 1 West Nurse to ambulance doors .(CNA #1) met me at the door .We went opposite directions out the door .didn't hear an alarm .I never thought she would be able to get up the hill back there . LPN #1 confirmed she had not obtained staff statements the night of the incident and that she had not written a statement about the incident until today, [DATE]. The facility failed to ensure Resident #1, a vulnerable resident with a history of delusions related to her deceased father, was free from neglect. The resident exited the facility on [DATE] unsupervised and without staff knowledge. Resident #1 was found in her wheelchair unsupervised in the facility parking lot by a Laundry Aide who went outside for a break. Resident #1's direct care staff were unaware Resident #1 was missing, which resulted in Immediate Jeopardy for Resident #1. The surveyors verified the Removal Plan by: 1. Resident #1 was placed on 15-minute checks on [DATE] and continued with 15-minute checks for monitoring. The Psychiatric Nurse Practitioner recommends that Resident #1 continue 15-minute checks and will re-evaluate the need for 15-minute checks on a weekly basis based on resident assessment and decrease in delusions. The surveyors reviewed the 15-minute checks, observed staff performing 15-minute checks, and interviewed staff on all shifts. 2. Resident #1's medical record was reviewed by the DON on [DATE] and all concerns addressed. The Care Plan was reviewed to reflect the current plan of care which includes every 15-minute behavior monitoring and an increase in room activities. The surveyors reviewed the Care Plan and interviewed staff on all shifts. 3. An elopement assessment was completed for Resident #1 on [DATE] and again on [DATE]. The Care Plan was updated to reflect elopement risk interventions. (On [DATE]-every 15-minute monitoring and [DATE]-recommendation for increased in room activities). The surveyors reviewed the Care Plan. 4. On [DATE], Resident #1's environment was assessed for items that could assist in exiting the facility with no items noted. 5. A full house census of residents was conducted on [DATE] and [DATE], all residents were observed accounted for by licensed staff. The surveyors reviewed the full house census that was conducted. 6. On [DATE], a cover was placed on the exit door button of the ambulance entrance to decrease exposure. The surveyors observed the cover to be intact and not accessible. 7. On [DATE], an alarm chime was replaced on the ambulance door to alert staff when someone is entering or exiting the facility. The surveyors observed and checked the alarm chime on the doors for functioning. 8. A facility-wide elopement risk assessment on all residents was completed by Nurse Management on [DATE] and again on [DATE]. Residents that triggered with an elopement score of 5 or greater were considered at risk and care planned accordingly. The results of the assessments were brought to the Interdisciplinary Team (IDT) meeting on [DATE]. The surveyors reviewed the assessments, reviewed the Care Plans, and interviewed Nurse Management. 9. An in-service regarding the elopement policy and procedure was conducted on [DATE] for all staff by the Unit Managers. This policy was revised on [DATE] and all staff received in-service training on this revised policy. The surveyors reviewed the revised elopement policy and procedure, reviewed the in-service training records, and interviewed staff on all shifts. 10. An in-service was conducted for all licensed nurses on [DATE] regarding behavior management and documentation. Staff on leave or absent have been called by the Nurse Manager or Administrator and in-serviced via phone. An additional staff member participated on the phone in-service as the witness, both parties signed in place for the employee. All as needed staff on leave such as sickness or vacation will not be placed on the schedule until in-service has been received. The surveyors reviewed the in-service training records and interviewed licensed staff on all shifts. Noncompliance at F-609 continues at a scope and severity of D for the monitoring and the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, review of facility investigation, medical record review, and interview, the facility failed to report an allegation of neglect to the State Survey Agency, within 24 hours of the event for 1 of 8 sampled residents (Resident #1) reviewed for neglect. The facility was cited F 609 on 7/11/2019 for failure to report an allegation of abuse to the State Agency. The facility's continued failure to report an allegation of neglect to the State Survey Agency resulted in Immediate Jeopardy when Resident #1, a vulnerable resident, exited the facility through a door, and was found unsupervised in the facility parking lot. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 8/26/2020 at 6:00 PM, in the Family Room. The facility was cited Immediate Jeopardy at F-609. The facility was cited F-609 at a scope and severity of J, which is Substandard Quality of Care. The IJ was effective from 8/18/2020 through 8/28/2020. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 8/28/2020 at 9:45 AM, and was validated onsite by the surveyors 8/28/2020 through 8/29/2020 through policy review, review of in-service training records, and staff interviews. The findings include: Review of the facility's undated policy titled, Abuse, Neglect and Exploitation, showed, .Report allegations or suspected abuse, neglect or exploitation immediately to: State Agencies .obtain witness statements .contact the State Agency .to report the alleged abuse . Review of the facility's policy titled, ABUSE PREVENTION AND INTERVENTIONS, revised September 2016, showed, .incidents of substantiated abuse and neglect are reported .in accordance with applicable local, State or Federal Law . The facility's undated policy titled, Incidents and Accidents, showed, .Incidents are categorized as .Incident Type II-an incident that, due to the nature, creates an increased adverse situation to the resident .in most circumstances these incidents .may be reportable to the state agency within 24 hours .Examples .allegations/suspicions of resident abuse, neglect .elopements where a resident leaves facility . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] from a psychiatric hospital with [DIAGNOSES REDACTED]. Review of the Progress Note dated 8/18/2020 at 7:57 PM, showed that resident #1 was found unattended outside the facility in the facility parking lot. During an interview on 8/24/2020 at 10:45 AM, the Administrator stated, .a resident got out of the building last week .do not have the date .did not know it was a reportable incident until the Ombudsman contacted me and told me it was a reportable incident .have not reported the incident yet (5 working days after the elopement) . The facility's incomplete investigation was provided on 8/24/2020 at 2:55 PM and only included the incident report completed on 8/18/2020, an interview with the resident on 8/19/2020, in-services on elopement procedures for safety and protection conducted on 8/19/2020, and 15 minutes checks for Resident #1. There were no witness statements included in the investigation and was listed as an ongoing investigation. The facility provided witness statements on 8/27/2020 at 8:35 AM, 7 working days after the incident, for the following staff members: a. An undated typed statement signed by the Laundry Aide #1. b. An undated statement signed by Licensed Practical Nurse (LPN) #1. c. An undated statement signed by Certified Nursing Assistant (CNA) #2. d. A statement dated 8/24/20 signed by CNA #3. e. A statement dated 8/26/20 signed by CNA #4. During an interview on 8/24/2020 at 2:42 PM, the DON stated the incident had not been reported to the State Survey Agency's Incident Reporting System, .my thoughts were .didn't leave the facility grounds, was gone less than 10 minutes, and the resident sustained [REDACTED].did not think it was reportable incident .the incident was reported to me that night . During an interview on 8/24/2020 at 4:50 PM, the DON again confirmed she had not reported the incident into the State Survey Agency's Incident Reporting System. The DON stated, .I will do it before I leave . During an interview on 8/25/2020 at 6:10 PM, the DON stated, .the night of the incident .I came back to the building. I got a folder out of my office and left .I thought it was wrapped up enough not to worry about it until in the morning .(Resident #1) in the building, no issues, resident being monitored . The DON confirmed the parking lot was not a safe area for a resident. The facility's failure to report an allegation of neglect to the State Survey Agency resulted in Immediate Jeopardy when Resident #1, a vulnerable resident, exited the facility through a door, and was found unsupervised in the facility parking lot. The surveyors verified the Removal Plan by: 1. The facility's incident report related to the elopement of Resident #1 was completed on 8/18/2020. The surveyors interviewed the DON regarding the facility incident report and reviewed the facility incident report. 2. LPN #1 was interviewed by the DON on 8/18/2020 regarding the incident. The surveyors interviewed the DON. 3. The elopement investigation was completed on 8/25/2020. The surveyors reviewed the investigation. 4. The facility updated the elopement policy on 8/26/2020 to include timely reporting of all incidents related to elopement and the policy states to report to governing agencies within 2 hours. The surveyors reviewed the updated elopement policy and procedure. 5. The DON reported the incident into the State Survey Agency's Incident Reporting System on 8/24/2020. The surveyors reviewed the form verifying the submission of the incident into the Incident Reporting System. 6. An in-service regarding the elopement policy and procedure was conducted on 8/26/2020 for all staff by the Unit Managers. The surveyors reviewed the elopement policy and procedure, reviewed the in-service training records, and interviewed staff on all shifts. 7. The Director of Nursing was in-serviced by the Administrator regarding timely reporting of neglect/elopement per Centers for Medicare and Medicaid Services (CMS) guidelines as of 8/25/2020. The surveyors reviewed the in-service training records and the DON was interviewed regarding the reporting requirements. 8. Review of current CMS guidelines on reporting requirements was conducted on 8/25/2020 by Administrator and Director of Nursing. The surveyors interviewed the Administrator and the DON regarding the guidelines of reporting. 9. An in-service education for all nursing staff on the pertinent information/documentation to ensure timely and complete investigation was conducted on 8/27/2020. Staff on leave or absent have been called by Nurse Manager or Administrator and in-serviced via phone. An additional staff member participated on the phone in-service as the witness, both parties signed in place for the employee. All as needed staff and staff on leave, such as sickness or vacation will not be placed on the schedule until they have completed the in-service. The surveyors reviewed the in-service records and interviewed staff on all shifts. 10. The DON has completed an audit of incident reports related to elopement. No other incident reports have been related to elopement. The audits will be daily for 3 months or 100% compliance. The surveyors reviewed the audit tool for incident reports and interviewed the Administrator and DON regarding the audit tools. Noncompliance at F-609 continues at a scope and severity of D for monitoring and the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, facility investigation review, medical record review, and interview, the facility failed to ensure a thorough investigation was conducted for an allegation of neglect within the required timeframe for 1 of 8 sampled residents (Resident #1) reviewed for elopement and wandering behaviors, which resulted in Immediate Jeopardy (IJ) for Resident #1. Resident #1, a vulnerable resident with a history of delusions, eloped from the facility through a door and was found unsupervised in the facility parking lot. The facility failed to ensure all witness statements were obtained in a timely manner related to Resident #1's location and the last time staff had observed Resident #1 in the facility and failed to implement a mechanism to prevent residents from accessing the exit release button on the exit door. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 8/26/2020 at 6:00 PM, in the Family Room. The facility was cited Immediate Jeopardy at F-610. The facility was cited at F-610 at a scope and severity of J, which is Substandard Quality of Care. The IJ was effective from 8/18/2020 through 8/28/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 8/28/2020 at 9:45 AM, and was validated onsite by the surveyors on 8/28/20 through 8/29/2020 through review of assessments, policy and procedures related to elopement, in-service training records, observations, and staff interviews. The findings include: Review of the facility's undated policy titled, Abuse, Neglect and Exploitation, showed, .when abuse, neglect or exploitation is suspected, the Licensed Nurse should .obtain witness statements .initiate an investigation immediately .When suspicion of abuse, neglect .or reports of abuse, neglect .an investigation is immediately warranted .an investigation should be conducted .include .interview all witnesses separately .staff members in the area .all statements should be signed and dated by the person making the statement .Document the entire investigation chronologically . The facility's undated policy titled, Incidents and Accidents, showed, .Incidents are categorized as .Incident Type II-an incident that, due to the nature, creates an increased adverse situation to the resident .Examples .allegations/suspicions of resident abuse, neglect .elopements where a resident leaves facility .initiate an investigation as soon as possible . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] from a psychiatric hospital with [DIAGNOSES REDACTED]. Review of the Progress Note dated 8/18/2020 at 7:57 PM, showed that Resident #1 was outside of the facility in the facility parking lot. The facility's investigation was provided on 8/24/2020 at 2:55 PM, which only included the incident report completed on 8/18/2020, an interview with the resident on 8/19/2020, in-services on elopement procedures for safety and protection done on 8/19/2020, and 15-minute checks for Resident #1. There were no witness statements included in the investigation and no mechanism identified to prevent residents from accessing the exit release button on the exit door. The facility provided witness statements on 8/27/2020 at 8:35 AM, 7 working days after the incident, for the following staff members: a. An undated typed statement signed by the Laundry Aide #1. b. An undated statement signed by Licensed Practical Nurse (LPN) #1. c. An undated statement signed by Certified Nursing Assistant (CNA) #2. d. A statement dated 8/24/20 signed by CNA #1. e. A statement dated 8/26/20 signed by CNA #4. Review of CNA #1's statement showed, .8/18/2020 .Date of Incident .The nurse and I were having a conversation and then .we noticed (Named Resident #1) was gone .(CNA #1's signature) .8-24-2020 (6 days after the incident occurred) .Today's Date . During an interview on 8/25/2020 at 6:10 PM, the DON stated, .I was notified the night of the incident .I came back to the building. I got a folder out of my office and left .I thought it was wrapped up enough not to worry about it until in the morning .(Resident #1) in the building, no issues, resident being monitored . The DON confirmed the parking lot was not a safe area for a resident. During an interview conducted on 8/26/2020 at 11:00 AM, the DON was asked who should have obtained witness statements. The DON stated, (Named LPN #1) should have started the statements . During an interview conducted on 8/26/2020 at 5:45 PM, the DON confirmed the investigation was not completed within the required timeframe, and stated, .but it would not have changed the outcome . During an interview conducted on 8/26/2020 at 5:50 PM, the Administrator stated, .were under the impression we (facility) didn't have to report it . The Administrator was asked why it took so long to provide the investigation of the incident. The Administrator stated, .because you (survey team) had entered and was requesting so much information . The Administrator confirmed witness statements were not obtained from staff immediately after the elopement incident that occurred on 8/18/2020. The surveyors verified the Removal Plan by: 1. On 8/18/2020, Resident #1 was assessed by licensed staff upon return to facility. The surveyors reviewed the documentation of the assessment. 2. Resident #1 had an initial interview conducted by the Charge Nurse to ascertain an exit plan. 3. On 8/18/2020, an elopement investigation was initiated by the DON. 4. Resident #1's physician was notified of the incident on 8/18/2020, a new order was obtained for a 1-time dose of [MEDICATION NAME]. The surveyors reviewed the orders and interviewed Resident #1's physician. 5. The DON was notified on 8/18/2020 and placed Resident #1 on 15-minute checks until evaluated by psychiatric services. The surveyors reviewed the documentation of the 15- minute checks, observed staff completing the checks and interviewed staff on all shifts regarding the checks. 6. Resident #1 was placed on 15- minute checks by the DON on 8/18/2020 and continues to be on 15-minute checks for continuous monitoring. The Psychiatric Nurse Practitioner recommends that Resident #1 continues to be on 15-minute checks and will re-evaluate the need for 15-minute checks on a weekly basis based on the resident assessment and a decrease in delusions. The surveyors reviewed the documentation of the 15-minute checks and interviewed staff on all shifts. 7. On 8/20/2020, Resident #1 was seen by a Psychologist and was seen by the Psychiatric Nurse Practitioner on 8/24/2020. An increase in antipsychotic medication was ordered, an order was written, and the medication was obtained. The surveyors reviewed the Psychologist and Psychiatric Nurse Practitioner progress notes. The surveyors reviewed Resident #1's medical record and verified the order. The surveyors reviewed the Medication Administration Record [REDACTED] 8. On 8/19/2020, Resident #1's elopement risk assessment was completed by the DON. The Care Plan was updated to reflect elopement at risk interventions. The surveyors reviewed the elopement risk assessment, reviewed the Care Plan for updates and interviewed staff on all shifts. 9. On 8/26/2020, a new elopement risk assessment was completed by the DON. The Care Plan was updated to reflect elopement risk interventions. The surveyors reviewed the new elopement risk assessment and reviewed the Care Plan for the elopement risk interventions. The surveyors interviewed staff on all shifts related to Resident #1's Care Plan interventions. 10. On 8/18/2020, Resident #1's environment was assessed for items that could assist in exiting facility, and there were no concerns. The surveyors interviewed staff on all shifts regarding Resident #1's environment. 11. An environmental audit was conducted on 8/18/2020 by nursing staff to ensure there were no further items that could assist residents in exiting the facility. The surveyors verified the audit through interviews with staff on duty the night of the incident. 12. The item used to assist the resident in exiting the facility was identified and discarded on 8/18/2020. The surveyors observed there was no stick by the ambulance doors. 13. On 8/19/2020 and 8/26/2020, a full house census of residents was conducted, all residents were observed and accounted for by the licensed staff. The surveyors reviewed the full house census that was conducted. 14. On 8/25/2020, a cover was placed over the exit door button of the ambulance entrance to decrease exposure. The surveyors observed the cover over the exit button. 15. On 8/25/2020, a loud, audible alarm chime was installed to replace the previous door chime on the ambulance door to alert staff when someone is entering and /or exiting the facility. The surveyors verified and checked the alarm chime on the door. 16. The Care Plan was updated to provide diversional activities when Resident #1 is observed sitting by exit doorways as of 8/27/2020. The surveyors reviewed the Care Plan and conducted staff interviews on all shifts related to the interventions for risk for elopement. 17. A complete facility elopement risk assessment on all residents was completed by nurse management on 8/19/2020. Residents that triggered with an elopement risk score of 5 or greater were considered at risk and care planned accordingly. The results of the assessment were brought to the Interdisciplinary Team meeting (IDT) meeting on 8/27/2020. The facility chose to complete another elopement risk assessment to ensure all areas of concern were addressed. No changes occurred with Resident #1 from the elopement risk assessment conducted on 8/19/2020 and 8/26/2020. The surveyors reviewed the assessments, reviewed the Care Plans and interviewed nurse management related to the elopement assessments. 18. An assessment of all doors was conducted by the Maintenance Director to ensure appropriate function on 8/26/2020. The surveyors conducted a random check of the exit doors to verify alarms were audible and functioning. 19. A daily audit of facility interior and exterior doors had been initiated as of 8/26/2020. This daily audit will be conducted by the Maintenance Director and/or designee and reviewed the following day during the IDT meeting. The surveyors reviewed the audit documentation of the door checks. 20. An in-service regarding the elopement policy and procedure was conducted on 8/19/2020 and 8/26/2020 for all staff by the Unit Managers. The surveyors reviewed the in-service records, and interviewed staff on all shifts. 21. A Certified Nursing Assistant (CNA) behavior communication log was initiated on 8/26/2020 by the Unit Manager. Staff in-service was conducted on 8/26/2020 regarding the behavior communication log (All nursing staff, CNA, and licensed nurses have been in-serviced on the behavior communication log). The surveyors reviewed the communication log and interviewed staff on all shifts. 22. An in-service was conducted for all licensed nurses on 8/26/2020 regarding behavior management and documentation. The surveyors reviewed the in-service training records and interviewed staff on all shifts. 23. An in-service was conducted by the Director of Nursing on 8/26/2020 for all licensed nurses to increase knowledge of the risk assessment tool including monitoring of behaviors and documentation. The surveyors reviewed the in-service training records and interviewed nurses on all shifts. 24. On 8/27/2020, the Clinical Psychologist will review all residents who scored a 5 or greater on the elopement risk assessment to determine if the resident is appropriate for a non-secured unit. The surveyors reviewed the Psychologist progress notes. 25. The CNAs were in-serviced by the Director of Nursing regarding reporting exit seeking behaviors to licensed staff on 8/26/2020. The surveyors reviewed the in-service training records and interviewed CNAs on all shifts. 26. On 8/27/2020, the DON/Designee had in-serviced nursing staff on the identification of behaviors that trigger exit seeking responses. The surveyors reviewed the in-service training records and interviewed nursing staff on all shifts. 27. The CNAs and licensed nurses were in-serviced by the DON on the implementation and use of the behavior communication log as of 8/26/2020. The surveyors reviewed the in-service training records and interviewed nursing staff on all shifts. 28. The Director of Nursing was in-serviced by the Administrator regarding thorough and timely neglect/elopement investigations as of 8/25/2020. The surveyors reviewed the in-service training records and interviewed the DON. 29. An all staff in-service was conducted on 8/26/2020 by the DON regarding CMS deficiency F 610-failure to thoroughly investigate. The surveyors reviewed the in-service records and interviewed staff on all shifts. 30. Review of current CMS guidelines on reporting requirement was conducted on 8/25/2020 by the Administrator and DON. The surveyors interviewed the Administrator and the DON. 31. The facility incident report packet was reviewed for appropriate content such as occurrence report, statements, and timeline/summation by the DON. The surveyors reviewed the facility's incident report packet and interviewed the DON regarding the incident report packet. 32. An in-service education for all nursing staff on the pertinent information/documentation to ensure timely and complete investigation was conducted on 8/27/2020. The surveyors reviewed the in-service records and interviewed nursing staff on all shifts. 33. The DON completed an audit of incident reports related to elopement. No other incident reports have been related to elopement. The surveyors reviewed and verified there were no other incidents of elopement. 34. Staff on leave or absent have been called by the Nurse Manager or Administrator and in-serviced via phone. An additional staff member participated on the phone in-service as the witness, both parties signed in place for the employee. All as needed staff and staff on leave such as sickness or vacation will not be placed on the schedule until they have completed the in-services. The surveyors verified the in-service training records and interviewed staff on all shifts. Noncompliance of F-610 continues at a scope and severity of D for the monitoring and effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure a safe environment and failed to provide supervision to prevent an incident of elopement for 1 of 8 sampled residents (Resident #1) reviewed. The facility's failure to ensure a safe environment resulted in Immediate Jeopardy (IJ) when Resident #1, a vulnerable resident, exited the facility through a door, and was found unsupervised in the facility parking lot. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy on [DATE] at 6:00 PM, in the Family Room. The facility was cited Immediate Jeopardy at F-689. The facility was cited at F-689 at a scope and severity of J, which is Substandard Quality of Care. The IJ was effective from [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE] at 9:45 AM, and was validated onsite by the surveyors on [DATE] through [DATE] by review of assessments, policies and procedures related to elopement, in-service training records, observations, and staff interviews. The findings include: The facility's undated policy titled, Elopements and Wandering Residents, showed, .Unsupervised activity outside the facility could lead to serious injury of a resident due to many hazards such as traffic, water, storms and hot/cold temperatures .'Elopement' means the unplanned, unauthorized leaving of the facility by a resident .Residents should be assessed for elopement risk on admission and throughout their stay by the interdisciplinary care planning team .facility should be equipped with door locks/alarms to help avoid elopements . The facility's undated policy titled, Incidents and Accidents, showed, .resident environment remains as free of accident hazards as is possible .when an accident occurs, prompt response and reporting occurs .Incidents are categorized as .Incident Type II-an incident that, due to the nature, creates an increased adverse situation to the resident .Examples .allegations/suspicions of resident abuse, neglect .elopements where a resident leaves facility . The facility was unable to provide a policy and procedure for checking the door alarms. The Maintenance Director Job Description was reviewed but did not address checking the door alarms. Review of the medical record showed Resident #1 was admitted to the facility on [DATE] from a psychiatric hospital with [DIAGNOSES REDACTED]. Review of the Care Plan initiated [DATE] and reviewed [DATE], showed, .(Resident #1) is at risk for impaired communication r/t (related to) impaired ability to understand others at times. Periods of delusion thoughts .Interventions .Speak slowly and clearly .Allow increased time for time for resident to respond .Provide cues . Review of the Nursing - Risk of Elopement Review dated [DATE], showed that Resident #1 was cognitively impaired with poor decision-making skills, and had a [DIAGNOSES REDACTED]. Review of the Care Plan updated [DATE], showed, .Behavioral Symptoms Delusions .Resident presents with delusions. Specifically in regards to her deceased father . Review of the quarterly Minimum Data Set ((MDS) dated [DATE], showed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. Resident #1 required extensive one-person assistance for transfers, independent once in a wheelchair, and no impairment to upper or lower extremities. Review of a Physician's Progress Note dated [DATE], showed, .periods of delusions per nursing staff .dementia . Review of a Nurse's Progress Note dated [DATE], showed, .resident having increased confusion and thinks people in another room has a gun on her she is really confused .went to check room and informed her there was no gun and she was not happy with this . Review of the Progress Note dated [DATE] at 7:57 PM, showed that resident #1 was found unattended outside the facility in the facility parking lot. Review of the Elopement Risk assessment dated [DATE] (after Resident #1's elopement), showed that Resident #1's total score was 15, which indicated she was at risk of elopement. Review of the medical record showed there was not a measurable Elopement Risk Assessment completed for Resident #1, to determine the risk for elopement, prior to [DATE]. Observation on the 1 West Hall on [DATE] beginning at 11:57 AM, during the initial tour of the facility, showed the exit door by the DON office had a green button located at an approximate height of 6 feet on the wall, there was no cover over the button. If the green button was pressed the door would unlock and the person pressing the button could push on the door and exit the building. Observation on [DATE] at 8:35 AM, showed Resident #1 propelling herself in a wheelchair in the hallway and back to her room. During an interview conducted on [DATE] at 2:41 PM, the DON stated, .she (Resident #1) sits in the doorway of my office which is next to the ambulance entrance almost every day .The other day she told me that her dad was coming to pick her up and they were going to eat if his wife would quit following them. Her father is deceased .after the incident on [DATE], staff found a stick in the floor by the door .used a stick to push the button to go out the door .it was a mop handle . During an interview conducted on [DATE] at 3:52 PM, the Laundry Aide stated, .I saw the resident at the corner of the building by the Dietary Porch .I asked her what she was doing outside by yourself (herself) and she said 'waiting on my daddy'. I looked around didn't see anyone in a car . During an interview conducted on [DATE] at 4:05 PM, Certified Nursing Assistant (CNA) #1 stated .(Named Resident #1) was sitting in her wheelchair by the Nurses Station. The nurse (Licensed Practical Nurse (LPN) #1) gave her medications and a snack .The nurse and I stepped away for a brief conversation for maybe 2 minutes .came back .she (Resident #1) was gone. I went and checked in her room, came back, told the nurse she wasn't there. (Named LPN #1) said 'I have a feeling something isn't right' . decided she was missing, checked out the double doors (by DON office ambulance entrance), found a broom stick by the door. Both of us went outside looking. I went up the driveway and the Laundry Aide pointed me around to where (Named Resident #1) was .CNA #2 found the resident .I never heard an alarm (door) go off . During an interview conducted on [DATE] at 1:00 PM, the Administrator stated, .The mop handle was right here (indicated the stick was propped by the DON's door, under the green exit button) .left there a couple of hours .The resident used it to push the green button to exit out the door .not sure why it was there . During an interview conducted on [DATE] at 2:25 PM, the Housekeeping Supervisor confirmed there were no in-services or education provided to housekeeping staff related to making sure housekeeping supplies, mops and brooms, were properly stored. During an interview conducted on [DATE] at 2:30 PM, Housekeeper #1 confirmed there had been no recent education provided related to the proper storage of mops and brooms. During an interview conducted on [DATE] at 2:45 PM, LPN #1 was asked to review the Nursing - Risk of Elopement Review form for Resident #1 dated [DATE], and she stated, .usually a score on the bottom (of the Nursing - Risk of Elopement Review form) .I don't know on that one .I don't understand why it doesn't give a score . LPN #1 confirmed she was assigned to provide care to Resident #1 on [DATE]. LPN #1 stated, .about 6:30 PM .she (Resident #1) was saying she needed to go take care of her father .I reminded her that she's here with us so we can take care of her and she can't take care of her father. I gave her a snack and juice .she was in her wheelchair by the nurse station .hadn't been 10 minutes, then I got a page overhead saying 1 West Nurse to ambulance doors .(CNA #1) met me at the door .We went opposite directions out the door .didn't hear an alarm .I never thought she would be able to get up the hill back there . Observation of the hill behind the facility showed a gradual incline. During an interview conducted on [DATE] at 6:10 PM, the DON stated, .the form (Nursing - Risk of Elopement Review form) in (the electronic medical record) has no score .it is more of a guide . The DON was asked how staff would know if a resident was an elopement risk. The DON stated, .depends on the resident's acclimation process . During an interview conducted on [DATE] at 6:45 PM, LPN #2 confirmed she did not hear an alarm the evening Resident #1 eloped. During an interview conducted on [DATE] at 9:10 AM, the Maintenance Director stated, .I just put those alarms on this door (ambulance entrance door) yesterday . The Maintenance Director was asked if there was an alarm on the door when Resident #1 eloped. The Maintenance Director stated, .there was a chirp alarm on the door but surprised anyone could hear it because it's so quiet .I guess it failed .I was told Monday of last week ([DATE]) it wasn't working .all I had done with it is changed the batteries . During an interview conducted on [DATE] at 11:00 AM, the DON stated, .there used to be an alarm .never thought not having an alarm was an issue .I thought the button for door was high enough that residents couldn't reach it and wasn't concerned much about the alarm .didn't strike me that the alarm was gone .thought it was pretty safe . The DON was asked how long the alarm had been off the door. The DON stated, .I'm not sure .maybe since Spring (2020) . During an interview conducted on [DATE] at 2:55 PM, CNA #3 confirmed she did not hear an alarm the evening Resident #1 eloped. The surveyors verified the Removal Plan by: 1. On [DATE], Resident #1 was assessed for injury related to incident with no injuries. The surveyors reviewed the documentation of the assessment. 2. Resident #1 was placed on 15- minute checks by the DON on [DATE] and continues to be on 15-minute checks for continuous monitoring. The Psychiatric Nurse Practitioner recommends that Resident #1 continues 15-minute checks and will re-evaluate the need for 15-minute checks on a weekly basis based on resident assessment and decrease in delusions. The surveyors reviewed the documentation of the 15-minute checks and interviewed staff on all shifts. 3. On [DATE] and [DATE], Resident #1's medical records were reviewed by the DON to make certain the medical record was accurate and complete. 4. On [DATE], Resident #1 was seen by a Psychologist and seen by the Psychiatric Nurse Practitioner on [DATE]. An increase in antipsychotic medication was ordered, an order was written, and the medication was obtained. The surveyors reviewed the Psychologist and Psychiatric Nurse Practitioner progress notes. The surveyors reviewed Resident #1's medical record and verified the order. The surveyors reviewed the Medication Administration Record [REDACTED]. 5. On [DATE] and [DATE], Resident #1's elopement risk assessment was completed by the DON. The Care Plan was updated to reflect elopement at risk interventions. The facility chose to complete another elopement risk assessment to ensure all areas of concern were addressed. No changes were needed from the elopement risk assessment conducted on [DATE] and [DATE]. The surveyors reviewed the elopement risk assessments completed on [DATE] and [DATE] and the Care Plan revisions. 6. On [DATE], Resident #1's environment was assessed for items that could assist in exiting facility, and no items were found. The surveyors interviewed staff on all shifts regarding Resident #1's environment. 7. An environmental audit was conducted on [DATE] by nursing staff to ensure there were no further items that could assist residents in exiting the facility. The surveyors verified the audit through interviews with staff on duty the night of the incident. 8. On [DATE], the activities department met with Resident #1 to determine whether the resident wanted an increase in room visits and to offer outdoor activities. The surveyors reviewed the Activity Director's documentation of the visit. The surveyors conducted an interview with the Activity Director and Resident #1 regarding preferred activities. 9. On [DATE], a complete census of residents was conducted, all residents were observed and accounted for by licensed staff. The surveyors reviewed the full house census that was conducted. 10. On [DATE], a full house census of residents was conducted, all residents were observed and accounted for by licensed staff. The surveyors reviewed the full house census that was conducted. 11. On [DATE], a cover was placed on the exit button of the ambulance entrance to decrease exposure. The surveyors observed the cover on the exit button. 12. On [DATE], a loud, audible alarm chime was installed to replace the previous door chime on the ambulance door to alert staff when someone is entering and /or exiting the facility. The surveyors verified and checked the alarm chime on the door. 13. A facility elopement risk assessment was completed on all residents by nurse management on [DATE]. All residents that triggered with an elopement risk score of 5 or greater were considered at risk and care planned accordingly. The results of the assessment were brought to the Interdisciplinary Team (IDT) meeting on [DATE]. The surveyors reviewed the assessments and the IDT meeting minutes. 14. An assessment of all doors was conducted by the Maintenance Director to ensure appropriate function on [DATE]. The surveyors reviewed the documentation of door assessments and interviewed the Maintenance Director related to door assessments. 15. A daily audit of facility interior and exterior doors had been initiated as of [DATE]. This daily audit will be conducted by the Maintenance Director and/or designee and reviewed the following day during the IDT meeting. The surveyors reviewed the audit documentation of the door checks. 16. An in-service regarding the elopement policy and procedure was again conducted on [DATE] for all staff by the Unit Managers. The surveyors reviewed in-service records and interviewed staff on all shifts related to the elopement policy. 17. A CNA behavior communication log was initiated on [DATE] by the Unit Manager. Staff in-service was conducted on [DATE] regarding the behavior communication log (All nursing staff, CNAs, and licensed nurses have been in-serviced on the behavior communication log). The surveyors reviewed the logs and interviewed staff on all shifts. 18. An in-service was conducted for all licensed nurses on [DATE] regarding behavior management and documentation. The surveyors reviewed in-service records and interviewed licensed nurses on all shifts. 19. An in-service was conducted by the DON on [DATE] for all licensed nurses to increase knowledge of the risk assessment tool including monitoring of behaviors and documentation. The surveyors reviewed the in-service records and interviewed licensed nurses on all shifts. 20. On [DATE], a Clinical Psychologist reviewed all residents who scored a 5 or greater on the elopement risk assessment to determine if the resident is appropriate for a non-secured unit. The surveyors reviewed the Psychologist Progress Notes. 21. The CNAs and licensed nurses were in-serviced by the DON on the implementation and use of the behavior communication log as of [DATE]. The surveyors reviewed the in-service records and interviewed licensed nurses and CNAs on all shifts. 22. The DON/Designee in-serviced staff on F689 on [DATE]. The in-service records were reviewed and staff interviews were conducted on all shifts. 23. Staff on leave or absent have been called by the Nurse Manager or Administrator and in-serviced via phone. An additional staff member participated on the phone in-service as the witness, both parties signed in place for the absent employee. All as needed staff and staff on leave such as sickness or vacation will not be placed on the schedule until they have completed the in service. The surveyors verified the in-service documentation and conducted interviews with staff on all shifts. Noncompliance of F-689 continues at a scope and severity of D for the monitoring and the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, observation and interview, it was determined the facility failed to adequately address and maintain the nutritional status for 2 of 4 (Residents #25 and 62) sampled residents of the 3 residents reviewed who experienced weight loss. The facility's failure to implement interventions resulted in a significant weight loss causing actual harm and substandard quality of care to Residents #25 and 62. The extended survey for substandard quality of care was done on 5/21/14. The findings included: 1. Review of the facility's "Weight Loss and Malnutrition" policy documented, "...Maintenance of adequate nutrition and hydration is necessary for the resident to maintain health, and prevent complications such as malnutrition and pressure sores... If intake is less than 50% (percent) alternate foods should be offered. Additional supplements may be provided. Consultation with the Registered Dietician (RD) may be obtained, and coordination with the nursing department should occur, to inform the physician of findings and to implement appropriate nutritional interventions... Severe weight loss is defined as: ...1 month > (greater than) 5%... 3 months > 7.5%... 6 months >10%... Consult with the Registered Dietitian to determine calorie, protein, vitamin and mineral requirements. Supplement intake as needed. Make recommendations and obtain orders for nutritional interventions as needed..." Review of the facility's "Nutritional Assessments" policy documented, "...A comprehensive nutritional assessment is completed to determine the resident's need for nutritional interventions, for the maintenance of acceptable parameters of body weight... The comprehensive assessment should be utilized to assist the interdisciplinary team with the development of care for each resident... The Registered Dietitian should be consulted for additional assessment in the presence of... weight loss..." 2. Medical record review for Resident #25 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 5/31/13 documented, "...AT NUTRITIONAL RISK R/T (related to) REQUIRES MECHANICALLY ALTERED THERAPEUTIC DIET: REGULAR MECHANICAL SOFT SNP (special nutritional program) DIET; HOUSE SUPPLEMENTS TID (three times a day)... START DATE 5/31/13 ...INTERVENTIONS... SERVE DIET AS ORDERED: REGULAR MECHANICAL SOFT SNP (with a line drawn through it) dc'd (discontinued) 9/11/13 ...MONITOR FOR CHANGES IN WEIGHT AS ORDERED ...HOUSE SUPPLEMENTS TID (with a line drawn through it) DC'D 9/11/13..." Review of the care plan dated 9/12/13 documented, "...PROBLEMS / STRENGTHS... AT NUTRITIONAL RISK R/T (related to) MECHANICALLY ALTERED DIET... GOALS... RESIDENT WILL TOLERATE DIET CONSUMING 75- (to) 100% OF MEALS WITH NO UNPLANNED SIGNIFICANT WEIGHT CHANGES..." Review of Resident #25's weight records documented the following: a. 11/11/13 - 168 pounds (#). b. 12/5/13 - 166#. c. 1/8/14 - 152#. d. 1/16/14 - 150#. The weight loss of 14# in one month, resulted in a significant weight loss of 8.4% and the loss of 16# in 6 weeks, resulted in a significant weight loss of 10% in 6 weeks. The facility was unable to provide documentation of nutritional interventions implemented for Resident #25's significant weight loss. Review of nurses' notes dated 11/15/13 through 1/15/14 did not address Resident #25's weight loss. Review of Resident #25's physician's progress notes dated 11/12/13 through 1/22/14 did not address weight loss. Review of the physician's progress noted dated 1/22/14 documented, "...weight 150..." Review of a dietary progress note dated 2/10/14 documented "...RD Review Jan (January) 2014 wgt (weight) 150# (sign for down) 16# 9.% Significant loss. No Feb (February) wgt Available 1. Weigh per physician note 1/27/14 1+ (plus) [MEDICAL CONDITION] extremities 2. Review in Risk. 3. Care Plan..." Review of a nutritional at risk subacute review dated 2/10/14 documented, " ...Supplement Order... 0 (indicating no interventions or supplements were put in place)..." During an interview in the 2nd floor restorative dining room on 5/19/14 at 6:35 PM the RD was asked if Resident #25 ever received any interventions to prevent weight loss from November 2013 through January 2014. The RD stated, "Doesn't look like it. December to January is where you should see the first interventions. Her (Resident #25) weight loss was acknowledged but there were no interventions put in place. I would have expected the (previous) RD to put something in place. It's when she went from 166 (pounds) to 150 (pounds), that's when something should have been done..." During an interview at the 2 east nurses' station on 5/20/14 at 10:30 AM the RD was shown a "Resident Meal Intake Graph" and was asked why she thought the resident lost weight if her intake showed she ate above 60% of her meals. The RD stated, "We think the person taking the weights during December (2013) and January (2014) was documenting incorrect weights, incorrectly weighing the residents, or was not weighing the residents and just putting something down that was close to the prior weight." During an interview at the 2 east nurses' station on 5/20/14 at 11:15 AM, the Activities Director (AD), was asked when she became the Activities Director and what her title was in December 2013. The AD stated, "I was Dietary Manager in December (2013) and was monitoring the weights during December 2013 and January 2014." The AD was asked if she was aware of Resident #25's weight loss. The AD stated, "Yes. I was aware..." The failure of the facility to implement nutritional interventions for the severe weight loss of 10% in 6 weeks, resulted in actual harm for Resident #25. 3. Review of the facility's "Change in Medical Condition of Residents" policy documented, "...Nurses notes should include documentation of the symptoms and observations associated with the change in condition, the date and time of contact with the physician and family member..." Medical record review for Resident #62 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #62's weight records documented the following: a. 4/8/14 - 194 pounds (#). b. 5/8/14 - 167#. c. 5/14/14 - 166#. d. 5/19/14 - 161#. The weight loss from 194 to 167, indicated a significant weight loss of 13.91 percent (%) in one month. The weight loss from 194 to 161 resulted in a significant weight loss of 17.01% in 6 weeks. The facility was unable to provide documentation of the physician or the family being notified of Resident #62's significant weight loss. Review of the physician progress notes [REDACTED].#62's weight loss. Review of the nurses' notes dated 4/8/14 through 5/12/14 did not document notification to the physician or family of Resident #62's weight loss. Review of a dietary progress note dated 5/14/14 documented, "...continues to receive regular mech. (mechanical) Soft/SNP diet. Consumed 43- (to) 78% meal served daily. Current wt 167#... Monitor po (by mouth) intake % and weight of any changes. Reviewed resident care plan, current nutrition intervention appropriate, continue plan of care..." Review of a "Nutrition Risk Review" dated 5/14/14 documented, "...Current Weight 167... Diet/consistency Regular Mech (Mechanical) Soft/SNP...% Intake 54-65%..." Observations in Resident #62's room on 5/19/14 at 8:00 AM, revealed the resident sitting up in bed drinking milk with a straw out of the carton. The cereal was not eaten, biscuit, sausage and eggs had very few bites eaten. There was no staff in Resident #62's room assisting him with breakfast. Observations and interview in Resident #62's room on 5/19/14 at 6:30 PM, revealed Resident #62 sitting on the side of his bed with a tray of regular food in front of him. Resident #62 had a bite of food in his mouth that he continually chewed and did not swallow. Resident #62 spit the bite of food out of his mouth into his hand and stated he was done. At 6:35 PM, the Activity Director was asked how much Resident #62 had eaten at supper. The Activity Director stated, "About 25 percent." During an interview in the activity room on 5/19/14 beginning at 4:00 PM, the RD was asked about the plan for Resident #62 and his weight loss. The RD stated, "I just saw that (weight loss) when I ran the weight log. He has lost 27 pounds in a month since April (2014). I asked the staff what was going on and they said he had pneumonia and he was pretty bad like not expected to make it but he is doing better now. I looked at the dietary note for May (2014) and saw where (named Dietary Manager) put in his note Regular Mechanical Soft/SNP and I checked for an order, but I did not see an order. We usually have an order for [REDACTED]. I can look at his tray card and see what he is getting." The RD stated, "We had a change over with the weight tech (technician) staff. In the care tracker the staff has documented he is eating 54 to 65 percent of his meals the past 7 days. Doesn't look like (named Dietary Manager) started anything. That is a 13 to 14 percent loss in a month." The RD was then asked what the process is for a resident identified with weight loss and who makes the recommendations and writes the orders. The RD stated, "The DON (Director of Nursing) can write the order, nursing can get an order from the doctor. A reweight was done but that was 6 days later and that was another pound less." The RD was asked who is in the risk meeting. The RD stated, "DON, Administrator, Certified Dietary Manager (CDM), the wound nurse that is the core group and I am if I am here." The RD was asked if weight loss was discussed in the risk meeting. The RD stated, "Yes." The RD was asked if the CDM was aware that he can call her for weight concerns. The RD stated, "Yes, he reaches out to me a lot." The RD was asked how often the risk meeting occurs. The RD stated, "I believe they do them every week." The RD confirmed Resident #62 had lost another 5 pounds with the 5/19/14 weight. The RD stated, "I checked his tray card and SNP was not on there." The failure of the facility to implement nutritional interventions for Resident #62's significant weight loss resulted in actual harm for Resident #62. During an interview at the 1 west nurses' station on 5/19/14 at 4:15 PM, the RD was asked if any interventions had been put in place after she had talked to the CDM. The RD shook her head and stated, "Nnh Mmm" for no. During an interview with the Administrator on 5/19/14 at 4:20 PM, the Administrator stated, "...going to get a reweight right now on the resident" and she verified that she had notified the RD after the risk meeting on 5/14/14 of some residents with weight loss for the RD to look at. During an interview in room [ROOM NUMBER] on 5/19/14 at 5:00 PM, the RD stated, the Administrator texted me last week after the risk meeting and she told me she had some weight changes that I needed to address. I came the next day (5/15/14) and I ran the weight report. I had several significant weight changes. I started at the top of the list and I started on the first floor and I started on the 2nd floor this week. The RD was then asked what should have been put in place. The RD stated, "I think they should have immediately put him (Resident #62) on SNP, house supplements and reweigh him if 5 pounds plus or minus difference and getting a reweight and they should call me and tell me." As of 5/19/14 Resident #62 was not on any supplements or the SNP program. During an interview by the 1st floor elevator on 5/19/14 at 5:25 PM, the Director of Nursing stated the weight for Resident #62 was "161.8 pounds." The DON was then asked if she weighed the resident. The DON stated, "Yes, I did." The DON was asked if the scales were correct. The DON stated, "I zeroed them (scales) out, yes they are (correct)." During an interview in room [ROOM NUMBER] on 5/19/14 at 5:45 PM, the DON was asked when the risk meeting was held. The DON stated, "Last week, things they look at was if he was getting SNP, if so, was he getting snacks and if so can he get them more often. He (Resident #62) was sick and not eating, a reweight was requested in the meeting." The DON was then asked what should occur after the risk meeting when there is a weight loss. The RD stated, "He (named Dietary Manager) was suppose to check, he would have to go to the nurses and get an order if not in place." The DON stated, "I asked the CDM if he (named Resident #62) was on SNP or supplements. He (CDM) wrote it down to check." The DON was then asked if the CDM checked. The DON stated, "No." The DON was asked if anyone assists the resident when he doesn't eat. The DON stated, "He (Resident #62) starts out feeding his self, then when they pick the tray up they would assist him." The DON was asked who would be responsible for helping Resident #62 to eat. The DON stated, "That would be the day tech (technician), she would help him." During an interview in room [ROOM NUMBER] on 5/19/14 at 6:10 PM, the CDM was asked what he does when a weight loss is identified. The CDM stated, "I write it down and look at the chart and see why the person is losing weight and I ask for a reweigh. If I thought something did not look as it seems. I should have went to the chart to see why he is losing." The CDM was then asked if he called the dietician to tell her about the weight loss. The CDM stated, "I am not sure." The CDM was asked if he went to the nurses to get an order for [REDACTED]. I don't think I did." The CDM was asked if something should have been put in place after last week's meeting. The CDM stated, "Yes." The CDM was asked if there was anything put in place after the meeting. The CDM stated, "No." The CDM was asked what should have been put in place for the weight loss. The CDM stated, "Should be SNP, high calorie high protein." During an interview in room [ROOM NUMBER] on 5/20/14 beginning at 7:40 AM, the DON was asked did anyone put any orders for supplements or any other interventions for weight loss on the chart. The DON stated, "He (Resident #62) was still not eating well. No." The DON was asked if anything else was put in place on 5/14/14. The DON stated, "The Doctor saw him 5/15/14. I don't think he wrote an order." The DON was asked when the assigned nurses would have known about the weight loss. The DON stated, "The restorative tech gives the weights to the DON the next morning. I would notify the nurse that has him the next morning. The charge nurse was not aware of the amount of pounds he (Resident #62) lost on 5/14/14. The technician weighed him again. I did not tell the charge nurse (about the amount of weight Resident #62 lost)." During an interview in room [ROOM NUMBER] on 5/20/14 at 8:15 AM, Nurse #1 stated, "The reweight was done on the same afternoon on 5/8/14 and the weight was 166. I asked the nurse about it she said he had been sick and not eating. I made the statement his weight is off by 10 pounds. (Named charge nurse) said he had pneumonia. I told the DON about the weight the next morning." During an interview in room [ROOM NUMBER] on 5/20/14 at 8:25 AM, Certified Nursing Assistant (CNA) #1 was asked if anyone had told her the resident had a weight loss. CNA #1 stated, "Mmmhmmm when he was sick about 2 weeks ago he just won't eat. I been reporting it. I reported it to (named nurse). I didn't have him yesterday I did lights." CNA #1 was asked if there was anyone assigned to assist the resident with eating. The DON stated, "Not anyone assigned to assist with residents feeding. Staff on the floor pick up trays and then help residents." During a telephone interview on 5/20/14 at 10:30 AM, Resident #62's primary care physician was asked if he was made aware of the amount of weight the resident had lost in the last month. Resident #62's primary care physician stated, "His dementia is quite advanced and my goal was more of keeping him comfortable than being aggressive. He had an episode there was a point somewhere in the last 2 months he had aspirated. The reality is dementia is so pronounced that the staff was aware of comfort philosophy. Resident #62's primary care physician was asked again if the facility notified him of the amount of weight loss the resident has in the last month. Resident #62's primary care physician stated, "I could see that visually (5/15/14 visit) he had lost weight." During an interview in room [ROOM NUMBER] on 5/21/14 at 9:00 AM, the DON was asked if she expected the physician and family to be notified of a resident's significant weight loss. The DON stated, "Yes." During an interview in the supervisor office on 5/21/14 at 1:00 PM, the Medical Director was asked if he was aware of any concerns with weight loss in the facility. The Medical Director stated, "Well we have utilization meeting and I have been to all of them except I did miss one month, but we talk about weight loss... If there is weight loss... definitely the physician and the family should be made aware of weight loss. There should definitely be some documentation in the record." The facility's failure to notify the physician and implement interventions for a significant weight loss resulted in actual harm to Residents #62. The facility's failure to implement interventions resulted in a significant weight loss causing actual harm and substandard quality of care for Residents #25 and 62.

Based on policy review, medical record review and interview, it was determined the facility failed to notify the physician or family of a significant unplanned weight loss for 1 of 3 (Resident #62) sampled residents of the 3 residents reviewed with weight loss. The failure of the facility to notify the physician of Resident #62' significant weight loss of 13.91 percent (%) in one month resulted in actual harm when the resident continued to loss weight. The findings included: Review of the facility's "Change in Medical Condition Of Residents" policy documented, "...Notification of the physician, legal representative, or interested family member, should occur promptly, according to federal regulations, when there is a change in the resident's condition... Loss of appetite/unplanned weight loss... Nurses notes should include documentation of the symptoms and observations associated with the change in condition, the date and time of contact with the physician and family..." Medical record review for Resident #62 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #62's weight records documented the following: a. 4/8/14 - 194 pounds (#). b. 5/8/14 - 167#. c. 5/14/14 - 166#. d. 5/19/14 - 161#. The weight loss from 194 to 167, indicated a significant weight loss of 13.91 percent (%) in one month. The weight loss from 194 to 161 # resulted in a significant weight loss of 17.01% in 6 weeks. The facility was unable to provide documentation of the physician or the family being notified of Resident #62's significant weight loss. Review of the physician progress notes [REDACTED].#62's weight loss. Review of the nurses' notes dated 4/8/14 through 5/12/14 did not document notification to the physician or family of Resident #62's weight loss. During an interview at the 2 west hall nurses' station on 5/20/14 at 10:00 AM, Resident #62's wife stated, "They called me last night (5/19/14) and told me he (Resident #62) wasn't eating." Resident #62's wife was asked did they tell you he was losing weight. The wife stated, "No they didn't. I guess they figured I would know that since he was so sick and wouldn't eat." During a telephone interview on 5/20/14 at 10:30 AM, Resident #62's primary care physician was asked if he was made aware of the amount of weight the resident had lost in the last month. Resident #62's primary care physician stated, "His dementia is quite advanced and my goal was more of keeping him comfortable than being aggressive. He had an episode there was a point somewhere in the last 2 months he had aspirated. The reality is dementia is so pronounced that the staff was aware of comfort philosophy. Resident #62's primary care physician was asked again if the facility notified him of the amount of weight loss the resident has in the last month. Resident #62's primary care physician stated, "I could see that visually (5/15/14 visit) he had lost weight." During an interview in room [ROOM NUMBER] on 5/21/14 at 9:00 AM, the DON was asked if she expected the physician and family to be notified of a resident's significant weight loss. The DON stated, "Yes." During an interview in the supervisor office on 5/21/14 at 1:00 PM, the Medical Director stated, "...If there is weight loss there are some things that could be put in place to try to help the patient stop losing... Definitely the physician and the family should be made aware of weight loss. There should definitely be some documentation in the record." There was no documentation the physician or the family member were notified of Resident #62's significant weight loss.

Based on policy review, medical record review and interview, it was determined the facility failed to ensure care plans were revised to reflect the current status for unplanned weight loss or the risk for emergency bleeding care related to [MEDICAL TREATMENT] shunt site for 3 of 35 (Residents #14, 25 and 62) sampled residents reviewed of the 19 included in the stage 2 review. The failure to put care plan interventions in place for unplanned signficant weight loss resulted in actual harm for Residents #25 and 62. The findings included: 1. Review of the facility's care plan policy documented, "...Plans of care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals for the resident... The team... should present findings from assessments... Existing goals and approaches should be reviewed and revised, as needed... When a new approach or goal is identified, the entry should be dated using the date the goal / approach is entered on the care plan..." 2. Medical record review for Resident #25 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of dietary progress notes documented the following: a. 12/6/13 - "...Quarterly Review - Current wt. (weight) 166# (pounds)." b. 2/10/13 (typo should be 14) - "...RD (Registered Dietitian) Review Jan (January) 2014 wgt (weight) 150# (arrow for down) 16# 9.% (percent) Significant loss. No Feb (February) wgt Available... 3. Care Plan..." Review of the care plan dated 9/12/13 documented, "...PROBLEMS / STRENGTHS... AT NUTRITIONAL RISK... MECHANICALLY ALTERED DIET... GOALS... RESIDENT WILL TOLERATE DIET CONSUMING 75%- (to) 100% OF MEALS WITH NO UNPLANNED WEIGHT CHANGES..." The care plan did not address Resident #25's significant weight loss. During an interview in the 2nd floor restorative dining room on 5/19/14 at 6:35 PM, the Registered Dietician (RD) was asked if Resident #25 ever received any interventions to prevent unplanned weight loss during November 2013 to January 2014. The RD stated, "Doesn't look like it. December to January is where you should see the first interventions. Her (Resident #25) weight loss was acknowledged but there were no interventions put in place. I would have expected the (previous) RD to put something in place. It's when she went from 166 (pounds) to 150 (pounds), that's when something should have been done." 3. Medical record review for Resident #62 documented an admitted 6/ 5 /12 with [DIAGNOSES REDACTED]. Review of the care plan dated 5/31/13 documented, "...AT NUTRITIONAL RISK R/T (Related To) REQUIRES MECHANICALLY ALTERED THERAPEUTIC DIET: REGULAR MECHANICAL SOFT SNP (special nutritional program) DIET; HOUSE SUPPLEMENTS TID (three times a day)... START DATE 5/31/13... INTERVENTIONS... SERVE DIET AS ORDERED: REGULAR MECHANICAL SOFT SNP (with line drawn through it) dc'd (discontinued) 9/11/13... MONITOR FOR CHANGES IN WEIGHT AS ORDERED... HOUSE SUPPLEMENTS TID (line through it) DC'D 9/11/13..." Resident #62's current significant weight loss was not on the care plan. Review of a dietary progress note dated 5/14/14 documented, "...Annual reviewed and MDS (minimum data set) assessment complete; continues to receive regular meds (medications). Mech (mechanical) Soft/SNP diet... Current weight 167# (pounds)... Reviewed resident care plan, current nutrition intervention appropriate, continue plan of care..." During an interview at the 1 west nurses' station on 5/19/14 at 4:15 PM, the RD was asked if any interventions had been put in place after she had talked to the Certified Dietary Manager (CDM). The RD shook her head and stated, "nnh mmm" for no. During an interview in room [ROOM NUMBER] on 5/20/14 at 8:20 AM, the Director of Nursing (DON) was asked if there should be a current care plan addressing Resident #62's current nutritional status and weight loss. The DON stated, "Yes." 4. Medical record review for Resident #14 documented an admission date of [DATE] with a readmitted [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of the care plan dated 7/26/13 and reviewed 4/15/14 documented, "PROBLEMS / STRENGTHS... At risk for complications of [MEDICAL CONDITION] requiring [MEDICAL TREATMENT] treatment... INTERVENTIONS... Monitor access site for signs and symptoms of infection or bleeding..." There was no care plan intervention for emergency bleeding. During an interview in the MDS office on 5/20/14 at 2:44 PM, the MDS nurse was asked if Resident #14's care plan addressed emergency bleeding. The MDS nurse stated, "No, it's not in there. It's not something I've ever thought of. I've only been doing this since February (2014)."